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how to actually evaluate a surgeon for peritoneal meso - what separates the experienced ones

Patient · · 547 views
So I'm about six weeks out from diagnosis and I'm starting to narrow down centers for HIPEC. I've already had two consultations and I'm trying to figure out what questions actually matter versus what sounds impressive but doesn't mean anything.

I know volume matters but I'm seeing conflicting numbers. One surgeon said she does 40 peritoneal cases a year, the other said 25. How much does that difference actually matter for outcomes? I found a study from 2021 that suggested anything above 20 cases annually showed better survival but I'm not sure if that's still current.

I'm also trying to understand the difference between someone who trained in surgical oncology versus someone who trained in general surgery and then specialized. Does that background actually affect how they approach HIPEC or is it more about the individual surgeon's focus after residency?

What I'm really trying to nail down: when you're evaluating someone, what did you actually ask about that made you confident they knew what they were doing? I'm keeping a list of questions and I want to make sure I'm not just asking things that sound like I did my homework but actually get at whether this person is the right fit.

Also curious if anyone has experience with centers that do peritoneal specifically versus centers that do pleural and peritoneal both. I know some surgeons split their focus and I'm wondering if that matters for outcomes.

8 Replies

Patient
Hey, I'm pleural not peritoneal so take this with a grain of salt, but the surgery shopping process is basically the same. I had my EPP back in February and here's what actually mattered to me when I was vetting surgeons.

The volume thing, yeah it matters but maybe not the way you're thinking. I asked one surgeon how many EPPs he'd done total in his career, not just per year. Turns out the 40-a-year guy had only been doing them seriously for like 5 years. The other one had been at it since the late 90s. That experience matters when stuff goes sideways in the OR. I wanted someone who'd seen complications and knew how to handle them.

What I really cared about was asking "walk me through your complication rate and what you do when you hit X problem." Not in a gotcha way, just asking them to describe their approach. A surgeon who knows their stuff will talk specifics. They'll tell you about infection rates, recurrence patterns, how they handle adhesions. They won't just say "we have excellent outcomes." Mine actually pulled up his own data from the last 50 surgeries and we went through it together. That's when I knew.

On the training background thing, honestly I think it matters less than who they trained under after residency. My surgeon did general surgery residency but spent 10 years as a fellow under a mesothelioma specialist. That apprenticeship is where the real skill lives.

One thing nobody talks about: ask them how many times they've had to convert from the planned procedure to something else. That answer tells you a lot about realistic expectations versus what they promise you.
Patient
That's actually a really good catch about the career timeline. I've been so focused on annual volume that I didn't think to ask how long they've actually been doing this. So the surgeon with fewer cases per year but more years of experience overall, did you feel like that showed in the consultation? Like was there a noticeable difference in how they talked through complications or problem-solving?
Medical ✓ Expert Response
The training pathway question is one I've seen come up a lot in our support groups and honestly the research is a little inconclusive on it, but what I've noticed over 12 years working with peritoneal patients is that the more telling question isn't where they trained, it's how many times in the last 24 months they've specifically managed a complication after HIPEC. Like a fistula, a bowel obstruction, a chemo toxicity event. Because anyone can do a clean case.

The 2021 Annals of Surgical Oncology data you found is still pretty widely cited, and 20 cases annually does seem to be where the outcome curve starts to shift. But honestly the gap between 25 and 40 may matter less than whether those cases were peritoneal meso specifically versus all peritoneal primaries lumped together. Ovarian, appendix, colon... those are different animals and surgeons sometimes count them all.

And the split focus thing, pleural plus peritoneal, that's a real concern worth pressing on. I had a patient at a Chicago center back in spring 2023 who specifically asked her surgeon what percentage of his OR time in the prior year was peritoneal only, and the answer changed her decision completely.

Journaling these consultations side by side, like literally the same questions asked in the same order, can help you see the differences more clearly than memory alone.
3 found this helpful
Family
Okay so Joe's pleural not peritoneal but I've been down the rabbit hole of surgeon evaluation with him and I picked up a thing or two. The volume question you're asking is exactly right to be asking.

When we were looking at centers back in September, I made a spreadsheet (old teacher habit, sorry) and one thing that jumped out was asking not just how many cases they do but what their complication rates actually are. Like one surgeon bragged about 50 cases a year and when I dug deeper through their hospital's public data, their readmission rate was way higher. The other one did 35 cases and had solid numbers. We went with the second one. That was at Moffitt in Tampa and honestly the difference in how they explained things to us was night and day.

The training background thing... we asked our surgical oncologist point blank what his fellowship was in and then asked him to walk us through his first HIPEC case versus his hundredth. How did your approach change? That tells you way more than looking at credentials. Someone who trained in general surgery but has been laser focused on peritoneal work for a decade might actually be sharper on the nuances than someone with the "right" training who does it alongside ten other things.

The question that made me feel confident about Joe's team was asking about what happens if they find something unexpected during surgery. Like what's your contingency plan. Not just for the surgery itself but for follow up care. Centers that only do peritoneal might actually have a tighter protocol but I've also seen places that do both peritoneal and pleural be really excellent because they understand the broader picture.

You're six weeks out so you've got time to be picky. How are you feeling about the two consultations so far?
Medical ✓ Expert Response
Six weeks out is such a hard place to be, and the fact that you're doing this level of research says a lot about how seriously you're taking this.

On the volume question, the study you found is roughly in line with what the literature has shown for a while. There's actually a 2019 Annals of Surgical Oncology paper that put the inflection point closer to 15 to 20 cases annually, with meaningful gains in complication rates up through about 35. So honestly, both surgeons you've seen are operating in a range where the data gets less dramatic. At that point I'd be looking at meso-specific volume, not just peritoneal. HIPEC for appendix cancer and HIPEC for mesothelioma are different animals and the numbers can get blurry when centers lump them together.

The training pathway question is one I hear a lot and in my experience what matters more is where the surgeon did their HIPEC fellowship and under whom. There are maybe eight or nine surgeons in the US who trained a significant percentage of the people doing this procedure now. Asking "who did you train with specifically for cytoreductive surgery" gets you more useful information than the general surgery vs. surgical oncology distinction.

The question that I've seen really separate the confident surgeons from the excellent ones is asking about their incomplete cytoreduction rate and what they do when they encounter disease distribution that wasn't visible on imaging. How a surgeon talks about those moments tells you everything. Some people get very vague very fast.

On the split focus question, I'd gently push back on any surgeon who describes their mesothelioma volume as part of a broader "peritoneal disease" practice without giving you meso-specific numbers. And if persistent issues around anxiety or anticipatory grief come up as you go through this process, working with a counselor who specializes in oncology can genuinely help you think more clearly through decisions like this one.
2 found this helpful
Family
I'm pleural not peritoneal so I might be off base here, but I asked my mom's surgeon something that stuck with me. I asked "what's your complication rate and how do you handle it when something goes wrong mid-surgery." And honestly it was less about the number and more about how he answered. Like he didn't dodge it. He said he's had to convert to palliative a handful of times and he walked me through what that meant and when he'd make that call. That felt real to me.

The other surgeon gave me this really polished answer about his outcomes being in the top percentile and it felt like he was selling me instead of just telling me what actually happens. I don't know if that matters for peritoneal the same way but maybe ask them what they'd do if they got in there and it looked worse than the imaging showed? How they pivot? That's the stuff that made me trust someone versus just impressive on paper.

Also I've been juggling this whole thing while trying to keep my job and some days I'm just exhausted so I get why you're trying to nail this down now. You're doing the right thing asking these questions early.
Patient
That's exactly the kind of question I need to ask. The honesty piece is what I'm realizing I haven't been drilling down on enough - I've been so focused on the statistics that I almost missed the part where someone just admits things don't always go perfectly. Did you ask your mom's surgeon anything else about how he decides between continuing HIPEC versus stopping, or was that the main thing that shifted your confidence in him?
Family
I asked my mom's surgeon point blank how many patients she's lost on the table in the last two years and what she learned from each one - sounds harsh but her answer told me everything about whether she actually reviews her outcomes or just moves on. That question got way more real than the polished stuff.

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