The Use of Indocyanin Green for Peroperative Diagnostic of Chylous Ascites and Autologous Tissue Glue (Vivostat) for the Treatment.

BACKGROUND: Chylous ascites or chyloperitoneum can be caused by peroperative injury of the lymphatic pathways; the lymph is accumulated in the abdominal cavity. The incidence of chylous ascites varies according to the type of surgery and the extent of the lymphadenectomy. The first choice of treatment is a conservative procedure - total parenteral nutrition or a strict low-fat diet. If this fails, a surgical revision is indicated. However, this is often difficult due to postoperatively altered terrain and the chronic presence of pathological secretion in the abdominal cavity. The application of a fat emulsion or indocyanine green (ICG) to the lymphatic drainage area may help identify the lymph source. Nowadays, ICG is used in various clinical indications, e.g. evaluation of liver function, angiography in ophthalmology, assessment of blood supply to the tissues, search for lymph nodes in oncological surgeries. The advantage of ICG lymphography is the possibility of observing the source of the leak in real time directly during surgical revision. CASE REPORT: A polymorbid 66-year-old patient after radical oncogynaecological surgery with aortopelvic lymphadenectomy was postoperatively complicated by persistent, high-volume chylous ascites, not responding to conservative treatment. Therefore, we performed surgical revision of the abdominal cavity and successful treatment of the leak source using ICG peroperative lymphography and subsequent application of Vivostat autologous tissue glue to this area. CONCLUSION: High-volume consistent chylous ascites is not a frequent postoperative complication but it has a significant impact on the quality of life, nutritional status of the patient and further patient prognosis. The treatment is strictly individual. The first choice should be a conservative approach. Where that fails, a difficult surgical revision is indicated. Today, however, the surgeon can be helped by modern technologies such as fluorescent navigated surgery or treatment of the source with autologous tissue adhesives. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedice papers.

Secondary cytoreductive surgery - viable treatment option in the management of platinum-sensitive recurrent ovarian cancer.

OBJECTIVE: This study aimed to evaluate the impact of the secondary cytoreductive surgery on survival parameters in women with platinum-sensitive recurrent ovarian cancer who undergone secondary cytoreduction following chemotherapy compared to women who recieved chemotherapy alone. STUDY DESIGN: In a retrospective study, data were rewieved from women who were diagnosed and treated with ovarian cancer and its primary platinum-sensitive recurrence at the University Hospital Brno in the Czech Republic between November 2009 and March 2016. Out of the total number of 62 patients with recurrence, 30 women underwent cytoreductive surgery plus chemotherapy and 32 were treated with chemotherapy alone. The good performance status expressed by ECOG score 0-1, the single site of recurrence regardless of platinum-free interval or multiple sites of recurrence but no carcinomatosis and platinum-free interval >12 months, and no or small-volume ascites (<500 ml) were considered inclusion criteria for cytoreductive surgery. Women not meeting these criteria were treated by chemotherapy alone. Descriptive statistics, Kaplan-Meier survival curves and Log-Rank test were used for statistical estimations. RESULTS: The analysis confirmed more favorable prognosis in patient group treated with a combination secondary cytoreduction and chemotherapy. Mean disease-free survival (DFS) was 49.8 months (95% CI; 33.2-66.3) and mean overall survival (OS) stood at 54.0 months (95% CI; 39.4-68.6) in this patient cohort, while in patient group treated with chemotherapy alone it was found that mean DFS was 16.6 months (95% CI; 7.4-25.8) and mean OS stood at 26.2 months (95% CI; 16.6-35.8). When testing the difference between survival curves, statistically significant differences were observed in both DFS (p = 0.010) and OS (p = 0.007) rates between two treatment groups. Age < 60 years at the time of recurrence and zero macroscopic residual disease after secondary cytoreduction were identified as favorable prognostic factors for both DFS and OS in a multivariate analysis. CONCLUSION: Secondary cytoreductive surgery is acceptable as a viable treatment option for highly selected women with ovarian cancer recurrence. Complete resection is considered ultimate goal of secondary cytoreduction on condition that the balance between maximal survival gain and minimal operative morbidity will be kept.

Modified posterior pelvic exenteration for advanced ovarian malignancies: a single-institution study of 35 cases.

INTRODUCTION: This study aimed to investigate the possible benefits of a complete cytoreduction in patients with advanced ovarian cancer and concomitant rectal invasion. Furthermore, we evaluated the morbidity associated with radical surgery. MATERIAL AND METHODS: A retrospective analysis examined 35 women who underwent radical surgery in the form of modified posterior pelvic exenteration. Descriptive statistics, Kaplan-Meier survival curves and log-rank test were used for statistical estimations. Surgical complications were analyzed using the Clavien-Dindo classification. RESULTS: The analysis of survival in relation to residual disease assessed according to Sugarbaker confirmed an optimistic prognosis in patients with optimal debulking with a mean disease-free survival period of 33.6 months in R0 patients, 19.6 months in R1 patients, and 14.3 months in R2 patients. A statistically significant difference in disease-free survival (p = 0.023) was observed between the R0 (without residual disease) and R1+2 (with residual disease) groups. Surgical complications occurred in 83% of patients, with early postoperative complications being most frequent (65.7%). While grade III-IV complications occurred in 37.7% of all patients, no cases of surgery-associated mortality occurred. CONCLUSIONS: Modified posterior pelvic exenteration is a highly effective method for achieving optimal debulking in cases of advanced ovarian cancer with the direct invasion of the rectum. Modified posterior pelvic exenteration does not delay the beginning of complementary chemotherapy. However, it is necessary to take into account surgery-related morbidity. As modified posterior pelvic exenteration represents an extremely invasive technique, the surgical plan and perioperative care should be personalized to address the individual medical and surgical conditions of each patient.