Comparative impact of replacing fish meal with azolla on growth, water quality, and physiology of red tilapia fingerlings at varying salinities.

A 210-day experiment to assess the efficacy of substituting azolla plant powder at levels of 0, 20, 40, and 60% for fish meal on red tilapia fingerlings (RTF, initial weight of 18.23 ± 0.12 g) performance under salinity levels of 5, 18, and 28ppt. Among the various conditions, RTF-fed 20% azolla at 28 and 5ppt salinity showcased the highest specific growth rate (SGR), whereas the lowest SGR was observed in fish-fed 60% azolla at 5ppt salinity. Upon azolla incorporation, noteworthy elevations in phytoplankton, zooplankton, dissolved oxygen (DO), pH, NH3, and NO3 were noted and conversely, azolla introduction led to decreased NH4 and NO2 concentrations in all salinity levels. Further, a significant (p < 0.05) interaction between azolla levels and water salinity (S×A) significantly impacted the hematological parameters of RTF. The highest levels of superoxide dismutase (SOD), catalase (CAT), and total protein (TP) were found in RTF-fed 20% azolla at 28ppt salinity, while the lowest CAT and TP levels occurred in RTF-fed 60% azolla at 5ppt salinity. The highest aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were recorded in the RTF group fed 60% azolla at 5ppt salinity, with the lowest values seen in the group given 20% azolla at 28ppt salinity. RTF fed a 20% azolla diet at 18ppt salinity exhibited the highest lysozyme value, in contrast to the lowest value observed in the RTF group fed the control diet at 18ppt salinity. In conclusion, this study recommends the utilization of azolla at inclusion levels ranging from 20 to 40%, as it has the potential to notably enhance the immune system and elevate the survival rate of RTF.

Prophylactic Cholecystectomy is Safe in Patients Undergoing Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: While cholecystectomy is one of the most common operations performed in the United States, there is a continued debate regarding its prophylactic role in elective surgery. Particularly among patients with peritoneal carcinomatosis who undergo cytoreduction surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), further abdominal operations may pose increasing morbidity due to intraabdominal adhesions and potential recurrence. This bi-institutional retrospective study aims to assess postoperative morbidity associated with prophylactic cholecystectomy at the time of CRS-HIPEC. METHODS: We performed a bi-institutional retrospective analysis of 578 patients who underwent CRS-HIPEC from 2011 to 2021. Postoperative outcomes among patients who underwent prophylactic cholecystectomy at the time of CRS-HIPEC were compared to patients who did not, particularly rate of bile leak, hospital length of stay, rate of Clavien-Dindo classification morbidity grade III or greater, and number of hospital re-admissions within 30 days. RESULTS: Of the 535 patients available for analysis, 206 patients (38.3%) underwent a prophylactic cholecystectomy. Of the 3 bile leaks (1.5%) that occurred among patients who underwent prophylactic cholecystectomy, all 3 occurred in patients who underwent a concomitant liver resection. There were no significant differences in hospital length of stay, postoperative morbidity, and number of hospital re-admissions among patients who underwent prophylactic cholecystectomy compared to those who did not. CONCLUSION: Prophylactic cholecystectomy in patients undergoing CRS-HIPEC is not associated with increased morbidity or increased bile leak risk compared to historical data. While the benefits of prophylactic cholecystectomy are not yet elucidated, it may be considered to avoid potential future morbid operations for biliary disease.

Outcomes and Histological Variations of Neuroblastoma and Ganglioneuroblastoma with Paraneoplastic Syndromes.

BACKGROUND: Neuroblastomas are the most common extracranial solid malignancy in children with variable manifestations and complications depending on the presence of paraneoplastic syndromes. MATERIALS AND METHODS: We performed a single institution retrospective cohort study of all patients less than 18 years old diagnosed with neuroblastoma or ganglioneuroblastoma between January 2002 and July 2022. Patients were identified through the pathology and cancer registry and cross-referenced with pediatric records. Patient demographics, clinical presentation, treatment, and outcomes were collected. A univariate descriptive analysis of the collected data was conducted. RESULTS: In our study period, 130 children were diagnosed with neuroblastoma, and 15 were diagnosed with ganglioneuroblastoma. There were 12 children with a paraneoplastic syndrome identified, 8 with NBL and 4 with ganglioneuroblastoma (GNBL). The average age at diagnosis was 22 months. All but 1 underwent resection prior to treatment of paraneoplastic syndrome, and 4 children required neoadjuvant therapy. Neurological complications were the most common with 10 children (83%). The average time from symptom onset to diagnosis was 0.7 months. Eight children had complete resolution of their symptoms after treatment and resection, 2 children recently started treatment within a year, 1 had partial resolution, and 1 died during treatment. The presence of tumor-infiltrating lymphocytes occurred in 4 children with neurologic paraneoplastic syndromes. Six children had neuropil rich tumors. CONCLUSION: The histological profile of paraneoplastic syndromes of neuroblastoma and ganglioneuroblastoma and their treatment across a single institution can be highly variable. The presence of tumor-infiltrating lymphocytes and neuropil may have an impact on paraneoplastic pathology.

Safety and Clinical Value of Prophylactic Ureteral Stenting Before Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: Prophylactic ureteral stents (PUS) are typically placed prior to complex abdominal or pelvic operations at the surgeon's discretion to help facilitate detection of iatrogenic ureteral injury. However, its usefulness and safety in the setting of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) have not been examined. This study aims to evaluate the potential clinical value and risk profile of prophylactic ureteral stent placement prior to CRS-HIPEC. METHODS: We performed a single-institutional retrospective analysis of 145 patients who underwent CRS-HIPEC from 2013 to 2021. Demographic and operative characteristics were compared between patients who underwent PUS placement and those that did not. Ureteral stent-related complications were evaluated. RESULTS: Of the 145 patients included in the analysis, 124 underwent PUS placement. There were no significant differences in patient demographics, medical comorbidities, or tumor characteristics. Additionally, PUS placement did not significantly increase operative time and was not associated with increased pelvic organ resection. However, patients who underwent prophylactic ureteral stenting had significantly higher peritoneal carcinomatosis index score (15.1 vs 9.1, P=.002) and increased rate of ureteral complications (24.2% vs 14.3%, P=.04), which led to lengthened hospital stay (13.2 days vs 8.1 days, P= .03). Notably, the sole ureteral injury and three cases of hydronephrosis were seen in patients who underwent PUS. CONCLUSION: Prophylactic ureteral stent placement in patients undergoing CRS-HIPEC may be useful, particularly in patients with predetermined extensive pelvic disease. However, PUS placement is not without potential morbidity and should be selectively considered in patients for whom benefits outweigh the risks.

A total neoadjuvant chemotherapy approach is associated with improved recurrence-free survival in patients with colorectal peritoneal metastases undergoing cytoreductive surgery and HIPEC.

BACKGROUND: The primary aim of this study is to evaluate the oncologic outcomes of two popular systemic chemotherapy approaches in patients with colorectal peritoneal metastases (CPM) undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: We performed a dual-center retrospective review of consecutive patients who underwent CRS-HIPEC for CPM due to high or intermediate-grade colorectal cancer. Patients in the total neoadjuvant therapy (TNT) group received 6 months of preoperative chemotherapy. Patients in the "sandwich" (SAND) chemotherapy group received 3 months of preoperative chemotherapy with a maximum of 3 months of postoperative chemotherapy. RESULTS: A total of 34 (43%) patients were included in the TNT group and 45 (57%) patients in the SAND group. The median overall survival (OS) in the TNT and SAND groups were 77 and 61 months, respectively (p = 0.8). Patients in the TNT group had significantly longer recurrence-free survival (RFS) than the SAND group (29 vs. 12 months, p = 0.02). In a multivariable analysis, the TNT approach was independently associated with improved RFS. CONCLUSION: In this retrospective study, a TNT approach was associated with improved RFS, but not OS when compared with a SAND approach. Further prospective studies are needed to examine these systemic chemotherapeutic approaches in patients with CPM undergoing CRS-HIPEC.

Association of Systemic Chemotherapy Approaches With Outcomes in Appendiceal Peritoneal Metastases.

INTRODUCTION: Many patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for appendiceal adenocarcinoma peritoneal metastases (APM) undergo preoperative systemic chemotherapy. The primary aim of this study is to evaluate differences in oncologic outcomes among two popular chemotherapy approaches in patients with APM undergoing CRS-HIPEC. METHODS: We performed a multicenter retrospective review of patients who underwent CRS-HIPEC for APM due to high or intermediate grade disease between 2013 and 2019. Patients in the total neoadjuvant therapy group (TNT) received 12 cycles of preoperative chemotherapy. Patients in the "sandwich" chemotherapy group (SAND) received six cycles of preoperative chemotherapy with a maximum of six cycles of postoperative chemotherapy. The primary outcomes were overall survival (OS) and recurrence-free survival (RFS) defined as months from date of first treatment or surgery, respectively. RESULTS: A total of 39 patients were included in this analysis, with 25 (64%) patients in the TNT group and 14 (36%) patients in the SAND group. Patients in the TNT group had a median OS of 62 mo, while median OS in the SAND group was 45 mo (P = 0.01). In addition, patients in the TNT group had significantly longer RFS compared to the SAND group (35 versus 12 mo, P = 0.03). In a multivariable analysis, TNT approach was independently associated with improved OS and RFS. CONCLUSIONS: In this multicenter retrospective analysis, a TNT approach was associated with improved overall and recurrence-free survival compared to a sandwiched chemotherapy approach in patients undergoing CRS-HIPEC for high or intermediate grade APM.

Stapled Full-Thickness Diaphragm Resection: A Novel Approach to Diaphragmatic Resection in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

Full-thickness diaphragm resection (FT-DR) during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is sometimes required to achieve a complete cytoreduction. It is conventionally performed with electrocautery with primary repair or mesh repair. FT-DR using a linear cutting stapler is a novel technique that avoids entry to the chest cavity and minimizes the use of electrocautery on the diaphragm. We performed an institutional retrospective review of a prospectively maintained database of 145 patients who underwent CRS-HIPEC between 2013 and 2019. Patients were divided into the Conventional or Stapled group based on the FT-DR approach indicated in the operative report. Of the 145 patients who underwent CRS-HIPEC, 27 underwent FT-DR, with 63% (n = 17) in the Stapled group. There were no significant demographic or oncologic differences between the 2 groups. Patients in the Stapled group underwent tube thoracostomy (13.3% vs 60%; p = 0.008), were diagnosed with pneumonia (12% vs 50%; p = 0.04), required reintubation (6% vs 40%; p = 0.03), and required mechanical ventilation more than 48 hours (6% vs 50%; p = 0.02) less frequently than the Conventional group. There was no difference in pleural recurrence between the 2 groups (Conventional 20% vs Stapled 12%, p = 0.56). Stapled full-thickness diaphragm resection is a novel approach to achieving a complete cytoreduction that excludes the pleural cavity, minimizes diaphragm manipulation, and is associated with improved postoperative pulmonary outcomes in patients undergoing CRS-HIPEC.

Impact of Insurance Status on Oncologic and Perioperative Outcomes After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: A growing body of research has shown that underinsured patients are at increased risk of worse health outcomes compared with insured patients. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is largely performed at highly specialized cancer centers and may pose challenges for the underinsured. This study investigates surgical outcomes following CRS-HIPEC for insured and underinsured patients with peritoneal carcinomatosis. METHODS: We performed a retrospective cohort study of 125 patients undergoing CRS-HIPEC between 2013 and 2019. Patients were categorized into two groups. The insured group was comprised of patients with private insurance at the time of CRS-HIPEC or who obtained it during the follow-up period. The underinsured group consisted of patients with Medicaid, or self-pay. Perioperative and oncologic outcomes were compared between the two groups. RESULTS: A total of 102 (82.3%) patients were insured, and 22 (17.7%) patients were underinsured. There were no significant differences in age, medical morbidities, primary tumor characteristics, peritoneal carcinomatosis index, or completion of cytoreduction score between the two groups. The median overall survival (OS) for insured patients was 64.8 months and was 52.9 months for underinsured patients (p = 0.01). Additionally, insured patients had a significantly longer follow-up time. Underinsurance status also was associated with increased hospital and intensive care unit length of stay, and higher rate of Clavien-Dindo classification III-IV complications. CONCLUSIONS: In this retrospective study conducted at a large, urban, specialized cancer center, private insurance status was associated with increased overall survival and longer follow-up period. Furthermore, underinsurance status was associated with increased perioperative morbidity.

Diagnostic Laparoscopy in Patients With Peritoneal Carcinomatosis Is Safe and Does Not Delay Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: Outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) among patients with peritoneal carcinomatosis (PC) depend largely on the extent of peritoneal disease. Since PC is not reliably evaluated with cross-sectional imaging, tumor burden is often evaluated with diagnostic laparoscopy (DLS). The aims of this study are to evaluate the safety of DLS in patients with peritoneal disease and determine if DLS delays time to CRS-HIPEC. METHODS: We performed an institutional retrospective review of 145 patients who underwent CRS-HIPEC between 2013 and 2020. Patients were divided into 2 groups: those who underwent an electively scheduled DLS prior to CRS-HIPEC and those who did not. Intraoperative and postoperative complications associated with DLS were determined from the surgeon's operative report. Time from diagnosis of PC to CRS-HIPEC was compared between the 2 groups. RESULTS: Of the 145 patients available for analysis, 47% (68) underwent DLS and 44% (64) did not. Of all the diagnostic laparoscopies performed, there was 1 (1.5%) intraoperative complication. The duration between diagnosis of peritoneal carcinomatosis and surgery was 4.9 months among patients who underwent DLS prior to CRS-HIPEC and 4.3 months among patients who did not (P = .79). CONCLUSION: In this retrospective analysis, diagnostic laparoscopy prior to CRS-HIPEC demonstrated a comparable rate of DLS-associated complications compared to other gastrointestinal malignancies and does not prolong time from diagnosis to CRS-HIPEC. Thus, in patients undergoing evaluation for CRS-HIPEC, diagnostic laparoscopy provides significant value in patient selection without incurring perioperative risk or delay in CRS-HIPEC.