Systemic chemotherapy and pressurized intraperitoneal aerosol chemotherapy (PIPAC): A case report of a multimodal treatment for peritoneal metastases of pancreatic origin

Introduction: Pancreatic ductal adenocarcinoma (PDAC) with peritoneal metastases (PM) has a dismal prognosis and palliative systemic chemotherapy, which represents the standard treatment option, has significant pharmacokinetics limitations and low efficacy. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new method of drug delivery that is expected to maximize exposure of peritoneal nodules to antiblastic agents. A combination of systemic chemotherapy and PIPAC may be valuable. Presentation of case: A 55 years old male affected by PDAC with synchronous PM underwent a multimodal treatment comprising systemic chemotherapy and PIPAC without any procedural-related adverse events. Tumor genomic profiling evaluation from peritoneal biopsies addressed further tailored systemic chemotherapy. Discussion: The presented case illustrates the possibility of adding PIPAC to systemic chemotherapy with a fair tolerance profile and good quality of life while allowing monitoring of therapy-response and tailoring of the antiblastic treatment

Prognostic Factors for Surgical Failure in Malignant Bowel Obstruction and Peritoneal Carcinomatosis

Introduction: Patients with peritoneal metastasis frequently develop malignant bowel obstruction (MBO). Medical palliative management is preferred but often fails. Conversely, the role of palliative surgery remains unclear and debated. This study aims to identify patients who could benefit from invasive surgical interventions and factors associated with successful surgical palliation. Materials and Methods: In this retrospective study, 98 consecutive patients who underwent palliative surgery for MBO over 5 years were reviewed. We evaluate as the primary outcome surgical failure to select patients who could benefit from palliative surgery, avoiding unnecessary surgery. A prognostic score was developed based on a logistic regression model to identify patients at risk of surgical failure. The score was evaluated for overall accuracy by receiver operating characteristic curve analysis. Results: Palliative surgery was achieved in 76 (77.5%) patients. The variables that were found to be significant factors for surgical failure are recurrent disease (P = 0.015), absence of bowel obstruction (P < 0.001), absence of bowel distension (P < 0.001), and mesenteric involvement (P = 0.001) and retraction (P < 0.001). The absence of bowel distension (P = 0.046) and bowel obstruction (P = 0.012) emerged as independent predictors of surgical failure. Carcinomatosis level assessment for peritoneum score, based on these factors, was built to evaluate the risk of surgical failure. Conclusion: Our proposed scoring system might help select patients most likely to benefit from palliative surgery

The new retained foreign body! Case report and review of the literature on retained foreign bodies in laparoscopic bariatric surgery

The advent of laparoscopic surgery has created a set of peculiar morbidities. As the laparoscopic devices, also the type of retained foreign bodies has changed. We present a case of unusual, apparently isolated and recurrent lung abscess, pleural effusion and poorly evident subphrenic abscess after laparoscopic gastric bypass, due to a retained Endo-Catch bag. A 27-year-old obese female underwent an uneventful laparoscopic Roux-en-Y gastric bypass. After surgery she developed a left basal lung abscess, that resolved in two weeks with heavy antibiotic therapy, while radiological abdominal imaging was apparently normal. Patient was discharged on p.o. day 30. After two months, she presented with fever and dyspnoea and no gastrointestinal complaints. Chest and abdominal computer tomography showed a left recurrent abscess with effusion but this time a 3 cm subphrenic mass with metallic clips inside was demonstrated on CT scan. Patient was treated with an explorative laparoscopy that identified an Endo-Catch bag with the jejunal blind loop inside. Postoperative left lung abscess can be a warning of a suphrenic surgical complication. Laparoscopic surgery requires even more attention to retained foreign bodies due to the reduced visibility of the surgical field. The recommendation to enforce recording of laparoscopic maneuvers is mandatory

Vacuum-assisted healing of a devastating retroperitoneal colonic perforation with a homemade device

Vacuum-assisted healing of a devastating retroperitoneal colonic perforation with a homemade devic

Gastroblastoma in old age

Gastroblastoma is a rare, distinctive gastric biphasic tumour affecting both sexes, with metastatic potential. To the best of our knowledge, 11 cases have been published so far, solidly supported by morphology, immunophenotype, and, in four instances, by identification of a characteristic MALAT–GLI1 fusion gene.1-6 A twelfth ‘gastroblastoma’, questionable because of the presence of cellular atypia significantly deviating from previous canonical examples, has been reported.7 A gastroblastoma‐like duodenal neoplasm has also been described.8 Finally, a series of six extragastric tumours harbouring GLI1 rearrangements has been published, showing focal cytokeratin positivity and scattered tubular structures in one case (bearing an ACTB–GLI1 fusion), leading to the proposal of an entity defined as ‘malignant epithelioid neoplasm with GLI1 fusions’.9 All reported canonical gastroblastomas occurred within the third decade of life, except for one in a patient aged 56 years. Grossly, gastroblastomas form multinodular/lobulated, often partly cystic/haemorrhagic, masses involving the gastric wall layers. Histologically, these tumours are biphasic, featuring spindle‐cell and epithelioid components, immature but non‐pleomorphic, with low mitotic activity. On immunohistochemistry, gastroblastoma variously expresses CD10, vimentin and cytokeratins, the former two prevailing in the spindle cells, and the latter prevailing in the epithelioid cells. The recently reported consistent finding of a MALAT1–GLI1 fusion gene in gastroblastoma allows a solid differential diagnosis with other biphasic neoplasms such as synovial sarcoma, carcinosarcoma, and teratoma. Intriguingly, the same genetic defect has been detected in some plexiform fibromyxomas, which are gastric mesenchymal tumours that are definitely benign, lack biphasic morphology and are most likely unrelated to gastroblastoma.6, 9 Table 1 summarises the features of the gastroblastomas published so far. Herein, we report a gastric antral tumour with morphological, immunophenotypic and genotypic features consistent with gastroblastoma in a 79‐year‐old male

Laparoscopic approach to recurrent incisional hernia repair. A 3-year experience

Background: Incisional hernias are one of the most frequent complications of open abdominal surgery. The incidence of relapses after a conventional repair procedure is higher in recurrent than in primary cases (30%-50% vs. 11%-20%). The laparoscopic approach can prevent the complications associated with the conventional approach when dealing with recurrent incisional hernias. The aim of this study was to evaluate the efficacy of laparoscopic treatment in such cases. Materials and Methods: We prospectively analyzed data from 41 consecutive patients with recurrent incisional hernias, who submitted to a laparoscopic repair procedure with an expanded polytetrafluoroethylene Dual Mesh (Gore-Tex® Dual Mesh® Plus Biomaterial; W.L. Gore 8 Associates) from December 2001 to December 2004. All of the patients underwent clinical follow-up at 1, 6, and 12 months and then yearly. An ultrasound scan of the abdominal wall was performed at 6 and 12 months after the procedure. The parameters considered for the analysis were: mesh size, operating time, hospital stay, postoperative complications, and recurrences. Results: The defects were usually localized along midline laparotomies. The mean mesh size was 400 cm2, the mean operating time was 68 minutes, and the mean length of hospital stay was 2.7 days. Complications were encountered in 17% of patients. The mean follow-up was 38 months (range, 18-54). Recurrence was reported in 1 case only (2.4%), which occurred within the first 6 months after the operation. Conclusions: The laparoscopic repair of recurrent incisional hernia seems to be an effective alternative to the conventional approach, as it can give lower recurrence and complication rates

Cytoreductive surgery and mitomycin C hyperthermic intraperitoneal chemotherapy with CO2 recirculation (HIPEC-CO2) for colorectal cancer peritoneal metastases: analysis of short-term outcomes

Peritoneal dissemination from colorectal cancer (CRC) has long been associated with unfavorable prognosis. However, in the last decades, the combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) was able to obtain up to 30% 5-year survival rate in selected centers. Despite the wide diffusion of CRS and HIPEC, until now, there are no clear recommendations on the drug of choice for HIPEC nor its technique, and safety and efficacy data of HIPEC regimens and techniques are lacking. We performed a retrospective analysis of a prospectively maintained database of 26 CRS and mitomycin C HIPEC with CO2 recirculation (HIPEC-CO2) for CRC peritoneal metastasis (PM) performed at our center. The main endpoints were morbidity, mortality, the temperature of perfusate during HIPEC and metabolic changes throughout the procedure. Morbidity was assessed by analysis of postoperative adverse events according to the Common Terminology Criteria for Adverse Events (CTCAE version 4.0). Continuous variables of Arterial Blood Gas (ABG) analysis at three time-points were compared by the Student t test. There were no postoperative deaths. The overall grade 3–4 CTCAE complications rate at 30 days was 38.4%, with ten severe adverse events occurring to six (23.0%) patients. The temperature within HIPEC perfusion maintained between 41 and 42 °C in all cases and we experienced no HIPEC-related intraoperative complications. We observed a significant difference between all baseline and pre-HIPEC ABG parameters evaluated but no statistically significant differences between pre- and post-HIPEC ABG outcomes. This study shows that mitomycin C HIPEC-CO2 is feasible and has a safety profile comparable to that of other HIPEC techniques reported in the literature. Further research is needed to validate prospectively the safety and efficacy of this technique

In memory of professor arsenio veicsteinas: aerobic fitness in female paralympic athletes with a locomotor impairment

Purpose: To investigate cardiovascular health and aerobic fitness (oxygen uptake peak—VO2peak) of female Paralympic athletes (FPA) competing in sports with different energy expenditure (EE). Methods: Forty-seven FPA with a locomotor impairment and different health conditions -HC (31 with a spinal cord injury, 1 with spina bifida and 15 with other HC, e.g. lower limb amputation and poliomyelitis, etc.), selected to compete in 6 following Paralympic Games were submitted to the health and fitness evaluations (HFE) carried out in Rome (Institute of Sports Medicine and Sciences) on the basis of the agreements among Italian Paralympic Committee, Italian Olympic Committee and Sapienza, University of Rome. Data from the HFE were retrospectively analysed. The HFE included: 1) a comprehensive maximal incremental cardiopulmonary exercise test (CPET) carried out with an arm cranking ergometer with pulmonary, metabolic and electrocardiographic monitoring to assess VO2peak; 2) two- dimensional and doppler echocardiography to assess end-diastolic and end-systolic left ventricular (LV) cavity dimensions, anterior ventricular septal and posterior free- wall thicknesses and to calculate LV mass also indexed to body surface area (LVM/BSA). The 47 FPA were divided into 2 groups (G) depending on the EE of the practiced sport. G1 included 35 FPA competing in lower EE sports (table tennis, fencing, archery, field events in athletics and alpine skiing). G2 included 12 FPA competing in higher EE sports (sitting nordic skiing, long distance track events in athletics and swimming). Results: VO2peak (ml/kg/min) measured in the FPA of G2 (39.04 ± 16.52) was significantly higher than that measured in FPA of G1 (24.1 ± 1.35). No difference was found in the LVM/BSA (g/m2) of the FPA of the 2 groups, 74.7 ± 15.17 vs 78.4 ± 9.62, respectively in G1 and in G2. Conclusions: VO2peak, the synthetic parameter of the body’s overall ability to take in oxygen from the external environment, transport it in the body and have it utilised by working muscles, as well known, is determined by the maximal cardiac output (cardiac, central adaptations) and the maximal arterious-venous difference of the oxygen. The differences in VO2peak between the FPA competing in endurance sports are presumably determined by peripheral adaptations

Intra-abdominal vacuum-assisted closure (VAC) after necrosectomy for acute necrotising pancreatitis. Preliminary experience

Infection of pancreatic necrosis, although present in less than 10% of acute pancreatitis, carries a high risk of mortality; debridment and drainage of necrosis is the treatment of choice, followed by 'open' or 'close' abdomen management. We recently introduced the use of intra-abdominal vacuum sealing after a classic necrosectomy and laparostomy. Two patients admitted to ICU for respiratory insufficiency and a diagnosis of severe acute pancreatitis developed pancreatic necrosis and were treated by necrosectomy, lesser sac marsupialisation and posterior lumbotomic opening. Both of the patients recovered from pancreatitis and a good healing of laparostomic wounds was obtained with the use of the VAC system. Most relevant advantages of this technique seem to be: the prevention of abdominal compartment syndrome, the simplified nursing of patients and the reduction of time to definitive abdominal closure. © 2010 Blackwell Publishing Ltd and Medicalhelplines.com Inc

Secondary Laparoscopic Cytoreduction in Recurrent Ovarian Cancer: A Large, Single-Institution Experience

Study Objective: To analyze the feasibility and safety of laparoscopic secondary cytoreductive surgery in a retrospective series of patients with platinum-sensitive recurrent ovarian cancer. Design: Retrospective cohort study (Canadian Task Force classification II-2). Setting: Catholic University of the Sacred Heart, Rome, Italy. Patients: Between October 2010 and October 2016, 58 patients with recurrent ovarian cancer were selected for a retrospective analysis of data. Interventions: All patients underwent a laparoscopic secondary cytoreduction with single or multiple procedures. Results: The most frequent pattern of recurrence was peritoneal (48.3%); 6 patients (10.3%) experienced parenchymal disease (spleen, n = 5; liver, n = 1), and 24 patients (41.4%) had lymph node recurrence. Complete debulking was achieved in all patients. The median operative time was 204 minutes (range, 55–448 minutes), median estimated blood loss was 70 mL (range, 20–300 mL), and the median length of hospital stay was 4 days (range, 1–21 days). Four patients (6.8%) experienced intraoperative complications. Early postoperative complications were documented in 6 patients (10.3%), but only 1 G3 complication was noted. The median duration of follow-up since secondary cytoreduction was 24 months (range, 9–71 months). Twenty-one patients (36.2%) experienced a second disease relapse. The median progression-free survival (PFS) was 28 months, and the 2-year PFS was 58.7%. Five patients died (8.6%); the 2-year overall survival was 90.7%. Conclusions: For selected patients, laparoscopy is a feasible and safe approach to optimal cytoreduction for patients with recurrent ovarian cancer