Feasibility of delayed hyperthermic intraperitoneal chemotherapy in case of unforeseen complications.

BACKGROUND: Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) can improve the prognosis of selected patients with peritoneal surface malignancy (PSM). Usually, treatment is performed as an extensive one-step approach. We investigated the feasibility of delayed HIPEC, if the one-step procedure was interrupted precociously. METHODS: 42 patients with PSM who underwent CRS and delayed HIPEC from 2006-2008 were studied. HIPEC was performed 5 days after treatment with mitomycin, cisplatin and hyperthermia. Perioperative complications and toxicity were analyzed. RESULTS: Delayed HIPEC was successfully completed in 40 of the 42 patients. In 2 cases, HIPEC was omitted because of complications during chemotherapy (anastomotic leakage and retroperitoneal edema). Minor and major surgical complications occurred in 18 and 9 of the 40 patients treated with HIPEC (45 vs. 22.5%), respectively. Toxicity grade II-IV (WHO criteria) was observed in 4 of them (10%). Median stay in the intensive care unit was 9 days (range 2-31) while the mean hospitalization time was 24 days (range 14-59). In this series, there was no mortality. CONCLUSION: Postponement of HIPEC after CRS (two-step approach) is feasible. Analysis of morbidity and mortality showed no significant difference to the one-step approach reported in the literature and no disadvantages for the patient. The two-step approach is an alternative option for patients who had to discontinue the one-step approach due to unpredictable intraoperative complications.

[CT-guided resection of pulmonary metastases]. / CT-gesteuerte Resektion pulmonaler Metastasen.

PURPOSE: To evaluate the feasibility and potential use of intraoperative computed tomography (IOP CT) as guidance for video-assisted thoracic surgery (VATS). MATERIAL AND METHODS: Fifteen consecutive patients with peripheral intrapulmonary nodules underwent a thoracoscopy with IOP CT. Solitary lesions were known in 6/15 patients (40 %, group II) whereas 9/15 (60 %, group I) patients had multiple lesions (n >/= 2). IOP CT was performed with the mobile CT scanner Philips Tomoscan M. Radiologists intraoperatively placed percutaneous marks of lung lesions after unsuccessful VATS by use of a lung marker set (Somatex, Teltow, Germany). VATS was performed under general anaesthesia and with double lumen endotracheal intubation for single lung ventilation. Imaging quality and imaging of pulmonary nodules were rated. RESULTS: IOP CT was evaluated as feasible combined with VATS. Thoracotomy was avoided in 5/15 patients where lesions could not be detected by VATS. A CT-guided biopsy was performed in two patients after an unsuccessful attempt of thoracoscopy. There were no documented side effects. CONCLUSION: First clinical results suggest that a combination of VATS and IOP CT is feasible. Thus, the number of open thoracoscopies might be decreased. Intrapulmonary lesions not detectable with VATS could be marked under CT -- guidance intraoperatively and then resected by thoracoscopy.

An implantable carotid sinus baroreflex activating system: surgical technique and short-term outcome from a multi-center feasibility trial for the treatment of resistant hypertension.

OBJECTIVES: To assess perioperative outcomes and blood pressure (BP) responses to an implantable carotid sinus baroreflex activating system being investigated for the treatment of resistant hypertension. METHODS: We report on the first seventeen patients enrolled in a multicenter study. Bilateral perivascular carotid sinus electrodes (CSL) and a pulse generator (IPG) are permanently implanted. Optimal placement of the CSL is determined by intraoperative BP responses to test activations. Acute BP responses were tested postoperatively and during the first four months of follow-up. RESULTS: Prior to implant, BP was 189.6+/-27.5/110.7+/-15.3 mmHg despite stable therapy (5.2+/-1.8 antihypertensive drugs). The mean procedure time was 202+/-43 minutes. No perioperative strokes or deaths occurred. System tests performed 1 or up to 3 days postoperatively resulted in significant (all p < or = 0.0001) mean maximum reduction, with standard deviations and 95% confidence limits for systolic BP, diastolic BP and heart rate of 28+/-22 (17, 39) mmHg, 16+/-11 (10, 22) mmHg and 8+/-4 (6, 11) BPM, respectively. Repeated testing during 3 months of therapeutic electrical activation demonstrated a durable response. CONCLUSIONS: These preliminary data suggest an acceptable safety of the procedure with a low rate of adverse events and support further clinical development of baroreflex activation as a new concept to treat resistant hypertension.

[Is breast saving therapy of breast carcinoma without postoperative radiotherapy justified?]. / Ist die brusterhaltende Therapie des Mammakarzinoms ohne postoperative Strahlentherapie gerechtfertigt?

We report a retrospective analysis of 388 patients treated by breast preserving surgery without postoperative radiotherapy. The lymphatic invasion by the carcinoma is one of the most important factors for local recurrence. The local recurrence shows a highly significant negative influence on metastases free survival and overall survival. However, we could not define any (sub) group of patients in whom a postoperative radiotherapy was not necessary.

Surgical oncology in the interplay of surgical and nonsurgical disciplines.

Advances in surgical tumor therapy are founded on a very close interaction between different surgical subspecialties as well as the inclusion of surgical into modern multimodality treatment concepts. The ongoing development of surgical techniques, e.g. microsurgical flap transfers or pouch reconstructions of intestinal reservoirs, has increasingly enabled organ- and function-preserving surgery. In addition, new materials (e.g. modular tumor endoprosthesis) has supported this development. The broad application of the sentinel node technique in melanoma and breast cancer and also in gastrointestinal tract cancers opens new concepts of diagnosis and therapy for lymphatic metastasized tumors. Locally advanced tumors can be treated in neoadjuvant protocols to increase the resectability rate and the probability for local control as a prerequisite for long-term survival. Especially for metastatic disease, interventional treatment techniques such as laser-induced thermotherapy (LITT) or photodynamic therapy have added valuable options to surgical treatment.