Preliminary Results of Hyperthermic Intraperitoneal Intraoperative Chemotherapy as an Adjuvant in Resectable Pancreatic Cancer

Background and Aims. 5-year survival in patients with pancreatic cancer is poor. Surgical resection is the only potentially curative resection. The results of adjuvant treatment either with chemotherapy or with radiotherapy have been contradictory and the incidence of local-regional recurrence remains high. If local-regional recurrence is controlled survival may be expected to increase. Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) may be used in order to control local-regional recurrences. The purpose of the study is to identify the effect of HIPEC in patients with pancreatic cancer undergoing potentially resection. Patients and Methods. From 2007–2011, 21 patients, mean age 69.4 ± 9.5 (50–86) years, underwent tumor resection, and HIPEC with gemcitabine. The hospital mortality and morbidity rate was 9.5% and 33.3%, respectively. 5-year and median survival was 23% and 11 months, respectively. The recurrence rate was 50% but no patient developed local-regional recurrence. No patient was recorded with gemcitabine-induced toxicity. Conclusions. This clinical study of 21 patients is the first to combine an R0 pancreas cancer resection with HIPEC. Increased morbidity and mortality from intraoperative gemcitabine was not apparent. Patients with pancreatic cancer undergoing potentially curative resection in combination with HIPEC may be offered a survival benefit. Data suggested that local-regional recurrences may be greatly reduced. Further studies with greater number of patients are required to confirm these findings

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

The effect of simvastatin on the complications after intraperitoneal mesh placement in a septic environment: experimental study in rats

Background: Hernia repair with the use of prosthetic meshes was a very important step forward in surgery, but it was accompanied by a series of complications. These were mainly caused by to the presence of a foreign body, the mesh. Intraperitoneal mesh placement, especially in a septic or potentially septic environment, represents a relatively dangerous situation for postoperative complications. The aim of the present experimental study was to investigate the effect of simvastatin on the complications of a hernia repair with an intraperitoneal mesh in a septic environment. Materials and method: Three groups of 20 Wistar rats were categorized into groups A, B and C. All rats underwent laparotomy and ciprofloxacin was administered. In groups B and C an enterectomy was performed, while in group C simvastatin was also administered intraperitoneally at a dose of 0.57 mg/kg. After the animals were sacrificed on day 21, laparotomy was performed again and adhesion formation was recorded while a part of the mesh was sent for cultivation. The degree of neovascularization and fibrosis were also histologically evaluated. Blood samples were taken on the 7th, 14th, and 21st postoperative days to assess the following inflammatory markers: TNF-a, IL-1a, and IL-6.Results: In group C where simvastatin was administered, the presence of significantly fewer adhesions as well as better histological results were reported compared to group B, where only ciprofloxacin was administered. In addition similar results were found in group C and the control group. Regarding the measurements of IL-1a, IL-6 and TNF-a significant effect was found οn all of them in the simvastatin group. Conclusion: Intraperitoneal administration of simvastatin provided results almost identical to mesh placement in a clean environment. Being an easily accessible drug we believe that it could become a new agent that will help us minimize the postoperative complications caused by intraperitoneal mesh placement.Εισαγωγή: Η αποκατάσταση των κηλών με τη χρήση προσθετικών πλεγμάτων αποτέλεσε ένα πολύ σημαντικό βήμα προόδου στη χειρουργική. Παρόλα αυτά συνοδεύτηκε από μία σειρά επιπλοκών οι σημαντικότερες από τις οποίες οφείλονται στην παρουσία ενός ξένου σώματος, του πλέγματος. Η τοποθέτηση ενδοπεριτοναϊκού πλέγματος, ειδικά σε σηπτικό ή δυνητικά σηπτικό περιβάλλον, αποτελεί μία σχετικά επικίνδυνη για την εμφάνιση των επιπλοκών κατάσταση. Σκοπός της παρούσας πειραματικής μελέτης ήταν να διερευνηθεί η επίδραση της σιμβαστατίνης στις επιπλοκές από την ενδοπεριτοναϊκή τοποθέτηση πλέγματος σε σηπτικό περιβάλλον. Υλικό και μέθοδος: Τρεις ομάδες από 20 επίμυες του στελέχους Wistar κατηγοριοποιήθηκαν στις ομάδες Α, Β και Γ. Σε όλους τους επίμυες εκτελέστηκε λαπαροτομία και χορηγήθηκε σιπροφλοξασίνη. Στις ομάδες Β και Γ πραγματοποιήθηκε εντερεκτομή, ενώ στην ομάδα Γ χορηγήθηκε και σιμβαστατίνη σε δόση 0,57mg/kg ενδοπεριτοναϊκά. Μετά τη θανάτωση των πειραματόζωων την 21η ημέρα εκτελέστηκε εκ νέου λαπαροτομία και καταγράφηκε ο σχηματισμός συμφύσεων, ενώ ένα μέρος του πλέγματος εστάλη για καλλιέργεια. Επίσης αξιολογήθηκε ιστολογικά ο βαθμός της νεοαγγειογένεσης και της ίνωσης. Την 7η, 14η και 21η μετεγχειρητική ημέρα έγιναν αιμοληψίες με σκοπό να εκτιμηθούν οι παρακάτω δείκτες φλεγμονής: TNF-a, IL-1a και IL-6. Αποτελέσματα: Στην ομάδα Γ που χορηγήθηκε η σιμβαστατίνη διαπιστώθηκε η παρουσία πολύ λιγότερων συμφύσεων καθώς επίσης και καλύτερα ιστολογικά αποτελέσματα σε σχέση με την ομάδα Β όπου χορηγήθηκε μόνο σιπροφλοξασίνη, ενώ τα αποτελέσματα ήταν περίπου όμοια με την ομάδα ελέγχου. Όσον αφορά τις μετρήσεις των IL-1a, IL-6 και TNF-a διαπιστώθηκε μεγάλη επίδραση σε όλες στην ομάδα της σιμβαστατίνης. Συμπεράσματα: Η ενδοπεριτοναίκή χορήγηση σιμβαστατίνης προσέφερε αποτελέσματα σχεδόν όμοια με τη χρήση πλέγματος σε καθαρό περιβάλλον. Καθώς αποτελεί ένα φάρμακο εύκολα προσβάσιμο και χωρίς μεγάλο κόστος, θεωρούμε ότι θα μπορούσε να αποτελέσει έναν νέο παράγοντα στην προσπάθεια μείωσης των επιπλοκών από την ενδοπεριτοναϊκή τοποθέτηση πλεγμάτων

Low-Grade Pseudomyxoma Peritonei Behaving as a High-Grade Disease: A Case Series and Literature Review

Patients with low-grade appendiceal mucinous carcinomas (LAMNs) treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have a favorable prognosis. However, a subgroup of patients presents a clinically aggressive course with disease progression despite receiving treatment. The purpose of this study is to report the experience of clinically aggressive LAMN patients treated by the same team, and to present a review of the literature. The cases of four patients with clinically aggressive LAMNs were reviewed. Clinical and histopathological characteristics were re-examined. Recurrences and the time of recurrence, as well as the survival time, were recorded. These patients were four men with clinically aggressive LAMNs treated with CRS plus HIPEC. One of them underwent CC-0 surgery, two underwent CC-1 surgery, and one underwent CC-3 surgery. All patients received systemic chemotherapy after surgery. Recurrence was recorded in three of the patients within 4–23 months after the initial treatment. Two of the patients underwent secondary CRS. Three patients died of disease recurrence within 13–23 months, and one is alive with a disease relapse at 49 months after his initial surgery. LAMNs were identified in both the initial specimens and the specimens obtained during reoperation. The prognosis of LAMN patients treated with CRS plus HIPEC is favorable. A small number of patients present a clinically aggressive course that is unresponsive to any treatment. Molecular and genetic studies are required to identify this group of LAMN patients who have an unfavorable prognosis

Cytoreductive Surgery Combined with Hyperthermic Intraperitoneal Intraoperative Chemotherapy in the Treatment of Advanced Epithelial Ovarian Cancer

Background/Aims. Intraperitoneal intraoperative hyperthermic chemotherapy (HIPEC) has been used in the treatment of ovarian cancer. The purpose of the study is to determine the efficacy of HIPEC after cytoreductive surgery in advanced ovarian cancer. Patients/Methods. From 2006 to 2010 patients with advanced ovarian cancer were enrolled in a prospective nonrandomized study to undergo cytoreductive surgery combined with HIPEC. Clinical and histopathological variables were correlated to hospital mortality, morbidity, survival, and recurrences. Results. The mean age of 43 women was 59.9±13.8 (16–82) years. The hospital mortality and morbidity rate were 4.7% and 51.2%, respectively. Complete cytoreduction was possible in 69.8%. The overall 5-year survival rate was 54%. The prognostic indicators of survival were the extent of prior surgery (=0.048) and the extent of peritoneal dissemination (=0.011). The recurrence rate was 30.2%. Conclusions. Maximal cytoreductive surgery combined with HIPEC is a well-tolerated, feasible, and promising method of treatment in advanced ovarian cancer

Morbidity and mortality of patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Abstract Background The purpose of this study was to record the incidence, and identify the prognostic variables of morbidity and mortality in patients with peritoneal malignancy undergoing cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Methods The files of patients with peritoneal malignancy who underwent CRS + HIPEC from 2015–2022 were retrieved. Morbidity and hospital mortality were recorded and correlated to a variety of clinical variables. Results A total of 44/192 (22.9%) patients were recorded with postoperative complications. Grade 3 and 4 complications were 12.5%. The possible prognostic variables of morbidity were the extent of peritoneal malignancy and the number of suture lines. The mortality rate was 2.5% (5 patients). The number of FFP units, and peritonectomy procedures were identified as possible prognostic variables of hospital mortality. Conclusions The morbidity rate in patients undergoing CRS + HIPEC is acceptable compared to morbidity of previous publications or major gastrointestinal surgical operations. The possible prognostic variables of morbidity are the extent of peritoneal malignancy, and the number of suture lines. The mortality rate is low. The possible prognostic variables of mortality are the number of FFP units, and the number of peritonectomy procedures