Cytoreductive surgery and HIPEC for peritoneal metastasis. Justified hope or desperate illusion? Fifteen years of experience from a Greek Peritoneal Surface Malignancy center.

PURPOSE: Peritoneal spread of neoplastic diseases is considered a fatal condition with a dismal prognosis. Few therapeutic options were offered to these patients and surgery had only palliative character. However, advances in surgical techniques and new drugs development, have changed the management of this terminal stage disease. Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC), has been proposed as a promising alternative to palliative surgery and systemic chemotherapy, since 1980s. Many changes through all these years have refined the technique and standardized indications and limits. METHODS: A retrospective study was performed in our medical records, of all patients treated with CRS and HIPEC since 2006. Survival, complications and prognostic factors were studied in a total of 632 patients. RESULTS: Female patients were 419 and males were 213. Mean age was 52.6 years. Peritoneal metastases secondary to colorectal cancer were the most frequent treated disease (87 patients), whereas hepatobilliary-pancreatic neoplastic diseases and sarcomas were the less frequent causes of peritoneal carcinomatosis. Patients with peritoneal metastases from ovarian cancer, treated with systemic chemotherapy and then received interval cytoreductive surgery with HIPEC, were the largest group that are still alive (43%), while only 35% of patients with hepatobilliary-pancreatic cancer and peritoneal disease are alive at present. Gender, age, peritoneal cancer index (PCI), completeness of cytoreduction score (CCs), and number of complications were important prognostic factors of overall survival. CONCLUSIONS: Peritoneal carcinomatosis is still considered a final stage disease with a poor prognosis. The confinement of the neoplastic disease in the peritoneal cavity has led to the development of local therapies with promising results. CRS and HIPEC have evolved significantly over the past several years and are at the present the most valuable treatment in highly selected patients with peritoneal carcinomatosis.

Intensive care unit hospitalization after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

PURPOSE: Peritoneal metastasis (PM) is nowadays treated with the complex procedure of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS+HIPEC). Given the fact that the procedure presents high morbidity and mortality rates, admitting patients to the Intensive Care Unit (ICU) seems inevitable. In our study, we have tried to determine the factors that indicate when admission in the ICU is necessary. METHODS: We retrospectively analyzed 230 patients (140 females, 90 males) with PM, who were operated on from November 2005 until October 2015, and underwent CRS+HIPEC. The patients were divided into two groups, based on whether they were extubated after the operation or not, thus being admitted to the ICU. We also distinguished a group of patients who, after the initial extubation, had to be re-intubated and transferred to the ICU. We assessed morbidity and mortality rates for each of the aforementioned groups, along with the complications developed in each case (thoracic, gastrointestinal, renal). RESULTS: We found that morbidity and mortality rates in both examined groups were approximately similar; the course changed when a complication occurred, and this increased mortality, especially if the onset of the symptoms was delayed. Also, these rates were much worse for the group that had to be re-intubated and transferred to the ICU. CONCLUSIONS: On the whole, we conclude that the decision of immediate admission to the ICU post-operatively is hard, as it depends on multiple factors; therefore, the use of an easy predictive method is not realistic and a more individualized and patient-to-patient approach is preferable.

Gastrointestinal Stromal Tumors (GIST): A Prospective Analysis and an Update on Biomarkers and Current Treatment Concepts.

Gastrointestinal stromal tumors (GIST) are the most common sarcomas of the gastrointestinal tract, with transformation typically driven by activating mutations of cKIT and less commonly platelet-derived growth factor receptor alpha (PDGFRA). Successful targeting of tyrosine-protein kinase Kit with imatinib, a tyrosine kinase inhibitor, has had a major impact in the survival of patients with GIST in both the adjuvant and metastatic setting. A recent modification of treatment guidelines for patients with localized, high-risk GIST extended the adjuvant treatment duration from 1 year to 3 years. In this paper, we review the clinical data of patients with GIST treated in the Oncology Outpatient Unit of "Attikon" University Hospital and aim to assess which patients are eligible for prolongation of adjuvant imatinib therapy as currently suggested by treatment recommendations.

Risk factors and consequences of incidental parathyroidectomy during thyroidectomy.

The objectives of this retrospective study were to investigate the incidence, risk factors, and clinical significance of incidental parathyroidectomy during thyroidectomy. In this study, there were 315 patients who underwent thyroidectomy between 1996 and 2006. All the operations were performed by a single experienced surgeon (J.S.). Pathology reports on all specimens were reviewed and information regarding patient demographics, diagnosis, operative details, and postoperative complications were collected. A total of 315 thyroidectomies were performed: 101 total thyroidectomies (32.1%) and 214 subtotal thyroidectomies (67.9%). Two hundred and eighty patients were operated on for benign disease (88.9%) and 35 for malignant disease (11.1%). Incidental parathyroidectomy was identified in 32 cases (10.2%). Preoperative diagnosis of malignant disease (P = 0.009) and duration of the disease (P = 0.001) were significant predictors of incidental parathyroidectomy. Incidental parathyroidectomy was significantly correlated with postoperative hypoparathyroidism (P = 0.03). Transient postoperative hypoparathyroidism occurred in 18 cases (6%) and permanent in three cases (1%). The duration of the disease was the sole significant predictor of postoperative hypoparathyroidism (P < 0.001). Incidental parathyroidectomy seems to be the result of the use of extensive surgical procedures. The preoperative diagnosis of malignant disease and the delay of the operation, which leads to a more advanced thyroid disease, make the use of extensive surgical procedures necessary.

Peritoneal carcinomatosis: intra-operative and post-operative assessment of patients undergoing cytoreduction and HIPEC.

BACKGROUND/AIMS: The aim of this study is to evaluate the results of intraoperative and postoperative parameters in patients presenting peritoneal carcinomatosis in which we performed cytoreductive surgery (CS) and hyperthermic introperitoneal chemotherapy (HIPEC). PATIENTS AND METHODS: The population included 55 patients with peritoneal carcinomatosis from colorectal origin in 19, gastric in 6, ovarian in 23, sarcomas in 5 and pseudomyxoma peritonei in 2. The peritoneal cancer index (PCI) which directly reflected the volume of the peritoneal disease in our study ranged from 3-29 (median 19,7). The main endpoints were morbidity, mortality, completeness of cytoreduction, survival rates and main intraoperative characteristics. RESULTS: The CS was considered as CCo (no residual disease) in 85% of patients. The mean survival in the patients with complete cytoreduction was 19 months versus 9,8 m in patients with incomplete cytoreduction (p < 0.05). The PCI was one of the most important factors concerning the long-term survival. Patients with PCI < 16 had better survival than these with PCI > 16 (11,8 vs 6,4 m p < 0.05). There are many intraoperative and postoperatives parameters with interesting results which predicts the postoperative outcome but not the long-term survival. The mortality rate was 3.6% (2 patients), twenty-two patients (41.5%) presented one or more complications. Actuarial 5 year survival was 52%. CONCLUSION: Interactive CS + HIPEC is on effective treatment strategy in PC patients.

Acute cholangitis due to afferent loop syndrome after a Whipple procedure: a case report.

INTRODUCTION: Patients with resection of stomach and especially with Billroth II reconstruction (gastro jejunal anastomosis), are more likely to develop afferent loop syndrome which is a rare complication. When the afferent part is obstructed, biliary and pancreatic secretions accumulate and cause the distention of this part. In the case of a complete obstruction (rare), there is a high risk developing necrosis and perforation. This complication has been reported once in the literature. CASE PRESENTATION: A 54-year-old Greek male had undergone a pancreato-duodenectomy (Whipple procedure) one year earlier due to a pancreatic adenocarcinoma. Approximately 10 months after the initial operation, the patient started having episodes of cholangitis (fever, jaundice) and abdominal pain. This condition progressively worsened and the suspicion of local recurrence or stenosis of the biliary-jejunal anastomosis was discussed. A few days before his admission the patient developed signs of septic cholangitis. CONCLUSION: Our case demonstrates a rare complication with serious clinical manifestation of the afferent loop syndrome. This advanced form of afferent loop syndrome led to the development of huge enterobiliary reflux, which had a serious clinical manifestation as cholangitis and systemic sepsis, due to bacterial overgrowth, which usually present in the afferent loop. The diagnosis is difficult and the interventional radiology gives all the details to support the therapeutic decision making. A variety of factors can contribute to its development including adhesions, kinking and angulation of the loop, stenosis of gastro-jejunal anastomosis and internal herniation. In order to decompress the afferent loop dilatation due to adhesions, a lateral-lateral jejunal anastomosis was performed between the afferent loop and a small bowel loop.

Wound dehiscence: is still a problem in the 21th century: a retrospective study.

BACKGROUND: The aim of this study was to evaluate the risk factors of wound dehiscence and determine which of them can be reverted. METHODS: We retrospectively analyzed 3500 laparotomies. Age over 75 years, diagnosis of cancer, chronic obstructive pulmonary disease, malnutrition, sepsis, obesity, anemia, diabetes, use of steroids, tobacco use and previous administration of chemotherapy or radiotherapy were identified as risk factors RESULTS: Fifteen of these patients developed wound dehiscence. Emergency laparotomy was performed in 9 of these patients. Patients who had more than 7 risk factors died. CONCLUSION: It is important for the surgeon to know that wound healing demands oxygen consumption, normoglycemia and absence of toxic or septic factors, which reduces collagen synthesis and oxidative killing mechanisms of neutrophils. Also the type of abdominal closure may plays an important role. The tension free closure is recommended and a continuous closure is preferable. Preoperative assessment so as to identify and remove, if possible, these risk factors is essential, in order to minimize the incidence of wound dehiscence, which has a high death rate.

Radiofrequency ablation combined with palliative surgery may prolong survival of patients with advanced cancer of the pancreas.

BACKGROUND AND AIM: The aim of this study is to identify the benefit acquired by the use of radiofrequency ablation in parallel to palliative therapy in patients with advanced cancer of the pancreas. MATERIALS AND METHODS: Data on 25 consecutive patients who underwent palliative therapy with or without radiofrequency ablation for unresectable pancreatic cancer were included in this retrospective review. Thirteen patients received palliative therapy alone, whereas 12 patients received palliative therapy plus radiofrequency ablation. RESULTS: Overall mean survival rate in patients receiving paliative therapy alone was 13 months and the maximum survival was 30 months. Where radiofrequency ablation was applied, mean survival was estimated at 33 months (p = 0.0048). Stage III and IV patients treated with palliative therapy alone have a mean survival of 15 and 10 months, respectively. All stage III patients receiving radiofrequency ablation are alive at present and maximum survival has reached 38 months (p = 0.0032), whereas stage IV patients who were treated with radiofrequency ablation have an estimated mean survival period of 14 months (p = 0.1095). CONCLUSION: Radiofrequency ablation in parallel to palliative therapy seems to provide survival benefit especially for stage III patients with unresectable pancreatic cancer. Further studies should be conducted to determine the usefulness of radiofrequency ablation in the treatment of advanced pancreatic cancer.