Bowel perforation with generalised peritonitis secondary to recurrent primary fallopian tube carcinoma after 17 years.

We describe a case of bowel perforation secondary to a recurrence of primary fallopian tube carcinoma treated more than a decade ago. A woman in her 70s presented to a rural centre with an acute abdomen. An abdominal CT showed a perforated ileum secondary to a pelvic mass. Emergency laparotomy identified the pelvic mass that was adherent to the side wall and invading the ileum at the site of perforation. Its adherence to the external iliac vessels posed a challenge to achieve en-bloc resection; therefore, a defunctioning loop ileostomy was created. Final histopathology and immunopathology were consistent with the recurrence of her primary fallopian tube carcinoma. The patient was further discussed in a multidisciplinary team meeting at a tertiary referral hospital. This case highlighted the importance of having a high index of suspicion for cancer recurrence, the utility of rapid source control laparotomy and multidisciplinary team patient management.

Outcomes and prognostic factors of cytoreductive surgery and perioperative intraperitoneal chemotherapy in high-volume peritoneal carcinomatosis.

BACKGROUND AND OBJECTIVES: The management of patients with extensive appendiceal mucinous neoplasms and mesothelioma is controversial. Our aims were to analyze overall survival (OS), disease-free survival (DFS) and independent prognostic factors associated with high peritoneal cancer index (PCI) status in patients who underwent cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC). METHODS: A prospectively-maintained database for patients with appendiceal neoplasms and mesothelioma undergoing CRS/PIC from year 1996 to 2018 was retrospectively analyzed. Patients who achieved complete cytoreduction were stratified into limited (PCI < 30) and extensive (PCI ≥ 30) disease groups. RESULTS: 260 female and 235 male patients were identified. The 5-year survival for low-grade appendiceal mucinous neoplasms (LAMN) was significantly higher in the low PCI group (96.2% vs. 63.5%, p < 0.001). There was no difference in the OS across both groups in high-grade appendiceal mucinous neoplasms (HAMN) (63 vs. 69 months; p = 0.942) and mesothelioma (72 vs. 42 months; p = 0.058). Overall mortality was 2%. Grade III/IV complications were significantly higher in extensive disease (68% vs. 36.6%, p < 0.001). On multivariate analysis, use of EPIC and blood transfusion (>8 units) were independent positive and negative prognostic factors, respectively, associated with OS. Meanwhile, use of EPIC conferred benefit in DFS while increased blood transfusion (>8 units) and elevated preoperative CA125 were predictive of a poor DFS. CONCLUSION: Long-term survivals following CRS/PIC are achievable with acceptable mortality and higher morbidity rates in extensive appendiceal mucinous neoplasms and mesothelioma. High PCI status does not preclude treatment with CRS/PIC.

Early recurrence in peritoneal metastasis of appendiceal neoplasm: Survival and prognostic factors.

INTRODUCTION: Early recurrence (ER) is defined as development of loco-regional peritoneal disease within 12-month of the initial CRS/PIC. Our aims were to identify overall survival (OS), recurrence-free survival (RFS) and independent prognostic factors associated with ER in PM of appendiceal neoplasm. MATERIALS AND METHODS: A prospectively-maintained database for patients with appendiceal neoplasm undergoing cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) from year 1996-2018 was retrospectively analysed. RESULTS: 208 female and 185 male patients were identified. With a median follow-up of 40-month, 40.2% of the patients developed ER. The median OS for ER was 24 months compared to late (LR) at 64 months. Median OS was not reached in non-recurrence (NR). 5-year survival for ER was less favourable compared to LR and NR (19.3%vs54.6%vs94%). No patients in ER group survived beyond 10-year. Independent negative predictors associated with ER on multivariate analysis were male patient (p = 0.013), blood transfusion of >8 units (p = 0.013), elevated preoperative CEA levels (>5 ng/ml; p = 0.002) and hard intraoperative tumour consistency (p < 0.001). Protective factor was a combination of CC1, hard tumour consistency and use of EPIC (p = 0.039). Independent prognostic factors that predicted recurrence of appendiceal PM were PCI >20 (p = 0.049), non-use of EPIC (p = 0.012), hard tumour consistency (p = 0.004) and use of previous chemotherapy (p = 0.023). CONCLUSION: ER following CRS and PIC of appendiceal PM is associated with reduced survival outcomes. Our data alludes to the importance of optimising the risk factors in order to delay loco-regional recurrence and improve long-term survival of these patients.

Case report: Intraoperative thrombosis cardiac arrest in extended right hepatectomy involving use of local haemostatic agent in intraoperative cell salvage (ICS) and administration of recombinant activated factor VII (rFVIIa).

INTRODUCTION: In modern surgical era, local haemostatic agents and blood components such as recombinant activated factor VII (rFVIIa) have expanded surgeons' armamentarium in controlling "surgical" and "nonsurgical bleeding". We report a case of intraoperative thrombosis and cardiac arrest involving use of local haemostatic agent in intraoperative cell salvage and rFVIIa administration in extended right hepatectomy. PRESENTATION OF CASE: A 46-year-old lady underwent extended right hepatectomy using cardiopulmonary bypass (CPB) and autotransfusion with ICS for metastatic gastrointestinal stromal tumour. She became extremely coagulopathic following weaning of CPB despite an array of fluid and blood products replacements. Decision to administer rFVIIa as a measure to arrest bleeding was unsuccessful. Extensive systemic thrombosis occurred which resulted in cardiac arrest and mortality. DISCUSSION: The thromboembolic event was unclear but likely multifactorial. Two important hypotheses were the administration of rFVIIa and use of local haemostatic agent in ICS. CONCLUSION: Reported incidence of thromboembolism with use of rFVIIa in refractory bleeding is variable. More randomised controlled trials are needed to ascertain the efficacy and safety profile of the haemostatic agent. At present, off-label use of rFVIIa should be guided by the risk:benefit profile on a case-to-case basis. The authors also feel strongly against the use of local haemostatic gel in conjunction with ICS due to potential systemic circulation of the thrombin.

Gastric perforation following cytoreductive surgery and perioperative intraperitoneal chemotherapy: a case series of six.

BACKGROUND: Incidence of gastric perforation following cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) is not widely reported. METHODS: Suitable patients were identified from our database of 1028 procedures. Relevant information was then gathered via medical records and operation reports for these patients. RESULTS: Six patients suffered early postoperative gastric perforation following the procedure (0.58%), all of whom received heated intraoperative intraperitoneal chemotherapy (HIPEC). Surgical exploration revealed protrusion of nasogastric (NG) tube through stomach wall defects which were either located at or near the greater curvature of stomach. These patients were managed successfully with operation, and no mortality was recorded. CONCLUSIONS: Gastric perforation following CRS and PIC is most likely the result of a multifactorial process. To reduce the risk of such complication, avoiding nasogastric suction in these patients may prove helpful. Any suspected perforated viscus must be addressed promptly to avoid unwanted morbidity and mortality from the procedure. To our knowledge, conservative management has not been documented to work in this subgroup and surgery remains the mainstay of treatment.

Microwave ablation of liver metastasis complicated by Clostridium perfringens gas-forming pyogenic liver abscess (GPLA) in a patient with past gastrectomy.

INTRODUCTION: Gas-forming pyogenic liver abscess (GPLA) caused by C. perfringens is rare but fatal. Patients with past gastrectomy may be prone to such infection post-ablation. PRESENTATION OF CASE: An 84-year-old male patient with past gastrectomy had MW ablation of his liver tumors complicated by GPLA. Computerised tomography scan showed gas-containing abscess in the liver and he was managed successfully with antibiotic and percutaneous drainage of the abscess. DISCUSSION: C. perfringens GPLA secondary to MW ablation in a patient with previous gastrectomy has not been reported in the literature. Gastrectomy may predispose to such infection. Even in high-risk patients, empirical antibiotic before ablation is not a standard of practice. Therefore following the procedure, close observation of patients' conditions is necessary to allow early diagnosis and intervention that will prevent progression of infection. CONCLUSION: Potential complication of liver abscess following MW ablation can never be overlooked. The risk may be enhanced in patients with previous gastrectomy. Early diagnosis and management may minimise mortality and morbidity.