Safe Anastomoses without Ostomies in Cytoreductive Surgery with Heated Intraperitoneal Chemotherapy: Technical Considerations and Modifications.

BACKGROUND: Gastrointestinal complications, predominantly anastomotic leak (AL), are the most frequent source of severe morbidity after cytoreductive surgery (CRS). OBJECTIVE: The aim of this study was to present the technical standards for colorectal anastomoses developed and systematically applied to all patients undergoing CRS in a high-volume tertiary center, and the associated AL rates. METHODS: This was a descriptive study reporting the technical characteristics of a standardized protocol for three types of colorectal anastomoses (colorectal, ileorectal, and ileocolic) in CRS with heated intraperitoneal chemotherapy (HIPEC), and a retrospective analysis of prospectively collected data on anastomotic outcomes. All patients (1172) undergoing CRS with HIPEC from September 2006 to September 2020 were included. The anastomotic complications were classified according to the International Study Group of Rectal Cancer Surgery (ISGRCS) classification. RESULTS: Overall, 1172 patients underwent 1300 procedures and 1359 gastrointestinal anastomoses. An ileocolic anastomosis was performed in 408 patients, colorectal anastomosis in 469 patients, and ileorectal anastomosis in 16 patients, none with diverting ileostomy; 345 other gastrointestinal reconstructions and 82 urinary reconstructions were performed in these patients. The AL rate was 1% (4/408) for the ileocolic anastomosis, 0.85% (4/469) for the colorectal anastomosis, and 0% (0/16) for the ileorectal anastomosis. One patient died postoperatively due to AL. CONCLUSIONS: Systematic application of standardized techniques adapted to ensure optimal tissue healing (stapled anastomoses avoiding overlap, accurate staple deployment, and hand-sewn reinforcement) are associated with a very high level of anastomotic safety in a large cohort of patients undergoing CRS and HIPEC.

Precision oncology and systemic targeted therapy in Pseudomyxoma Peritonei.

PURPOSE: Pseudomyxoma peritonei (PMP) is a rare and poorly understood malignant condition characterized by the accumulation of intra-abdominal mucin produced from peritoneal metastases. Currently, cytoreductive surgery remains the mainstay of treatment but disease recurrence and death after relapse frequently occur in PMP patients. New therapeutic strategies are therefore urgently needed for these patients. EXPERIMENTAL DESIGN: A total of 120 PMP samples from 50 patients were processed to generate a collection of 50 patient-derived organoids (PDO) and xenograft (PDX) models. Whole exome sequencing (WES), immunohistochemistry analyses and in vitro and in vivo drug efficacy studies were performed. RESULTS: In this study, we have generated a collection of PMP preclinical models and identified druggable targets, including BRAFV600E, KRASG12C and KRASG12D,that could also be detected in intra-abdominal mucin biopsies of PMP patients using droplet digital PCR. Preclinical models preserved the histopathological markers from the original patient sample. The BRAFV600E inhibitor encorafenib reduced cell viability of BRAFV600E PMP-PDO models. Proof-of-concept in vivo experiments showed that a systemic treatment with encorafenib significantly reduced tumor growth and prolonged survival in subcutaneous and orthotopic BRAFV600E-PMP-PDX mouse models. CONCLUSIONS: Our study demonstrates for the first time that systemic targeted therapies can effectively control PMP tumors. BRAF signaling pathway inhibition represents a new therapeutic opportunity for BRAFV600E PMP patients who have a poor prognosis. Importantly, our present data and collection of preclinical models pave the way for evaluating the efficacy of other systemic targeted therapies toward extending the promise of precision oncology to PMP patients.

Preoperative Progressive Pneumoperitoneum in the Treatment of Hernias With Loss of Domain. Our Experience in 50 Cases.

Introduction: Surgical planning for repair of giant hernias with loss of domain needs to consider patient comorbidities, potential risks and possible postoperative complications. Some postoperative complications are related to the increase in intra-abdominal pressure caused by the reintroduction of abdominal contents into the peritoneal space. Preoperative progressive pneumoperitoneum (PPP) increases the capacity of abdominal cavity prior to hernia repair and allows for better physiological postoperative adaptation. The aim of this study is to analyze perioperative and intraoperative characteristics as well as outcomes of a cohort of patients treated with PPP prior to giant hernia repair at a single, high volume center. Methods: Prospective, descriptive, observational single-center study including 50 patients undergoing PPP prior to hernia with loss of domain repair between January 2005 and June 2022. We analysed epidemiological, surgical and safety variables. Results: Fifty patients were included: 43 incisional hernias, 6 inguinal hernias and 1 umbilical hernia. Mean age was 66 years (36-85). Median insufflation time was 12 days (4-20) and median insufflated volume of ambient air was 10,036 cc. There were complications during PPP in nine patients: 2 decompensation of chronic respiratory disease and 7 subcutaneous emphysema. PPP was prematurely suspended in patients with respiratory decompensation. All patients with incisional and umbilical hernias underwent open repair with mesh placement. Preperitoneal repair was performed in inguinal hernias. Three cases of hernia recurrence were reported during the follow up. Conclusion: PPP is a safe and effective tool in the preoperative management of patients with giant hernias. It helps to achieve the decrease or absence of abdominal wall tension and can favour the results of complex eventroplasty techniques.

Comparative study of access routes for Port-A-Cath® implantation. / Estudio comparativo entre vías de acceso de implantación de Port-A-Cath.

INTRODUCTION: There has been an increase in the implantation of subcutaneous reservoirs in recent years. The objective of this study was to compare puncture techniques against venous dissection. METHODS: This retrospective cohort study included patients who required a Port-a-Cath and were divided into two groups: venous puncture (PV) and venous dissection (DV). Patients were over 18 years of age, requiring continued intravenous treatment, with no restriction of pathology. Patients with a previous reservoir and <18 years old were excluded. The choice of the technique was based on the surgeon's preferences. We analyzed the clinical parameters of age, sex, ASA, BMI, reason for placement and laterality, and data related to the complications and withdrawal rate in each of the groups. RESULTS: 386 patients were included for 5 years: 228 DV group and 155 PV group. In three cases, the technique was not documented. There were no differences between the two groups with respect to age, sex, ASA, BMI and reason for implantation (p>0.05). The average follow-up was two years. The DV group was found to have a lower number of complications, while the PV group had an increased incidence of catheter replacement and removal. However, these differences were not statistically significant (p=0.113). CONCLUSIONS: Both DV and PV are safe and effective techniques. In our experience, DV presented better intraoperative and long-term results. Further studies are recommended to discern which technique to use more safely.