The length of peritoneal surgical manipulation correlates with serum CA 125 levels.

BACKGROUND: Peritoneal recovery after uncomplicated serum manipulation usually lasts 7 days and high values of serical CA 125 are measured following abdominal surgery. The aim of this study was to assess a possible correlation between peritoneal manipulation and serical CA 125 levels following abdominal surgery for benign diseases. PATIENTS AND METHODS: Twenty-eight patients with abdominal benign disease were operated on. They were pooled into three groups of low, intermediate and high peritoneal manipulation, according to the extent of laparotomy and length of surgical peritoneal manipulation. Venous blood samples (5 ml) were taken from each patient 24-48 hours before surgery, 12-24 hours after surgery and on the 4th and 7th postoperative day. CA 125 levels were quantified by microparticle enzyme immunoassay. RESULTS: After surgery, patients having high peritoneal manipulation showed significantly higher levels of CA 125 compared to the preoperative levels. In particular, the length of peritoneal manipulation was correlated with increasing levels of the marker (p<0.0001). CONCLUSION: Peritoneal manipulation was significantly correlated to serum CA 125 levels; therefore its role as marker of peritoneal surgical injury should be considered.

Intra-arterial hepatic chemotherapy for unresectable colorectal liver metastases: a review of medical devices complications in 3172 patients.

BACKGROUND: Hepatic artery infusion (HAI) is indicated to treat unresectable colorectal hepatic metastases, with recent applications as a neoadjuvant or adjuvant treatment. Traditionally performed with the infusion of fluoropyrimidine-based chemotherapy, it has been now tested with oxaliplatin or irinotecan and associated with systemic chemotherapy. METHODS: To evaluate the impact of medical devices complications we carried out a search of the published studies on HAI in unresectable colorectal liver metastases. Complications were pooled according to the applied medical system: 1) surgical catheter, 2) radiological catheter, and 3) fully implantable pump. The surgical catheter is inserted into the hepatic artery from the gastro-duodenal artery. The radiological catheter is inserted into the hepatic artery through a percutaneous transfemoral or transaxillar access. The fully implantable pump is a totally internal medical device connected to the arterial hepatic catheter during laparotomy. RESULTS: The selection criteria were met in 47/319 studies. The complications of surgical and radiological medical devices connected to a port were found in 16 and 14 studies respectively. Meanwhile, complications with a fully implantable pump were reported in 17 studies. The total number of complications reported in studies evaluating patients with surgical or radiological catheter were 322 (322/948, 34%) and 261 (261/722, 36.1%) respectively. In studies evaluating patients with a fully implantable pump, the total number of complications was 237 (237/1502, 15.8%). In 18/319 studies the number of cycles was reported. The median number of cycles with surgically and radiologically implanted catheters was 8 and 6 respectively. The fully implantable pump allows a median number of 12 cycles. CONCLUSIONS: The fully implantable pump, maintaining a continuous infusion through the system, allows the lowest risk for thrombosis and infection and the best median number of cycles of loco-regional chemotherapy in HAI.

Embolisation of arteriovenous intrahepatic fistulas associated with diffuse haemangiomatosis of the liver. Report of a case in an adult and review of the literature.

Diffuse hepatic haemangiomatosis is rare in adults. Association with high output intrahepatic arteriovenous fistulas has been described. To avoid heart failure complications, treatment is essential. The second case in the literature, treated with repeated transcatheter arterial embolizations (TAE) but complicated by infection of multiple haemangiomas and by Kasabach-Merritt syndrome, is presented. Complications were due to the persistent presence of haemangiomas within the liver, where an impressive collection of platelets and a superinfection were observed. Therefore, to treat arteriovenous fistula-related problems and to prevent possible complications due to persistence of the haemangiomas, surgical removal should be preferred over embolisation.

Potential advantages of loco-regional intra-arterial chemotherapy.

Arterial infusion or perfusion are currently used to treat hepatic tumours, head and neck malignancy, melanomas and sarcomas of the limbs. An experimental study with epirubicin and cis-platinum infused into the hepatic artery was performed. Epirubicin was injected via the systemic vein or the hepatic artery in 27 rats. Cis-platinum was injected via a systemic route or the hepatic artery in 29 rats. Drug concentrations were evaluated in liver and tumour tissues. In the rats the tumour tissue drug concentration after hepatic artery infusion was 6- and 4-fold higher than with systemic infusion for epirubicin and cis-platinum, respectively. Arterial administration appeared to be better than systemic in terms of drug concentration within the tumours and systemic toxicity.

Adrenal incidentalomas: indications for surgery.

Adrenalectomy represents the gold standard treatment for hyperfunctioning adrenal incidentaloma. In cases of silent adrenal masses, on the other hand, the surgical removal of an adrenocortical cancer entails the sacrifice of a large number of safe benign masses, and in most cases surgery is therefore unjustified. The aim of this paper was to clarify the surgical indications for adrenal incidentaloma by reviewing our experience in comparison with the main reference literature. Over the period from 1995 to 2001 we managed 40 cases of incidentaloma. US and CT abdominal scans, adrenal scintigraphy and biochemical tests were performed on an outpatient basis. Seven pre-Cushing syndromes were removed. Ten incidentalomas measured 4 cm or more in diameter: 5 of these were operated on and in 5 cases surgery was not feasible or was refused. Only one malignant mass was detected (an angiosarcoma). Four postoperative minimal complications (18.7%) were observed. The follow-up (median: 48 months) was uneventful. The surgical approach was traditional in 11 cases and laparoscopic in 1 case. Surgery should be considered mandatory in cases of hyperfunctioning adrenal masses in the presence of suspect radiological evidence, in cases of discordant CT and scintigraphy findings and when the maximum diameter is 4 cm or more.

Adrenal angiosarcoma: report of a case.

Adrenal epithelioid angiosarcoma is an extremely rare tumor. Even if such tumors are very aggressive, a long survival may occasionally be observed after an adrenal ectomy. A 70-year-old woman suffering from persistent right flank pain showed a 5-cm right adrenal mass plus a 2-cm liver mass at the radiologic workup, and both were suspected of being malignant. No adrenal hypersecretion was demonstrated. During an explorative median laparotomy the right adrenal gland with the whole periadrenal tissue and locoregional lymph nodes was removed. A histological examination revealed an adrenal angiosarcoma. The resection margin was tumor-free with no lymph node infiltration. The liver mass turned out to be a cistobiliary adenoma. Since no distant metastases were observed, no adjuvant chemotherapy was performed. After an 18-month follow-up the patient is still well with no sign of a relapse. When this rare adrenal tumor is encountered and curative treatment is attempted initially extensive surgical procedures are essential.