Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Effects of postoperative fluids beyond the first 24 h.

BACKGROUND AND OBJECTIVES: There are no guidelines for intravenous fluid (IVF) administration after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). This study assessed rates of post-CRS/HIPEC morbidity according to perioperative IVF administration. METHODS: All patients undergoing CRS/HIPEC March 2007 to June 2018 were reviewed, recording clinicopathologic, operative, and postoperative variables. Patients were divided by peritoneal cancer index (PCI), comparing IVF volumes and types administered intraoperatively and during the first 72 h postoperatively. Optimal IVF rate cutoffs calculated using area under the receiver operating characteristic curves and Youden's index determined associations with complications. RESULTS: Overall, 185 patients underwent CRS/HIPEC, and 81 (51%) had low PCI (<10) and 77 (49%) had high PCI (≥10). In low-PCI patients, high IVF rates on postoperative days (POD) #0-2 were associated with higher overall complications: POD#0 (46% vs. 89%, p = 0.001), POD#1 (40% vs. 86%, p < 0.05), and POD#2 (42% vs. 72%, p < 0.05). High IVF rates were associated with respiratory distress (7% vs. 26%, p = 0.02) on POD#0, ileus (14% vs. 47%, p = 0.007) and intensive care unit stay (11% vs. 33%, p = 0.022) on POD#1, and ICU stay (8% vs. 33%, p = 0.003) on POD#2. CONCLUSIONS: For low PCI patients undergoing CRS/HIPEC, higher IVF rates were associated with postoperative complications. Post-CRS/HIPEC, IVF rates should be limited to prevent morbidity.

Gallbladder Cancer: A Single-Institution 10-Year Experience-Analysis of Adenocarcinoma Subtypes and Tumors Arising from Intracholecystic Papillary Neoplasms.

BACKGROUND: Gallbladder cancer accounts for 1.2% of global cancer diagnoses. Literature on biliary-type adenocarcinoma (BTA), and specifically carcinoma arising from intracholecystic papillary-tubular neoplasms (ICPNs), is limited. This study describes a retrospective, single-institution experience with gallbladder cancer, focusing on histological subtypes and prognosis. METHODS: A retrospective review was performed of patients who underwent cholecystectomy for a malignant neoplasm of the gallbladder between 2007 and 2017. Demographic, clinicopathologic, and operative variables, as well as survival outcomes, were analyzed. RESULTS: From a total of 145 patients, BTAs were most common (93, 64%). Compared with non-BTAs, BTAs were diagnosed at a lower American Joint Committee on Cancer stage (p = 0.045) and demonstrated longer median recurrence-free survival (38 vs. 16 months, p = 0.014; median follow-up 36 months). Tumors arising from ICPNs (18, 12%) were more commonly associated with BTA (14 cases). Compared with BTAs not associated with ICPNs (29 patients), associated cases demonstrated lower pathologic stage (p = 0.006) and lower rates of liver and perineural invasion (0% vs. 49% and 14% vs. 48%, respectively; p < 0.05). Cumulative 5-year survival probability was higher for patients with gallbladder neoplasm of any subtype associated with ICPNs compared with those that were not associated with ICPNs (54% vs. 41%, p = 0.019; median follow-up 23 months). This difference was also significant when comparing BTAs associated with ICPNs and non-associated cases (63% vs. 52%, p = 0.005). CONCLUSIONS: This study demonstrated unique pathological and prognostic features of BTAs and of carcinomas arising from ICPNs. Histopathological variance may implicate prognosis and may be used to better guide clinical decision making in the treatment of these patients.

Perforated jejunal diverticulitis: a rare but important differential in the acute abdomen.

BACKGROUND: Diverticulosis of the small bowel is rare and, in most cases, discovered incidentally. However, diverticulitis and other complications are important to consider in the differential of an acute abdomen, especially in the elderly population. CASE PRESENTATION: The patient was a 59-year-old female who presented with acute lower abdominal pain progressing to peritonitis. Computed tomography scan showed a large inflamed and perforated diverticulum on the mesenteric side of the jejunum. Exploratory laparotomy revealed a dilated proximal jejunum with a 5-cm inflamed and perforated mesenteric diverticulum. A small bowel resection with primary anastomosis was performed. CONCLUSIONS: Jejunal diverticulitis remains a diagnostic challenge. Although uncommon, owing to its high mortality rate, it is an important clinical entity to consider and requires timely management.

Distal pancreatectomy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Identifying risk and improving patient selection.

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has become a principal tool in the management of peritoneal carcinomatosis (PC), but inclusion of pancreatic resection to obtain optimal debulking remains controversial. METHODS: We performed a retrospective review of 419 patients with PC who underwent CRS/HIPEC. The patients were divided into two cohorts, those with distal pancreatectomy (DP) and those without (NP), and morbidity and survival outcomes were compared. RESULTS: The DP cohort (n = 37) and the NP cohort (n = 371) had similar clinicopathologic characteristics (age, p = 0.596; gender, p = 0.328; ASA, p = 0.072). Operative time, number of organs resected, and EBL were greater in the DP cohort (<0.0001). A complete cytoreduction was achieved in 90% of the NP cohort versus 69% of the DP cohort (p = 0.0004). Major perioperative morbidity was more common in those with pancreatic resection (41% vs 19%, p = 0.002). However, there was no significant difference in 90-day mortality or overall survival. CONCLUSION: Achieving complete cytoreduction is critical to improving long term outcomes for patients with PC. Although pancreatic resections are associated with higher morbidity, short-term survival is not impacted adversely. Pancreatic involvement should not be a strict exclusion criterion for CRS/HIPEC, but patients need to be selected carefully, with close attention to disease burden prior to proceeding.

Recurrent metastatic primary inflammatory myofibroblast tumour of the gallbladder following pancreaticoduodenectomy.

Inflammatory myofibroblast tumour (IMT) is an uncommon soft tissue tumour with an unpredictable clinical course: mostly benign, occasionally locally aggressive and rarely capable of metastasis. Diagnosed mainly in the mesentery, omentum, retroperitoneum, pelvis and lungs, IMT is extremely rare as a primary gallbladder tumour. Despite improved radiographical capabilities, differentiating the tumour from other more common causes of gallbladder neoplasms necessitates histopathological and immunohistochemistry tests. Once diagnosed, malignant potential should be taken into consideration, striving for an en bloc R0 resection and postoperative long-term follow-up with routine ancillary imaging. The authors present the case of a recurrent primary IMT of the gallbladder, after two surgical treatments, including a pancreaticoduodenectomy. Now 3 years after initial diagnoses the patient is asymptomatic, but has developed local and distant metastases and is being treated with systemic corticosteroid.

Diaphragmatic Peritoneal Stripping Versus Full-Thickness Resection in CRS/HIPEC: Is There a Difference?

BACKGROUND: Pleural recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is rare and poorly delineated. Specifically, data are limited on the effect that diaphragmatic peritoneal stripping versus full-thickness resection has on the nature of ipsilateral pleural recurrence and postoperative morbidity. METHODS: Patients with peritoneal carcinomatosis who underwent CRS/HIPEC were included from a prospectively maintained database. The patients were divided into three cohorts based on surgical management of the diaphragm as follows: diaphragm-stripping (DS) cohort, full-thickness resection (FTR) cohort, and no diaphragm manipulation (ND) cohort. Postoperative morbidity and incidence of ipsilateral pleural recurrence were evaluated. All diaphragmatic defects were closed before abdominal chemoperfusion. RESULTS: The inclusion criteria were met by 409 CRS/HIPEC procedures: 66 in DS, 122 in FTR, and 238 in ND. Ipsilateral pleural recurrence rates did not differ significantly between the three cohorts (DS 6%, FTR 3%, ND 3%; p = 0.470). Postoperative respiratory complications and overall morbidity were significantly greater for the patients who underwent diaphragmatic disruption (stripping and/or resection) than for the patients who did not (p ≤ 0.0001), but the two groups did not differ in terms of 30-day mortality. However, comparison of FTR with DS showed no impact on major morbidity or pleural recurrence. CONCLUSION: Although patients undergoing surgical manipulation of the diaphragm during CRS/HIPEC experienced significantly greater morbidity, diaphragmatic stripping did not differ from full-thickness resection in terms of grades 3 and 4 complications or incidence of ipsilateral pleural recurrences. When deemed necessary to achieve complete cytoreduction, full-thickness diaphragmatic resection should be undertaken. In addition, the data support the observation that definitive repair of the diaphragmatic defect before abdominal chemoperfusion does not adversely influence ipsilateral pleural recurrence.

Microsurgery Fellows' Impression of Clinical and Educational Offerings during Fellowship Year.

BACKGROUND: Acquisition of microsurgical skill and clinical knowledge is the primary goal of a microsurgery fellowship. There has yet to be any comprehensive reporting in the literature of how American microsurgery fellows viewed their curricula and training at the conclusion of their fellowship year. METHODS: An anonymous, electronic survey was developed and distributed to all 2016 to 2017 microsurgery fellows (n = 37) at the U.S.-based microsurgery fellowship programs (n = 23). Qualitative questions were assessed using either a Likert-type scale of 1 (not at all) to 5 (very), multiple choice, or free response. RESULTS: Twenty-six of 37 fellows (70%) responded to the survey. Respondents reported a mean of 14.4 lectures offered, with a range of 0 to 100. Dry laboratory simulation training was formally incorporated into 32% of microsurgery fellowships and live animal simulation training was formally incorporated into 12%. The median number of free deep inferior epigastric perforator flap cases performed was 112.5, ranging from 60 to 230. A majority felt that an organized microsurgical educational curriculum would be "beneficial," with 42% reporting that an organized microsurgery curriculum would be "very beneficial." Twenty-six of the respondents (100%) said that they would choose to do a microsurgery fellowship again if given the choice. CONCLUSION: Respondent data show that microsurgery fellows are satisfied with training, clinical experience is variable but adequate, educational experiences and opportunities vary from program to program, simulation skills training are perceived to be underutilized, and a program-organized microsurgery curriculum is believed to be advantageous to optimize development of technical and clinical skills.

A unique presentation of superinfected pseudomyxoma peritonei secondary to a low-grade appendiceal mucinous neoplasm.

BACKGROUND: Pseudomyxoma peritonei (PMP) is an uncommon condition characterized by diffuse mucinous material in the abdomen and pelvis, generally arising from a perforated epithelial neoplasm. Typically, the disease presents as suspected acute appendicitis, ovarian mass, abdominal distension, or ventral hernia. Our case represents a very rare presentation of superinfected PMP. CASE PRESENTATION: A 46-year-old female with a past medical history notable for depression, asthma, and uterine leiomyomas presented to an urgent care with 5 days of progressive abdominal pain, bloating, nausea, and subjective fevers. The patient had a diffusely tender abdomen, without peritonitis, was mildly tachycardic, and had a white blood cell count of 15 K. A CT of the abdomen/pelvis was consistent with PMP with a ruptured appendiceal mucocele versus PMP secondary to an adnexal ovarian neoplastic pathology with an infectious component. The patient initially improved on antibiotics but ultimately required two surgeries, the first of which controlled intraabdominal sepsis while the second permitted definitive management of PMP with cytoreductive surgery (CRS) and HIPEC. CONCLUSION: Superinfected PMP is a rare entity with very few documented cases. A staged approach that incorporates clearing the peritoneal infection, with or without resection of the primary tumor, followed by rehabilitation and definitive surgery appears to be a safe and effective management strategy.

Treatment dilemma for survivors of rituximab-induced bowel perforation in the setting of post-transplant lymphoproliferative disorder.

Post-transplant lymphoproliferative disorder (PTLD) is a recognised complication of solid and haematopoietic stem cell transplant. It consists of a heterogeneous group of lymphoid neoplasms that arises secondary to post-transplant immunosuppression. Although there is no definite standard of care for the optimal treatment for PTLD, rituximab, a monoclonal antibody, with and/or without chemotherapy (usually CHOP=cytoxan, doxorubicin, vincristine, prednisone) has become a routine part of the treatment of any CD20 (+) PTLD, with response rates similar to chemotherapy with decreased toxicity. A rare and often lethal, complication of rituximab therapy for PTLD is bowel perforation secondary to tumour lysis of lymphoma involving the intestine. A small number of cases of bowel perforation have been reported, with very few documented survivors. The risk for recurrent perforation in the setting of ongoing rituximab treatment is unknown. There is sparse data supporting how to best treat the survivors.