Effects of the Use of Automatic Tube Current Modulation on Patient Dose and Image Quality in Computed Tomography

Objectives: The frequency of abdominal computed tomography examinations is increasing, leading to a significant level of patient dose. This study aims to quantify and evaluate the effects of automatic tube current modulation (ATCM) technique on patient dose and image quality in contrast-enhanced biphasic abdominal examinations

Primary versus Repeated Cytoreduction for Peritoneal Metastasis: A paired Analysis of Surgical Outcomes

Background:Cytoreductivesurgery(CRS) with hyperthermic intraperitoneal chemotherapy(HIPEC) has becomethe treatment of choice for resectable peritoneal metastasis(PM) to improve theoverall survival of these patients. It’s so difficult to predict how the morbi-mortalityresults and oncologic outcomes will be in repeated CRS(re-CRS). Objectives:Toevaluate the surgical and oncologic outcomes of primary CRS&amp;HIPEC and re-CRS&amp;HIPEC.Methods: Prospectivelymaintained database of 661 PM patients treated with potentially curative intentCRS&amp;HIPEC thorough the years of 2007 and 2020 was evaluated. Re-cytoreductive surgery was performed in51 of them. Seven of these patients underwent CRS for the third time. The median age was 54 (ranging, 16-76) yearsand 72.5 % of the patients was female. The most common primaries were ovarian(39.2%)and colorectal(37.2%) tumors. The median Peritoneal Cancer Index(PCI) was 7(ranging, 3-21) and 84.3% of the patients underwent CC-0. Allstandart clinico-pathological characteristics, re-operative findings, morbi-mortalityresults, and final oncologic outcomes were reviewed and were compared with thoseof patients who had primary CRS&amp;HIPEC.Results: Themedian operating time was 300 minutes(range, 120–570) and 305 minutes(ranging,120–650) during the primary CRS and re-CRS. While less than five organs wereresected in 82.7%(n=42) of the patients who underwent primary CRS, it was84.3%(n=43) for the patients who underwent re-CRS. The median length of hospital stay(LoHS) after primaryCRS and re-CRS were 15 days(ranging, 4-48) and 12 days(ranging, 5-90), respectively.Themorbidity rates were 31.3%(n=16) and 7.8%(n=4), respectively. Thehigh grade morbidity rate was lower in re-CRS group(grade III-IV 21.5% vs 7.8%).The mortality rates were similar in between the patients who underwent primaryCRS(5.8%) and re-CRS(5.8%). When the patients who underwent CRS for the thirdtime were compared with patients who underwent re-CRS, no significantdifference was found in terms of surgical outcomes. Thepatients in the group who underwent re-CRS had significantly shorter meanhospital(LoHS)(p&lt;0.05) and lower postoperative high grademorbidity(p&lt;0.05) than the patients in the group who underwent primary CRS.The overall survival of the patients in the primary CRS group was 81.29 months,whereas it was 79.77 months in the re-CRS group. The3- and 5-year survival rates were lower in re-CRS group(17% and 5% vs 22% and11%), respectively.Conclusions: Re-CRSand HIPEC can be safely and effectively performed with acceptablemorbi-mortality results and oncologic outcomes in carefully selected andintensely followed-up PM patients at experienced centers.Key words: Repeated cytoreductive surgery, hyperthermicintraperitoneal chemotherapy, peritoneal metastasis.</p

Hipertermik intraperitoneal kemoterapi ile sitoredüksiyon sonrası gastrointestinal anastomoz kaçağı için risk faktörleri

BACKGROUND: Gastrointestinal anastomotic leak (GAL) is a major cause of morbidity and mortality after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to determine the risk factors associated with GAL in peritoneal metastases (PM) surgery. METHODS: Patients who underwent CRS and HIPEC with gastrointestinal anastomosis were included. Charlson Comorbidity Index (CCI) and Eastern Cooperative Oncology Group (ECOG) performance status were used to assess preoperative condition of the patients. GAL was recorded as gastrointestinal extralumination diagnosed clinically, radiologicaly, or during reoperation. RESULTS: Among 362 patients who were analyzed, the median age was 54 years, 72.6% were female, and the most common histopathologies were ovarian cancer (37.8%) and colorectal (36.2%) cancer. The median Peritoneal Cancer Index was 11 and 80.1% of the patients underwent complete cytoreduction. A single anastomosis was performed in 293 (80.9%) patients, two anastomoses in 51 (14.1%) and three anastomoses in 18 (5%) patients. Diverting stoma was performed in 43 (11.8%) patients. GAL was seen in 38 (10.5%) patients. Smoking (p<0.001), ECOG performance status (p=0.014), CCI score (p=0.009), pre-operative albumin level (p=0.010), and number of resected organs (p=0.006) were significantly associated factors with GAL. Independent risk factors for GAL were smoking (Odds Radio [OR]: 6.223, confidence interval [CI]: 2.814-13.760; p<0.001), CCI score ≥7 (OR: 4.252, CI: 1.590-11.366; p=0.004), and pre-operative albumin level ≤3.5 g/dl (OR: 3.942, CI: 1.534-10.130; p=0.004). CONCLUSION: Patient-related factors such as smoking, comorbidity, and pre-operative nutritional status had an impact on anasto-motic complications. Proper patient selection and prediction of an index patient requiring a prehabilitation program with a high level of care are essential prerequisites to obtaining lower anastomotic leak rates and improving outcomes in PM surgery.AMAÇ: Gastrointestinal anastomoz kaçağı (GAK), sitoredüktif cerrahi (SRC) ve hipertermik intraperitoneal kemoterapi (HİPEC) sonrası önemli bir morbidite ve mortalite nedenidir. Bu çalışmanın amacı peritoneal metastaz (PM) cerrahisinde GAK ile ilişkili risk faktörlerini belirlemektir. GEREÇ VE YÖNTEM: Çalışmaya gastrointestinal anastomozlu SRC ve HİPEK uygulanan hastalar dahil edildi. Hastaların ameliyat öncesi durumunu değerlendirmek için Charlson Komorbidite İndeksi (CCI) ve Eastern Cooperative Oncology Group (ECOG) performans durumu kullanıldı. GAK klinik, radyolojik veya yeniden ameliyat sırasında teşhis edilen gastrointestinal ekstralüminasyon olarak kaydedildi. BULGULAR: Analiz edilen 362 hastanın ortanca yaşı 54 idi. Hastaların %72.6’sı kadın ve en sık görülen histopatolojiler over kanseri (%37.8) ve kolorektal kanser (%36.2) idi. Medyan Periton Kanser İndeksi 11 idi ve hastaların %80.1’ine tam sitoredüksiyon uygulandı. İki yüz doksan üç (%80.9) hastada tek anastomoz, 51 (%14.1) hastada iki anastomoz ve 18 (%5) hastada üç anastomoz yapıldı. Kırk üç (%11.8) hastaya saptırıcı stoma uygulan-dı. Otuz sekiz (%10.5) hastada GAK görüldü. Sigara kullanımı (p<0.001), ECOG performans durumu (p=0.014), CCI skoru (p=0.009), preoperatif albümin düzeyi (p=0.010) ve rezeke edilen organ sayısı (p=0.006) GAK ile anlamlı ilişkili faktörlerdi. GAK için bağımsız risk faktörleri sigara (OR: 6.223, CI: 2.814–13.760; p<0.001), CCI skoru ≥7 (OR: 4.252, CI: 1.590–11.366; p=0.004) ve preoperatif albümin seviyesi ≤3.5 g/dl (OR: 3.942, CI: 1.534–10.130; p=0.004) idi. TARTIŞMA: Sigara kullanımı, komorbidite ve ameliyat öncesi beslenme durumu gibi hasta ile ilişkili faktörlerin anastomoz komplikasyonları üzerinde etkisi vardı. Uygun hasta seçimi ve yüksek düzeyde bakım gerektiren prehabilitasyon programı ihtiyacı olan indeks hastanın tahmini, daha düşük anastomoz kaçak oranları elde etmek ve PM cerrahisinde sonuçları iyileştirmek için temel ön koşullardır

Urgent Relaparotomies in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background:Urgentre-laparotomy(URL) can be accepted as an important index of quality indicatorin cytoreductive surgery(CRS) and hyperthermic intraperitonealchemotherapy(HIPEC). Complications after CRS are usually associated withshortened survival, early recurrence of primary tumor, exhaustion of center’ssources, and high costs. However, reports of URL tend to be scarce, very limited,and fragmented.Objectives:Toevaluate/determine the morbi-mortality outcomes of the urgent re-laparotomizedpatients treated with CRS and HIPEC. Methods:Prospectivelymaintained database of 661 patients treated with potentially curative intent ofCRS&amp;HIPEC in years of 2007 and 2020 were evaluated. URL was done for 28patients as planned re-exploration(4.2%): 22(78.6%) of them was female. Themedian age was 57 year (ranging, 24 to 76). There were 22(78.6%) patients over65 years old. Sixty-four(n=18) percent of the URL patients were receivedneoadjuvant chemotherapy. All standart clinico-pathological characteristics,re-operative findings, and final outcomes were analyzed. The well-knownimmunoscores such as neutrophile-lymphocyte(N/L), neutrophile-thrombocyte (N/T),and CRP-albumin ratios(CAR) were determined.Results: Themain indication for URL was small bowel anastomotic leak(n=13; 46.4%). Theabdominal wall disruption(n=5; 17.9%) was the second indication. The frequentlocalization of damaged organ was again small bowel. The 28.6% of patients(n=8)were re-operated in early postoperative period(in 7 days), whileas the rest ofthem [71.4%(n=20)] in 90 days. There was only one re-URL patient in thisseries. Many of them(n=16; 57.1%) had more than one co-morbidities. Delvinginto the overall group, there were Dindo-Clavien(D-C) grade I-II complicationsin 104(16.4%) patients and D-C grade III-IV in 88(13.9%) patients, whereas inURL patient group, D-C grade III-IV complications were seen in 22(78.6%). Inthis prospective cohort, the mortality rate was 3.2%(n=20) without anyre-exploration. However, six(21.4%) patients were also lost in URL patients.The main reason for failure-to-rescue was sepsis due to entero-enteralanastomotic leak. In four of them, multiple co-morbidities were affected thepost-URL care. Fifty percent of mortal patients had neoadjuvant chemotherapy.The cut-off PCI scores of URL, saved-URL, and lost-URL patients were 13, 14,and 12, respectively. CC-0 score was detected in 23 URL patients in whom fourof them were lost, whileas CC-1 in 5 in whom two of them were lost. ForURL-patients, pre-urgent re-laparotomy median N/L, N/T, and CAR values were9.12(ranging, 1.72 to 37.5), 0.03(ranging, 0.01 to 0.12), and 41.4(ranging, 4.2to 181.3), respectively. Interestingly, N/L and CAR values(4.71 and 28.8)estimated before pre-CRS were also significantly higher(p=.01 and p&lt;.01)inpatients who were going to be treated with URL. These immunoscore values didnot show any association in between pre-CRS and pre-URL mortal patients.Conclusions:Thejudgemental factors at work were complex in even planned URL. The overallsurvival depends almost entirely on the severity of disease. Patients with highrisk factors could be selected to an intense care postoperatively for closemonitoring. Timely intervention and proper management strategy are utmost importantissues to lower further morbi-mortality in patients treated with URL.&nbsp;</p

Tumoral and Parenchymal Morphological Assessment in Liver Metastases of Colorectal Carcinoma: Micrometastasis, Peritumoral Lymphocytes, Tumor Budding and Differentiation are Potential Prognostic Factors

Introduction: Various potential prognostic histopathologic factors for colorectal carcinoma liver metastasis have been proposed. However, there is still no consensus on pathological reporting of colorectal carcinoma liver metastasis resection materials. The aim of this study was to investigate the relation between selected tumoral and parenchymal histopathologic features and prognostic factors for better characterization and prognostic prediction of the patients with colorectal carcinoma liver metastasis. Methods: Hematoxylin-eosin stained slides from 100 patients who underwent hepatic resection were evaluated. Pathologic characteristics; including number of tumor nodules, largest tumor size, status of surgical margin, tumor distance to closest margin, tumor necrosis, the presence of tumor capsule, tumor differentiation, perineural and lymphovascular invasion, micrometastasis, tumor budding, peritumoral lymphocytic infiltrate and parenchymal features including steatosis, steatohepatitis, lobular inflammation, confluent necrosis, hepatocyte ballooning, portal inflammation were assessed. For 49 patients who were treated with preoperative chemotherapy, tumor regression grade and chemotherapy-related parenchymal changes such as sinusoidal damage, venous obstruction, nodular regenerative hyperplasia, steatosis and steatohepatitis were also evaluated. Results: The presence of lymphovascular invasion (p < 0.001), micrometastasis (p=0.004), absent or mild peritumoral lymphocytic infiltration (p =0.013), high tumor budding score (p=0.033) and moderate/poor differentiation (p=0.022) were significantly associated with shorter overall survival. Lymphovascular invasion (p < 0.001) was an independent predictor of mortality in multivariate analysis. Conclusions: We conclude that tumor differentiation, lymphovascular invasion, micrometastasis, peritumoral lymphocytic reaction and tumor budding score are potential prognostic histopathological features and candidates for inclusion in pathology reports of colorectal carcinoma liver metastasis resections