Is there a correlation of positive peritoneal washing cytology during interval debulking surgery on the survival outcomes of ovarian cancer patients? A systematic review and meta-analysis of the literature.

OBJECTIVE: The aim of the present study was to evaluate the prognostic impact of peritoneal washing cytology (PWC) on progression-free (PFS) and overall survival (OS) of patients undergoing interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT) for ovarian cancer (OC). METHODS: We systematically searched Medline (1966-2020), Scopus (2004-2020), EMBASE (1980-2020), Cochrane Central Register of Controlled Trials CENTRAL (1999-2020), Clinicaltrials.gov (2008-2020) and Google Scholar (2004-2020). All the studies that investigated the correlation of peritoneal washing cytology with survival outcomes of patients undergoing interval debulking for ovarian cancer, were finally included in the present meta-analysis. RESULTS: A total of 7 retrospective studies were included, comprising 907 patients, of whom 535 had positive peritoneal washing cytology on interval debulking surgery. The methodological quality of the included studies was assessed as moderate, primarily due to the lack of data referring to the adequacy of the follow-up of patients and secondarily due the lack of comparability of patients. Progression - free survival was significantly better in the negative peritoneal cytology group (HR 2.07, 95% CI 1.73, 2.48 respectively), however, overall survival did not reach a significant difference among the two groups (HR 1.90, 95% CI 0.99, 3,65, p = 0.052). CONCLUSIONS: Our data support a negative correlation between positive peritoneal washing cytology at interval debulking surgery and the survival of ovarian cancer patients.

Announcement: The International System for Reporting Serous Fluid Cytopathology.

Serous fluids are a common but important specimen type in a cytopathology laboratory. There is as yet no agreed standardized terminology to allow uniformity in reporting on these specimens. Given that serous fluids are a rich source of cytopathological as well as molecular information on a range of benign and often advanced malignant conditions, a unified approach to handling and reporting these specimens covering the pre-analytical, analytical and postanalytical stages seems timely. Representatives of the international cytology community have come together once again to develop an algorithmic diagnostic and management approach to the reporting of these samples.

Seriate cytology vs molecular analysis of peritoneal washing to improve gastric cancer cells detection.

BACKGROUND: Intraperitoneal malignant cells detection in patients with gastric cancer is associated with a significant decrease in overall survival. The overall accuracy of cytological examination of peritoneal lavages, however, is quite low, and intraperitoneal recurrence has been observed even in patients with negative cytology. Immunocytochemistry and molecular techniques have been investigated to improve high-risk patients' identification with variable results. The aim of this study was to compare the performance of different laboratory methods applied to peritoneal washing, to improve the cytological identification of malignant cells. METHODS: We prospectively evaluated 21 patients who underwent surgery and peritoneal lavage for gastric cancer. Among them, 18 had negative cytology and three were positive for malignant cells. For each patient, immunohistochemistry with BerEP4 antibody was performed on seriate sections of cellblock preparation at different levels, using the method reported for sentinel nodes in other types of cancer. Paired frozen quotes of washing fluids were evaluated by qRT-PCR with primer for mRNA of Ceacam5. RESULTS: In 4 of 18 patients with previous negative routine cytology, isolated neoplastic cells in seriate sections of the cellblock inclusion have been found. Results showed to be coherent with molecular analysis for CEA mRNA. CONCLUSION: The sensitivity and specificity of peritoneal washing analyses should be notably improved by immunohistochemistry applied to multilevel cellblock sectioning. The method is less expensive and more widely applicable than molecular analysis, in each laboratory setting. This approach allows detection of minimum peritoneal seeding in patients with gastric cancer.

Automated peritoneal lavage: an extremely rapid and safe way to induce hypothermia in post-resuscitation patients.

INTRODUCTION: Mild therapeutic hypothermia (MTH) is a worldwide used therapy to improve neurological outcome in patients successfully resuscitated after cardiac arrest (CA). Preclinical data suggest that timing and speed of induction are related to reduction of secondary brain damage and improved outcome. METHODS: Aiming at a rapid induction and stable maintenance phase, MTH induced via continuous peritoneal lavage (PL) using the Velomedix Inc. automated PL system was evaluated and compared to historical controls in which hypothermia was achieved using cooled saline intravenous infusions and cooled blankets. RESULTS: In 16 PL patients, time to reach the core target temperature of 32.5°C was 30 minutes (interquartile range (IQR): 19 to 60), which was significantly faster compare to 150 minutes (IQR: 112 to 240) in controls. The median rate of cooling during the induction phase in the PL group of 4.1°C/h (IQR: 2.2 to 8.2) was significantly faster compared to 0.9°C/h (IQR: 0.5 to 1.3) in controls. During the 24-hour maintenance phase mean core temperature in the PL patients was 32.38 ± 0.18°C (range: 32.03 to 32.69°C) and in control patients 32.46 ± 0.48°C (range: 31.20 to 33.63°C), indicating more steady temperature control in the PL group compared to controls. Furthermore, the coefficient of variation (VC) for temperature during the maintenance phase was lower in the PL group (VC: 0.5%) compared to the control group (VC: 1.5%). In contrast to 23% of the control patients, none of the PL patients showed an overshoot of hypothermia below 31°C during the maintenance phase. Survival and neurological outcome was not different between the two groups. Neither shivering nor complications related to insertion or use of the PL method were observed. CONCLUSIONS: Using PL in post-CA patients results in a rapidly reached target temperature and a very precise maintenance, unprecedented in clinical studies evaluating MTH techniques. This opens the way to investigate the effects on neurological outcome and survival of ultra-rapid cooling compared to standard cooling in controlled trials in various patient groups. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01016236

A prospective comparison of the selective observation and routine exploration methods for penetrating abdominal stab wounds with organ or omentum evisceration.

BACKGROUND: Both routine laparotomy and selective observation methods have been used in the treatment of penetrating abdominal stab wounds with organ or omentum evisceration. There still are some conflicts about these treatment methods. METHODS: Between 1998 and 2003, 61 patients treated in the authors' emergency clinic because of penetrating abdominal stab wounds with organ or omentum evisceration were evaluated prospectively. Excepting those with absolute indications for mandatory laparotomy, these patients were treated by either routine laparotomy or selective observation methods. Their prognosis, rates of unnecessary laparotomy, length of hospital stay, and complications were compared using Fisher's exact test and Student's t test. RESULTS: Nine patients underwent mandatory laparotomy and were therefore excluded from the study. The overall incidence of the patients who had no significant abdominal pathology was 54.1% (33/61). The overall incidence of significant injuries among the asymptomatic patients was 36.5% (19/52). Routine laparotomy was performed for 21 patients, who experienced unnecessary laparotomy and complication rates of 33.33% and 19%, respectively. The mean length of hospital stay in this group was 137.38 +/- 53.25 hours. Of 31 patients, 24 who had been treated by selective observation methods were discharged without laparotomy. The unnecessary laparotomy and complication rates for this group were 6.45% (28.6% for the patients treated surgically) and 3.2%, respectively, whereas the mean length of hospital stay for this group was 81.22 +/- 42.46 hours. There were statistically significant differences in terms of unnecessary laparotomy rates and mean lengths of hospital stay, but no difference in terms of complication rates. CONCLUSION: The selective observation method is safe and superior to routine laparotomy for the treatment of penetrating abdominal stab wounds with omentum evisceration.

The hand-held ultrasound examination for penetrating abdominal trauma.

BACKGROUND: An evaluation of hand-held ultrasonography (US) in the assessment of penetrating torso trauma has not yet been reported. METHODS: A 2.4 kg hand-held ultrasound device was used to examine penetrating trauma victims in an exam designated as the Hand-Held Focused Assessment with Sonography for Trauma (HHFAST). Results were compared with other US examinations including formal FAST (FFAST), computed tomography, diagnostic peritoneal lavage, operative and autopsy findings, and serial examination. Performance considered both the detection of fluid and injuries requiring intervention. RESULTS: The HHFAST was excellent for detecting free intraperitoneal fluid, which had 100% specificity for peritoneal penetration, but was only moderately sensitive for injuries requiring therapy. CONCLUSIONS: Hand-held sonography can quickly detect intraperitoneal fluid, which has good test performance in determining the presence of an intra-abdominal injury. Negative FAST examinations after penetrating trauma should be followed up with another diagnostic modality.

Distilled water peritoneal lavage after colorectal cancer surgery.

PURPOSE: Tumor cells exfoliated into the peritoneal cavity during colorectal cancer surgery are viable and tumorigenic and may contribute to peritoneal recurrence. Although commonly used, the tumoricidal effectiveness of antiseptics in peritoneal lavage is doubted because of their chemical alteration by peritoneal secretions. In contrast, osmotic lysis by incubation in distilled water may offer an effective tumoricidal activity. Data defining the susceptibility of colorectal carcinoma cells to osmotic lysis are lacking and hence there is no consensus on optimal lavage methodology. METHODS: We examined the cytocidal activity of water on colorectal cancer cell lines in culture and determined the effect of peritoneal secretions in vivo on the tumoricidal effectiveness of water. RESULTS: Incubation of cells in distilled water resulted in cell lysis, with 100 percent lysis achieved after 14 minutes of incubation. In vivo, contamination of lavage water by peritoneal secretions produced a resultant solution with an osmolality of 50 mM. Sequential lavages reduced this contamination, enabling a final resultant solution with an osmolality of 10 mM, which produced 100 percent cell lysis after 32 minutes of incubation. CONCLUSIONS: Current peritoneal lavage methodology is inadequate because complete cell lysis requires water incubation for longer time periods than is currently practiced. Solutions to this problem are discussed.

Diagnostic peritoneal lavage in the evaluation of abdominal trauma using the dipstick.

OBJECTIVE: To determine the accuracy and sensitivity of diagnostic peritoneal lavage in the assessment of intra-abdominal injury using the dipstick method. DESIGN: Prospective study, involving the performance of diagnostic peritoneal lavage in the out patient department and surgical wards prior to surgical intervention. SETTING: Kenyatta National Hospital-General Surgical and Orthopaedic wards and outpatient department. The study was conducted over a duration of six months, starting from January 1995 to July 1995. RESULTS: Ninety six patients with penetrating (68) and blunt (28) abdominal trauma underwent diagnostic peritoneal lavage as evaluation of the severity of abdominal trauma. Dipstick (combur 9 strips) was used to evaluate lavage effluent for red blood cells, white blood cells, protein and bilirubin. Forty three patients had positive diagnostic peritoneal lavage (DPL) results, of which 40 (93%) had positive findings at laparatomy and three (7%) had negative findings at laparatomy. The remaining 53 patients had negative DPL results and were managed conservatively. One patient with a negative DPL result became symptomatic and had a positive laparatomy. Conservatively managed patients were discharged after 24 hours observations without any complications. DPL had an accuracy and sensitivity of 93% and specificity of 98%. CONCLUSION: Diagnostic peritoneal lavage is a cheap, safe and reliable method for assessment of abdominal trauma. The method is easy to perform by trained junior doctors in the OPD, or as a bedside procedure. Use of this method reduced negative laparotomy rate from 50% to 6.9% and average duration of stay from 6.5 days to 1.9 days. This method is recommended as a basic tool in the assessment of abdominal trauma patients.

Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma.

OBJECTIVE: To assess in randomized prospective format sensitivity, laparotomy rate, and cost-effectiveness of using diagnostic peritoneal lavage (DPL) in a complementary role with computed tomography (CT) in the evaluation of blunt abdominal trauma. METHODS: Blunt trauma patients greater than 18 years of age were eligible for entry in the study. The study period was from February 1999 to July 2000 at an urban Level I trauma center. All patients were hemodynamically stable upon study entry and had abdominal tenderness with Glasgow Coma Scale (GCS) scores > 13 or GCS < 14. Patients were randomized to a DPL arm (DPL-CT) versus a CT arm. If randomized to the CT arm, patients underwent abdominal/pelvis CT. If CT was positive for solid organ injury, patients were observed. If free fluid was identified on CT without solid organ injury, patients were explored. If randomized to DPL-CT, patients underwent closed infraumbilical DPL, except pelvic fractures that were done with the open supraumbilical technique. If the DPL result was > 20,000 RBCs/mm3, patients underwent abdominal/pelvis CT. If the CT following DPL was consistent with solid organ injury, patients were observed. If the CT following DPL identified free fluid without solid organ injury and DPL was > 100,000 RBCs/mm3, patients were explored. RESULTS: Two hundred fifty-two patients were entered; 127 patients were randomized to DPL-CT and 125 to CT. Of the 125 patients randomized to CT, 102 (82%) CT scans were negative, 19 (15%) were positive for solid organ injury, and 3 (2%) had free fluid. Three (2%) of the initial negative CT scan patients underwent delayed laparotomy for missed injuries. Of the 127 patients randomized to DPL-CT, 26 (20%) required CT scan, of which 13 (10%) were positive for solid organ injury and 13 (10%) for free fluid. Positive DPL results that were indications for CT ranged from 21,000 to 1 million RBCs/mm3. Eight of the 13 DPL-CT patients with free fluid on CT had DPL results less than 100,000 RBCs/mm3 and did not require laparotomy. There were no known missed injuries in the DPL-CT arm. Seven (6%) laparotomies were performed in the DPL-CT arm and 10 (8%) in the CT arm. The average cost to the patient for abdominal evaluation in the CT arm was 1611 dollars and 650 dollars in the DPL-CT arm. CONCLUSION: Screening DPL with complementary CT has a low nontherapeutic laparotomy rate and is a sensitive and cost-effective method for the evaluation of blunt abdominal trauma.

Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study.

BACKGROUND: Focused Assessment with Sonography for Trauma (FAST) is rapidly establishing its place in the evaluation of blunt abdominal trauma. However, no prospective study specifically evaluates its role in penetrating abdominal trauma. METHODS: Data were collected prospectively in 75 consecutive stable patients with penetrating trauma to the abdomen, flank, or back, from December 1998 to June 1999. Those with an obvious need for emergent laparotomy were excluded. FAST was performed as the initial diagnostic study on all patients. Wound location, type of weapon, and findings of diagnostic peritoneal lavage, triple-contrast computed tomographic scan, or laparotomy were recorded. The presence of peritoneal blood was noted. Data were analyzed using the chi(2) test. RESULTS: Of the 75 patients, there were 32 stab and 43 gunshot wounds. There were 66 male patients and 9 female patients; the mean age was 30 years; 41 had proven abdominal injury and 34 had no injury; and 21 patients had a positive FAST. Nineteen had peritoneal blood and injuries requiring repair at the time of laparotomy. There were two false-positive studies. Fifty-four patients had a negative FAST. In 32 patients, this was a true-negative study. Thirteen patients had a false-negative FAST and had peritoneal blood and significant injury on further evaluation. Nine patients had a negative FAST and no peritoneal blood but still had abdominal injuries requiring operative repair, including liver (four), small bowel (four), diaphragm (three), colon (three), and stomach (one). The overall sensitivity of FAST was 46% and the specificity was 94%. The positive predictive value was 90%, and the negative predictive value was 60%. CONCLUSION: FAST can be a useful initial diagnostic study after penetrating abdominal trauma. A positive FAST is a strong predictor of injury, and patients should proceed directly to laparotomy. If negative, additional diagnostic studies should be performed to rule out occult injury.

Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury.

BACKGROUND: Although the routine use of FAST (focused assessment with sonography for trauma) in the evaluation of trauma victims is increasing, to our knowledge, a prospective comparison of contemporary adult trauma victims managed with and without FAST has not been reported in North America. METHODS: Adult victims of blunt trauma for whom there was a suspicion of abdominal injury were managed with one of two diagnostic algorithms, FAST or no-FAST. The two algorithms were compared for diagnostic accuracy, cost, time, and delayed diagnoses. RESULTS: Among 706 patients (mean Injury Severity Score, 23), 460 were managed with FAST and 246 with no-FAST. The two groups were similar with respect to age, Injury Severity Score, prehospital time, and mortality (p = not significant). There were 3 of 460 (0.7%) delayed diagnoses in the FAST group and 4 of 246 (1.6%) in the no-FAST group (p = not significant). The diagnostic accuracy for the FAST and no-FAST algorithms was 99% and 98%, respectfully. The FAST and no-FAST algorithms led to similar rates of laparotomy, 13% and 14%, respectfully, but nonoperative management was more common in the no-FAST group (p < 0.01). The mean diagnostic cost for the FAST algorithm was $156, compared with $540 with the no-FAST algorithm (p < 0.0001) and the mean time required for diagnostic work-up was 53 minutes with the FAST algorithm, compared with 151 minutes with the no-FAST algorithm (p < 0.0001). CONCLUSION: This study has provided prospective evidence that a FAST-based algorithm for blunt abdominal injury was more rapid, less expensive, and as accurate as an algorithm that used computed tomography or diagnostic peritoneal lavage only. Trauma centers are encouraged to incorporate a FAST-based algorithm into their initial management of blunt trauma victims.

[Peritoneal lavage in standardized peritonitis models]. / Die Abdominal-Lavage im standardisierten Peritonitismodell.

The peritoneal lavage in peritonitis can be studied in a standardized manner only in animal models, because peritonitis is too variable and dependent on too many patient related factors. In this article answers are given to questions on the influence of different lavage substances on survival, local and systemic concentrations of bacteria, endotoxin, and TNF as well as on mesothelial adherence of bacteria. These data refer to results from acute models of infection published in the literature. Furthermore, we show from our own chronic peritonitis model the influence of the peritoneal lavage on abscess formation and translocation. After inoculation of a Bacteroides fragilis suspension, a chronic abscess forming peritonitis was induced. At day 3/7/14 intraabdominal abscesses were found in 2/4/6 of 8/5/6 animals in an untreated, in 1/3/5 of 5/5/5 animals in a saline lavaged, and in 5/0/2 of 5/5/5 animals in a Taurolidin lavaged group, respectively. Both, the intraabdominal and the systemic bacterial dissemination were more effectively inhibited by the Taurolidin lavage than by the saline lavage.

A method of determining peritoneal penetration in gunshot wounds to the abdomen.

BACKGROUND: It has previously been shown that 98% of gunshot wounds that penetrate the peritoneal cavity cause injuries that require surgical repair. Many gunshot wounds in the vicinity of the abdomen (GSWA) may actually be tangential and not penetrate the peritoneal cavity at all. Patients with such wounds may not require laparotomy. It is important to determine which patients with a potential tangential GSWA actually have penetration of the peritoneal cavity to minimize negative laparotomies. This study was undertaken to determine the sensitivity, specificity, and accuracy of diagnostic peritoneal lavage (DPL) in the determination of peritoneal penetration for patients who sustain GSWA. METHODS: DPL was performed for all patients who had sustained a GSWA in whom peritoneal penetration was unclear, i.e., patients whose GSWA appeared to be tangential, thoracoabdominal, or transpelvic and for whom a clear indication for laparotomy (shock, peritonitis, etc.) did not exist. Our threshold for a positive DPL was 10,000 red blood cells (RBC)/mm3. A prospective data base was kept with information on the location of the wound, DPL result, findings at laparotomy, and outcome. RESULTS: During a 4-year period, 429 consecutive DPLs were performed for GSWA at our urban Level I trauma center. One hundred fifty DPLs were positive, with more than 10,000 RBC/mm3. Six of these patients were found to have no peritoneal penetration at laparotomy (false-positive). The remaining 144 patients with positive DPLs were found to have operative injuries (true-positive). Of the 279 patients with DPL counts less than 10,000 RBC/mm3, 2 developed indications for laparotomy and were found to have intraperitoneal injuries (false-negative). The remaining 277 patients had no peritoneal injuries (true-negative). This was demonstrated either by laparotomy done for another indication (n = 7) or by uneventful inpatient observation for 24 hours (n = 270). The sensitivity, specificity, and accuracy of DPL in determining peritoneal penetration in GSWA is therefore 99, 98, and 98%, respectively. CONCLUSION: For patients who sustain GSWA for whom peritoneal penetration is unclear, DPL is a sensitive, specific, and accurate test to determine the need for laparotomy. It remains our test of choice when confronted with these patients.

La ecografía abdominal en el manejo de pacientes politraumatizados / The abdominal sonography in trauma patients

Se presenta el análisis de una serie de 250 pacientes politraumatizados con certero o posible traumatismo cerrado de abdomen, a los cuales se les efectuó ecografía abdominal como método de estudio inicial para la detección de líquido libre dentro de la cavidad abdominal. El método presentó una sensibilidad del 88,4 por ciento, una especificidad del 99,5 por ciento, un poder predictivo positivo del 95,8 por ciento y negativo del 98,6 por ciento. Se describen las ventajas sobre otros métodos como el lavado peritoneal, la T.A.C. y la Laparoscopía. Se concluye que la ecografía es un excelente método diagnóstico y que puede ser utilizado como primer estudio en el manejo inicial de los pacientes politraumatizados con compromiso abdominal. Se destaca la necesidad de que los Cirujanos de guardia cuenten con un entrenamiento básico en ecografía como para poder realizar el método independientemente de la presencia del radiólogo

La ecografía abdominal en el manejo de pacientes politraumatizados / The abdominal sonography in trauma patients

Se presenta el análisis de una serie de 250 pacientes politraumatizados con certero o posible traumatismo cerrado de abdomen, a los cuales se les efectuó ecografía abdominal como método de estudio inicial para la detección de líquido libre dentro de la cavidad abdominal. El método presentó una sensibilidad del 88,4 por ciento, una especificidad del 99,5 por ciento, un poder predictivo positivo del 95,8 por ciento y negativo del 98,6 por ciento. Se describen las ventajas sobre otros métodos como el lavado peritoneal, la T.A.C. y la Laparoscopía. Se concluye que la ecografía es un excelente método diagnóstico y que puede ser utilizado como primer estudio en el manejo inicial de los pacientes politraumatizados con compromiso abdominal. Se destaca la necesidad de que los Cirujanos de guardia cuenten con un entrenamiento básico en ecografía como para poder realizar el método independientemente de la presencia del radiólogo (AU)

[Experimental study of postoperative lavage: standardization of the method]. / Studio sperimentale sul lavaggio postoperatorio: standardizzazione del metodo.

Postoperative infections are an outstanding problem in a surgical department. We have been studying them from a clinical and experimental point of view has a long time. In this study we present a method standardisation of postoperative peritoneal lavage as prevention of surgical infections. Winstar mice, infected with intra peritoneal E. coli cultures, underwent peritoneal lavage with saline solution or sterile water. The results showed the right amount of solution and the exact administration of lavage according to grade of infection. Encouraged by this result we are going to test the efficacy of anti microbial agents for the postoperative peritoneal lavage.

The treatment of complicated appendicitis in children using peritoneal drainage: results from a public hospital.

During the 2-year period from January 1, 1987 to December 31, 1988, 656 emergency appendectomies were performed on the Pediatric Surgery Service at the Los Angeles County-USC Medical Center. Of these, 398 patients were 12 years of age or less, and 227 appendices (57%) were perforated or gangrenous. The records of 167 of those patients with perforated or gangrenous appendices, treated by a standardized protocol are summarized. The protocol included perioperative antibiotics of gentamicin and clindamycin, appendectomy through a muscle-splitting incision, irrigation of the peritoneal cavity with saline, and peritoneal drainage through the lateral aspect of the wound with skin closure. There was no mortality, and the major complication rate was 8%, with 3% developing intraabdominal abscesses and 5% with bowel obstructions. The minor complication rate was 11%, and included prolonged ileus and prolonged fever, with no wound infections. The average hospital stay was 8.7 days. Our experience suggests that the adopted protocol is reliable for preventing wound infections without increasing the rate of intraabdominal abscesses in an innercity population with particularly advanced stages of appendicitis.