Ropivacaine, Interleukin-6 and Tumor Necrosis Factor Alpha Plasma Levels during Intermittent Epidural and Continuous Wound Infusion of Ropivacaine for Analgesia after Hysterectomy or Myomectomy: An Observational Study.

BACKGROUND/AIMS: The concentration-time profile of the long-acting local anesthetic ropivacaine after epidural (EP) administration at fixed time intervals or continuous subcutaneous (SC) infusion has not been fully evaluated. The objective of this work was to determine total plasma concentrations of ropivacaine and changes in cytokine interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) levels during EP and SC. METHODS: In this prospective randomized controlled trial, 18 patients undergoing abdominal hysterectomy or myomectomy were randomly selected to receive ropivacaine either every 6 h via an EP catheter or by continuous wound infusion along the skin incision, after a bolus dose, for 48 h. Total plasma ropivacaine concentrations were measured before the bolus and 2, 4, 8, 24, 48, and 50 h after the bolus using high-performance liquid chromatography-UV and IL-6 and TNF-α levels were measured at 0, 8 and 24 h with ELISA and analyzed statistically. RESULTS: During EP, mean ± SD ropivacaine concentrations were relatively stable up to 50 h postoperatively, that is, 239 ± 89 ng/ml, while during SC, initial concentrations between 2 and 8 h were comparatively lower (101.5 ± 42.9 ng/ml) than 24-50 h concentrations (437.1 ± 206 ng/ml). An increase in IL-6 levels was noted between 0 and 24 h during EP and SC, but TNF-α levels increased slightly, between 0 and 24 h, only during EP. CONCLUSION: Ropivacaine plasma concentrations with both EP and SC were found to be safe throughout the administration time interval. IL-6 levels increased during the same time interval, while TNF levels varied only slightly.

Clinical presentation and management of gastro-intestinal and pancreatic secondary metastatic tumors.

PURPOSE: As progress regarding the treatment has occurred over recent years in oncology, more patients with metastatic disease are presented for diagnosis and further management. The purpose of this study was to reveal the incidence, location and to describe the clinical characteristics and outcome in a series of patients diagnosed with pancreatic, small and large bowel metastatic tumors that underwent metastasectomy. METHODS: A total of 12 patients (7 male and 5 female) diagnosed with extrahepatic gastrointestinal (GI) and pancreatic metastases from 2001 to 2013 were operated for resection of secondary metastatic tumors to the small and large bowel and the pancreas. Four out of 12 patients were asymptomatic and a secondary tumor was detected during follow up. RESULTS: The median interval revealing the metastatic tumor since the management of the primary tumor was 6.5 years (range 1-27). Primary tumors were malignant melanoma (4 patients), renal cell carcinoma (RCC; 2 patients), leiomyosarcoma of the uterus (2 patients), lobular breast cancer, mesenchymal chondrosarcoma of the skull, endometrial adenocarcinoma and a non-Hodgkin lymphoma (one case each). The median follow-up was 15 months (range 4-120). CONCLUSIONS: Metastatic secondary tumors have to be considered especially when the patient's medical history includes a previous malignancy. They may also occasionally present as the initial manifestation of an occult primary lesion leading to diagnostic difficulty. Although radical surgery is the most effective approach, treatment and survival grossly depend on histological type and the stage of the primary disease. Hence, management of these patients should be individualized by a multidisciplinary team.

Intermittent epidural vs continuous wound infusion of ropivacaine for acute and chronic pain control after hysterectomy or myomectomy: a randomized controlled trial.

OBJECTIVE: Adequate postoperative analgesia may enhance recovery. The efficacy of continuous wound infusion vs intermittent epidural ropivacaine for postoperative analgesia was investigated. DESIGN: Prospective randomized, observer blind trial. SETTING: Aretaieio University Hospital. SUBJECTS: Patients scheduled for open abdominal hysterectomy or myomectomy. METHODS: Patients received 10 mL of 0.75% ropivacaine along the skin incision before skin closure, followed by wound infusion 2 mL/hour of 0.375% ropivacaine or epidurally 10 mL of 0.75% ropivacaine in the beginning of surgery followed by 10 mL of 0.2% ropivacaine 6 hourly. The epidural injections or the wound infusion of ropivacaine lasted 48 hours. Rescue analgesia consisted of patient-controlled analgesia morphine up to 48 hours and acetaminophen/codeine tablets the next 24 hours. Analgesic consumption and visual analog scale pain at rest and during cough were assessed 2, 4, 8, 24, 48, and 72 hours postoperatively. One and three months later, patients were interviewed by phone for analgesic consumption at home and presence of pain. RESULTS: The subcutaneous group consumed more morphine during the first 2, 4, and 8 hours postoperatively (P < 0.001, P < 0.001, and P < 0.001, respectively). Subsequent morphine and acetaminophen/codeine requirements did not differ between the two groups. Pain intensity during cough was higher only 2 hours after surgery in the subcutaneous group (P = 0.002). Three months postoperatively, the two groups did not differ in the analgesic requirements and presence of persisting and/or burning pain. CONCLUSION: Based on our results, there is no clinical significant difference between the epidural ropivacaine and the subcutaneous ropivacaine group or a clear superiority to one management strategy.

Pregabalin vs. opioids for the treatment of neuropathic cancer pain: a prospective, head-to-head, randomized, open-label study.

OBJECTIVES: Neuropathic cancer pain (NCP) is a common manifestation of cancer and/or its treatment. Treatment following the WHO analgesic ladder provides relief for the majority of cancer pain patients; however, concern remains that opioids may be less efficacious for neuropathic pain (NP) compared with nociceptive pain, often necessitating the use of higher doses. Adjuvants, such as pregabalin, have shown to be efficacious for the treatment of NP, although data come mostly from noncancer studies. The comparative efficacy and safety of opioids versus adjuvants has not been studied for NCP. The aim of this study was to directly compare pregabalin versus a strong opioid for the treatment of NCP. METHODS: A total of 120 patients, diagnosed with "definite" NCP, were randomized into two groups and received increasing doses of either oral pregabalin or transdermal fentanyl for 28 days. VAS score, patient satisfaction, need for opioid rescue, and adverse events (AEs) were recorded. RESULTS: In the pregabalin group, a significantly higher proportion of patients achieved at least 30% reduction in VAS compared with the fentanyl group (73.3%, 95% CI: 60.3%-83.93 vs. 36.7%, 95% CI: 24.5%-50.1%, P < 0.0001, respectively), while the percentage mean change from baseline was also significantly different [46% (95% CI: 39.5%-52.8%) for pregabalin and 22% (95% CI: 14.9%-29.5%) for fentanyl (P < 0.0001)]. Patient-reported satisfaction was more frequent with pregabalin, while AEs and treatment discontinuations were more frequent in the fentanyl group. DISCUSSION: Prompt use of a neuropathic pain-specific adjuvant, such as pregabalin, in NCP may lead to better control of the neuropathic component, with opioid-sparing effects.

Non-functioning pancreatic endocrine tumors: eleven-year experience in a single institute.

PURPOSE: Non-functioning pancreatic endocrine tumors (NF-PETs) comprise the majority of pancreatic endocrine tumors. We present our experience from the management of 18 patients with NF-PET. METHODS: From May 2002 to June 2013, 18 patients were admitted in our hospital for the management of NF-PETs. We analyzed their clinical presentation, preoperative evaluation, surgical and postoperative management and the outcome. RESULTS: The tumor was located in the pancreatic head in 13 (72%) patients and in the body and tail of the pancreas in the remaining 5 (28%). Four patients (22%) had stage IIIa, 7 (39%) stage IIIb and 7 (39%) stage IV. Twelve (67%) patients with pancreatic head tumor underwent pancreatoduodenectomy (PD). In one case (5%), the tumor was deemed unresectable and the remaining 5 (28%) patients underwent distal pancreatectomy and splenectomy (DPSP). Four (22%) patients with unilobar metastatic liver disease underwent hemihepatectomy or segmentectomy. Perioperative mortality was 0%. Postoperatively, all stage IV patients received peptide receptor radionuclide treatment (PRRT). The 5-year overall survival rate was 61%, with a median survival of 71 months, whereas the 5-year overall survival rate after diagnosis of hepatic metastases was 45%. CONCLUSION: Surgical resection is the gold standard for the treatment of NF-PETs. A formal resection appears to be the standard procedure when malignancy is verified or suspected. Aggressive surgery should be undertaken in patients with locally advanced or metastatic NF-PETs, as it may prolong survival. In stage IV patients, intra-arterial PRRT, after super-selective catheterization of the hepatic artery, is a promising therapeutic modality.

Epidural Anesthesia for Neuromyelitis Optica in Obstetrics: A Case Report and Literature Review.

Neuromyelitis optica (NMO), also known as Devic disease, poses unique challenges in obstetrical anesthesia, with limited research available. This case report presents the anesthetic management of a 43-year-old gravida 2 para 1 (G2P1) woman with NMO undergoing labor induction at 39 weeks of gestation. Having received uneventful epidural labor analgesia in her first pregnancy, she faced the delicate decision of neuraxial anesthesia in light of her NMO diagnosis, which was made following her initial pregnancy. Collaborative discussions resulted in the choice of labor epidural analgesia, and an indwelling epidural catheter was placed successfully. An unplanned cesarean section with effective epidural supplementation followed. The case highlights the intricacies of balancing pain relief and neurological risks in NMO patients. Existing literature reflects varying perspectives on neuraxial anesthesia in NMO, with reports both supporting and cautioning against its use. The case aligns with the current view that epidural labor analgesia appears safe in NMO, but conclusive recommendations await larger studies. The decision for neuraxial anesthesia in NMO should be individualized, guided by comprehensive pre-anesthetic counseling and ongoing research developments.

Neuroendocrine differentiation in embryonal type hepatoblastoma.

Hepatoblastoma, a malignant tumor which arises occasionally in older children but very rarely in adults, exhibits divergent differentiation with embryonal cells, fetal hepatocytes and immature elements. This report describes an embryonal type hepatoblastoma with neuroendocrine differentiation in a 16-year-old patient, which was diagnosed postoperatively. Clinical and radiologic work-up failed to reveal a primary gastrointestinal malignancy and no primary lesions were detected in any other organ. This feature of hepatoblastoma is considered to be a multidirectional differentiation of the small epithelial or stem cells of the liver. At 2-year follow up, the patient remains symptom-free, with normal laboratory and diagnostic imaging studies, and no recurrent or metastatic disease identified.

Perioperative pregabalin for acute and chronic pain after abdominal hysterectomy or myomectomy: a randomised controlled trial.

CONTEXT: The antiepileptics gabapentin and pregabalin are used as adjuvants to control postoperative pain. OBJECTIVE: The aim of the present study was to investigate the effect of perioperative administration of pregabalin on postoperative acute and chronic pain and analgesic requirements. SETTING: Department of Anaesthesiology, Aretaieio University Hospital, Athens, Greece. PATIENTS: Eighty patients scheduled for abdominal hysterectomy or myomectomy were randomly assigned to the pregabalin or to the control group. INTERVENTION: The pregabalin group received 150 mg of pregabalin 8-hourly, starting on the afternoon before surgery and continued until the fifth postoperative day. The control group was similarly treated, but received placebo capsules instead. MEASUREMENTS: Postoperative intravenous morphine and Lonalgal (30 mg codeine with 500 mg paracetamol) tablet consumption, visual analogue pain scores at rest and on coughing, sedation, anxiety, dizziness, ataxia, blurred vision and diplopia were recorded. One and 3 months postoperatively patients were interviewed for the presence of pain and analgesic needs due to surgery. RESULTS: The pregabalin-treated patients consumed less morphine during the first 48 h postoperatively (P = 0.0001). However, consumption of Lonalgal tablets and visual analogue scores for pain at rest and on coughing did not differ between the groups. No difference was found in sedation and anxiety scores between the patients who received placebo or pregabalin. Patients in the control group had lower incidences of dizziness (29 versus 58%, P = 0.015), ataxia (0 versus 18%, P = 0.011), blurred vision (6 versus 26%, P = 0.028) and diplopia (0 versus 16%, P = 0.023). Presence of pain, analgesic intake due to surgery and decreased or absent sensation around the wound did not differ between the groups 1 and 3 months postoperatively. CONCLUSION: Pregabalin in the doses given decreased morphine requirements for the first 48 h postoperatively, but neither altered the analgesic requirements beyond 48 h nor had any effect on acute, late or chronic pain.

Two cases of primary splenic hydatid cyst in Greece.

Cystic disease of the spleen is an uncommon entity in general population. Most cases result from parasitic infection by Echinococcus granulosus, a form called splenic hydatid disease (SHD), with a reported frequency of 0.5-6.0% within abdominal hydatidosis. On the contrary, an isolated splenic involvement of hydatid disease is very uncommon even in endemic regions. Two cases of primary SHD managed with open and laparoscopic radical surgery in our department are reported herein. Primary SHD is a rare entity with non-specific symptoms underlying clinical suspicion by the physician for prompt diagnosis. Surgical treatment is the mainstay therapy, while laparoscopic approach when feasible is safe, offering the advantages of laparoscopic surgery.

Postoperative abdominal free air: How much and when is enough? Report of two cases.

Postoperative intraperitoneal or ectopic free air may occur after abdominal surgery, gynecologic surgery, laparoscopic surgery, or endoscopic procedures and, in rare cases, represent gastrointestinal perforation, requiring emergency laparotomy. Evaluating patients with postoperative signs of bowel perforation may be difficult, especially when day-case laparoscopic or endoscopic surgery is performed, with the patient readily discharged from hospital. Delayed diagnosis of gastrointestinal perforation due to underestimation of postoperative free air is associated with a high morbidity and mortality rate. We report two cases of patients presenting with postoperative free air along with the clinical presentation and management.

Free air after laparoscopic hysterectomy; from sigmoid perforation to upper airway compromise: a case report.

BACKGROUND: Free air after laparoscopic hysterectomy is a common finding; in rare cases, free air represents gastrointestinal perforation, requiring emergency laparotomy. Ectopic air localizations after pneumoperitoneum have been reported in various laparoscopic surgical techniques. Delayed diagnosis of visceral perforation is associated with high mortality rates. CASE PRESENTATION: We present a white Caucasian female in which dysphonia due to air entrapment in the cervical area, pneumomediastinum and pneumothorax, occured afterlaparoscopic hysterectomy. CONCLUSIONS: Upon mobilization of the patient, air from sigmoid perforation moved cephalad. Through the same path, pneumoperitoneum, causes subcutaneous emphysema in the neck and face, pneumomediastinum and pneumothorax.

Leiomyoma of the uterine round ligament: A case report.

Leiomyomas are common benign tumours that can arise in any anatomical structure containing smooth muscle. Their localization in the uterine round ligament is rare, although leiomyomas are the most frequent tumour of this structure. Leiomyomas present as inguinal, labial or intra-abdominal masses, and are often misdiagnosed as hernias or enlarged lymph nodes. The aim of the present study was to describe a rare case of a large intra-abdominal mesenchymal neoplasm arising from the right round ligament of the uterus. A 51-year-old asymptomatic female patient (gravida 3, para 3) presented herself for a routine gynaecological examination. A transvaginal ultrasound examination revealed a solid heterogeneous mass with a maximum diameter of 9 cm localized at the right parametrial space. Further preoperative evaluation using magnetic resonance imaging revealed that the mass contained solid and cystic components, which was suggestive of a mesenchymal neoplasm with possible involvement of the right ovary. Complete excision of the tumour and total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed via laparotomy under general anaesthesia. The intraoperative findings, frozen section biopsies and final histological examination of the tumour established the diagnosis of an intra-abdominal myoma of the right uterine round ligament. The majority of abdominal round ligament myomas are initially asymptomatic. The role of synchronous imaging examinations, such as ultrasonography and magnetic resonance imaging, in the diagnosis of these lesions is crucial.

Pharmacology of sedation agents and reversal agents.

Sedation for gastrointestinal endoscopies is obtained by opioids, benzodiazepines, propofol, ketamine and/or droperidol. The pharmacokinetic profile of some sedatives/anesthetics renders them advantageous over others. Opioids, mainly pethidine and fentanyl, are the most popular. Though newer opioids provide a faster recovery, fentanyl is safe and advantageous due to its lower cost. Remifentanil, due to its pharmacokinetic profile (elimination half-life: 9 min), is advantageous for ambulatory patients, though it is not known whether the high cost compensates the benefits. Midazolam is the benzodiazepine of choice as it has a shorter duration of action and a better pharmacokinetic profile than diazepam. Propofol, an intravenous anesthetic, has become very popular for gastrointestinal endoscopies in sedative doses. The opioid and benzodiazepine antagonists, naloxone and flumazenil, are indicated only in particular circumstances, like deep sedation with threatening respiratory depression. Ketamine and droperidol are not popular agents for sedation in the modern endoscopic practice.

Severe anaphylactic shock after anesthesia induction: An unusual initial manifestation of Churg-Strauss syndrome.

Churg-Strauss syndrome or eosinophilic granulomatosis with polyangiitits (EGPA) is a rare multisystem disorder. A case of anaphylactic shock after induction of anesthesia, as the initial clinical presentation of Churg-Strauss syndrome in a 15-year-old girl is reported. It is extremely rare to see pediatric patients with previous perioperative anaphylaxis receiving future anesthesia; a multidisciplinary approach including allergist, rheumatologist, anesthesiologist, and surgeon is necessary in order to provide a better future anesthetic plan.

Intravenous morphine and droperidol after caesarean delivery under subarachnoid anaesthesia has no effect on postoperative pain or analgesic requirements.

BACKGROUND AND OBJECTIVE: Opioids are routinely administered to obtain a better control of postoperative pain. The aim of the present study was to assess the intravenous morphine effect after caesarean delivery on the postoperative morphine requirements and pain. METHODS: Sixty-two parturients undergoing elective caesarean section under subarachnoid anaesthesia were randomly assigned in a double-blinded manner to the morphine or to the control group, to receive intraoperatively 0.15 mg kg morphine in 100 ml of isotonic saline or equal volume of normal saline. Postoperative analgesia was ensured with patient-controlled analgesia morphine. Postoperative pain at rest and after cough was assessed using the visual analogue scale (VAS) 2, 4, 8, and 24 h. Morphine consumption was recorded at the same time points. RESULTS: Cumulative morphine consumption 2, 4, 8, and 24 h postoperatively was 6 +/- 4.8, 14 +/- 6.6, 22 +/- 9.6, and 42 +/- 15.7 mg in the morphine and 8 +/- 5.1, 18 +/- 7.7, 28 +/- 9.4, and 43 +/- 17.4 mg in the control group (F = 2.70, DF = 1, and P = 0.105 for intergroup comparisons). The VAS scores at rest did not differ between the two groups, being 28 +/- 22.3, 40 +/- 21.4, 28 +/- 18.5, and 28 +/- 22.2 mm in the morphine group and 28 +/- 21.5, 43 +/- 23.5, 29 +/- 24.2, and 19 +/- 24.8 mm in the controls (F = 0.37, DF = 1, P = 0.848). Similar results apply to the VAS scores recorded after cough. VAS values were 35 +/- 20.6, 51 +/- 22.5, 42 +/- 18.2, and 46 +/- 23.6 mm in the morphine and 40 +/- 22.1, 54 +/- 28.9, 47 +/- 26.5, and 38 +/- 26.9 mm in the control group, respectively. CONCLUSION: Morphine given after caesarean delivery under subarachnoid anaesthesia has no effect on analgesic requirements or acute postoperative pain.

Ischemic postconditioning decreases iNOS gene expression but ischemic preconditioning ameliorates histological injury in a swine model of extended liver resection.

BACKGROUND: Both pre- and postconditioning have been shown to protect the liver parenchyma from ischemia/reperfusion (I/R) injury during hepatectomy by altering the production of NO. However, to date there is no study to compare their effect on the inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS) gene expression, who are the main modulators in the pathway of NO during the acute phase of I/R injury. METHODS: We designed a prospective experimental cohort comprising of three groups (sham group-SG, preconditioning-PrG and postconditioning group-PoG) and consisting of 10 animals per group. All animals underwent extended hepatectomy (70%) under prolonged warm ischemia either after preconditioning or followed by postconditioning or without any protective maneuver (SG). Following reperfusion blood samples and liver biopsies were obtained at the start of reperfusion (0 hours), at 6 and 12 hours post reperfusion. iNOS and eNOS gene expression was assessed on liver tissue by polymerase chain reaction (PCR); in addition, the extent of hepatocellular injury was histologically assessed. RESULTS: At the beginning of reperfusion iNOS expression was significantly reduced in the PoG in comparison to the SG (Kruskal-Wallis test, P=0.012; Mann-Whitney U test, P<0.0005 Bonferroni correction) and continued to remain at low levels until 6 hours post reperfusion (Kruskal-Wallis test, P=0.01; Mann-Whitney U test, P<0.0005-Bonferroni correction) This difference was eliminated by 12 hours. No significant differences were found in the expression of eNOS between groups and within time measurements. Aspartate aminotransferase (AST) and Alkaline phosphatase (ALP) were found increased at the start of reperfusion; their levels continued to increase by 6 hours in all groups, however only in the PoG the increase attended statistical significance at 12 hours after reperfusion. ALT levels presented only minor alterations during the course of reperfusion. The PrG was found to have more intense hepatocellular injury at the start of reperfusion than the PoG however, that appeared to gradually settle by 12 hours in contrast to PoG where the hepatocellular injury continued to deteriorate. CONCLUSIONS: PoG appeared to decrease iNOS overexpression more effectively than PrG in comparison to animals who have undergone no protective maneuver (SG). However, PrG was more effective than PoG in ameliorating the hepatocellular injury observed at 12 hours after the ischemic insult.

Preoperative gabapentin: the effect on ropivacaine subarachnoid block and hemodynamics.

BACKGROUND: Gabapentin is an adjuvant analgesic and may enhance the spread of subarachnoid block. We investigated the effects of pretreatment with gabapentin on subarachnoid block characteristics and hemodynamics. METHODS: Seventy patients undergoing transurethral procedures under subarachnoid anesthesia with 2.2 mL of 0.75% ropivacaine were randomly assigned to receive preoperatively 400 mg of gabapentin 6 hourly, up to a total dose of 1200 mg, or placebo. Sensory and motor blocks were assessed every 30 min until regression of sensory block to L4. At the same time intervals, systolic and diastolic arterial blood pressures and heart rate were recorded. RESULTS: There were no differences between groups in the sensory block levels or degree of motor block. Sensory block 150 min after the subarachnoid injection had regressed to L4 in 26 of 32 patients in the gabapentin group and in 25 of the 33 patients in the control group. Systolic arterial blood pressure was decreased in the gabapentin group (P = 0.002 for the main effect of group, and P = 0.03 at 60 min between the groups). The diastolic arterial blood pressure did not differ between the groups, but overall, the heart rate was more rapid in the gabapentin group (P = 0.002, but only for baseline values between the groups, P = 0.036). CONCLUSION: Pretreatment with gabapentin had no effect on the spread of sensory block or the regression of motor block but was associated with lower systolic arterial blood pressure values in patients undergoing subarachnoid anesthesia with ropivacaine.

Postoperative pain and analgesic requirements after anesthesia with sevoflurane, desflurane or propofol.

BACKGROUND: General anesthetics may have nociceptive actions that affect postoperative pain. In studies evaluating postoperative pain, the effect of general anesthetics on analgesic requirements has not been considered except for one recent study suggesting that propofol anesthesia provides better analgesia after surgery than isoflurane. METHODS: In this prospective, blind, randomized trial we recorded postoperative analgesic requirements (mg of morphine) and pain scores (visual analog scale in mm) 2, 4, 8, and 24 h postoperatively in patients undergoing abdominal hysterectomy or myomectomy under sevoflurane, desflurane or propofol anesthesia, titrated to maintain Bispectral Index values between 35 and 45. Pain scores were also recorded immediately after transfer to the postanesthesia care unit. RESULTS: Cumulative morphine consumption did not differ among the three groups 2, 4, 8, or 24 h postoperatively (P = 0.50). The morphine consumed within 24 h postoperatively was 28 +/- 13.8 mg in the sevoflurane group, 25 +/- 11.7 mg in the desflurane group and 27 +/- 16.1 mg in the propofol group. The visual analog scale values at rest or after cough immediately after patient transport to the postanesthesia care unit and 2, 4, 8, and 24 h after surgery did not differ among the three groups (P = 0.40, 0.39, 0.50, 0.47, 0.06 at rest and P = 0.67, 0.45, 0.22, 0.26, 0.29 after cough respectively). CONCLUSION: Morphine consumption and pain 24 h postoperatively did not differ among the sevoflurane, desflurane, and propofol groups.

Pseudomyxoma Peritonei: Presentation of Two Cases and Challenging Issues in the Literature.

Pseudomyxoma peritonei (PMP) is a rather uncommon syndrome in oncology with a unique biological behavior and an estimated incidence of one to two cases per million per year. Clinically, it usually presents with a variety of unspecific signs and symptoms including abdominal pain and distention, ascites, or even bowel obstruction. Despite its intimidating clinical manifestation, PMP is characterized by satisfactory survival rates when treated with cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). We present two interesting cases of PMP deriving from the appendix with a rather atypical presentation, which was successfully treated with cytoreduction and HIPEC. In addition, we intend to raise clinical suspicion on the diagnosis of PMP and comment on several challenging issues concerning the origin and classification of PMP.