Assessment of Anastomotic Viability With Spectroscopic Real-time Oxygen Saturation Measurement in a Porcine Study.

OBJECTIVE: Anastomotic leakage (AL) is a severe complication following intestinal procedures. Intra.Ox™ by ViOptix Inc (Newark, CA, USA) is a novel, FDA-approved spectroscopic device which enables real-time measurement of mixed tissue oxygen saturation (StO2). Using a porcine model, this study explores the correlation between StO2 measurements and AL formation as well as investigates the applicability of Intra.Ox™ in the clinical setting. METHODS: Eleven female swine were divided into 3 groups to explore AL formation in different ischemic conditions. Group 1: 100% mesenteric-vascular ligation, n = 3; Group 2: 50% ligation, n = 5; Group 3: No mesenteric ligation, n = 3. StO2 at the anastomotic line was measured before and after vessel ligation and anastomosis. Measurements were taken at 6 distinct locations along afferent and efferent loops. AL was evaluated on postoperative day 5 by re-laparotomy. RESULTS: AL rate was 100%, 60% and 0% in groups 1, 2 and 3, respectively. Post-anastomotic StO2 in group 1 (22.9 ± 18.5%) and 2 (39.2 ± 20.1%) were significantly lower than in group 3 (53.1 ± 8.3%, p<.0001). Post-anastomotic StO2 readings ≤40% indicated AL potential with 100% sensitivity,+ 80% specificity, positive predictive value of 85.7% and negative predictive value of 100%. CONCLUSION: This study demonstrates the value of Intra.Ox™ in assessing local perfusion and indicate the association between low StO2 and AL by providing accurate, real-time, noninvasive tissue oxygenation measurements at anastomotic sites. Further studies are required to investigate the clinical application of this novel device in intestinal surgery.

Misdiagnosis of appendiceal neoplasms as ovarian tumors: Impact of prior gynecologic surgery on definitive cytoreduction and HIPEC.

BACKGROUND: Female patients with pelvic/adnexal masses often undergo gynecologic operations due to presumed ovarian origin. The diagnosis of an appendiceal tumor is often only made postoperatively after suboptimal cytoreduction has been performed. We hypothesized that an index gynecological procedure increases the morbidity of definitive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in patients with appendiceal mucinous tumors. METHODS: A single-center retrospective review was performed to identify female patients undergoing CRS/HIPEC for appendiceal tumors from 2012 to 2020. RESULTS: During the 8-year period, CRS/HIPEC was performed in 36 female patients with appendiceal mucinous tumors. Eighteen patients (50.0%) had received a prior pelvic operation by gynecologists (PPO Group) for presumed ovarian origin before referral for definitive CRS/HIPEC. The median peritoneal cancer index (PCI) was higher in the PPO group (21 vs. 9, p = 0.04). The median number of days from gynecologic procedure to definitive CRS/HIPEC was 169 days. Compared to patients who did not undergo a prior gynecologic operation, those in the PPO group had higher intraoperative blood loss (650 vs 100 mL, p < 0.01) during CRS/HIPEC as well as longer length of stay (12 vs 8 days, p = 0.02) and higher overall morbidity (72.3% vs 33.3%, p = 0.02). After controlling for PCI, prior gynecologic operation increased risk of 30-day morbidity after definitive CRS/HIPEC (OR 11.6, p < 0.01). CONCLUSION: A multi-disciplinary approach is needed for the primary evaluation of patients with pelvic masses of undetermined origin. A gynecological resection is associated with increased morbidity during definitive cytoreduction and HIPEC for appendiceal mucinous tumors.

Female pediatric and adolescent genitalia trauma: a retrospective analysis of the National Trauma Data Bank.

PURPOSE: Pediatric genitalia injury represents 0.6% of all pediatric trauma. It is crucial for providers to understand whether pediatric patients are at risk for violent mechanisms, such as rape, assault, or other abuse. Therefore, we sought to perform a large database analysis of pediatric and adolescent female genitalia trauma, comparing mechanisms of injury (i.e., sexual abuse) and need for operative intervention between adolescent and pediatric cohorts. METHODS: The National Trauma Data Bank was queried (years 2007-2015) for female patients ≤ 16 years old with external genitalia (vaginal or vulvar) trauma. Two groups were compared: pediatrics (< 12 years old) and adolescents (12-16 years old). RESULTS: Out of 303,992 female patients, 3206 (1.1%) were identified to have genitalia trauma with the majority being pediatric patients (92.1%) and with injury to the vagina (62.6%). Pediatric patients with vaginal injury were less likely to be victims of rape (4.1% vs. 17.3%, p < 0.001) and assault (2.1% vs. 7.2%, p < 0.001) but more likely to be victims of other abuse (9.5% vs. 3.4%, p = 0.003). More of the adolescent patients with vaginal trauma required repair (58.7% vs. 43.2%, p < 0.001). Pediatric patients with injury to the vulva were less likely to be victims of rape (0.7% vs. 2.8%, p = 0.01) and motor vehicle accidents (4.2% vs. 11.0%, p < 0.001). CONCLUSION: Genitalia trauma occurs in 1.1% of pediatric and adolescent trauma cases with the vagina being more commonly injured compared to the vulva. Adolescent patients with vaginal injuries were more likely to be victims of rape and assault and required repair more often, while those with vulvar injuries were more likely due to motor vehicle accidents. Health care providers must be aware of these at-risk populations and the differences between them to identify female victims of violence and provide resources to assist with recovery.

Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated Diaphragm Injury After Penetrating Trauma.

BACKGROUND: Isolated diaphragm injury (IDI) occurs in up to 30% of penetrating left thoracoabdominal injuries. Laparoscopic abdominal procedures have demonstrated improved outcome including decreased postoperative pain and length of stay (LOS) compared to open surgery. However, there is a paucity of data on this topic for penetrating IDI. The aim of this study was to examine the prevalence and outcome of laparoscopic diaphragmatic repair versus open diaphragmatic repair (LDR vs ODR) of IDI. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for patients with IDI who underwent ODR versus LDR. A bivariate analysis using Pearson chi-square and Mann-Whitney test was performed to determine LOS among the two groups. RESULTS: From 2039 diaphragm injuries, 368 patients had IDI; 281 patients (76.4%) underwent ODR and 87 (23.6%) underwent LDR. Compared to LDR, the ODR patients were older (median, 31 vs 25 years, P < .001) and had a higher injury severity score (mean, 11.2 vs 9.6, P = .03) but had similar rates of intensive care unit LOS, unplanned return to the operating room, ventilator days, and complications (P > .05). Patients undergoing ODR had a longer LOS (5 vs 4 days, P = .01), compared to LDR. There were no deaths in either group. CONCLUSIONS: Trauma patients presenting with IDI undergoing ODR had a longer hospital LOS compared to patients undergoing LDR with no difference in complications or mortality. Therefore, we recommend when possible an LDR should be employed to decrease hospital LOS. Further research is needed to examine other benefits of laparoscopy such as postoperative pain, incisional hernia, and wound-related complications.

Particle stability and structure on the peritoneal surface in pressurized intra-peritoneal aerosol chemotherapy (PIPAC) analysed by electron microscopy: First evidence of a new physical concept for PIPAC.

Pressurized intra-peritoneal aerosol chemotherapy (PIPAC) has been introduced to the clinical setting as a novel approach for the treatment of peritoneal metastasis. The local interaction of chemoaerosol droplets with the peritoneal surface as well as their distribution pattern is considered the main advantage over conventional liquid intraperitoneal chemotherapy. The aim of the present study was to investigate the behavior of these aerosol particles during PIPAC application via electron microscopy. Solutions of doxycycline, liposomal doxorubicin and macrophage cells were aerosolized using an established ex-vivo model. PIPAC was performed on peritoneum samples via microcatheter (MC) at a pressure of 12 mmHg C02 at 27°C. Following PIPAC the surface structure of applied particles was measured via electron microscopy. The aerosol particle contact of doxycyclin created a nanofilm of ~200 nm height on the peritoneal surface, and this height was revealed to be independent of the size of the initial particle hitting. These nanofilm blocks of 'cylinders' are of different diameters depending on the initial aerosol particle hitting that spot. Diameters of these 'cylinders' are far wider than the original diameter of the initial aerosol particle. However, coated particles such as liposomal doxorubicin and macrophages remained intact following contact with the peritoneal surface. Based on this and other data, the concept that aerosol particles exhibit a gas-like behavior in the abdomen creating a therapeutic capnoperitoneum should be revised. Fluid aerosol particles collide with the peritoneum creating a nanofilm. The interaction of pressurized intraperitoneal aerosol on the peritoneum is therefore closer to the distribution of a liquid film than to that of a gas. Further studies are required to further analyze the interaction of this nanofilm on the peritoneum.

Comparing the cytotoxicity of taurolidine, mitomycin C, and oxaliplatin on the proliferation of in vitro colon carcinoma cells following pressurized intra-peritoneal aerosol chemotherapy (PIPAC).

BACKGROUND: Besides its known antibacterial effect commonly used in intraperitoneal lavage, taurolidine has been observed to possess antineoplastic properties. In order to analyse this antineoplastic potential in a palliative therapeutic setting, taurolidine (TN) was compared to mitomycin C (MMC) and oxaliplatin (OX), known antineoplastic agents which are routinely used in intraperitoneal applications, following pressurized intra-peritoneal aerosol chemotherapy (PIPAC). METHODS: An in vitro model was established using a colon adenocarcinoma cell line (HT-29 human cells). Different experimental dosages of TN and combinations of TN, MMC, and OX were applied via PIPAC. To measure cell proliferation, a colorimetric tetrazolium reduction assay was utilized 24 h after PIPAC. RESULTS: We demonstrated a cytotoxic effect of TN and OX (184 mg/150 mL, p < 0.01) on tumor cell growth. An increasing dosage of TN (from 0.5 g/100 mL to 0.75 g/150 mL) correlated with higher cell toxicity when compared to untreated cells (p < 0.05 and p < 0.01, respectively). PIPAC with OX and both OX and TN (0.5 g/100 mL) showed the same cytotoxic effect (p < 0.01). No significant impact was observed for MMC (14 mg/50 mL, p > 0.05) or MMC with OX (p > 0.05) applied via PIPAC. CONCLUSIONS: The intraperitoneal application of TN is mostly limited to lavage procedures in cases of peritonitis. Our results indicate a substantial antineoplastic in vitro effect on colon carcinoma cells following PIPAC application. While this effect could be used in the palliative treatment of peritoneal metastases, further clinical studies are required to investigate the feasibility of TN application in such cases.

Effect of Liposomal Doxorubicin in Pressurized Intra-Peritoneal Aerosol Chemotherapy (PIPAC).

Background: This ex-vivo study was performed to compare the impact of doxorubicin vs. liposomal doxorubicin on penetration depth in peritoneal tissue during Pressurized Intra-Peritoneal Aerosol Chemotherapy (PIPAC) via microcatheter (MC). Methods: Fresh post mortem swine peritoneum was cut into proportional sections. One group of samples was treated with PIPAC with Doxorubicin (D), and the other was treated with PIPAC with liposomal doxorubicin (LD). Tissue specimens were placed as follows: at the bottom of the plastic box (1), at the side wall (2), at the top cover (3) and the side of the box covered by a plastic tunnel (4). In-tissue doxorubicin penetration was measured using fluorescence microscopy on frozen thin sections. Results: Medium penetration levels with D were 325 µm (1), 152 µm (2), 84 µm (3) and 71 µm (4), respectively. Medium penetration levels with LD were significantly lower with 10 µm (1), 2 µm (2), 0 µm (3) and 0 µm (4), respectively. In most samples that were treated with LD no doxorubicin could be detected at all. Conclusion: Our data indicate that liposomal coating of doxorubicin and possibly other chemotherapeutical drugs might inhibit their interaction with the peritoneal surface. This inhibition appears to be relatively strong, since doxorubicin is partially undetectable due to liposomal coating. Further studies are warranted to investigate this interaction and its potential benefit in peritoneal applications.

Feasibility and Characteristics of Pressurized Aerosol Chemotherapy (PAC) in the Bladder as a Therapeutical Option in Early-stage Urinary Bladder Cancer.

BACKGROUND: Pressurized aerosol chemotherapy (PAC) is a novel approach to the treatment of surface malignancies. This study aimed to investigate whether PAC is a feasible treatment of early-stage bladder cancer. MATERIALS AND METHODS: PAC via inserted microcatheter was performed on a fresh urinary bladder in a post-mortem swine model (n=3), creating a pressurized doxorubicin chemoaerosol. Drug penetration of aerosolized doxorubicin at different concentrations (3 mg/50 ml, 9 mg/50 ml and 15 mg/50 ml) and different locations on the mucosa was measured via fluorescence microscopy. RESULTS: Mean endoluminal penetration rates for the urothelium following PAC reached 149±61 µm (using 15 mg/50 ml). Doxorubicin penetration was significantly increased with higher drug concentration (15 vs. 3 mg/50 ml: p<0.01). This study demonstrated the feasibility of PAC for intravesical use. CONCLUSION: PAC is a feasible minimally-invasive approach to the treatment of early-stage bladder cancer.

Slurring of Speech and Lip Paresthesia: Symptoms of Levodopa End of Dose Wearing Off in Parkinson's Disease.

The prolonged use of levodopa for treating Parkinson's disease is associated with motor and nonmotor complications. These include wearing-off, delayed-on, partial-on, no-on, and on-off phenomena. In the wearing-off effect, symptoms return before a patient's next scheduled dose of levodopa. Patients may present with motor, sensory, or autonomic fluctuations. In this report, we present a female patient experiencing numbness of lips and slurred speech as a symptom of wearing-off effect. The major differential for sudden numbness of lips and slurred speech includes transient ischemic attacks. Therefore, it is imperative to identify the cause of these episodes so that appropriate treatment can be initiated. Our patient underwent extensive cardiac and neurological investigations, the findings of which were unremarkable. Her symptoms were likely due to levodopa wearing-off. Her condition improved on changing her levodopa to a sustained release form with more frequent dosing along with the addition of ropinirole to her treatment regimen.

Particle Stability During Pressurized Intra-peritoneal Aerosol Chemotherapy (PIPAC).

BACKGROUND/AIM: Pressurized intra-peritoneal aerosol chemotherapy (PIPAC) is a new approach in the treatment of peritoneal carcinomatosis. With PIPAC currently limited to liquid chemotherapeutic solutions, this study aims to investigate whether the application range may be extended to the delivery of therapeutic nano- or microparticles. MATERIALS AND METHODS: Human serum, bacteria cultures and macrophage cells were aerosolized in an established ex vivo model. Human serum composition was analyzed via gel electrophoresis. The viability of bacteria and macrophage cells was measured prior to and following PIPAC. RESULTS: No structural disintegration of the plasma solution was detected. While the concentration and viability of Escherichia coli and Salmonella Enteritidis did not significantly change following aerosol formation, macrophage cells showed structural disintegration. CONCLUSION: Our ex vivo data suggest that PIPAC can be used to deliver complex particles. The delivery of small and less complex particles was feasible, yet the mechanical and physical properties of PIPAC might alter the stability of larger and more complex particles.

Ileocolic Resection for Crohn's Disease: A Minimally Invasive Approach Claims Its Place.

Ileocolic resection is the most common operation performed for Crohn's disease patients with terminal ileum involvement. We sought to evaluate the outcomes in Crohn's disease patients who underwent open ileocolic resection (OIC) and laparoscopic ileocolic resection (LIC) by using the ACS-NSQIP database from 2006 to 2015. Of 5670 patients, 48.3 per cent (2737) patients had OIC and 51.7 per cent (2933) had LIC. The number of LIC increased from 40 per cent in 2006 to 60.7 per cent in 2015. Moreover, the annual number of LIC surgeries has exceeded the number of OIC surgeries since 2013. Patients in the LIC group had shorter hospital length of stay compared with OIC group (6 ± 5 days vs 8.6 ± 8 days, P < 0.01). The LIC procedure also had shorter operation time compared with OIC (148 ± 58 vs 153 ± 76 minutes, P = 0.01). Overall morbidity (15.8% vs 25.3%, AOR: 0.54, confidence interval (CI): 0.46-0.62, P < 0.01), serious morbidity (10.9% vs 18%, AOR: 0.55, CI: 0.46-0.65, P < 0.01), and SSI (9.9% vs 15.5%, AOR: 0.59, CI: 0.49-0.70, P < 0.01) rates were lower in the LIC group than the OIC group. We demonstrated that in Crohn's disease patients, LIC has improved outcomes for ileocolic resection compared with OIC and has been chosen as the preferential treatment approach for most patients.