Indigenous way of hyperthermic intraperitoneal chemotherapy

Introduction: Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a form of highly concentrated, heated chemotherapy that is delivered directly to the abdomen intra-operatively. Currently for peritoneal surface malignancy (PSM), either primary or secondary from gastrointestinal (GI) or gynecologic cancers, cytoreductive surgery (CRS) combined with peri-operative HIPEC therapy is recommended. Aims & objectives: The primary objective of this case report is to show that in the current era of malignancy, resource poor centers can adopt our innovative way of HIPEC therapy and can treat peritoneal neoplasms which were considered to have only palliative treatment. Methods: After proper pre-operative work up, 61 year old lady diagnosed with adenocarcinoma of the sigmoid colon with peritoneal deposits was taken up for cytoreductive surgery and HIPEC. In the absence of a proper HIPEC machine, we used the hotline fluid warmer used by Anesthesiologists to heat the chemotherapy solution which was then re-circulated manually. Results: The patient had an excellent post-operative recovery and was discharged in a hemodynamically stable condition on post-operative day (POD) 6. She has completed 18 months of follow-up and has no signs of recurrence. Conclusions: To treat cancer like peritoneal neoplasm in resource-poor centers, the hotline machine can be a good option.

Which prognostic score for abdominal sepsis? Analysis of final results of PIPAS (Physiological Indicators for Prognosis in Abdominal Sepsis) study in a single center

Intra-abdominal infections (cIAIs) constitute an important cause of morbidity and mortality. Numerous risk factors may influence prognosis of cIAIs. This study aims to evaluate which parameters and scores may better predict prognostic outcomes in cIAIs. This is a single-center prospective observational study. Data from sixty-five patients were collected during a four-month period. Univariate and multivariate analysis for physiological parameters and ROC curves for SIRS, qSOFA and WISS scores were calculated in relation to mortality, intensive care unit (ICU) admission and surgical complications. Blood oxygen saturation level (SpO2), heart and respiratory rate, systolic blood pressure (SBP), level of consciousness, INR, C-reactive protein (CRP), white blood cells, source control and health care-acquired infections affect prognosis in cIAIs according to univariate analysis. On multivariate analysis level of consciousness, SpO2, CRP, diffuse peritonitis, INR and SBP significantly influenced prognosis in cIAIs. AUROC for WISS score were 0.89 for mortality, 0.86 for major complications, 0.76 for ICU admission. In our study many risk factors adversely affect prognostic outcomes in cIAIs; PIPAS study probably may provide even better results on that. Moreover, WISS score reached remarkable performance in predicting mortality and major surgical complications in abdominal sepsis; qSOFA did not achieve satisfactory results in none of analyzed outcomes.

The effect of hyperthermia (42°C) on the anti-tumoral effect of bromelain, N-acetyl cysteine, chemotherapeutic agents and their combinations - an in vitro evaluation

Bromelain, N-acetyl cysteine and their combinations show cytotoxicity at 37°C. Similarly, their combinations with common chemotherapeutic agents (gemcetabine, Mitomycin C, oxaliplatin and 5-FU) show enhanced cytotoxicity. Since, hyperthermia (42°C) inhibits cellular proliferation, we set out to determine if it would further enhance the effect of these agents. Tumour cells (pancreatic and colorectal) were grown in a 96 well plate and treated to various agents and their combinations at 37° and 42°C. The survival of cells at 72 hours was evaluated with sulfhordamine assay. Colony formation assay was performed to evaluate development of resistance to these agents and finally PAS staining was carried out to determine the effect of bromelain, Nacetylcysteine (NAC), oxaliplatin and their combinations on mucin secretion in ASPC-1 (pancreatic) cancer cells. Hyperthermia (42°C) enhanced cytotoxicity of certain agents or their combinations in some of the cell lines. It also showed the absence or a reduction of effect, with certain agents. Hyperthermia reduced colony formation in CFPAC cells and with agents (bromelain + NAC, gemcitabine, NAC + gemcitabine, Bromelain + NAC + Gemcitabine). A similar effect with 5FU, 5FU + NAC and 5FU + bromelain was observed. Hyperthermia reduced mucin secretion in ASPC-1 cells, with bromelain and its combinations with NAC and oxaliplatin. NAC as a single agent increased mucin with hyperthermia. The effect of hyperthermia on cytotoxicity of bromelain, NAC and their combinations with chemotherapeutic agents varied with agents, their combinations and cell types, showing an increase, null effect or a decrease. However, hyperthermia reduced colony formation and mucin secretion.

Gastric cancer indocyanine green lymph node navigation surgery: systematic review

Sentinel lymph node (LN) biopsy is a common practice to determinate if a lymphadenectomy is needed in various malignancies. Recent studies have investigated the possibilities to extend sentinel LN biopsy in gastric cancer. Indocyanine green (ICG) is a diagnostic reagent recently introduce in sentinel LN biopsy field. This review aims to determinate the feasibility to used ICG to detect sentinel LN in gastric cancer.

Abdominal pain and fever in a patient with familial periodic fever: an extremely rare mutation of the TNF receptor superfamily member 1A gene

Periodic fever syndromes (PFSs) are a clinically inhomogeneous group of diseases based on peculiar genetic mutations. PFSs have to be suspected in young patients presenting with recurrent attacks of abdominal pain, skin rashes, arthritis, myalgia and fever as soon as more prevalent diseases have been excluded. An unconsidered hypothesis of PFSs may lead in delaying the diagnosis and unnecessary medical and surgical treatments. In this article, we described the case of a young man presented to our attention due to recurrent abdominal pain and fever caused by TNF-receptor-associated periodic syndrome (TRAPS) sustained by the TNFRSF1A gene mutation.

Mucinous neoplasm of the appendix: management according to reviewed histologic spectral aspects

Of the diseases affecting the cecal appendix, mucinous neoplasms, although rare, are the most common epithelial tumor. They are often asymptomatic and diagnosed by anatomopathological exams of sections, collected during appendectomies due to acute appendicitis. These tumors have the potential to become malignant, and their early surgical handling are the most important prognostic factor. So, clinical, image, operatory and histologic spectral aspects should always take into account. The present study reports a case of mucinous neoplasm of the appendix that manifested with intestinal partial obstruction and suggests the need for a comprehensive and uniform classification, which could address the best disease first approach. The information was obtained through a patient records review, photographic documentation of the diagnostic tests and histologic study of operative specimen. In addition, the manuscript opens a discussion about the approach of choice of this complex neoplasia, since great variability persists in clinical and pathological records, due to variations in classifications and definitions. This variability in disease nomenclature may significantly impact the treatment and prognosis.

Different ways to manage indocyanine green fluorescence to different purposes in liver surgery: A systematic review

Fluorescent properties of indocyanine green (ICG) for hepatic tumor identification and features have been recently studied. The aim is to review the published data on the use of ICG enhanced fluorescence surgery during liver resection. A systematic search of literature was performed using MEDLINE, EMBASE, Cochrane and Web of Science libraries. For all eligible studies, the following data were extracted: study design, number of cases, management of indocyanine green (dose, time and method of administration), type of surgery, outcome variables, false positive and accuracy value, if reported. For statistical analysis, it was considered significant P<0.05, when published. 19 articles were fully analyzed and data were extracted. A total of 718 cases were globally analyzed as study group. No side effects of ICG were reported in any articles. 12 prospective observational, 1 randomized and 2 case-control studies were found. Three case reports and one experimental on animal model were also included. Detection of superficial lesions, segmental staining, biliary anatomy investigation (biliary leakage detection, biliary tree anatomy) were the main clinical application of fluorescence liver guided surgery. The overall quality of the data currently available is limited but the role of fluorescence guided liver surgery seems promising.

An innovative duodenal perforation surgical repair technique: the BIOPATCH technique

The treatment of duodenal perforations has scarce options and it is very difficult with an high failure rate. The aim of this work is to describe a new surgical technique that was used to treat ten patients suffering from duodenal perforation. The procedure based on the concept to enforce the duodenal suture with remodeling material allowing to the inflamed and oedematous tissues to heal without to be cut by the repairing stitches themselves, is performed with biological prosthesis patches. 90% of patients treated with this innovative technique experienced a complete healing of the duodenal perforation. This unique surgical technique not only proved to be safe, but it also solved the 90% of duodenal perforations in patients at risk to die.

WARNING in Surgery

Surgeons prescribing antibiotics have two potentially conflicting responsibilities. First, they should offer optimal therapy for all patients under their care by offering antibiotics. Second, they should preserve the efficacy of antibiotics and minimize the development of antimicrobial resistance (AMR). The Global Alliance for Infections in Surgery and the World Society of Emergency Surgery have promoted a coalition that should call for increased awareness and action across all surgical departments worldwide in order to combat AMR. The project has been named World Antimicrobial Resistance Nationally Internationally Networking Globally in Surgery (WARNING in Surgery).

A rare case of diaphragmatic hernia after cytoreductive surgery and hypertermic intraperitoneal chemotherapy

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is an effective therapeutic approach for selected patients with gastrointestinal and gynecological malignancies with peritoneal spread. The most frequent postoperative surgical complications are anastomotic leakage, digestive perforations, fistulas, intestinal obstruction, abscess and peripancreatitis. This report presents case of a patient with late postoperative diaphragmatic hernia after CRS and HIPEC. A 50- year-old woman previously treated with CRS and HIPEC for a pseudomyxoma peritonei was admitted to our unit with diagnosis of intestinal obstruction. At the CT scan a left diaphragmatic hernia involving the splenocolic flexure was found. Both stripping of the diaphragmatic peritoneum during CRS, sometimes combined with diaphragmatic resection and the heat of HIPEC might be responsible for such complication. The diaphragmatic hernia is rarely diagnosed after CRS and HIPEC. Surgical techniques for repair can be the direct suture of the defect or closure with synthetic or biological tissue, both are possible surgical techniques for repair with a good long term results.