Antiperistaltic Transverse Coloplasty: A Salvage Procedure in Extensive Bowel and Colorectal Resections to Avoid Intestinal Failure.

INTRODUCTION: After extensive small and colon resections, quality of life can be affected. We propose the antiperistaltic transverse coloplasty as a solution that allows for preservation of the transverse colon after both right and left colectomies while achieving a tension-free colorectal anastomosis slowing the transit and increasing the absorption time, resulting in better stool consistency and quality of life compared with an ileorectal anastomosis. METHODS: This technique was performed in a 41-year-old woman with Goblet cell adenocarcinoma of the appendix with peritoneal metastasis. The transverse colon is rotated anticlockwise over the axis of the middle colic vessels toward the left parietocolic flank and relocated to the usual position of the descending colon. RESULTS: After 1 year of follow-up, the patient led a normal life without parenteral nutrition with five bowel movements per day and a weight gain of 15%. CONCLUSIONS: The use of an antiperistaltic transverse coloplasty may be worthwhile to perform in cases of extensive bowel resections during cytoreductive surgery leading to short-bowel syndrome to avoid a permanent stoma or intestinal failure and improve patient outcomes.

Simultaneous Surgical Approach with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in Patients with Concurrent Peritoneal and Liver Metastases of Colon Cancer Origin.

Background: Simultaneous liver resection and peritoneal cytoreduction with hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial today. The aim of the study was to analyze the postoperative outcomes and survival of patients with advanced metastatic colon cancer (peritoneal and/or liver metastases). Methods: Retrospective observational study from a prospective maintained data base. Patients who underwent a simultaneous peritoneal cytoreduction and liver resection plus HIPEC were studied. Postoperative outcomes and overall and disease free survival were analyzed. Univariate and multivariate analyses were performed. Results: From January 2010 to October 2022, 22 patients operated with peritoneal and liver metastasis (LR+) were compared with 87 patients operated with peritoneal metastasis alone (LR-). LR+ group presented higher serious morbidity (36.4 vs. 14.9%; p: 0.034). Postoperative mortality did not reach statistical difference. Median overall and disease free survival was similar. Peritoneal carcinomatosis index was the only predictive factor of survival. Conclusions: Simultaneous peritoneal and liver resection is associated with increased postoperative morbidity and hospital stay, but with similar postoperative mortality and OS and disease free survival. These results reflect the evolution of these patients, considered inoperable until recently, and justify the trend to incorporate this surgical strategy within a multimodal therapeutic plan in highly selected patients.

Challenges in precision medicine in pancreatic cancer: A focus in cancer stem cells and microbiota.

Pancreatic cancer adenocarcinoma (PDAC) is a lethal disease, with the lowest 5-years survival rate of all cancers due to late diagnosis. Despite the advance and success of precision oncology in gastrointestinal cancers, the frequency of molecular-informed therapy decisions in PDAC is currently neglectable. The reasons for this dismal situation are mainly the absence of effective early diagnostic biomarkers and therapy resistance. PDAC cancer stem cells (PDAC-SC), which are regarded as essential for tumor initiation, relapse and drug resistance, are highly dependent on their niche i.e. microanatomical structures of the tumor microenvironment. There is an altered microbiome in PDAC patients embedded within the highly desmoplastic tumor microenvironment, which is known to determine therapeutic responses and affecting survival in PDAC patients. We consider that understanding the communication network that exists between the microbiome and the PDAC-SC niche by co-culture of patient-derived organoids (PDOs) with TME microbiota would recapitulate the complexity of PDAC paving the way towards a precision oncology treatment-response prediction.

Duodenopancreatectomía por adenocarcinoma ductal de páncreas en ancianos. ¿Podemos asumirla con seguridad? / Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

Introducción: La cirugía y la quimioterapia han aumentado la supervivencia de los pacientes con neoplasias pancreáticas. La disminución de la morbimortalidad postoperatoria y el aumento de la esperanza de vida han ampliado las indicaciones de la duodenopancreatectomía cefálica (DPC), aunque sigue siendo controvertida en la población geriátrica. Métodos: Estudio observacional retrospectivo sobre una base de datos prospectiva, de pacientes con adenocarcinoma ductal de páncreas sometidos a una DPC entre 2007-2018. El objetivo principal fue analizar la morbimortalidad y supervivencia asociada a la DPC en pacientes≥75 años (ancianos). Resultados: Se incluyeron 79 pacientes, 21 de ellos mayores de 75 años (27%); dentro de este grupo el 23,9% tenían más de 80 años. El ASA de ambos grupos fue similar. Los pacientes≥75años requirieron más transfusiones. No se observaron diferencias en el tiempo operatorio, aunque en los ancianos se realizaron más resecciones vasculares (26 vs. 8,7%; p=0,037).La morbilidad fue mayor en los ancianos (61,9 vs. 46,6%), aunque sin diferencias. Los≥75años presentaron más complicaciones no quirúrgicas (33,3%; p=0,050) siendo la neumonía la más frecuente. La mortalidad postoperatoria fue superior en los≥75años (9 vs. 0%; p=0,017), constituyendo la resección venosa un factor de riesgo (p=0,01). La supervivencia global y la supervivencia libre de enfermedad no mostraron diferencias significativas en ambos grupos. Conclusiones: Los pacientes ancianos presentaron una mayor mortalidad postoperatoria y más complicaciones no quirúrgicas. La supervivencia no mostró diferencias, por lo que, con una adecuada selección de pacientes, la edad no debe constituirse por sí misma como una contraindicación para la DPC(AU).

Introduction: Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. Methods: Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018.The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients≥75 years (elderly). Results: 79 patients were included, 21 of them older than 75 years (27%); within this group, 23.9% were over 80 years old. The ASA of both groups was similar. Patients≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P=.037). Morbidity was higher in the elderly (61.9 vs. 46.6%), although without differences. Patients aged≥75 years had more non-surgical complications (33.3%, P=.050), being pneumonia the most frequent. Postoperative mortality was higher in the≥75 years (9 vs. 0%; P=.017). The overall survival and disease-free survival did not show significant differences in both groups. Conclusions: Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC(AU).

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

INTRODUCTION: Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. METHODS: Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018. The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients ≥75 years (elderly). RESULTS: 79 patients were included, 21 of them older than 75 years (27%); within this group, 23'9% were over 80 years old. The ASA of both groups was similar. Patients ≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P = .037). Morbidity was higher in the elderly (61.9% vs. 46.6%), although without differences. Patients aged ≥75 years had more non-surgical complications (33.3%, P = .050), being pneumonia the most frequent. Postoperative mortality was higher in the ≥75 years (9 vs. 0%; P = .017). The overall survival and disease-free survival did not show significant differences in both groups. CONCLUSIONS: Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

Abdominal metastatic melanoma invading the transverse colon and stomach.

Gastrointestinal melanoma metastases are not uncommon, with the jejunum and ileum being the most common locations (58 %), followed by the stomach (26 %), colon (22 %), duodenum (12 %), and rectum (5 %).

Laparoscopy technique in the setting of peritoneal metastases to avoid port site relapse.

BACKGROUND: Laparoscopy is indicated in many patients with abdominal and pelvic malignancy. If cancer cells are present within the peritoneal space, there is a possibility for port site metastases to develop. METHODS: The pathophysiology for occurrence of port site metastases was reviewed. Technical modifications to reduce the incidence of these abdominal wall sites for disease progression were suggested. RESULTS: Evacuation of all gases and all fluid from the peritoneal space through the trocars prior to their removal will reduce the contamination of the tissue surrounding the port site by intraperitoneal cancer cells. If port sites are confined to the midline, they can be removed as part of a midline abdominal incision if metastases occur. If port site metastases occur through lateral port sites, the rectus abdominus muscle may need to be widely excised to achieve negative margins. CONCLUSION: Technical modifications of laparoscopy in patients with peritoneal metastases may reduce incidence of this iatrogenic dissemination of cancer.

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely? / Duodenopancreatectomía por adenocarcinoma ductal de páncreas en ancianos. ¿Podemos asumirla con seguridad?

INTRODUCTION: Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. METHODS: Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018.The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients≥75 years (elderly). RESULTS: 79 patients were included, 21 of them older than 75 years (27%); within this group, 23.9% were over 80 years old. The ASA of both groups was similar. Patients≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P=.037). Morbidity was higher in the elderly (61.9 vs. 46.6%), although without differences. Patients aged≥75 years had more non-surgical complications (33.3%, P=.050), being pneumonia the most frequent. Postoperative mortality was higher in the≥75 years (9 vs. 0%; P=.017). The overall survival and disease-free survival did not show significant differences in both groups. CONCLUSIONS: Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

Diaphragmatic Peritonectomy and Full-Thickness Resection in CRS/HIPEC May Allow Higher Completeness of Cytoreduction Rates with a Low Rate of Respiratory Complications.

BACKGROUND: Cytoreductive surgery (CRS) provides a survival benefit when achieved without residual disease. As diaphragm is frequently affected in peritoneal malignancies, complete cytoreduction often requires surgical techniques over the diaphragm. The purpose of the study was to assess diaphragmatic resection impact on cytoreduction completeness, morbidity and mortality compared to less aggressive diaphragmatic peritonectomy in CRS and hyperthermic intraperitoneal chemotherapy (HIPEC) settings. MATERIALS AND METHODS: Patients with peritoneal carcinomatosis and supramesocolic disease undergoing CRS/HIPEC from 2011 to 2019 were included in a prospectively collected database. We compared patients who underwent full-thickness diaphragmatic resection (DR) and diaphragmatic peritonectomy (DP). Epidemiological and clinical data, morbidity, and mortality within 90 days of surgery were documented. RESULTS: 232 patients were initially selected. Inclusion criteria were met by 88 procedures. DR was performed on 32 patients and DP on 56. Number of resected organs was 5.21 in the DR cohort vs. 3.57 in the DP cohort (p<0.0001). Rate of Peritoneal Cancer Index (PCI) score >14 was higher in the DR group (75%) than in the DP group (50.9%) (p=0.027). Tumor invasion of diaphragmatic muscle after DR was confirmed in 89.3% patients. Postoperative pleural effusion was observed in 28 patients (50%) in the DP group and in 17 (53.1%) in the DR group. CONCLUSIONS: CRS/HIPEC requires specific surgical techniques over the diaphragm to achieve complete cytoreduction. As diaphragmatic muscle invasion is frequent, full-thickness resection may allow a cytoreduction completeness increase without an increased morbidity. Pleural drains are not systematically required as these procedures show low incidence of major respiratory complications.

Cirugía citorreductora en feocromocitomatosis peritoneal funcionante / Cytoreductive surgery in functioning peritoneal pheochromocytomatosis

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Prophylactic HIPEC with oxaliplatin might be of benefit in T4 and perforated colon cancer: another possible interpretation of the COLOPEC results

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Prophylactic HIPEC with oxaliplatin might be of benefit in T4 and perforated colon cancer: another possible interpretation of the COLOPEC results.

The COLOPEC trial failed to show evidence for improved relapse-free survival (RFS) between the two study groups: 80,9% (95% CI 73.3-88.5) in the experimental group and 76.2 % (68.0-84.4) in the control group (one-sided log-rank p = 0.28). Nevertheless only 87 patients received the adjuvant HIPEC treatment in the experimental arm (n = 100). This group had a peritoneal relapse of 19 %, but only 10 % had a truly peritoneal relapse as 9 of them had stablished peritoneal carcinomatosis and 1 case was a peritoneal recurrence but did not receive adjuvant HIPEC. We conducted a per-protocol analysis comparing the 87 patients which truly received the adjuvant HIPEC to the 102 patients in the control arm and obtained an OR 0.396 (95 % CI 0.17-0.91) with a (Pearson Chi-Square p = 0.026, two-tailed Fisher exact test p = 0.032). This contradicts the COLOPEC reported conclusions and shows that adjuvant HIPEC could have an important protective role against peritoneal recurrence.

Secondary surgical cytoreduction needs to be assessed taking into account surgical technique, completeness of cytoreduction, and extent of disease.

Recent evidence suggested that secondary surgical cytoreduction followed by chemotherapy does not result in longer overall survival in patients with platinum-sensitive recurrent ovarian cancer.This statement is based on a phase III multicenter, randomized clinical trial that lacks a description of the surgical protocol, the surgical technique, and the surgical variables. In a study that evaluates surgical cytoreduction, it is mandatory to assess the grade of cytoreductive surgery achieved (Sugarbaker PH, Langenbeck's Arch Surg 384:576-87, 1999), the extent of disease using PCI (Peritoneal Cancer Index), the technique itself, and the existence of a multidisciplinary approach with extensive upper abdominal procedures in experienced centers (Ren et al, BMC Cancer 15:1-12, 2015). There is evidence proving that the quality of cytoreduction (Al Rawahi et al, Cochrane Database Syst Rev 2013, 2013), the measurement of the amount of disease by PCI (Elzarkaa et al, J Gynecol Oncol 29, 2018), and a multidisciplinary approach with supramesocolic procedures (Ren et al, BMC Cancer 15:1-12, 2015) impact overall survival.This study fails to compare chemotherapy with secondary cytoreductive surgery since, due to the lack of variables, we can assess neither the performed surgery nor its criteria. This study should not be taken into account to recommend chemotherapy alone over a surgical approach in this group of patients.