An Alternative and Up-To-Date Recommendation for a Proper Site for Parathyroid Transplantation: The Omentum.

OBJECTIVES: Various sites have been used for parathyroid allotransplant, such as injection into the forearm, sternocleidomastoid, or deltoid muscles. However, transplant efficiency in these regions varies according to the results reported in the literature and also obtained from our previous studies. Using the omentum "as a natural incubator" for composite tissue-derived cell transplants to increase transplant success is possible. MATERIALS AND METHODS: To examine the efficiency of transplant sites for parathyroid allotransplant, we compared clinical cases from the literature and our experience with 23 cases. The omental transplant process is performed under general anesthesia by laparoscopic intervention. The abdominal cavity is visualized with an endocamera from a 5-mm trocar. With the help of a flexible catheter from another 5-mm trocar, microencapsulated or naked parathyroid cells are deposited on the omentum in approximately 30 mL of isotonic saline. The trocar sites are then sutured, and the surgery is terminated. Recipients were followed for 6 months with examination of biochemical parameters (parathormone, calcium, and phosphorus levels), medication use, and clinical scoring. RESULTS: In the 23 patients who received parathyroid allotransplants over the omentum, 7 recipients did not exhibit any changes according to the scoring system criteria. However, on average, serum calcium and phosphorus levels remained within the healthy reference range. In addition, use of oral medications among patients decreased, indicating successful transplant survival. These results were consistent with a significant decrease in hypocalcemia symptoms among patients. CONCLUSIONS: In the 23 patients, the success rate was 69.5% for the first 6-month period after transplant. Recent developments and large cohorts are needed to demonstrate the higher efficacy of parathyroid allotransplant over the omentum.

Staged laparoscopic management of locally advanced gastric cancer with outlet obstruction.

BACKGROUND: The prognosis of patients with locally advanced gastric cancer with outlet obstruction is poor. Gastrectomy with curative intent is often initially impossible or difficult. OBJECTIVE: We report our experience of curative distal gastrectomy after laparoscopic gastrojejunostomy and fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) chemotherapy to examine the feasibility and safety of this modified strategy for locally advanced gastric cancer with outlet obstruction, initially deemed unresectable. METHODS: Between October 2017 and June 2019, 15 patients diagnosed with locally advanced gastric cancer with outlet obstruction sequentially underwent gastrojejunostomy, received four cycles of FLOT chemotherapy, and underwent laparoscopic distal gastrectomy with curative intent (R0 resection + D2 lymphadenectomy). Clinical data were retrospectively collected and analyzed. RESULTS: R0 resection was possible in 12/15 patients, laparoscopically in 11, and one conversion to laparotomy was necessary. There was no perioperative mortality in the 12 patients. Pathologic evaluation of the resected specimens revealed that complete tumor grade regression 1a (TRG1a), TRG1b, TRG2, and TRG3 occurred in 3, 2, 4, and 3 patients, respectively. CONCLUSION: This case series showed that curative surgical resection was feasible as a staged approach for patients with locally advanced gastric cancer with outlet obstruction, after initial staged gastrojejunostomy and chemotherapy.

Predicting Survival After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Appendix Adenocarcinoma.

BACKGROUND: Appendix adenocarcinomas are rare tumors with propensity for peritoneal metastasis. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is an established treatment with curative intent, but, to date, studies reporting survival have been heterogeneous with regard to their patient groups (including other tumor types), interventions (not all patients receiving intraperitoneal chemotherapy), and follow-up (varying surveillance protocols). OBJECTIVE: The aim of this study is to quantify the impact of this intervention on survival in a homogeneous group of patients with appendix adenocarcinoma receiving standardized treatment and follow-up, and to determine the impact of prognostic indicators on survival. DESIGN: This is a retrospective analysis of a prospective database at a national peritoneal tumor center where all patients had their appendix pathology reviewed and management planned by a specialized peritoneal tumor multidisciplinary team. MAIN OUTCOME MEASURES: Data were extracted on prognostic indicators including peritoneal cancer index, completeness of cytoreduction score, preoperative tumor markers, and histological features. Overall and disease event-free survival from the date of intervention were evaluated using Kaplan Meier curves and univariate Cox proportional hazards regression analysis. RESULTS: A total of 65 patients underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for appendix adenocarcinoma between 2005 and 2015. Median follow-up was 44.3 months. The overall survival was 55.5% and disease event-free survival was 36.1% (5-year rate). Peritoneal Cancer Index <7, complete cytoreduction score of 0, and preoperative CEA of <6 were all associated with significantly higher overall and disease event-free survival. CA19-9 <38 and CA125 <31 were not associated with a significantly higher overall or disease event-free survival. LIMITATIONS: The sample size was limited because of the rarity of this tumor type. CONCLUSIONS: This study quantifies the impact of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy on overall and disease event-free survival for appendix adenocarcinoma, identifying key prognostic indicators that may guide treatment. It supports the referral of these rare tumors to specialist centers with appropriate expertise for initial management and follow-up. See Video Abstract at http://links.lww.com/DCR/A595.

Effects of vitamin E and selenium supplementation on blood lipid peroxidation and cortisol concentration in dairy cows undergoing omentopexy.

Twenty dairy cows with left abomasal displacement were used to investigate the effects of vitamin E and selenium treatment on thiobarbituric acid reactive substances (TBARS) and blood cortisol in dairy cows stressed by omentopexy. The cows were randomly divided into two groups. Ten hours before surgery 6 g of DL-α-tocopheryl acetate (6 mg/kg) and 67 mg of natrium selenite (0.1 mg/kg) in volume of 40 ml (Vitaselen® ) were administered subcutaneously to 10 cows; the control animals (n = 10) received an equivalent volume of injectable water (40 ml). The injection of vitamin E and selenium produced a rapid rise (p < .05) in blood α-tocopherol and selenium concentrations. The serum vitamin E increased several times 10 hr after vitamin E and Se injection and raised continuously to the highest average concentration 21.6 mg/L at hr 24 after the surgery. The highest selenium concentration was seen 10 hr after selenium administration with holding the increased concentrations in comparison with initial ones during the whole study. Two-way ANOVA did not show significant treatment effect on plasma concentrations TBARS in the study. The plasma concentrations of thiobarbituric acid reactive substances reached the maximum value of 0.18 µmol/L in the control group 5 hr after the surgery. Twenty-four hours after the surgery, the TBARS values returned to the initial ones. Serum cortisol increased in both groups after surgery. The highest cortisol concentrations were reached at 1 hr after surgery in the experimental and control group (56.7 ± 28.8 and 65.3 ± 26.1 µg/L respectively). A return to the levels similar to the initial ones was recognized 24 hr after the surgery. The ANOVA revealed a significant effect of vitamin E and selenium injection on plasma cortisol (p < .05). In conclusion, we have demonstrated that abdominal surgery resulted in typical stress changes with no significant effects of a single vitamin E/Se injection on blood lipid peroxidation. In addition, a weaker cortisol response to the abdominal surgery was recognized in animals treated with vitamin E and selenium.

Minimally invasive hysterectomy surgery rates for endometrial cancer performed at National Comprehensive Cancer Network (NCCN) Centers.

OBJECTIVES: Minimally invasive surgery (MIS) is a quality measure for endometrial cancer (EC) established by the Society of Gynecologic Oncology and the American College of Surgeons. Our study objective was to assess the proportion of EC cases performed by MIS at National Comprehensive Cancer Network (NCCN) centers and evaluate perioperative outcomes. METHODS: A retrospective cohort study of women who underwent surgical treatment for EC from 2013 to 2014 was conducted at four NCCN centers. Multivariable mixed logistic regression models analyzed factors associated with failure to perform MIS and perioperative complications. RESULTS: In total 1621 patients were evaluated; 86.5% underwent MIS (robotic-assisted 72.5%, laparoscopic 20.9%, vaginal 6.6%). On multivariable analysis, factors associated with failure to undergo MIS were uterine size >12cm (Odds Ratio [OR]: 0.17, 95% CI 0.03-0.9), stage III (OR: 0.16, 95% CI 0.05-0.49) and IV disease (OR: 0.07, 95% CI 0.02-0.22). For stage I/II disease, complications occurred in 5.1% of MIS and 21.7% of laparotomy cases (p<0.01). Laparotomy was associated with increases in any complication (OR: 6.0, 95% CI 3.3-10.8), gastrointestinal (OR: 7.2, 95% CI 2.6-19.5), wound (OR: 3.7, 95% CI 1.5-9.2), respiratory (OR 37.5, 95% CI 3.9-358.0), VTE (OR 10.5, 95% CI 1.3-82.8) and 30-day readmission (OR: 2.6, 95% CI 1.4-4.9) compared to MIS. CONCLUSIONS: At NCCN-designated centers, the MIS hysterectomy rate in EC is higher than the published national average, with low perioperative complications. Previously identified disparities of age, race, and BMI were not observed. A proposed MIS hysterectomy benchmark of >80% in EC care is feasible when performed at high volume centers.

Ruptured Primary Omental Pregnancy Mimicking Adnexal Implantation.

Ectopic pregnancies occur when the implantation of a fertilized ovum occurs outside of the endometrial cavity. The majority of ectopic pregnancies encountered in clinical practice are located within the fallopian tube. Abdominal pregnancies represent 1% of all ectopic pregnancies. Primary omental pregnancy, in which the extrauterine site of implantation is the greater omentum, is the least common form of abdominal pregnancy. The rarity of an ectopic pregnancy in the omentum and the absence of clinical symptoms often delays diagnosis and proper identification before rupture. The authors describe the case of a 23-year-old woman who had hemoperitoneum from a ruptured omental ectopic pregnancy that mimicked adnexal implantation. Her omental pregnancy was diagnosed through intraoperative exploration and osteopathic structural examination findings.

Multimodal oncosurgery approach to treat peritoneal carcinomatosis in a patient with occlusive ovarian carcinoma.

UNLABELLED: Summary BACKGROUND: This paper aims to present a "pattern" of oncosurgery solution in a case generally considered unrecoverable: intestinal occlusion in case of ovarian carcinoma and carcinomatosis. CASE REPORT: A 62-year-old female patient with ascites, carcinomatosis, unresectable pelvic tumour, and intestinal obstruction suffered a five-step oncosurgery "model": three surgical interventions overlapping chemotherapy administered via the systemic and intraperitoneal route: Step 1: colostomy and partial omentectomy; Step 2: five courses of systemic chemotherapy supported by granulocyte colony-stimulating factor; Step 3: radical surgery--total hysterectomy, bilateral adnexectomy, pelvic lymphadenectomy, omentectomy, appendectomy, pelvic peritonectomy, and hyperthermic intraperitoneal chemotherapy; Step 4: consolidation systemic chemotherapy consisting of three more similar cycles; Step 5: closure of the colostomy. Nine months after the beginning of treatment, the patient is with no evidence of disease. CONCLUSIONS: The association of surgical and oncologic treatment and the use of hyperthermic intraperitoneal chemotherapy (HIPEC) technology can solve some of these complex cases.

[Successful treatment of chronic empyema by the omentopexy after aggressive nutritional support].

Since general thoracic surgery requires a short fasting period, the number of cases that require nutrition support after surgery is limited and few reports exist about nutrition in general thoracic surgery and chronic empyema. Here we report 2 cases of chronic empyema treated with nutritional support team (NST) followed by omentopexy. For chronic empyema, a long period is required to sterilize the thoracic cavity by closed or open drainage before radical treatment. During this period, improvement of the nutrition status is important to control local infection, and to increase the volume of the omentum or muscle flaps used for filling the empyema space effectively. In our 2 cases, radical surgeries using omental flap were successfully performed after the improvement of general condition by aggressive nutritional support.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for gallbladder cancer: a retrospective review.

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) often prolongs survival in patients with peritoneal surface disease, yet is generally avoided in patients with peritoneal spread from gallbladder cancer as a result of its aggressive biologic behavior. Therefore, we reviewed our experience with CRS/HIPEC for patients with gallbladder cancer. We retrospectively evaluated the outcomes of CRS/HIPEC procedures performed from 1991 to 2013 using a prospectively maintained database of 1069 procedures. Patient and tumor characteristics, morbidity, mortality, and survival were reviewed. CRS/HIPEC was performed six times in five patients with peritoneal spread from gallbladder cancer. Patients were young (age 28 to 54 years) without pre-existing comorbidities. Eighty per cent had an Eastern Cooperative Oncology Group score of 0 or 1. At CRS, organs resected included omentum (n = 4), liver (n = 3), colon (n = 2), ovaries (n = 1), and diaphragm (n = 1). A complete macroscopic cytoreduction of intraperitoneal disease was achieved in every case. Clavien graded major morbidity was 17 per cent. There was no observed mortality. Median and 3-year survival were 22.4 months and 30 per cent, respectively. CRS/HIPEC may be performed safely in patients with peritoneal dissemination from gallbladder cancer. Carefully selected patients with low-volume disease amenable to complete cytoreduction may experience a meaningful survival benefit.

Treatment of peritoneal carcinomatosis from ovarian cancer by surgical cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC).

AIM: Ovarian cancer may be considered as an "intraperitoneal disease" by itself. When surgical removal associated with systemic chemotherapy fails, usually, the history of the patients is characterized by poor prognosis. Some encouraging results have been reported by the treatment of peritoneal carcinomatosis (PC) from ovarian cancer by complete surgical cytoreduction, peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC). The purpose of this article was to evaluate the survival benefit and the morbidity of patients with ovarian cancer treated at our institution by cytoreductive surgery associated with hyperthermic intraperitoneal perioperative chemotherapy (HIPEC). METHODS: Between October 1995 and December 2012 more than 600 operations for PC were performed; in 308 cases surgical cytoreduction associated with HIPEC was carried out. Eighty-five patients treated by cytoreduction associated with HIPEC were affected by recurrent epithelial ovarian cancer (EOC). Statistical analysis was performed on 70 patients (last 15 patients were too recent for evaluation). Two trials were applied: 1) patients presenting first peritoneal relapse after surgery and systemic chemotherapy (CT), 6 months later from last CT administration; 2) multiple relapse patients. RESULTS: On 70 patients, morbidity and mortality rates were 35.7% and 7.1%, respectively. Overall median survival was 42.0 months, but in primary EOC was 48.0 months and in recurrent EOC was 28 months (P=0.12). Statistical analysis revealed that the completeness of cytoreduction was the most statistically significant factor related to survival: in completely citoreduced patients, overall survival was 48 months. CONCLUSION: Citoreductive surgery associated to platinum compounds HIPEC is feasible and relatively safe in recurrent and primary PC from ovarian cancer. Better selection of patients and second-look surgery in high risk-patients have to be investigated to improve those encouraging results.

Peritonectomy and hyperthermic chemotherapy in patients with advanced or recurrent ephitelial ovarian cancer: a single center cohort study.

AIM: The present study reports our experience concerning with the advanced cancer treatment (cytoreductive surgery and hyperthermic intraperitoneal chemotherapy) in patients with advanced ovarian cancer ephitelial (AEOS) or recurrent ovarian cancer ephitelial (REOC). METHODS: In a period from October 2006 to December 2009, we observed 25 patients affected by advanced ephitelial ovarian cancer or recurrent ephitelial ovarian cancer. All patients underwent CRS + HIPEC procedures. Peritoneal involvement was valued according to the Peritoneal Cancer Index (PCI) and the remaining postoperative disease according to the Completeness of Cytoreduction score (CC). HIPEC was always performed with closed technique for 60 min, with an average inflow temperature of 42.5 °C. The drugs were administered in combination according two schemes: 1) cisplatin 60 mg/m2/L and caelyx 20 mg/m2/L; 2) 60 mg/m2/L taxotere and caelyx 20 mg/m2/L. Morbidity and mortality were evaluated in accordance with the NCI CTCAE v. 3.0 (USA). Finally, the Disease Free Survival and Overall Survival by the Kaplan-Meier method was rated. RESULTS: The average age observed was 64 years (range 46-76). Fourteen patients (56%) were affected by AEOC. From this group, 12 (48%) were subjected to neoadjuvant therapy and 2 (8%) to surgery as a first; 11 (44%) patients had REOC and all of them had previously undergone to surgery and adjuvant CHT. The average PCI was 12.63 (range 2-27). In 22 patients (88%), cytoreduction was considered total or almost total (CC-0 in 14 patients, CC-1 in 8); in 3 patients (12%), it had not been optimal (CC-2 or CC-3). In all 18 patients with PCI less than 15, it was possible to achieve an optimal cytoreduction, and this was possible only in 3 of the 7 patients who had a PCI greater than 15. The average operative time, including HIPEC, was of 612 min (range 425 min-840 min). In 9 patients (36%), the postoperative course was uncomplicated, in 10 patients (40%) complications were minor (G1-G2) and in 4 patients (16%) morbidity was important (G4). Mortality rate was 8%. The average OS was 30.8 months and the median OS was 30.8 months (respectively 36.5 months for AEOC and 27 months for REOC). The median DFS total (calculated from the day of surgery or from the day of the beginning of the CHT) was 12months (respectively 12.9 months for AEOC, 11.9 months for REOC). CONCLUSION: Although the CRS and HIPEC procedure in the treatment of advanced or recurrent ovarian cancer represents now a reliable method with good results both in terms of morbidity and of distance results, there are still many controversial aspects that may in the future be better clarified only with a randomized phase III study, which is in progress, involving international working groups and experts on the procedure.

The Diagnostic Significance of a Mucocele of the Appendix.

Appendiceal mucoceles are rare lesions with a variable clinical presentation often identified incidentally on imaging or at laparotomy/laparoscopy for an unrelated diagnosis. Mucocele of the appendix may be a benign or malignant process, making early recognition based on symptoms and key radiographic characteristics of the utmost importance for optimal patient management. Here we present the case of a patient presenting with non-specific abdominal complaints suffering from appendiceal mucocele perforation due to low-grade mucinous adenocarcinoma.

Cytoreductive surgery with selective versus complete parietal peritonectomy followed by hyperthermic intraperitoneal chemotherapy in patients with diffuse malignant peritoneal mesothelioma: a controlled study.

BACKGROUND: Combined treatment involving peritonectomy procedures, multivisceral resections, and hyperthermic intraperitoneal chemotherapy (HIPEC) has reportedly resulted in survival benefit for peritoneal surface malignancies, including diffuse malignant peritoneal mesothelioma (DMPM). Many unanswered questions remain regarding the surgical options in the management of DMPM. The aim of this case­control study was to assess the impact of the type and extent of parietal peritonectomy on survival and operative outcomes. METHODS: Thirty patients with DMPM undergoing selective parietal peritonectomy (SPP) of macroscopically involved regions, and 30 matched patients undergoing routine complete parietal peritonectomy (CPP), regardless of disease distribution, were retrospectively identified from a prospective database. RESULTS: Groups were comparable for all characteristics, except for a higher proportion of patients treated before July 2003 and undergoing preoperative systemic chemotherapy in the SPP group. Median follow-up was 86.2 months in the SPP group and 50.3 months in the CPP group. Median overall survival was 29.6 months in the SPP group and not reached in the CPP group; 5-year overall survival was 40.0% and 63.9%, respectively (P = 0.0269). At multivariate analysis, CPP versus SPP was recognized as an independent predictor of better prognosis, along with complete cytoreduction, negative lymph nodes, epithelial histology, and lower MIB-1 labelling index. Morbidity and reoperation rates were not different between groups. No operative mortality occurred. In 12 of 24 patients undergoing CPP, pathologic examination detected disease involvement on parietal surfaces with no evident tumor at surgical exploration. CONCLUSIONS: CPP improved survival in patients with DMPM undergoing combined treatment. This information may contribute to standardize surgical options for DMPM and other peritoneal malignancies.

Aggressive management of peritoneal carcinomatosis from mucinous appendiceal neoplasms.

BACKGROUND: Peritoneal carcinomatosis (PC) in the setting of mucinous appendiceal neoplasms is characterized by the intraperitoneal accumulation of mucinous ascites and mucin-secreting epithelial cells that leads to progressive compression of intra-abdominal organs, morbidity, and eventual death. We assessed postoperative and oncologic outcomes after aggressive surgical management by experienced surgeons. METHODS: We analyzed clinicopathologic, perioperative, and oncologic outcome data in 282 patients with PC from appendiceal adenocarcinomas between 2001 and 2010 from a prospective database. Kaplan­Meier survival curves and multivariate Cox-regression models were used to identify prognostic factors affecting oncologic outcomes. RESULTS: Adequate cytoreduction was achieved in 82% of patients (completeness of cytoreduction score (CC)-0: 49%; CC-1: 33%). Median simplified peritoneal cancer index (SPCI), operative time, and estimated blood loss were 14 (range, 0­21), 483.5 min (range, 46­1,402), and 800 ml (range, 0­14,000), respectively. Pathology assessment demonstrated high-grade tumors in 36% of patients and lymph node involvement in 23% of patients. Major postoperative morbidity occurred in 70 (25%) patients. Median overall survival was 6.72 years (95% confidence interval (CI), 4.17 years not reached), with 5 year overall survival probability of 52.7% (95% CI, 42.4, 62%). In a multivariate Cox-regression model, tumor grade, age, preoperative SPCI and chemo-naïve status at surgery were joint significant predictors of overall survival. Tumor grade, postoperative CC-score, prior chemotherapy, and preoperative SPCI were joint significant predictors of time to progression. CONCLUSIONS: Aggressive management of PC from mucinous appendiceal neoplasms, by experienced surgeons, to achieve complete cytoreduction provides long-term survival with low major morbidity.

Effect of preservation of the right gastro-epiploic artery on delayed gastric emptying after cytoreductive surgery and HIPEC: a randomized clinical trial.

BACKGROUND: Delayed gastric emptying (DGE) is a main complication with unknown origin after a cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS-HIPEC). The aim of this study was to investigate if preservation of the right gastro-epiploic artery (GEA) during standard omentectomy would have a positive effect on gastric emptying after CRS-HIPEC. METHODS: Forty-two patients subjected to a CRS-HIPEC were randomized into two groups perioperatively before performing an omentectomy: in Group I (N = 21) omentectomy was performed with preservation of the GEA; in Group II (N = 21) omentectomy was performed with resection of the GEA. The primary endpoint was the number of days to full oral intake of solid food. Secondary endpoints were number of days to intended occlusion of gastrostomy catheter and total hospital admission time. RESULTS: No significant differences were discovered between both groups in any of the study endpoints after CRS-HIPEC. No significant differences were observed in patient or operation characteristics between the randomized groups. CONCLUSIONS: No association was demonstrated between preservation of the gastro-epiploic artery during omentectomy and gastric emptying after CRS-HIPEC. The extensive intestinal manipulation or the heated intra-peritoneal chemotherapy during surgery are more plausible causes of this phenomenon. This clinical trial was registered in the Netherlands at the Central Committee on Research involving Human Subjects (CCMO) under registration number P06.0301L.

[The techniques of peritonectomy and hyperthermic intraperitoneal chemotherapy]. / Technik der Peritonektomie sowie der hyperthermen intraperitonealen Chemotherapie.

The treatment of peritoneal carcinomatosis represents a challenge in the therapy for gastrointestinal cancer. A multimodal approach with complete surgical cytoreduction and hyperthermic intraperitoneal chemotherapy can improve the prognosis in selected patients. Complete surgical cytoreduction, consisting of parietal and visceral peritonectomy, is a sophisticated procedure, frequently requiring multivisceral resections and should only be performed by experienced visceral surgeons. In addition, hyperthermic intraperitoneal chemotherapy is of some complexity. Furthermore, regarding the learning curve for this procedure, combined treatment should only be performed in specialised centres. Under optimal conditions, the therapy can be carried out with reasonable morbidity and mortality rates. Patients with peritoneal carcinomatosis should be evaluated by an interdisciplinary team concerning this multimodal therapy option and, if applicable, they should be referred to therapy within the framework of clinical studies.

Pseudomyxoma peritonei: clinical pathological and biological prognostic factors in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: Surgical cytoreduction combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has been recently advocated as the standard of care for pseudomyxoma peritonei (PMP). We reviewed our 10-year monoinstitutional case series to identify selection factors predicting postoperative outcome. METHODS: One hundred and four patients with PMP were operated on with the aim of performing adequate cytoreduction (residual tumor nodules < or =2.5 mm) and closed-abdomen HIPEC with mytomicin-C and cisplatin. Previously, 26 patients had systemic chemotherapy. PMP was histologically classified into disseminated peritoneal adenomucinosis (DPAM), peritoneal mucinous carcinomatosis (PMCA), and intermediate/discordant group (ID). Immunohistochemical stains were performed for cytokeratin (CK)-7, CK-20, CDX-2, MUC-2, MUC-5AC, CD-44s. The significance of 22 potential clinical, pathological, and biological prognostic variables was assessed by multivariate analysis. RESULTS: Adequate cytoreduction was performed in 89 patients, suboptimal cytoreduction in six, palliative surgery in nine. Operative mortality was 1%. Seventy-eight patients were diagnosed with DPAM, 26 with PMCA, and none with ID. Median follow-up was 37 months (range, 1-110) for the overall series. Five-year overall survival (OS) and progression-free survival (PFS) were 78.3% and 31.1%, respectively. At multivariate analysis, adequate cytoreduction, no previous systemic chemotherapy, and DPAM correlated to better OS and PFS, elevated serum CA19.9 correlated only to better PFS. In most cases, CK20, CDX-2, and MUC-2 were diffusely positive, while CK-7, MUC-5AC, and CD44s were variably expressed. CK20 expression correlated to prognosis at univariate analysis. CONCLUSIONS: Favorable outcome after comprehensive treatment can be expected in patients with DPAM, not treated with preoperative systemic chemotherapy and amenable to adequate cytoreduction. MUC-2, CK-20, and CD44s expression may be related to PMP unique biologic behavior.

The interval from surgery to chemotherapy in the treatment of advanced epithelial ovarian carcinoma.

BACKGROUND: To study the effect of the interval between surgery and the start of chemotherapy in the treatment of patients with advanced ovarian cancer. METHODS: We stratified patients according to the start of platinum-based chemotherapy in group 1 (within 4 weeks from surgery), group 2 (between 4 and 8 weeks) and group 3 (between 8 and 12 weeks). RESULTS: Three hundred and ninty-four stage III ovarian cancer patients were analysed. In the multivariate analysis there were no differences in survival according to the interval between surgery and chemotherapy among the three groups. The independent prognostic variables were type of procedure (p = 0.014), performance status (p = 0.040) and post-chemotherapy CA-125 (p < 0.0001). CONCLUSIONS: The interval between surgery and chemotherapy does not affect outcome.

[Multiorgan resection in combination with intraoperative, hyperthermic chemotherapy in recurrent fibrolamellar hepatocellular carcinoma. An individual therapeutic concept for a 21-year-old patient]. / Multiviszerale Resektion in Kombination mit intraoperativer, hyperthermer Chemotherapie beim Rezidiv des fibrolamellären, hepatozellulären Karzinoms. Ein individuelles, therapeutisches Konzept bei einem 21jährigen Patienten.

The fibrolamellar karzinoma of the liver (FLC) as an uncommon variant of the hepatocellular karzinoma (HCC) is an indolent growing tumor. In its prior manifestation the FLC occurs at the adolescence and young adult stage. Early stage diagnosis and aggressive surgical treatment achieve better long-term results than usual resection of the HCC. Usually the FLC is, caused by its inconspicuous clinical appearance, diagnosed at a stage too advanced for effective surgical treatment. Especially the young patient's age and the remaining therapeutic options for palliative or curative treatment postulate a difficult decision for the surgeon. When a subtotal hepatectomy cannot be performed, total hepatectomy with liver transplantation is a valuable option. Palliative treatment protocols include systemic chemotherapy, ethanol instillation and chemoembolisation. We report the case of a 21-year-old male patient who presented with a recurrent intrahepatic FLC, peritoneal karzinomatosis confined to the right lower abdomen including gastric, splenic, diaphragmatic and colon transversum metastasis 14 months after primary surgery. We selected this patient as a reasonable candidate for an extended resection in trying to offer the optimal therapeutic modality. Thus we performed a right hemihepatectomy, near complete resection of the right diaphragm, total gastrectomy with lymphadenectomy including en bloc resection of spleen, colon transversum, omentum majus and peritonectomy of the paravesical region. Furthermore hyperthermic intraperitoneal chemotherapy was carried out the next day. The patient's postoperative course remained uncomplicated with fast recovery. Presently, 6 months after surgery, the patient has no evidence of recurrence.

[Prevention of anastomotic dehiscence in colorectal surgery]. / Prévention des déhiscences anastomotiques en chirurgie colorectale.

Anastomotic leakage is a major cause of mortality in colorectal surgery. Some variables associated with a high-risk level for anastomotic leakage have been identified, including denutrition, obesity, smoking, level of the anastomoses, qualification of the surgeon. Several methods have been evaluated in order to prevent anastomotic leakage. Prophylactic antibiotic therapy has been recommended, but has no effect on the rate of anastomotic leakage. Optimal preoperative colonic preparation appears to be obtained with povidone iodine enemas associated with a low residue diet. Stapling gives better results than sutures only for difficult anastomoses. Colostomy does not prevent leakage but minimizes its consequences. Omentoplasty, peritoneal drainage, gastric tube, biofragmentable anastomotic ring, and Coloshield have demonstrated their efficacy.