Re-admissions for delayed complications after cytoreductive surgery and HIPEC.

BACKGROUND: Peritoneal metastasis (PM) is currently treated with the complex procedure of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS + HIPEC). This procedure presents high morbidity and mortality rates, but they have only been examined in the immediate post-operative period. The aim of our study is to present, describe and analyze the post-operative events, secondary to a cytoreductive surgery and HIPEC procedure that occurs after the patients' discharge from the hospital. PATIENTS AND METHODS: We examine retrospectively 219 patients who were discharged from our hospital from the initial 230 patients with PM, who were operated on from August 2005 to August 2015 and underwent CRS and HIPEC. Complications are investigated from the patient's discharge date until the 90th post-operative day, and are categorized with the Clavien-Dindo classification. RESULTS: We identified 17 patients (7.8%) who developed late complications. No major differences in patient characteristics were identified between this group of 17 patients and the rest, apart from a slightly higher PCI (23.5 vs. 22.3). Mean length of stay at the re-admission was 11.7 days. 5 of the patients (29.4%) had to be re-operated on, whereas we found a mortality of 11.8% (2/17 patients). The most common complications involved abdominal abscesses (17.6%), ureteral strictures (17.6%) and enterocutaneous fistulae (17.6%). CONCLUSION: Our study highlights the late complications following CRS plus HIPEC procedures, that occur after the patient's discharge from the hospital, an issue that has not been investigated thoroughly yet and may have serious impact on the post-operative quality of life. The role of adjuvant chemotherapy following CRS and HIPEC procedures in the onset of such complications appears to be important and needs further investigation.

Peritoneal carcinomatosis: intraoperative parameters in open (coliseum) versus closed abdomen HIPEC.

BACKGROUND: Peritoneal carcinomatosis (PC) is associated with a poor prognosis. Cytoreductive surgery (CRS) and HIPEC play an important role in well-selected patients with PC. The aim of the study is to present the differences in the intraoperative parameters in patients who received HIPEC in two different manners, open versus closed abdomen. PATIENTS AND METHODS: The population includes 105 patients with peritoneal carcinomatosis from colorectal, gastric, and ovarian cancer, sarcoma, mesothelioma, and pseudomyxoma peritonei. Group A (n = 60) received HIPEC using the open technique and Group B (n = 45) received HIPEC with the closed technique. The main end points were morbidity, mortality, and overall hospital stay. RESULTS: There were two postoperative deaths (3.3%) in the open group versus no deaths in the closed group. Twenty-two patients in the open group (55%) had grade III-IV complications versus 18 patients in the closed group (40%). There are more stable intraoperative conditions in the closed abdomen HIPEC in CVP, pulse rate, and systolic pressure parameters. CONCLUSIONS: Both methods are equal in the HIPEC procedures. Perhaps the closed method is the method of choice for frail patients due to more stable hemodynamic parameters.

Reoperation combining re-cytoreductive surgery and re-HIPEC for recurrent peritoneal carcinomatosis.

PURPOSE: Cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the proper treatment for resectable peritoneal carcinomatosis (PC). The aim of this study was to evaluate the postoperative course and long-term outcome of repeat CS (reCS) plus repeat HIPEC (reHIPEC) in patients with recurrent disease, after primary CS plus primary HIPEC. METHODS: From 2004 to 2012 85 patients were subjected to primary CS + HIPEC. Fourteen of those patients developed recurrent PC and were subjected to reCS+reHIPEC during the same time period. Eligibility criteria included limited extent of the peritoneal disease, and interval of more than 12 months from the primary CS+HIPEC. The origins of the tumors were ovarian cancer (n=7) colorectal cancer (n=3), pseudomyxoma peritonei (n=3), and uterine sarcoma (n=1). RESULTS: At second laparotomy, mean peritoneal cancer index (PCI) was 5.3 + 2.8. Among the 14 procedures, HIPEC was used in all patients. The postoperative mortality was 0% and grade 3-4 postoperative complications occurred in 4 patients. The overall 1-, 2- and 3- year overall survival rate was 90, 40 and 30%, respectively. CONCLUSION: ReCS+reHIPEC is feasible and yields an accepted survival in highly selected patients.

The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of recurrent advanced ovarian cancer: a prospective study.

PURPOSE: Ovarian cancer is the leading cause of death from gynecological cancer. The current treatment of this type of cancer consists of cytoreductive surgery (CRS) and systemic chemotherapy. The aim of this study was to examine if the hyperthermic intraoperative chemotherapy (HIPEC) is an alternative modality to treat this category of patients along with a second attempt of surgical resection and second or third line systemic chemotherapy. METHODS: Forty-eight patients suffering from advanced ovarian cancer (FIGO stages III and IV) who recurred after initial treatment with conservative or debulking surgery and systemic chemotherapy were included in this study. Twenty-four patients (group A) were treated with CRS followed by HIPEC and then systemic chemotherapy. Due to various reasons the remaining 24 patients (group B) were treated with CRS and systemic chemotherapy alone. RESULTS: The median survival for group A was 19.4 months vs. 11.2 months in group B (p <0.05). One-year survival was 85% in group A vs. 35% in group B (p <0.05). The 3-year survival rate was 50% in group A vs. 18%. in group B (p <0.01). The resection status was found to be a significant predictor of overall survival (p <0.05). Patients with peritoneal cancer index (PCI) score < 15 appeared also to have longer survival. CONCLUSION: The use of HIPEC along with the extent of the disease and the extent of cytoreduction play an important role in the survival of patients with a recurrence in an initially advanced ovarian cancer.

Doppler-guided haemorrhoidal artery ligation, rectoanal repair, sutured haemorrhoidopexy and minimal mucocutaneous excision for grades III-IV haemorrhoids: a multicenter prospective study of safety and efficacy.

OBJECTIVE: The isolated use of Doppler-guided haemorrhoidal artery ligation (DGHAL) may fail for advanced haemorrhoids (HR; grades III and IV). Suture haemorrhoidopexy (SHP) and mucopexy by rectoanal repair (RAR) result in haemorrhoidal lifting and fixation. A prospective evaluation was performed to evaluate the results of DGHAL combined with adjunctive procedures. METHOD: The study included 147 patients with HR (male patients: 102; grade III: 95, grade IV: 52) presenting with bleeding (73%) and prolapse (62%). RESULTS: More ligations were required for grade IV than grade III HR (10.7 + 2.8 vs 8.6 + 2.2, P < 0.001). SHP (28 patients) and RAR (18 patients) at 1-4 positions were deemed necessary in 46 (31%) patients. Minimal (muco-)cutaneous excision (MMCE) was added in 23 patients. SHP/RAR was applied more frequently in grade IV HR (60%vs 16%, P < 0.001). In patients not having MMCE, SHP/RAR was added in 57% of grade IV cases (P < 0.001). Complications included residual prolapse (10; two second surgery), bleeding (15; two second DGHAL), thrombosis (four), fissure (three) and fistula (one). Analgesia was required not at all, up to 1-3 days, 4-7 days and >7 days by 30%, 31%, 16% and 14% of the patients, respectively. SHP/RAR was associated with greater discomfort (17%vs 6%, P < 0.001). No differences were found between SHP and RAR. At an average follow-up of 15 months, 96% of patients were asymptomatic and 95% were satisfied. CONCLUSIONS: DGHAL with the selective application of SHP/RAR is a safe and effective technique for advanced grade HR.

Morbidity and mortality of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal carcinomatosis.

PURPOSE: Peritoneal carcinomatosis (PC), which has been regarded as a lethal condition, may now be treated, achieving a long-term disease-free survival with cytoreductive surgery by treating macroscopic tumor seeding and hyperthermic intraperitoneal chemotherapy (HIPEC) by treating residual microscopic disease. The purpose of this study was to analyse the morbidity and mortality of this procedure. METHODS: A total of 39 consecutive patients were included in this retrospective study. After complete resection of the PC, HIPEC was performed via the coliseum technique. The chemotherapeutic agents used depended on the tumors' histology. RESULTS: Postoperative mortality and morbidity rates were 5.1%% (2/39) and 43.5% (17/39), respectively. The most frequent complications were pulmonary complications (31%), gastrointestinal fistulas (20%), hematologic toxicity (16%) and postoperative bleeding (11%). Statistical correlations were evidenced between morbidity and PC index (p<0.004), duration of surgery (p<0.001) and blood loss (p<0.001). CONCLUSION: This approach has resulted in a relatively high but acceptable percent of adverse events considering the expected advantage for survival.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal carcinomatosis. Preliminary results and cost from two centers in Greece.

PURPOSE: To report our preliminary experience in the combined treatment of peritoneal carcinomatosis (PC) using cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC). PATIENTS AND METHODS: This prospective study included patients with PC from gynaecological, gastric and colon cancer, treated in two centers. Cytoreductive surgery included the peritonectomy procedures described by Jacquet and Sugarbaker as well as multivisceral resections in order to achieve a complete macroscopical cancer eradication. The HIPEC that followed was performed via the open abdomen technique. RESULTS: Twenty-four patients (3 men and 21 women, mean age 60 years) were treated. Twelve patients had PC from ovarian cancer, 7 from colon, 3 from gastric and 2 from uterine cancer. The mean duration of the procedure was 7.83 h (range 5 -12.30). Macroscopically, complete cytoreduction (CC) was achieved in 18 (75%) patients. Two (8.3%) patients died in the first 30 days. The overall morbidity was 42% and 2 patients were reoperated. The mean follow up was 22 months (range 3-36). The overall 1-year survival was 59.1%; concerning the gynaecological cancers it was 53.8% (mean survival 11.7 months) and for gastrointestinal cancers it was 44.4% (mean survival 9.5 months). CONCLUSION: Our preliminary data suggest that the combined treatment of cytoreduction plus HIPEC for PC is associated with acceptable mortality and morbidity and offers an improved survival in these patients. An optimal patient selection and establishment of experienced centres are of paramount importance.

Management of advanced abdominopelvic tumors with combined radiofrequency ablation and surgical debulking.

AIM: Advanced abdominopelvic tumors due to rectal cancer, gynecological cancer or sarcomas are often unresectable using surgery alone. This study presents the combination of radiofrequency ablation (RFA) and surgical debulking for such tumors. METHODS: Between November 2005 and June 2007 we treated 4 patients with tumor fixation to the pelvic side wall and to the sacroiliac joint. Two of these patients had recurrent gynecological cancer while the other 2 had rectal cancer. All 4 of them had received prior treatment. The radiofrequency probe was placed in the center of the tumor. A 5- to 8-cm tissue core was ablated and aspirated or curetted out. This was repeated centrifugally out to the tumor capsule. RESULTS: Control of the tumor for more than 12 months was achieved in 3 patients. One patient died 14 months after the procedure due to tumor progression. Two patients are still alive 12 and 14 months after the operation without symptoms. The other patient is alive 6 months after the operation in a disease-free condition. CONCLUSIONS: Combined RFA and surgical debulking is beneficial as an alternative palliative method in patients with inoperable abdominopelvic tumors.

Is local excision and chemoradiation an acceptable alternative in the treatment of early rectal cancer?

Local excision has a limited but important role in the modern management of patients with rectal tumors. The main criticism of the local treatment of early rectal cancer (T1N0M0 or T2N0M0) is the neglect of any potential metastatic mesorectal lymph nodes. This article presents the combined experience of several trials and indicates that neoadjuvant preoperative or adjuvant postoperative treatment may reduce the risk of local recurrence in a selected group of patients, and local excision results in overall survival comparable to the most aggressive treatment. Although the hypothetical improvement in morbidity and quality of life with local excision has not been demonstrated, the advantages of the local excision vs. radical surgery in the oncologic results seem obvious and require prospective randomized studies comparing both types of treatment.

Colorectal carcinoma: contribution of growth pattern on prognosis.

BACKGROUND: Recent studies have reported poor prognosis in colorectal carcinomas with non-polypoid growth pattern. The aim of the present study is to investigate this issue in the patients referred to "Hatzikostas" General Hospital of Messolonghi, Greece. MATERIALS AND METHODS: A total of 13 patients who were treated for primary colorectal adenocarcinoma in a one-year period were studied. Colorectal carcinomas were classified into two types based on the presence or absence of elevation of tumour as compared with adjacent mucosa: polypoid growth (PG-type) and non-polypoid growth (NPG-type) carcinomas. Clinical and tumour histopathologic parameters were analysed. RESULTS: Unlike PG-type carcinomas, NPG-type carcinomas had a high proportion of poorly differentiated adenocarcinoma cells, a high likelihood of being advanced, and a high frequency of lymph node as well as distant metastases at the time of diagnosis. CONCLUSIONS: Colorectal carcinomas with NPG pattern tend to show more malignant characteristics than those with PG pattern, explaining their poorer outcome.

The presence and significance of iron in neoplasia of the colorectum.

BACKGROUND: To investigate the presence and distribution of tissue iron in colon adenomas of all grades of dysplasia as well as colorectal carcinomas of all grades of differentiation. MATERIALS AND METHODS: Formalin-fixed, paraffin-embedded tissue blocks from 8 biopsies of colon adenomas and 13 surgical specimens of colorectal carcinoma were studied. Consecutive sections were stained using Perls' stain that demonstrates the presence of ferric iron by staining it blue. RESULTS: Iron was absent in all cases of colon adenoma. On the other hand, iron was present in 9 of the 13 cases of colorectal carcinoma (69.23%), regardless of the degree of differentiation, the location and the stage of development. The iron was stored in mesenchymal cells in the stroma and various types of inflammatory cells. CONCLUSIONS: Our results suggest association of iron presence in the environment of malignant cells. Thus, iron may be a carcinogenic factor, possibly facilitating tumour growth and modulating local immune response.

The surgical approach to locally recurrent rectal cancer.

The incidence of rectal cancer recurrence after surgery is 5-45%. Predictive factors relating to local recurrence (LR) are the surgical experience, the location of the tumour, the tumour's pathology, the circumferential margins, the successful total mesorectal excision (TME) and the use of radiochemotherapy. The use of TME and preoperative radiotherapy reduce the risk of LR. Diagnosis is done using imaging techniques. Computed tomography with rectal contrast is the preferred imaging technique. The surgical strategy for LR at and around a previous anastomosis is the resection of the anastomosis with a sphincter-saving procedure. LR isolated to one side after anterior resection is an indication for en bloc resection of the rectum with a portion of the bladder. LR fixed to the sacrum requires a composite abdominosacral resection. Extrapelvic disease is a contraindication to curative resection. The composite sacropelvic resection is a reasonable alternative to palliative radiation with long-term survival of 20-30%.

Sandostatin as a "hormonal" temporary protective ileostomy in patients with total or subtotal colectomy.

BACKGROUND/AIMS: We describe our experience with the use of a new method of so-called "hormonal" ileostomy by using Octreotide, a long-acting analog of the inhibitory peptide Somatostatin (Sandostatin Novartis), aiming to advocate protective ileostomy or colostomy, in patients who underwent total or subtotal colectomy for ulcerative colitis or obstruction of left colon, due to carcinoma or diverticulitis. METHODOLOGY: "Hormonal" protective ileostomy by using Sandostatin (Novartis) was performed in 10 patients after subtotal colectomy for ulcerative or left colon obstruction without a protective ileostomy or colostomy. Sandostatin 0.5 mg/mL was given from the day of operation to the 10th postoperative day, in a dose of 2 x 3 per day subcutaneously. The time of return of peristalsis, number of bouts of diarrhea and postoperative complications were evaluated. RESULTS: The patients were classified in two groups: First group (40% of all patients) with bowel obstruction and second group (60% of all patients) with ulcerative colitis. In the first group the mean time of return of peristalsis was 4.5 days and the mean number of bouts of diarrhea was 4.2 per day. One patient was reoperated for intraabdominal abscess and the morbidity was 50% with minor postoperative complications. In the second group the mean time of peristalsis return was 5 days and the mean number of bouts of diarrhea was 5.4 per day. One patient was reoperated for intestinal bleeding and the morbidity was 60% with minor postoperative complications. CONCLUSIONS: The use of Octreotide appears to serve as a useful adjunctive and important role in controlling intestinal output, so that it is an available method of "hormonal" protective ileostomy in very low rectal or anal anastomosis, by avoiding a second operation for ileostomy or colostomy closure and reducing the median hospital stay and total socioeconomic cost.

Simple closure of chronic duodenal ulcer perforation in the era of Helicobacter pylori: an old procedure, today's solution.

BACKGROUND/AIMS: To evaluate the risk of recurrence in our patients with chronic duodenal ulcer perforation, who underwent a simple closure and postoperative Helicobacter pylori eradication therapy. METHODOLOGY: Within 4.5 years (3/1996 to 7/2000), 21 patients with chronic duodenal ulcer perforation, were operated in our hospital. All of them underwent simple closure with omental patch repair plus Helicobacter pylori eradication with omeprazole, clarithromycin and amoxycillin for two weeks. On December 2000, in 14 (66.6%) of these patients, urea breath test for Helicobacter pylori was performed, followed by endoscopy. RESULTS: The mean age of our 14 patients is 55 years. The urea breath test was positive for Helicobacter pylori in 3 (21.4%) patients. Two of them had endoscopically gastritis, confirmed by pathological examination. None of our patients had ulcer relapse. The three patients with positive urea breath test received another course of the same eradication therapy. CONCLUSIONS: Simple closure of perforated chronic duodenal ulcer in combination with postoperative Helicobacter pylori eradication, seems to be an accepted treatment, so the immediate acid-reduction surgery (vagotomy) in the contaminated environment caused by perforation, is probably unnecessary.

Effects of prolonged stay in hospital on gastric flora.

OBJECTIVE: To find out if a long preoperative stay in hospital results in the introduction of micro-organisms into the gastric flora that are resistant to the usual perioperative chemoprophylaxis. DESIGN: Observational study. SETTING: Teaching hospital, Greece. SUBJECTS: 145 consecutive patients admitted for abdominal or pelvic operations. INTERVENTIONS: Aspiration of gastric fluid for measurement of pH and culture. MAIN OUTCOME MEASURES: Growth and type of pathogens in gastric aspirate. RESULTS: 125 patients spent a mean (range) of 13.6 days (7-69) in hospital preoperatively and 20 patients spent 3.1 (1-7) days. In the long-stay group 103 had a gastric pH of <4 and in 22 it was 4 or more; in 40 patients pathogens were grown from the gastric aspirate but resistant Pseudomonas cepacia was grown from only 2. In the short-stay group 16 patients had a pH of <4 and in 4 it was 4 or more; in 4 patients pathogens were grown from the aspirate. CONCLUSION: Prolonged stay in hospital preoperatively does not seem to affect the gastric flora, so routine chemoprophylaxis should be sufficient in abdominal operations.

Long chain versus medium chain lipids in patients with ARDS: effects on pulmonary haemodynamics and gas exchange.

OBJECTIVE: To compare pulmonary haemodynamic and gas exchange alterations in septic patients with ARDS receiving long-chain triglycerides (LCT) versus medium-chain triglycerides (MCT). DESIGN: Prospective, randomised, clinical study. SETTING: Surgical ICU patients in a University Hospital. PATIENTS: Twenty-one septic patients with ARDS were randomly assigned to receive 50 % of their non-protein caloric requirements as either 20 % LCT (group 1, n = 10) or 20% 1:1 mixture of LCT/MCT (group 2, n = 11). INTERVENTION: Intravenous infusion of LCT and LCT/MCT combinations at a rate of 12 g x h(-1). MEASUREMENTS AND RESULTS: The LCT infusion was associated with an increase of pulmonary venous admixture (Qva/Qt) from 24 % +/- 5 % to 37 % +/- 6 %, an increase of mean pulmonary artery pressure (MPAP) from 25 +/- 5 to 33 +/- 4 mmHg and decrease of PaO2/FIO2 from 240 +/- 30 to 180 +/- 35. LCT/MCT administration was only associated with an elevation of oxygen consumption (VO2) from 329 +/- 14 to 396 +/- 12 ml/ min. During lipid infusion group 1 patients presented higher Qva/Qt (37% +/- 6% vs 25% +/- 4%), MPAP (33 +/- 4 vs 27 +/- 3 mmHg) and VO2 (359 +/- 11 vs 396 +/- 12 ml/min) and lower PaO2/FIO2 (180 +/- 35 vs 235 +/- 30) values compared to group 2. CONCLUSION: In conclusion, we have shown that, in septic patients with respiratory failure, LCT administration was associated with more significant changes of Qva/Qt, MPAP and PaO2/FIO2 compared to infusion of an LCT/MCT 1:1 emulsion. Clinically, these transient alterations might cause serious problems in patients with marginal arterial oxygenation and cardio-respiratory impairment.

Tubuloreticular structures in pyridoxine deficiency.

Electron microscopic studies on renal tissue obtained from animals subjected to pyridoxine deficiency have revealed the presence of round and/or tubular bodies in the cytoplasm of endothelial cells of the glomeruli. The bodies generally occur as aggregates in association with the endoplasmic reticulum. Along with the round forms other profiles are also observed. It is believed that they represent one of the many images of a system of undulating tubules. Since these bodies occur irrespective of the presence of virus particles in the tissue under study it is concluded that they are not viral in nature.