Novel use of the Bakri balloon to minimize empty pelvis syndrome following laparoscopic total pelvic exenteration.

AIM: Pelvic exenteration is the only surgical option for locally advanced pelvic malignancies infiltrating the surrounding organs. The resultant pelvic void after the procedure is responsible for a number of complications, collectively termed empty pelvis syndrome (EPS). We aim to show how EPS can be minimized by presenting a case series demonstrating the surgical technique of laparoscopic total pelvic exenteration with bilateral pelvic node dissection along with a novel use of the Bakri balloon. METHOD: This is a case series of three successive patients undergoing laparoscopic total pelvic exenteration for locally advanced primary, nonmetastatic rectal adenocarcinoma over a period of 1 month in a specialized colorectal unit at a tertiary cancer centre. The Bakri balloon was deployed in all three patients and retained for variable time intervals postoperatively. Features of EPS were prospectively documented. RESULTS: In the first patient, the Bakri balloon was completely deflated and removed on postoperative day (POD) 5. The patient developed subacute intestinal obstruction which resolved with conservative management by POD 12. In the second and third patients, the Bakri balloon was deflated in a sequential manner, beginning on POD 8, until it was finally removed on POD 11. Neither of these patients had any abdominal complaints. A postoperative CT scan of both these patients showed the small bowel loops clearly above the pelvic inlet. CONCLUSIONS: The Bakri balloon is a simple, safe and cost-effective method to reduce the complications of EPS following laparoscopic total pelvic exenteration. A prospective study is ongoing to objectively quantify the benefits of this technique.

In vivo selection of autologous MGMT gene-modified cells following reduced-intensity conditioning with BCNU and temozolomide in the dog model.

Chemotherapy with 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU) and temozolomide (TMZ) is commonly used for the treatment of glioblastoma multiforme (GBM) and other cancers. In preparation for a clinical gene therapy study in patients with glioblastoma, we wished to study whether these reagents could be used as a reduced-intensity conditioning regimen for autologous transplantation of gene-modified cells. We used an MGMT(P140K)-expressing lentivirus vector to modify dog CD34(+) cells and tested in four dogs whether these autologous cells engraft and provide chemoprotection after transplantation. Treatment with O(6)-benzylguanine (O6BG)/TMZ after transplantation resulted in gene marking levels up to 75%, without significant hematopoietic cytopenia, which is consistent with hematopoietic chemoprotection. Retrovirus integration analysis showed that multiple clones contribute to hematopoiesis. These studies demonstrate the ability to achieve stable engraftment of MGMT(P140K)-modified autologous hematopoietic stem cells (HSCs) after a novel reduced-intensity conditioning protocol using a combination of BCNU and TMZ. Furthermore, we show that MGMT(P140K)-HSC engraftment provides chemoprotection during TMZ dose escalation. Clinically, chemoconditioning with BCNU and TMZ should facilitate engraftment of MGMT(P140K)-modified cells while providing antitumor activity for patients with poor prognosis glioblastoma or alkylating agent-sensitive tumors, thereby supporting dose-intensified chemotherapy regimens.

In vivo selection of human embryonic stem cell-derived cells expressing methotrexate-resistant dihydrofolate reductase.

Human embryonic stem cells (hESCs) provide a novel source of hematopoietic and other cell populations suitable for gene therapy applications. Preclinical studies to evaluate engraftment of hESC-derived hematopoietic cells transplanted into immunodeficient mice demonstrate only limited repopulation. Expression of a drug-resistance gene, such as Tyr22-dihydrofolate reductase (Tyr22-DHFR), coupled to methotrexate (MTX) chemotherapy has the potential to selectively increase the engraftment of gene-modified, hESC-derived cells in mouse xenografts. Here, we describe the generation of Tyr22-DHFR-GFP-expressing hESCs that maintain pluripotency, produce teratomas and can differentiate into MTXr-hemato-endothelial cells. We demonstrate that MTX administered to nonobese diabetic/severe combined immunodeficient/IL-2Rgammac(null) (NSG) mice after injection of Tyr22-DHFR-hESC-derived cells significantly increases human CD34(+) and CD45(+) cell engraftment in the bone marrow (BM) and peripheral blood of transplanted MTX-treated mice. These results demonstrate that MTX treatment supports selective, long-term engraftment of Tyr22-DHFR cells in vivo, and provides a novel approach for combined human cell and gene therapy.

Intraperitoneal hyperthermic chemotherapy in ovarian cancer.

We investigated the effect of intraperitoneal hyperthermic perfusion chemotherapy as consolidation therapy in stage IIIB-IIIC ovarian cancer, following cytoreductive surgery and systemic chemotherapy (cisplatin-cyclophosphamide--six cycles). Disease-free survival, overall survival, and side effects were compared with a control group of patients who refused a second-look surgery and intraperitoneal chemotherapy. In a multicenter prospective trial, 29 patients with complete or optimal cytoreductive surgery and systemic treatment were included in the consolidation group and received intraperitoneal hyperthermic perfusion chemotherapy. Patients were recruited between January 1991 and December 1997. The intraperitoneal hyperthermic perfusion was performed with open-abdomen technique, using physiologic solution containing cisplatin 100 mg/m2, for 60 min in hyperthermic phase (41-43 degrees C). Intraperitoneal hyperthermic perfusion chemotherapy was locally and systemically well tolerated. The consolidation therapy group showed a better 5-year survival rate and lower recurrent disease rate, but differences were not statistically significant. Our results suggest that intraperitoneal hyperthermic perfusion chemotherapy is a feasible, well-tolerated, and promising alternative as consolidation therapy in ovarian cancer.

Quimioterapia intraperitoneal con hipertermia en el cáncer de ovario / Intraperitoneal Hyperthermic Chemotherapy in ovarian cancer treatment

Se presentan los resultados de un estudio prospctivo multicéntrico, con la administración de qimioterapia intraperito a cielo abierto, como tratamiento de consolidación en pacientes con cáncer de ovario Estadios IIIB y IIIC; posterior a una cirugía de citorreducción completa u óptima y 6 ciclos de Platino y ciclofosfamina. Se analiza tolerancia y se comparan tiempo libre de fermedad y sobrevida con los de un grupo control, con iguales estadios, posibilidades de citorreducción y terapia sistémica, que no aceptaron el second look y quimioterapia intraperitonal

Quimioterapia intraperitoneal con hipertermia en el cáncer de ovario / Intraperitoneal Hyperthermic Chemotherapy in ovarian cancer treatment

Se presentan los resultados de un estudio prospctivo multicéntrico, con la administración de qimioterapia intraperito a cielo abierto, como tratamiento de consolidación en pacientes con cáncer de ovario Estadios IIIB y IIIC; posterior a una cirugía de citorreducción completa u óptima y 6 ciclos de Platino y ciclofosfamina. Se analiza tolerancia y se comparan tiempo libre de fermedad y sobrevida con los de un grupo control, con iguales estadios, posibilidades de citorreducción y terapia sistémica, que no aceptaron el second look y quimioterapia intraperitonal

Conservative treatment vs. mastectomy without radiotherapy in aged women with breast cancer--a prospective and randomized trial.

OBJECTIVE: To determine whether tumorectomy with tamoxifen in women over 70 years achieves the same treatment results as mastectomy plus tamoxifen. MATERIAL AND METHODS: Prospective randomized analysis of 121 patients over 70 with breast cancer clinically negative axilla and tumor up to 4 cm diameter. Randomization was according to even or odd birth month. Branch A: Madden operation + tamoxifen 20 mg OD (once/day). Branch B: Tumorectomy to disease free margins + tamoxifen 20 mg OD. RESULTS: Survival rate of five years for the Madden operation was 69% and for tumorectomy 71.4% with a mortality from other causes of 23.1%. Survival probability (specific death) at 5 years was of 93.4% for the Madden group and 95.2% for tumorectomy. A significant increase of the mortality was observed in those patients that had recurrences, no matter of treatment given. Specific death cause did not vary with age, but did for other causes, this being significant. CONCLUSIONS: Tumorectomy plus tamoxifen demonstrated to be as effective as Madden Op. plus tamoxifen in women over 70 years with T1-T2-N0 disease.

Endometrosis intestinal / Bowel Endometriosis

El tratamiento de la endometrosis, patología habitual en mujeres en edad reproductiva y cuya etiología es desconocida, es tema de controversia. La localización intestinal de esta patología es rara y su diagnóstico preoperatorio difícil.Objetivo: Analizar los resultados del tratamiento de la endometrosis intestinal y efectuar revisión bibliográfica....La endometrosis intestinal es una patología poco frecuente, difícil de diagnosticar en forma preoperatoria y cuyo tratamiento de elección varía de acuerdo con la edad de presentación, deseos de fertilidad, y localización de las lesiones. La resección de la zona afectada, asociada a una anexectomía bilateral, lleva a la cura de la paciente

Endometrosis intestinal / Bowel Endometriosis

El tratamiento de la endometrosis, patología habitual en mujeres en edad reproductiva y cuya etiología es desconocida, es tema de controversia. La localización intestinal de esta patología es rara y su diagnóstico preoperatorio difícil.Objetivo: Analizar los resultados del tratamiento de la endometrosis intestinal y efectuar revisión bibliográfica....La endometrosis intestinal es una patología poco frecuente, difícil de diagnosticar en forma preoperatoria y cuyo tratamiento de elección varía de acuerdo con la edad de presentación, deseos de fertilidad, y localización de las lesiones. La resección de la zona afectada, asociada a una anexectomía bilateral, lleva a la cura de la paciente

Uretropexia retropubiana transvaginal (modificacion de la operacion de Pereyra). / Transvaginal uretropexia retropubic (modification of Pereyras surgical technic)

Se presenta la tecnica quirurgica de la operacion de Pereyra modificada, detallando dichas modificaciones. Se analizan 30 casos efectuados entre los anos 1979 y 1981 en el Servicio de Ginecologia del Policlinico Don Bosco, comparando sus resultados y su adaptabilidad a las situaciones que acompanan a la incontinencia de orina de esfuerzo

Uretropexia retropubiana transvaginal (modificacion de la operacion de Pereyra). / Transvaginal uretropexia retropubic (modification of Pereyra's surgical technic)

Se presenta la tecnica quirurgica de la operacion de Pereyra modificada, detallando dichas modificaciones. Se analizan 30 casos efectuados entre los anos 1979 y 1981 en el Servicio de Ginecologia del Policlinico Don Bosco, comparando sus resultados y su adaptabilidad a las situaciones que acompanan a la incontinencia de orina de esfuerzo