Interval cytoredutive surgery and HIPEC in advanced ovarian cancer with small-bowel disease: results and reflections

Introduction: Small-bowel involvement in patients with ovarian cancer has been strongly correlated with the possibility of cytoreduction and thus with survival. The main objective of this study was to evaluate the prognostic significance of small-bowel involvement in patients undergoing optimal-complete interval cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).Methods: We included a series of patients diagnosed with stage IIIC-IVA (pleural effusion) high-grade serous epithelial ovarian cancer and in whom CRS + HIPEC was indicated after neoadjuvant systemic chemotherapy (NACT). The study period extended from January 2008 to January 2020, with a minimum follow-up of 12 months from the inclusion of the last patient. A multivariate analysis using Cox regression allowed us to identify the variables that were independently related to disease-free survival.Results: A total of 144 patients were selected, 13 (9%) of whom were excluded from the analysis, because their disease was considered unresectable. The study included a series of 131 patients with a median age of 62 years (34-79 years) and a median Peritoneal Cancer Index (PCI) calculated during surgery of 9 (1-35). The median PCI of bowel areas 9-12 (SB-PCI) was 3 (1-10). Performance of a CC-1 cytoreduction (HR: 1.93, 95% CI: 1.02-3.64, p = 0.042) and SB-PCI greater than 3 (HR: 2.25, 95%CI: 1.13-4.48, p = 0.21) were independent factors associated with shorter disease-free survival.Conclusion: Small-bowel involvement, even in patients with a macroscopically complete resection, showed a correlation with worse prognostic outcomes and could be considered as a variable in the postoperative management of these patients. (AU)

Dietary modulation of gut microbiota in patients with colorectal cancer undergoing surgery: A review.

Colorectal cancer (CRC) is the third most frequent malignancy and the second cause of cancer death worldwide. Several factors have been postulated to be involved in CRC pathophysiology, including physical inactivity, unhealthy dietary habits, obesity, and the gut microbiota. Emerging data suggest that the microbiome may play a key role in CRC prognosis and derived complications in patients undergoing colorectal surgery. On the other hand, dietary intervention has been demonstrated to be able to induce significant changes in the gut microbiota and related metabolites in different conditions; therefore, the manipulation of gut microbiota through dietary intervention may constitute a useful approach to improve perioperative dysbiosis and post-surgical outcomes in patients with CRC. In this article, we review the role of the gut microbiota in CRC surgery complications and the potential therapeutic modulation of gut microbiome through nutritional intervention in patients with CRC undergoing surgery.

Gut Microbiome Modification through Dietary Intervention in Patients with Colorectal Cancer: Protocol for a Prospective, Interventional, Controlled, Randomized Clinical Trial in Patients with Scheduled Surgical Intervention for CRC.

Colorectal cancer (CRC) is the third most common cancer and the second cause of cancer death worldwide. Several factors have been postulated to be involved in CRC pathophysiology, including heritable and environmental factors, which are the latest to be closely associated with nutritional habits, physical activity, obesity, and the gut microbiota. The latter may also play a key role in CRC prognosis and derived complications in patients undergoing surgery. This is a single-center, open, controlled, randomized clinical trial, in patients with scheduled surgical intervention for CRC. The primary objective is to assess whether a pre-surgical nutritional intervention, based on a high-fiber diet rich in polyunsaturated fatty acids (PUFAs), can reduce disturbances of the gut microbiota composition and, consequently, the rate of post-surgical complications in patients with CRC. Patients will be randomized in a 1:1 ratio after receiving a diagnosis of CRC. In the control arm, patients will receive standard nutritional recommendations, while patients in the intervention arm will be advised to follow a high-fiber diet rich in PUFAs before surgery. Participants will be followed up for one year to evaluate the overall rate of postsurgical complications, recurrences of CRC, response to adjuvant therapy, and overall/disease-free survival.

Interval cytoredutive surgery and HIPEC in advanced ovarian cancer with small-bowel disease: results and reflections.

INTRODUCTION: Small-bowel involvement in patients with ovarian cancer has been strongly correlated with the possibility of cytoreduction and thus with survival. The main objective of this study was to evaluate the prognostic significance of small-bowel involvement in patients undergoing optimal-complete interval cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). METHODS: We included a series of patients diagnosed with stage IIIC-IVA (pleural effusion) high-grade serous epithelial ovarian cancer and in whom CRS + HIPEC was indicated after neoadjuvant systemic chemotherapy (NACT). The study period extended from January 2008 to January 2020, with a minimum follow-up of 12 months from the inclusion of the last patient. A multivariate analysis using Cox regression allowed us to identify the variables that were independently related to disease-free survival. RESULTS: A total of 144 patients were selected, 13 (9%) of whom were excluded from the analysis, because their disease was considered unresectable. The study included a series of 131 patients with a median age of 62 years (34-79 years) and a median Peritoneal Cancer Index (PCI) calculated during surgery of 9 (1-35). The median PCI of bowel areas 9-12 (SB-PCI) was 3 (1-10). Performance of a CC-1 cytoreduction (HR: 1.93, 95% CI: 1.02-3.64, p = 0.042) and SB-PCI greater than 3 (HR: 2.25, 95%CI: 1.13-4.48, p = 0.21) were independent factors associated with shorter disease-free survival. CONCLUSION: Small-bowel involvement, even in patients with a macroscopically complete resection, showed a correlation with worse prognostic outcomes and could be considered as a variable in the postoperative management of these patients.

Intraperitoneal hyperthermic chemotherapy after cytoreduction in patients with peritoneal metastases from endometrial cancer. The next frontier?

BACKGROUND: Endometrial cancer is the most common malignancy of the female genital tract. For cancers detected at an advanced stage or intraperitoneal relapse, the prognosis is poor. Optimal cytoreductive surgery (CRS) is the most accepted treatment; however, patients with advanced intraperitoneal disease might benefit from hyperthermic intraoperative peritoneal chemotherapy (HIPEC). The aim of this study was to analyze recurrence-free survival (RFS) after CRS and HIPEC in a large series of patients with peritoneal metastases from endometrial cancer. METHODS: Patients with a diagnosis of endometrial cancer with primary or recurrent peritoneal dissemination were included. All patients underwent CRS plus HIPEC. Data were prospectively collected in the Spanish Group of Peritoneal Oncological Surgery (GECOP) database. RESULTS: Forty-three patients with endometrial cancer and peritoneal metastasis were included. Fifteen patients (35%) were diagnosed with G3 endometrioid carcinomas and 28 (65%) with other non-endometroid histologies. A completeness of cytoreduction score of CC-0 was achieved in 41 patients (95%). RFS at 5 years was 23%, being factors related to worse RFS: treatment with preoperative chemotherapy (p = 0.027), resection of more than three peritoneal areas (p = 0.010), cytoreduction of the upper abdominal space (p = 0.023), HIPEC treatment with paclitaxel (p = 0.013), and the presence of metastatic lymph nodes (p = 0.029). CONCLUSIONS: Better RFS rates after CRS and HIPEC were observed for patients with the following characteristics: cytoreductive surgery without preoperative chemotherapy, complete surgery performed with limited surgical maneuvers, treated with cisplatin, and no lymph node metastases. SYNOPSIS: Endometrial cancer has a poor prognosis when diagnosed at advance stage. Patients with intraperitoneal metastases from endometrial cancer may benefit from CRS plus HIPEC with improvement in the recurrence-free survival results.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Gastric Cancer with Peritoneal Carcinomatosis: Multicenter Study of Spanish Group of Peritoneal Oncologic Surgery (GECOP).

BACKGROUND: Gastric cancer (GC) with peritoneal carcinomatosis (PC) is traditionally considered a terminal stage of the disease. The use of a multimodal treatment, including cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), can benefit these patients. Our goal was to evaluate the morbidity and survival outcomes of these patients. METHODS: This is a retrospective, multicenter study from a prospective national database of patients diagnosed with PC secondary to GC treated with CRS and HIPEC from June 2006 to October 2017. RESULTS: Eighty-eight patients from seven specialized Spanish institutions were treated with CRS and HIPEC, with median age of 53 years; 51% were women. Median Peritoneal Cancer Index (PCI) was 6, and complete cytoreduction was achieved in 80 patients (90.9%). HIPEC was administered in 85 cases with 4 different regimens (Cisplatin + Doxorubicin, Mitomycin-C + Cisplatin, Mitomycin-C and Oxaliplatin). Twenty-seven cases (31%) had severe morbidity (grade III-IV) and 3 patients died in the postoperative period (3.4%). Median follow-up was 32 months. Median overall survival (OS) was 21.2 months, with 1-year OS of 79.9% and 3-year OS of 30.9%. Median disease-free survival (DFS) was 11.6 months, with 1-year DFS of 46.1% and 3-year DFS of 21.7%. After multivariate analysis, the extent of peritoneal disease (PCI ≥ 7) was identified as the only independent factor that influenced OS (hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.26-4.46, p = 0.007). CONCLUSIONS: The multimodal treatment, including CRS and HIPEC, for GC with PC can improve the survival results in selected patients (PCI < 7) and in referral centers.

Cooperación en cirugía en el siglo XXI / Cooperation in surgery of the 21st century

La necesidad de cooperación sanitaria en países de bajo desarrollo es conocida y se implementa día a día. Sin embargo, la asistencia sanitaria quirúrgica en estos países, en el siglo XXI, es más discutida, y se encuentra por debajo de niveles deseables y con soluciones más complejas. Por otra parte, el número de cirujanos que buscan implicarse aumenta progresivamente. Se analizan las causas que originan estos bajos niveles de asistencia, como la falta de personal cualificado, fuga de profesionales, coste de la asistencia o la falta de cuantificación de las necesidades. Las oportunidades de mejora, como el hermanamiento institucional, las misiones quirúrgicas de corta duración o la realización de acciones dirigidas a la educación, evaluación, evidencia y formación son algunas de las posibilidades propuestas

The need for healthcare cooperation in low- and middle-income countries is known and is implemented day by day. However, the surgical sanitary assistance in these countries in the 21st century is very controversial, as it is still below desirable levels and entails complex solutions. On the other hand, the number of surgeons seeking to get involved is increasing progressively. We analyze the causes of the low levels of medical assistance, such as the lack of qualified personnel, the brain drain of surgeons, healthcare costs or the lack of quantified needs. Opportunities for improvement, such as institutional twinning, short-term surgical missions or activities aimed at education, evaluation, evidence and training, are some of the possibilities proposed

Cooperation in surgery of the 21st century. / Cooperación en cirugía en el siglo XXI.

The need for healthcare cooperation in low- and middle-income countries is known and is implemented day by day. However, the surgical sanitary assistance in these countries in the 21st century is very controversial, as it is still below desirable levels and entails complex solutions. On the other hand, the number of surgeons seeking to get involved is increasing progressively. We analyze the causes of the low levels of medical assistance, such as the lack of qualified personnel, the brain drain of surgeons, healthcare costs or the lack of quantified needs. Opportunities for improvement, such as institutional twinning, short-term surgical missions or activities aimed at education, evaluation, evidence and training, are some of the possibilities proposed.

Alteraciones de la hemostasia durante la cirugía con quimioterapia intraperitoneal hipertérmica en pacientes con carcinomatosis peritoneal / Alterations in hemostasis during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis

INTRODUCCIÓN: La cirugía citorreductora seguida de quimioterapia intraperitoneal hipertérmica (HIPEC) se asocia frecuentemente a alteraciones de la hemostasia y a elevados requerimientos transfusionales perioperatorios. El propósito de este estudio fue analizar los trastornos hemostáticos asociados a cada una de las fases de este procedimiento terapéutico mediante tromboelastometría rotacional (ROTEM), niveles de fibrinógeno y recuento plaquetario, así como su posible relación con las necesidades transfusionales. MÉTODOS: Se efectuó un estudio prospectivo longitudinal. Se registraron niveles de hemoglobina, recuento plaquetario, niveles de fibrinógeno y parámetros tromboelastométricos: tiempo de coagulación (CT), tiempo de formación del coágulo (CFT), firmeza máxima del coágulo (MCF), y ángulo α (EXTEM, INTEM, FIBTEM). Las mencionadas determinaciones se realizaron: antes del inicio de la cirugía; al finalizar la cirugía citorreductora y al concluir la HIPEC. Se utilizaron los test estadísticos apropiados. Los valores de p < 0,05 se consideraron estadísticamente significativos. RESULTADOS: Se incluyó en el estudio a 41 mujeres con una mediana de edad de 54 años (rango: 34-76). Tras la cirugía citorreductora se observó una caída de la tasa de hemoglobina desde 11,4 ± 1,5 a 10,6 ± 1,6 g/dl; un descenso del fibrinógeno sérico desde 269 ± 69 hasta 230 ± 48 mg/dl (p < 0,01) y una reducción de MCF en FIBTEM desde 20 ± 10 hasta 16 ± 8 mm (p < 0,01). La HIPEC no se asoció a alteraciones hemostáticas. Se observó una moderada relación negativa entre el número de concentrados de hematíes administrados y los niveles de fibrinógeno (ρ = −0,5; p = 0,002) y los valores de MCF EXTEM (ρ = −0,43; p = 0,006) registrados tras la HIPEC. CONCLUSIONES: Las alteraciones hemostáticas observadas aparecen tras la cirugía citorreductora, probablemente a consecuencia de la hemorragia quirúrgica. Se requieren más estudios para confirmar una correlación entre las necesidades transfusionales y las pruebas de coagulación postoperatorias

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is frequently associated with coagulation impairment and perioperative blood transfusion. Our aim was to investigate the impact of each procedure step on hemostasis, as measured by rotational thromboelastometry™ (ROTEM), fibrinogen level and platelet count as a primary outcome, along with its relationship with transfusion needs. METHODS: A prospective longitudinal study was performed. Hemoglobin level, fibrinogen level, platelet count and ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), α-angle (EXTEM, INTEM, FIBTEM) were measured before the procedure, at the end of cytoreductive surgery and after HIPEC. Appropriate statistical tests were used for comparison. A P<.05 was considered as significant. RESULTS: Forty-one women, with median age 54 (range 34-76) were recruited. Cytoreductive surgery was followed by a reduction of hemoglobin level from 11,4 ± 1,5 g/dl to 10,6 ± 1,6 g/dl, a reduction of serum fibrinogen level from 269 ± 69 mg/dl to 230 ± 48 mg/dl (P<.01) and MCF decline from 20 ± 10 to 16 ± 8 mm (P<.01), in the FIBTEM test. HIPEC was followed by no hemostatic impairment. The number of packed red blood cells administered during patients stay kept a mild significant relationship with both fibrinogen level (ρ = −0.5, P=.002), and MCF EXTEM values (ρ= -0.43, P=0.006), recorded after HIPEC. CONCLUSIONS: The mild observed hemostatic impairment appeared after cytoreductive surgery instead of HIPEC, involving surgical hemorrhage as the most likely responsible factor. Further studies are required to confirm a correlation between transfusion needs and postoperative hemostatic tests

Alterations in hemostasis during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal carcinomatosis.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is frequently associated with coagulation impairment and perioperative blood transfusion. Our aim was to investigate the impact of each procedure step on hemostasis, as measured by rotational thromboelastometry™ (ROTEM), fibrinogen level and platelet count as a primary outcome, along with its relationship with transfusion needs. METHODS: A prospective longitudinal study was performed. Hemoglobin level, fibrinogen level, platelet count and ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), α-angle (EXTEM, INTEM, FIBTEM) were measured before the procedure, at the end of cytoreductive surgery and after HIPEC. Appropriate statistical tests were used for comparison. A P<.05 was considered as significant. RESULTS: Forty-one women, with median age 54 (range 34-76) were recruited. Cytoreductive surgery was followed by a reduction of hemoglobin level from 11,4±1,5g/dl to 10,6±1,6g/dl, a reduction of serum fibrinogen level from 269±69mg/dl to 230±48mg/dl (P<.01) and MCF decline from 20±10 to 16±8mm (P<.01), in the FIBTEM test. HIPEC was followed by no hemostatic impairment. The number of packed red blood cells administered during patients stay kept a mild significant relationship with both fibrinogen level (ρ = -0.5, P=.002), and MCF EXTEM values (ρ= -0.43, P=0.006), recorded after HIPEC. CONCLUSIONS: The mild observed hemostatic impairment appeared after cytoreductive surgery instead of HIPEC, involving surgical hemorrhage as the most likely responsible factor. Further studies are required to confirm a correlation between transfusion needs and postoperative hemostatic tests.

Fibrosarcoma del adulto: manejo quirúrgico en países en vías de desarrollo / Adult fibrosarcoma: Surgical management in developing countries

No disponible

Peritoneal dissemination of hepatoid carcinoma of the ovary treated with cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy.

Hepatoid carcinoma of the ovary (HCO) was first reported in 1987 in 5 cases of malignant ovarian tumors which were similar to hepatocarcinoma in the histological analysis. We report the first case in the literature of a patient diagnosed with HCO treated using HIPEC after extensive cytoreductive surgery, and we discuss the value of this therapeutical option in patients with HCO.