RESUMO
BACKGROUND: Cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is a procedure that has had encouraging results for peritoneal metastases (PM) from diverse tumour origins, but it is not exempt from high morbidity. Recently, the important role of laparoscopy in oncologic surgeries and its benefits have been evaluated for CRS + HIPEC in selected patients, which has yielded promising results. The aim of our study is to analyse the use of laparoscopy for CRS + HIPEC in patients with limited peritoneal disease. METHODS: We have conducted a retrospective study from a prospective database in our tertiary referral hospital within the period of January 2009 to July 2019, which includes 825 patients who had PM from varying tumour origins. We have compared the patients treated with the laparoscopic approach (L-CRS-HIPEC) to a matched population who have undergone the open approach (O-CRS-HIPEC) and fulfil the same selection criteria. We have analysed the postoperative outcomes and survival results. RESULTS: We have confirmed the homogeneity between the sample of the O-CRS + HIPEC (n = 42) and the L-CRS + HIPEC (n = 18) regarding preoperative and intraoperative features. The L-CRS + HIPEC group had shorter hospital stays, (median of 4 [2-10] days versus 9 [2-19] days) and reduced wait time to return to chemotherapy (median of 4 [3-7] weeks and a median of 8 [4-36] weeks) than the O-CRS + HIPEC group. No differences were found regarding the need for perioperative blood transfusion, surgery time or postoperative morbi-mortality. No early locoregional relapse occurred in the L-CRS + HIPEC group and short term disease-free survival did not differ between groups. CONCLUSIONS: Laparoscopy for CRS + HIPEC is feasible and safe in highly selected patients, with no significant differences concerning postoperative morbi-mortality or early oncological results. We have found that patients who have undergone laparoscopic operations have shorter hospital stays and that they return to adjuvant chemotherapy sooner. Further investigation is required to confirm the benefits of minimally invasive procedures for the management of PM.
Assuntos
Procedimentos Cirúrgicos de Citorredução , Laparoscopia , Adulto , Idoso , Intervalo Livre de Doença , Humanos , Quimioterapia Intraperitoneal Hipertérmica , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Morbidade , Neoplasias Peritoneais/cirurgia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Vísceras/cirurgia , Adulto JovemRESUMO
BACKGROUND: The aim of our study was to present the technique for, and early results of complete laparoscopic pelvic peritonectomy (LPP) plus hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: We conducted a study on consecutive patients who had LPP for limited peritoneal carcinomatosis (peritoneal carcinomatosis index < 10) from ovarian cancer, colon cancer and benign multicystic mesothelioma, from January 2017 to November 2019 at 2 referral centers in Spain. Perioperative, pathologic, 30-day major morbidity and mortality characteristics were analyzed. The surgical technique is shown in the attached video. RESULTS: Twelve LPP + HIPEC were performed. Complete cytoreduction was achieved in 100% of the patients, the median duration of the operation was 450 min (range 360-600 min). There were 2 cases (16%) of IIIa morbidity (trocar hernia and pleural effusion), and no mortality. The median length of hospital stay was 5.5 days (range 4-10 days). The median length of follow-up was 10 months (range 2-30 months). There was a recurrence at the splenic hilum in 1 patient which was treated by laparoscopic splenectomy and one nodal recurrence at 13 months while all other patients are alive and free of disease at last follow-up. CONCLUSIONS: This is the first technical video of a minimally invasive approach for complete pelvic peritonectomy plus omentectomy associated with HIPEC. For highly selected patients, this procedure presents a feasible and safe alternative to the maximally invasive approach.
Assuntos
Hipertermia Induzida , Laparoscopia , Protocolos de Quimioterapia Combinada Antineoplásica , Terapia Combinada , Feminino , Humanos , Quimioterapia Intraperitoneal Hipertérmica , Recidiva Local de Neoplasia , EspanhaRESUMO
BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are currently the most accepted treatment for peritoneal metastases from colorectal cancer. Restrictive selection criteria are essential to obtain the best survival benefits for this complex procedure. The most widespread score for patient selection, the peritoneal surface disease severity score (PSDSS), does not include current biological factors that are known to influence on prognosis. We investigated the impact of including RAS mutational status in the selection criteria for these patients. METHODS: We studied the risk factors for survival by multivariate analysis using a prospective database of consecutive patients with carcinomatosis from colorectal origin treated by CRS and HIPEC in our unit from 2009 to 2017. The risk factors obtained were validated in a multicentre, international cohort, including a total of 520 patients from 15 different reference units. RESULTS: A total of 77 patients were selected for local análisis. Only RAS mutational status (HR: 2.024; p = 0.045) and PSDSS stage (HR: 2.90; p = 0.009) were shown to be independent factors for overall survival. Early PSDSS stages I and II associated to RAS mutations impaired their overall survival with no significant differences with PSDSS stage III overall survival (p > 0.05). These results were supported by the international multicentre validation. CONCLUSIONS: By including RAS mutational status, we propose an updated RAS-PSDSS score that outperforms PSDSS alone providing a quick and feasible preoperative assessment of the expected overall survival for patients with carcinomatosis from colorectal origin undergone to CRS + HIPEC.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimioterapia do Câncer por Perfusão Regional/mortalidade , Neoplasias Colorretais/mortalidade , Procedimentos Cirúrgicos de Citorredução/mortalidade , Hipertermia Induzida/mortalidade , Mutação , Neoplasias Peritoneais/mortalidade , Proteínas ras/genética , Neoplasias Colorretais/genética , Neoplasias Colorretais/patologia , Neoplasias Colorretais/terapia , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Peritoneais/genética , Neoplasias Peritoneais/secundário , Neoplasias Peritoneais/terapia , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Minimally invasive surgery is playing an increasing role in the treatment of patients with gastrointestinal and gynaecological malignancies as the data show reduced morbidity, faster recovery and similar oncological outcome when compared to open procedures. MATERIALS AND METHODS: The American Society of Peritoneal Surface Malignancies (ASPSM) conducted a retrospective study to analyse peritonectomy procedures and HIPEC done via the laparoscopic route. A database with standard clinical and pathological parameters was set up and distributed amongst ASPSM members. Rate of relapse, morbidity and mortality were the primary endpoints of the study. RESULTS: A total of 90 patients from 7 centres around the world were identified. Sixty percent were female. Mean age was 50 years. Peritoneal carcinomatosis from appendiceal origin was the most common diagnosis in a 64.9% of patients and colon origin was diagnosed in 16.5% of patients. Mean peritoneal cancer index (PCI) was 4.1 (0-10). Forty-one percent of patients had a bowel resection. Mean operative time was 4.7 h (2.5-8). All patients had a complete cytoreduction and HIPEC. Grade 3 and 4 morbidity was 3.0 and 6.5%, respectively. The most common reason for re-operation was an internal hernia in 2 out of 5 cases. Operative mortality and re-admission rates were 0 and 5%, respectively. Mean hospital stay was 7.4 days (1-18). At a mean follow-up of 31.6 months, 15/90 patients have a disease relapse but loco-regional relapse was identified in only five patients. CONCLUSIONS: Analysis of these data suggests that minimally invasive approach for peritonectomy procedures and HIPEC is feasible, safe and should be considered as part of the armamentarium for highly selected patients with peritoneal surface malignancies with limited tumour burden, defined as PCI of 10 or less and borderline tumours as low-grade pseudomyxoma and benign multicystic mesothelioma.
Assuntos
Procedimentos Cirúrgicos de Citorredução/métodos , Hipertermia Induzida , Laparoscopia , Neoplasias Peritoneais , Complicações Pós-Operatórias/epidemiologia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Feminino , Humanos , Hipertermia Induzida/efeitos adversos , Hipertermia Induzida/métodos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia , Avaliação de Processos e Resultados em Cuidados de Saúde , Neoplasias Peritoneais/tratamento farmacológico , Neoplasias Peritoneais/patologia , Neoplasias Peritoneais/cirurgia , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos RetrospectivosRESUMO
BACKGROUND: Local relapse and peritoneal carcinomatosis (PC) for pT4 colon cancer is estimated in 15,6% and 36,7% for 12 months and 36 months from surgical resection respectively, achieving a 5 years overall survival of 6%. There are promising results using prophylactic HIPEC in this group of patients, and it is estimated that up to 26% of all T4 colon cancer could benefit from this treatment with a minimal morbidity. Adjuvant HIPEC is effective to avoid the possibility of peritoneal seeding after surgical resection. Taking into account these results and the cumulative experience in HIPEC use, we will lead a randomized controlled trial to determine the effectiveness and safety of adjuvant treatment with HIPEC vs. standard treatment in patients with colon cancer at high risk of peritoneal recurrence (pT4). METHODS/DESIGN: The aim of this study is to determine the effectiveness and safety of adjuvant HIPEC in preventing the development of PC in patients with colon cancer with a high risk of peritoneal recurrence (cT4). This study will be carried out in 15 Spanish HIPEC centres. Eligible for inclusion are patients who underwent curative resection for cT4NxM0 stage colon cancer. After resection of the primary tumour, 200 patients will be randomized to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy in the experimental arm, or to systemic chemotherapy only in the control arm. Adjuvant HIPEC will be performed simultaneously after the primary resection. Mitomycin C will be used as chemotherapeutic agent, for 60 min at 42-43 °C. Primary endpoint is loco-regional control (LC) in months and the rate of loco-regional control (%LC) at 12 months and 36 months after resection. DISCUSSION: We assumed that adjuvant HIPEC will reduce the expected absolute risk of peritoneal recurrence from 36% to 18% at 36 months for T4 colon-rectal carcinoma. TRIAL REGISTRATION: NCT02614534 ( clinicaltrial.gov ) Nov-2015.
Assuntos
Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/terapia , Hipertermia Induzida/métodos , Mitomicina/uso terapêutico , Adulto , Idoso , Antibióticos Antineoplásicos/uso terapêutico , Terapia Combinada , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The cytoreductive surgery (CRS) associated with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard treatment in patients with carcinomatosis peritoneal from different origins. The use of a minimally invasive approach for this high complex procedure might be an alternative that provides them less morbidity and faster recovery with similar oncologic outcomes. METHODS: We describe the initial experience of CRS and HIPEC done via the laparoscopic route in patients with minimal peritoneal metastases in our Unit from March 2016 to January 2018. RESULTS: A total of eight patients were operated by this minimally invasive approach. The different diagnoses were low-grade pseudomyxoma peritonei (2), benign multicystic mesothelioma (2), primary epithelial ovarian carcinomatosis (2) and locally advanced colon carcinoma T4 (2). The median age was 54 (20-62) years, the median PCI was 3 (2-4), the median operative time was 287 min (240-360), complete cytoreduction CC0 was achieved in all the patients, and no major morbidity was observed. The median length of stay was 4.75 days (4-5). After a median follow-up of 9.5 months, no relapse has been observed. CONCLUSION: The results suggest that this minimally invasive approach for CRS and HIPEC is feasible and safe in a highly selected group of patients with peritoneal surface malignancies.
Assuntos
Procedimentos Cirúrgicos de Citorredução , Hipertermia Induzida , Neoplasias Peritoneais/cirurgia , Pseudomixoma Peritoneal/tratamento farmacológico , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma/cirurgia , Neoplasias do Colo/tratamento farmacológico , Neoplasias do Colo/cirurgia , Feminino , Humanos , Laparoscopia , Masculino , Mesotelioma/tratamento farmacológico , Mesotelioma/cirurgia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/cirurgia , Intervenção Coronária Percutânea , Neoplasias Peritoneais/secundário , Peritônio , Estudos Prospectivos , Pseudomixoma Peritoneal/cirurgia , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Inflammatory markers may help monitor postoperative evolution of surgical patients and detect complications. However, to date, the effect that neoadjuvant chemotherapy and hyperthermic intraperitoneal chemotherapy (HIPEC) may have in the postoperative kinetics of these parameters remains unknown. METHODS: Between July 2011 and June 2014, all patients who underwent neoadjuvant chemotherapy, cytoreductive surgery, and HIPEC for ovarian peritoneal carcinomatosis were studied. Patients were divided into four groups: no complications, noninfective complication, and infective complications during the first and second postoperative weeks. Retrospectively, C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), white blood cell count, platelet-to-lymphocyte ratio, and prothrombin ratio were collected from postoperative days 1-14. Postoperative behavior of each parameter was carefully evaluated across groups. RESULTS: The study included 122 patients. Only CRP and NLR showed promising results. CRP presented a mean peak value at 48 h (186.1 mg/L), while NLR peaked at 24 h (10.21 mg/L). Both parameters rose with infective complications. Statistically significant differences were found at several time points compared with uncomplicated patients. A simple test comparing the peak value of CRP with the value when an infective complication was suspected accurately diagnosed these complications with sensitivity of 81 %, specificity of 91 %, and negative and positive predictive value of 93.1 and 76 %, respectively. This comparison presented lower diagnostic performance when NLR was used. CONCLUSIONS: Both CRP and NLR are useful in monitoring postoperative evolution in these patients; however, only CRP is useful for detecting infective complications.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Procedimentos Cirúrgicos de Citorredução , Hipertermia Induzida , Mediadores da Inflamação/análise , Terapia Neoadjuvante , Neoplasias Ovarianas/patologia , Neoplasias Peritoneais/patologia , Complicações Pós-Operatórias , Proteína C-Reativa , Carboplatina/administração & dosagem , Quimioterapia Adjuvante , Quimioterapia do Câncer por Perfusão Regional , Terapia Combinada , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Ovarianas/metabolismo , Neoplasias Ovarianas/terapia , Paclitaxel/administração & dosagem , Neoplasias Peritoneais/metabolismo , Neoplasias Peritoneais/terapia , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
INTRODUCTION: Neutral argon plasma (NAP) system could meet the requirements to achieve oncological cytoreduction of peritoneal carcinomatosis with miliary lesions, minimizing the associated morbidity. This phase I/II trial aims to establish the desirable dose that is safe and effective in eliminating tumor cells with lower penetration. METHODS: Patients diagnosed with different origins for peritoneal carcinomatosis and miliary implants were selected for the study. The safe and potentially effective dose (desirability) of NAP was evaluated according to three factors: distance (mm), application time (s) and power (%), to evaluate the response variables such as the presence of tumor cells (Y/N) and the depth of penetration. RESULTS: Ten patients and 120 samples were evaluated and treated with NAP. There was no vascular or organ injury intraoperative using a pre-established dose of 100% (coagulation mode) at a distance of 2-3 cm. The distance was found to be correlated with the presence of the tumor cells in ex-vivo analysis, with an OR of 15.4 (4.0-111.4). The time and energy used were protective factors to eliminate tumor cells with an OR of 0.4 (0.1-0.9) and 0.8 (0.8-0.9), respectively. The safest and most effective desirability results were as follows i) energy 80% during 2-4 s with a distance of 2 cm (0.89), and ii) energy 100% during 2-4 s with a distance of 3 cm (0.90). CONCLUSIONS: The use of NAP during a CRS and HIPEC is safe and effective for eradicating tumor cells on the peritoneal surface at suggested doses of energy, distance and duration. TRIAL IDENTIFICATION: ClinicalTrials.gov Identifier: NCT04904042.
Assuntos
Hipertermia Induzida , Neoplasias Peritoneais , Gases em Plasma , Humanos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução , Neoplasias Peritoneais/cirurgia , Taxa de SobrevidaRESUMO
INTRODUCTION: A laparoscopic approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (L-CRS+HIPEC) in highly selected patients has been reported in small cohorts with a demonstrable reduction in length of stay and post-operative morbidity. This study aims to analyse individual patient data from these international centres collected through the Peritoneal Surface Oncology Group International (PSOGI) L-CRS+HIPEC registry. METHODS: An international registry was designed through a networking database (REDCAP®). All centres performing L-CRS+HIPEC were invited through PSOGI to submit data on their cases. Patient's characteristics, postoperative outcomes and survival were analysed. RESULTS: Ten international centres contributed a total of 143 L-CRS+HIPEC patients during the study period. The most frequent indication was low grade pseudomyxoma peritonei in 79/143 (55%). Other indications were benign multicyst mesothelioma in 21/143(14%) and peritoneal metastasis from colon carcinoma in 18/143 (12,5%) and ovarian carcinoma in 13/143 (9%). The median PCI was 3 (2-5). The median length of stay was 6 (5-10) days, with 30-day major morbidity rate of 8.3% and 30-day mortality rate of 0.7%. At a median follow-up of 37 (16-64) months 126/143 patients (88.2%) were free of disease. CONCLUSIONS: Analysis of these data demonstrates that L-CRS+HIPEC is a safe and feasible procedure in highly selected patients with limited peritoneal disease when performed at experienced centres. While short to midterm outcomes are encouraging in patients with less invasive histology, longer follow up is required before recommending it for patients with more aggressive cancers with peritoneal dissemination.
Assuntos
Neoplasias do Colo/patologia , Procedimentos Cirúrgicos de Citorredução , Quimioterapia Intraperitoneal Hipertérmica , Mesotelioma/terapia , Neoplasias Ovarianas/patologia , Neoplasias Peritoneais/patologia , Neoplasias Peritoneais/terapia , Pseudomixoma Peritoneal/terapia , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carboplatina/administração & dosagem , Cisplatino/administração & dosagem , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Procedimentos Cirúrgicos de Citorredução/métodos , Intervalo Livre de Doença , Doxorrubicina/administração & dosagem , Feminino , Seguimentos , Humanos , Quimioterapia Intraperitoneal Hipertérmica/métodos , Laparoscopia/efeitos adversos , Tempo de Internação , Masculino , Mesotelioma/patologia , Pessoa de Meia-Idade , Mitomicina/administração & dosagem , Terapia Neoadjuvante , Neoplasia Residual , Oxaliplatina/administração & dosagem , Paclitaxel/administração & dosagem , Neoplasias Peritoneais/secundário , Pseudomixoma Peritoneal/patologia , Sistema de Registros , Índice de Gravidade de Doença , Taxa de Sobrevida , Carga TumoralRESUMO
In recent years, donation after circulatory death (DCD) has increased as an option to overcome the organ donor shortage crisis and to decrease the large number of patients on liver transplant waiting lists. The "super-rapid" technique is now the "gold standard" procurement method because of its availability, reproducibility, low cost, and extensive experience. Recently, extracorporeal support has been implemented, with encouraging results. Strict donor acceptance criteria have proven to be essential to optimize the DCD liver graft outcomes and minimize biliary complication rates. In this study we assessed the state of the art of DCD liver transplantation with regard to its development and the actual strategies to prevent graft complications, with aim of expanding the pool of marginal liver donors.
Assuntos
Transplante de Fígado/métodos , Doadores de Tecidos/provisão & distribuição , Obtenção de Tecidos e Órgãos/métodos , Adulto , Morte , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: To analyze the different factors predictive of survival associated with optimal R0-cytoreduction in c-kit-positive gastrointestinal stromal tumors. METHODS: Thirty-five patients were operated on in our Oncological Surgery Department from January 2002 to February 2007 because of CD117/c-kit-positive gastrointestinal stromal tumors, and an optimal surgical cytoreduction was obtained without macroscopical residual disease. Demographic, anatomical, clinical, pathological, and immunohistochemical variables were analyzed from a specific database. Survival and multivariate analyses were developed using Kaplan-Meier and multiple Cox regression models, respectively. RESULTS: Five-year overall survival was 77% with a mean survival of 52 months. Risk of malignant behaviour according to Fletcher s classification and tumor size higher than 10 cm had a significantly negative influence on overall survival in the univariate analysis (p < 0.05). Proliferative Ki-67 activity higher than 50% was the only statistically significant variable in the multivariate analysis. Twenty percent of tumors recurred. Only 3 patients with metastatic disease received adjuvant treatment with imatinib mesylate, all of them with Ki-67 > 50% and currently alive. CONCLUSIONS: The poliferative Ki-67 index could represent an excellent predictive factor for survival in patients with c-kit-positive stromal gastrointestinal tumors. Confirmation and an adequate cut-off level should be the main objectives for future prospective studies, mostly focused on the appropriate selection of optimal candidates to imatinib-mesylate-based treatment.
Assuntos
Tumores do Estroma Gastrointestinal/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Feminino , Tumores do Estroma Gastrointestinal/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Taxa de SobrevidaRESUMO
OBJECTIVE: The goal of this research has been to evaluate the survival, in long and short term, of the patient receiving liver transplant for hepatocellular carcinoma (HCC), the risk of post-transplant tumor relapse and factors related to this complication. DESIGN: Retrospective study of a consecutive series of patients having had liver transplant for HCC. PATIENTS AND METHODOLOGY: Transplant patients for HCC from 1989 to November 2003. Patients were selected due to general limitations of nodule size and quantity, which were subsequently published as Milan criteria. Also, criteria agreed in the Conference of Barcelona were followed in the pre-transplant diagnosis. RESULTS: The survival of this 81 patients group was of the 80, 61 and 52% for 1, 5 and 10 years respectively. In the 32% of the cases the HCC was an incidental finding in the explant. In the 12.3%, the tumor relapse was verified. The multivariate research identified the size of the nodule (OR=1,7944) (IC 95%=1,1332-2,8413) and the vascular invasion (OR=6,6346) (IC 95%=1,4624-30,1003) as risk factors of relapse. CONCLUSIONS: The liver transplant in selected patients with HCC has good results in medium and long term. The risk of post-transplant tumor relapse becomes notably reduced and is associated with the size of the nodule and the microscopic vascular invasion.
Assuntos
Carcinoma Hepatocelular/mortalidade , Neoplasias Hepáticas/mortalidade , Transplante de Fígado/mortalidade , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/cirurgia , Humanos , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/cirurgia , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Estudos Retrospectivos , Risco , Espanha/epidemiologia , Análise de Sobrevida , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: The acute renal dysfunction (ARD) is a common complication in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Our aim is evaluate the ARD post-HIPEC procedures using the RIFLE and AKIN criteria. Evaluate the risk factors and analyze ARD's impact on postoperative course. METHODS: From 2011 to 2014, in a retrospective way using a prospective database were operated by HIPEC procedure. The ARD was analyzed by RIFLE and AKIN criteria. The perioperative features were analyzed and a multivariate analysis was performed to define the risk factors to develop the ARD. RESULTS: 141 patients were treated and analyzed. The ARD was detected in 30.5% (Injury 18.4% and Failure 12.1%) when RIFLE criteria were applied. The multivariate analysis detected that decrease of pH during HIPEC [OR = 29.39 (5.09-169.76)], PCI [OR = 1.07 (1.01-1.15)] and ureteral catheters [OR = 12.71 (1.44-111.85)] were associated to the development of acute renal injury (ARI) post-HIPEC. Decrease of Na during HIPEC [OR = 1.15 (1.01-1.30)], intraoperative inotrope use [OR = 3.83 (1.12-13.09)] and PCI [OR = 1.06 (1.0-1.14)] were associated to acute renal failure (ARF) post-HIPEC. The ARD was related to a higher length of stay hospital (17.2 ± 11 vs. 13.8 ± 8 days) (p = 0.05) but no impact in early survival was observed in ARD group. CONCLUSIONS: The widespread use of RIFLE criteria for ARD would have major benefits in terms of accurately diagnosing patients undergone HIPEC procedures. The ARD has a detrimental impact in length of stay hospital. The knowledge of risk factors helps us to prevent the ARD post-HIPEC by means of an aggressive and multidisciplinary perioperative management.
Assuntos
Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/diagnóstico , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Quimioterapia do Câncer por Perfusão Regional/métodos , Procedimentos Cirúrgicos de Citorredução , Diagnóstico Precoce , Hipertermia Induzida/efeitos adversos , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Peritoneais/tratamento farmacológico , Injúria Renal Aguda/prevenção & controle , Adulto , Idoso , Quimioterapia do Câncer por Perfusão Regional/efeitos adversos , Feminino , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Neoplasias Ovarianas/cirurgia , Equipe de Assistência ao Paciente , Neoplasias Peritoneais/cirurgia , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Cytoreductive surgery with peritonectomy procedures and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) represents a radical therapeutic approach to achieve complete cytoreduction in ovarian peritoneal carcinomatosis. The aim of the present study was to analyze the outcomes obtained by the application of these procedures in a single center with extensive experience treating peritoneal carcinomatosis. PATIENTS AND METHODS: A series of 218 consecutive patients diagnosed with peritoneal carcinomatosis from primary or recurrent ovarian cancer (FIGO stage IIIC-IV) and treated with CRS + HIPEC between January 1996 and June 2012 were included in this observational study. RESULTS: Peritoneal carcinomatosis was treated primarily in 56% (124/218) of the cases and recurrently in 43% (94/218). A total of 42/218 patients (19%) presented with FIGO stage IV. Compared to recurrent cases, patients with primary ovarian carcinomatosis were older and presented higher Peritoneal Cancer Index (PCI) and percentage of FIGO stage IV; however, no significant differences in survival (5-year overall survival in patients with R0 cytoreduction, 63% and 56%, respectively) were observed. Cytoreduction score, PCI, lymphatic involvement and surgical morbidity ≥Grade III were statistically significant prognostic factors for survival in both univariate and multivariate analysis. CONCLUSIONS: CRS + HIPEC treating macroscopic and microscopic disease is currently an excellent surgical approach to achieve high rates of complete cytoreduction and improve survival in patients with peritoneal carcinomatosis from ovarian cancer. In order to minimize the high potential morbidity of these procedures, CRS + HIPEC should be performed in highly experienced centers.
Assuntos
Carcinoma/terapia , Hipertermia Induzida , Recidiva Local de Neoplasia/patologia , Neoplasias Ovarianas/patologia , Neoplasias Peritoneais/terapia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma/mortalidade , Carcinoma/secundário , Cisplatino/administração & dosagem , Procedimentos Cirúrgicos de Citorredução , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Infusões Parenterais , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Paclitaxel/administração & dosagem , Neoplasias Peritoneais/mortalidade , Neoplasias Peritoneais/secundário , Taxa de Sobrevida , Adulto JovemRESUMO
UNLABELLED: With continuous development of liver transplantation, the need of better tests for selecting donors and improving diagnosis of postransplant hepatic dysfunction, is increasing. OBJECTIVE: To determine the prognostic value of a number of parameters, including the lidocaine test (MEGX) in selecting donors, and assessing the efficacy of this test in the postransplant follow-up as an indicator of morbidity and mortality. METHODS: A consecutive series of forty donor-receptor pairs was studied for six months postransplant. In addition to the lidocaine test, different clinical, analytical and histological variables were analysed. Death, retransplantation, graft dysfunction and days in hospital were considered as indicators of morbimortality. RESULTS: Among the variables selected by univariate analysis, only ALT value at day 1 and Child-Pugh score at day 7 reached independent prognostic value in a Cox's regression model. However, both a cut-off level of 50 ng/ml for MEGX in donors and 40 ng/ml for MEGX test at day 1 postransplant, allowed to identify statistically different survival curves (p < 0.05). The lidocaine test at day 7 showed a significant association with the number of rejection episodes. CONCLUSIONS: ALT value at day 1 and Child-Pugh score at day 7 turned out to be the only variables with independent prognostic value for survival during the first six months postransplant. The MEGX value may be of help in selecting donors and a subgroup of receptors (day 1 < 40 ng/ml) with a high risk of mortality.
Assuntos
Lidocaína , Transplante de Fígado , Adolescente , Adulto , Feminino , Seguimentos , Humanos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Análise de Regressão , Taxa de Sobrevida , Fatores de Tempo , Doadores de TecidosRESUMO
OBJECTIVE: This study seeks to evaluate the role of the somatostatin analogue Octreotide as postoperative prophylaxis in the prevention of pancreatic fistula following Pancreaticoduodenectomy (PD). METHODS: A prospective and randomized study has been completed in 34 patients undergoing PD. Sixteen patients were randomly assigned to receive Octreotide 0.1 cc (100 mcg) three times daily subcutaneously during the first seven days of the post-operative period and the remaining 18 constituted the control group. All patients were fed parenterally until normal oral feeding was restored (mean 8 days). Fisher's exact test was used to compare complications in both groups. Pancreatic fistula was defined as the persistence of an amylase-rich discharge at least 50 ml daily during a minimum period of two weeks. RESULTS: The mortality rate was 3% and the morbidity 26%. No significant differences were observed regarding the total number of complications. The appearance of pancreatic fistula was considerably smaller (p = 0.03) in the Octreotide group than in control group. Postoperative hospital stay and the number of subsequent surgical interventions were significantly higher (p < 0.05) in the control group. CONCLUSION: Octreotide prevents the occurrence of pancreatic fistula after PD when it is administered prophylactically during the immediate postoperative period.
Assuntos
Fármacos Gastrointestinais/uso terapêutico , Octreotida/uso terapêutico , Pancreaticoduodenectomia , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fístula Pancreática/prevenção & controle , Estudos ProspectivosRESUMO
BACKGROUND: The use of expanded criteria for donors to expand the donor pool has increased the number of discarded liver grafts in situ. The aim of our study was to elaborate a prediction model to reduce the percentage of liver grafts discarded before the procuring team is sent out. METHODS: We analyzed the donor factors of 244 evaluated candidates for liver donation. We performed a multiple logistic regression to evaluate the probability of liver grafts discarded (PD). RESULTS: The PD was determined by use of 3 variables: age, pathological ultrasonography, and body mass index >30. The area under curve was 82.7%, and, for a PD of 70%, the false-positive probability was 1.2%. CONCLUSIONS: We have created a useful clinical prediction model that could avoid up to 20% of discarded liver grafts.
Assuntos
Transplante de Fígado , Obtenção de Tecidos e Órgãos , Adulto , Idoso , Aloenxertos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Curva ROC , Doadores de Tecidos , TransplantesAssuntos
Tratamento de Emergência , Laparotomia , Paniculite Peritoneal/cirurgia , Idoso , Feminino , HumanosRESUMO
INTRODUCTION: Management of the exocrine drainage of the pancreatic graft in simultaneous pancreas kidney (SPK) transplantation has been a matter of debate for years. There is currently a trend toward a more physiological enteric drainage (ED). This study compared short- and long-term complications and graft survival in patients with enteric versus bladder exocrine secretion drainage. PATIENTS AND METHODS: Between January 1995 and November 2005, we performed 75 SPK transplants: 55 with ED and 20 with bladder drainage (BD). The rates of complications and graft survival were monitored over at least 36 months after transplantation. RESULTS: Mean posttransplant follow-up was 119.5 +/- 6.6 months. Urinary infection, hematuria, reflux pancreatitis, and repeat surgery rates were all significantly higher among the BD area. There was no intergroup difference in rejection rates or in the incidence of graft thrombosis, transplantectomy, anastomotic dehiscence, or intra-abdominal abscesses. Pancreas and kidney graft survival rates were similar in the two groups. CONCLUSIONS: In our experience, ED was more physiological than BD, and was associated with fewer complications.
Assuntos
Glândulas Exócrinas/metabolismo , Transplante de Rim/métodos , Transplante de Pâncreas/métodos , Adolescente , Adulto , Complicações do Diabetes/cirurgia , Diálise/métodos , Drenagem/métodos , Feminino , Seguimentos , Sobrevivência de Enxerto , Hemorragia/epidemiologia , Humanos , Transplante de Rim/mortalidade , Masculino , Transplante de Pâncreas/mortalidade , Pancreatite/epidemiologia , Diálise Peritoneal/métodos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Bexiga Urinária/metabolismo , Infecções Urinárias/epidemiologiaRESUMO
INTRODUCTION: Carney's triad is a rare pathogenic entity which consists of the association in young women of multiple condromatosis in the lung, gastric leiomyosarcoma, and extradrenal paraganglioma; although the presence of three at the same time is not required for its diagnosis. CASE REPORT: We present the case of a 27-year-old woman who was diagnosed of pulmonary multiple hamartomatosis and gastric stromal tumor. DISCUSSION: A review of the literature shows the most important prognosis factors and therapeutic options. Surgery for gastrointestinal stromal tumors and extradrenal paraganglioma seems to be the best treatment up to date.