Repeat Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for Recurrent Mucinous Appendiceal Adenocarcinoma: A Viable Treatment Strategy with Demonstrable Benefit.

INTRODUCTION: Many patients with mucinous appendiceal adenocarcinoma experience peritoneal recurrence despite complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Prior work has demonstrated that repeat CRS/HIPEC can prolong survival in select patients. We sought to validate these findings using outcomes from a high-volume center. PATIENTS AND METHODS: Patients with mucinous appendiceal adenocarcinoma who underwent CRS/HIPEC at MD Anderson Cancer Center between 2004 and 2021 were stratified by whether they underwent CRS/HIPEC for recurrent disease or as part of initial treatment. Only patients who underwent complete CRS/HIPEC were included. Initial and recurrent groups were compared. RESULTS: Of 437 CRS/HIPECs performed for mucinous appendiceal adenocarcinoma, 50 (11.4%) were for recurrent disease. Patients who underwent CRS/HIPEC for recurrent disease were more often treated with an oxaliplatin or cisplatin perfusion (35%/44% recurrent vs. 4%/1% initial, p < 0.001), had a longer operative time (median 629 min recurrent vs. 511 min initial, p = 0.002), and had a lower median length of stay (10 days repeat vs. 13 days initial, p < 0.001). Thirty-day complication and 90-day mortality rates did not differ between groups. Both cohorts enjoyed comparable recurrence free survival (p = 0.82). Compared with patients with recurrence treated with systemic chemotherapy alone, this select cohort of patients undergoing repeat CRS/HIPEC enjoyed better overall survival (p < 0.001). CONCLUSIONS: In appropriately selected patients with recurrent appendiceal mucinous adenocarcinoma, CRS/HIPEC can provide survival benefit equivalent to primary CRS/HIPEC and that may be superior to that conferred by systemic therapy alone in select patients. These patients should receive care at a high-volume center in the context of a multidisciplinary team.

Complications and Surveillance After Bariatric Surgery.

OPINION STATEMENT: Bariatric surgery represents a durable and safe treatment modality for morbid obesity. Bariatric surgery results in weight loss by one of two-and possibly both-primary mechanisms, reducing the amount of tolerable intake (restrictive) and reducing the amount of nutrients absorbed by bypassing absorptive intestine (malabsorptive). These procedures have consistently demonstrated superior resolution of obesity and many associated co-morbid conditions as compared to medical management. Beyond the periprocedural complications of surgery, there are longitudinal risks such as weight regain, anatomic complications, and micronutrient deficiencies. Complications related to the anatomic alteration after bariatric surgery include internal herniation, marginal ulcers, dumping syndrome, and gastric band-related complications. Physicians who take care of bariatric patients at any point in their post-operative care must be vigilant for these complications, as they may necessitate urgent intervention or re-operation. Micronutrient deficiencies, which commonly occur after malabsorptive procedures, may present with a wide range of symptoms-including neuropathies, anemia, poor wound healing, and hair loss, among others. Deficiencies of vitamins and minerals frequently result in the need for long-term supplementation and may necessitate intravenous repletion when severe. Bariatric surgery may also alter the absorption of commonly prescribed medications, including anti-psychotic medications.