Gastric perforation following cytoreductive surgery with perioperative intraperitoneal chemotherapy.

OBJECTIVE: Gastrointestinal tract perforation after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has an incidence of 6%. The most common site is the small bowel. The trauma of CRS and delay in wound healing due to HIPEC has been thought to cause this complication. METHODS: From our database of 1,251 patients we recorded the treatments that resulted in a stomach perforation, the clinical manifestations, and the final outcome. We formulated a pathophysiology for the development of this postoperative complication. RESULTS: Four patients had postoperative gastrointestinal perforation limited to the wall of the stomach (incidence 0.3%). All patients underwent greater omentectomy with ligation of the gastroepiploic vessels on the surface of the greater curvature, received HIPEC and early perioperative intraperitoneal chemotherapy. All perforations occurred along the greater curvature of the stomach. Successful management of the perforation was by suture plication of the gastric defect. CONCLUSION: Perforation of the stomach following CRS and HIPEC likely results from vascular compromise, delay in wound healing from chemotherapy, seromuscular tears related to traction on the stomach wall and point pressure on the greater curvature from a long-term indwelling nasogastric tube. Reperitonealization of the greater curvature, if seromuscular tears occur, may help prevent this complication.

Mesenteric cyst: report of a case-resulting in pseudomyxoma peritonei.

BACKGROUND: A mesenteric cyst may have an embryonic, traumatic, neoplastic or infectious origin. In rare cases mesenteric cysts may contain neoplastic epithelium. A mesenteric cyst has not previously been recorded as the cause of pseudomyxoma peritonei. METHODS: A patient who developed widespread mucinous intraperitoneal tumor as a result of a ruptured mesenteric cyst is reported. A literature review of the clinical features, diagnosis, treatment, and prognosis of the mesenteric cyst is presented. RESULTS: This patient was treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy. Her recovery was uneventful and she remains well two years after treatment. CONCLUSION: Mesenteric cyst is a rare cause of pseudomyxoma peritonei. The definite treatment of a ruptured neoplastic mesenteric cyst can, by analogy, be compared to the treatment for pseudomyxoma peritonei of appendiceal origin. The results of cytoreductive surgery with perioperative intraperitoneal chemotherapy are expected to be good.

Interstitial pneumonitis following intrapleural chemotherapy.

BACKGROUND: Mucinous neoplasms within the abdomen may disseminate by direct extension through the diaphragm to involve the pleural space. Treatment of this condition is by parietal and visceral pleurectomy followed by hyperthermic intrapleural chemotherapy. CASE PRESENTATION: In this case report a patient developed persistent right upper lobe interstitial pneumonitis and progressive parenchymal fibrosis following intrapleural chemotherapy treatment with mitomycin C and doxrubicin. The condition persisted until death 28 months later. Death was from progressive intraabdominal disease with intestinal obstruction and sepsis associated with progressive pulmonary parenchymal disease. The right pleural space disease did not recur. CONCLUSION: This manuscript is the first case report describing interstitial pneumonitis and lung fibrosis following intrapleural chemotherapy. Since pulmonary toxicity from chemotherapy is a dose-dependent phenomenon, dose reduction of intrapleural as compared to intraperitoneal hyperthermic chemotherapy may be necessary.

Tailgut cyst, an unusual cause of pseudomyxoma peritonei.

BACKGROUND: Retrorectal hamartoma, also known as tailgut cyst, is a rare tumor that arises from remnants of the embryonic postanal gut. The tumor occurs in the retrorectal space and may undergo malignant degeneration. METHODS: The clinical information on a single patient with pseudomyxoma peritonei associated with a tailgut cyst was reviewed and a literature review of the subject performed. RESULTS: In this patient there was malignant degeneration of a tailgut cyst localized to the pelvis. Twenty months later a local recurrence in the pelvis and pseudomyxoma peritonei widely distributed in the abdomen were successfully treated by cytoreductive surgery and perioperative chemotherapy. CONCLUSION; Tailgut cyst may, if resected with tumor spillage, result in pseudomyxoma peritonei. Our treatment--which has maintained a disease-free status for one year--was cytoreductive surgery plus perioperative chemotherapy.

Thin-walled cysts as a pathognomonic CT finding in cystic mesothelioma.

AIM: Cystic mesothelioma is a rare disease that results in abdominal distention and poorly defined abdominal pain. Diagnosis has always been made by tissue biopsy rather than by radiologic studies. MATERIALS AND METHODS: Our experience with 7 patients with cystic mesothelioma includes 4 patients who had not had prior surgery before the performance of a high resolution CT scan. A special review of the radiology of these cases was performed in order to identify any pathognomonic signs of this disease. RESULTS: In all patients who did not have a distortion of the radiologic images (as a result of surgical interventions) prior to the performance of a high resolution CT scan at our institution, a pathognomonic thin-wall cystic structure located within the gelatinous appearing mass was observed. These thin-walled cysts were of variable size and preferentially located within the greater omentum, pelvis and beneath the right hemidiaphragm. CONCLUSION: Cystic mesothelioma can be diagnosed preoperatively by a high resolution abdominal and pelvic CT. The thin-walled cysts with great variation in size are located beneath the right hemidiaphragm, within the greater omentum and in the pelvis. No other disease with these radiologic findings has been identified.

Splenic metastases from mucinous neoplasms of the appendix and colon.

AIMS AND BACKGROUND: Splenic metastases associated with mucinous intraabdominal tumors have been an enigma in the radiologic and oncology literature. These focal parenchymal defects from a non-metastasizing malignancy within an organ that rarely develops metastatic foci, even with high-grade cancer, were studied. METHODS: Information on 9 patients who underwent splenectomy with intraparenchymal splenic masses associated with appendiceal or colorectal mucinous tumors with peritoneal dissemination was collected. The CT scan, the histopathology and the clinical parameters of these patients were studied. A literature review searching for prior reports of this subject was performed. RESULTS: Eight of these patients had mucinous appendiceal tumors and 1 a mucinous sigmoid colon cancer. All patients had mucinous carcinomatosis at some time in their clinical course. These splenic tumor masses had a CT image compatible with metastases and not compatible with mucinous tumor layered out of the splenic capsule. None of the patients had evidence of metastases to other sites such as liver or lymph nodes. All patients had a mucinous histopathology. Splenectomy may be associated with prolonged survival. CONCLUSIONS: From our review of the clinical information available on these 9 patients, these splenic lesions were thought to be an entrapment of mucinous tumor within splenic surface trabeculae, which expand into the splenic parenchyma resembling metastatic disease. These CT findings may be more accurately referred to as splenic pseudometastases.

Compartment syndrome of the leg associated with lithotomy position for cytoreductive surgery.

BACKGROUND: Compartment syndrome is seen in patients who have ischemic damage to muscle that is contained within a fascial compartment. A pathologic cycle is initiated when tissue injury produces swelling and compromises muscle perfusion. Patients undergoing cytoreductive surgery combined with intraperitoneal chemotherapy are required to be in the lithotomy position for many hours. Compartment syndrome can develop necessitating fasciotomy. METHODS: In a study of 473 operative procedures to perform cytoreductive surgery and intraperitoneal chemotherapy, eight patients required fasciotomy on an emergency basis to treat compartment syndrome and were recorded in a prospective database over a 4-year time period. RESULTS: During the hospitalization five of the eight patients developed venous thrombotic complications. In order to prevent movement of the patient on the operating table during steep Trendelenburg position, shoulder braces were used in the subsequent 250 patients and no episodes of compartment syndrome occurred. CONCLUSION: Compartment syndrome in patients undergoing cytoreductive surgery may be related to changes in position on the operating table induced by steep Trendelenburg position. Minimizing this change in position has reduced the likelihood of developing Compartment syndrome.

Perioperative outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy for non-appendiceal peritoneal carcinomatosis from a prospective database.

BACKGROUND: Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has expanded its application in the management of peritoneal carcinomatosis from gastrointestinal and ovarian malignancies. An accurate assessment of perioperative outcomes is crucial for integration of this combined procedure into clinical practice. METHODS: A prospective study of 80 patients undergoing the combined treatment for non-appendiceal peritoneal carcinomatosis was conducted. Forty-seven adverse events by eight organ-systems were rated from Grade I to IV with increasing severity. RESULTS: One patient (1.3%) died postoperatively. Postoperative adverse events affected genitourinary system (38%), hematological system (31%), gastrointestinal system (25%), infection (20%), intravenous catheters status (15%), pulmonary system (14%), cardiovascular system (11%) and neurological system (4%). Thirty-six patients (45%) experienced 49 Grade III adverse events. Six patients (8%) experienced eight Grade IV adverse events. More than four peritonectomy procedures (P = 0.010), and length of hospital stay of more than 21 days (P = 0.007) were strongly associated with Grade III and/or Grade IV morbidity. CONCLUSION: The morbidity and mortality rates after the combined treatment for non-appendiceal peritoneal carcinomatosis were within the acceptable range of surgical treatments for other gastrointestinal cancers. A standardized prospective database is required for an accurate assessment of perioperative outcomes.