Pleura and Peritoneum最新文献

Objectives: Malignant peritoneal mesothelioma (MPM) is a rare disease with unspecific abdominal symptoms which is therefore often diagnosed at an advanced stage. Curative therapy is delivered by radical surgery, whereas palliative therapy consists of systemic chemotherapy. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a laparoscopically applied chemotherapy which was invented to administer high doses of chemotherapy intraperitoneally in palliative cases of peritoneal malignancies.

Methods: The case of a male patient who received PIPAC treatment as individualized approach for unresectable malignant peritoneal mesothelioma is reported.

Results: The patient began treatment with PIPAC procedures in 2017 for MPM that was unresectable because of extensive disease on the small bowel and refused systemic chemotherapy as the usual standard of care. We initiated PIPAC with doxorubicin and cisplatin and could reach stable disease within one year of treatment so that the therapy was discontinued for 2.5 years. Due to progressive disease, PIPAC was continued resulting in stable disease for 2 years. In total, the patient received 24 PIPAC procedures with no major surgical or toxic side effects over seven years timespan.

Conclusions: We report the case of a patient with MPM who could reach long-term survival of seven years due to a total of 24 PIPAC procedures.

There is growing interest in the role of the microbiome in carcinogenesis, but few studies examine the microbiome of pseudomyxoma peritonei (PMP). This scoping review summarises the microorganisms identified in PMP samples and examines the evidence of their role in disease outcomes. The methodology was developed in accordance with the PRISMA-ScR framework and checklist. Nine relevant studies were included. Microbiological testing was performed on PMP samples from 85 patients. At the phylum level, Proteobacteria was detected in greatest relative abundance in tumour tissue, cellular and acellular mucin. The relative proportion of different phyla more closely resembled the gut microbiome in inflammatory bowel disease than in a healthy gut. High-grade specimens showed significantly higher bacterial density than low-grade specimens and non-neoplastic non-perforated appendix specimens. Survival data of 58 patients were published, correlating outcomes to pre-operative antibiotic administration. Observed differences were not statistically significant. There is evidence of an altered bacterial profile in PMP samples compared to a healthy gut microbiome, the significance of which is unclear. Significant methodological challenges remain in this field of study. This scoping review supports the need for further analysis of the PMP bacterial profile, using methodologies that incorporate controls and deliver taxonomic resolution at species level.

Objectives: peritoneal surface malignancy in children is rare with a dismal prognosis. This bicentric study evaluated CRS with HIPEC in patients aged 2-25 years.

Methods: Clinicopathological and treatment-related factors were retrospectively analyzed from 21 patients undergoing CRS and HIPEC between 2009 and 2022. Endpoints were feasibility, chemotherapeutic compound, complications, and overall survival (OS).

Results: The mean age was 20.4 years. The mean peritoneal cancer index (PCI) was 12.8. Mean follow-up period was 6.8 years. Median overall survival time was 2.4. 5-year survival rate was 42.9 %. 76.2 % had primary and 23.8 % recurrent disease. The most common primary tumor locations were colon (33.3 %) and appendix (14.3 %). Adenocarcinoma was the most common histological subtype (71.4 %). Univariable Cox regression analysis showed significant impaired OS after previous chemotherapy (p=0.46) and incomplete cytoreduction CCR-2 (p=0.43). No perioperative mortalities occurred. The incidence of major complications was 24 %.

Conclusions: Multimodal treatment can be considered in pediatric patients with peritoneal carcinomatosis. It presents a safe and feasible therapy with manageable complications and no perioperative mortality when performed by an experienced multidisciplinary team. Indication for CRS and HIPEC in children should be an individual decision by an interdisciplinary tumor board in the absence of better alternatives.

Objectives: To evaluate the implementation, compliance, and impact of the enhanced recovery after surgery (ERAS) protocol on perioperative outcomes in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for Stage IIIc ovarian cancer.

Methods: From September 2020 to March 2022, the ERAS protocol (62 perioperative and special consideration guidelines) was prospectively implemented in 75 patients. Based on compliance rates, patients were divided into three groups: Group A (<70 %, 13 patients), Group B (70 %-80 %, 52 patients), and Group C (>80 %, 10 patients). Compliance rates, length of stay, postoperative complications, and readmission rates were analyzed. Ethical committee approval was obtained.

Results: The cohort's average compliance was 74.5 %, with group averages of 68.4 %, 74.4 %, and 82.5 % (p<0.001). Tolerance to normal diet (p=0.008), postoperative ileus (p=0.161), and mobilization rates (p<0.001) improved with higher compliance. Higher compliance also led to shorter hospital stays (p=0.008) and ICU stays (p<0.001). Complications like ileus and infections were lowest in Group C. No significant differences were found in re-surgery or mortality.

Conclusions: Implementation of the ERAS protocol in patients undergoing CRS and HIPEC for Stage IIIc ovarian cancer is feasible and associated with improved postoperative outcomes. Higher compliance with ERAS guidelines significantly reduced length of hospital and ICU stay, enhanced early mobilization, and improved tolerance to diet, while also decreasing postoperative complications. Compliance above 80 % is necessary for achieving optimal outcomes and protocol modifications may improve compliance.

Objectives: Surgical staging procedures are used to select patients with peritoneal metastases for surgery. We aimed to evaluate the impact of surgical staging procedures and the risk of abdominal wall recurrences in patients with peritoneal metastases scheduled for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

Methods: Data were collected from a prospective maintained HIPEC register January 2012-December 2019. Patients with colorectal peritoneal metastases were included. Information about surgical staging procedures was registered. Results were then compared with those registered at definite CRS-HIPEC surgery and survival was analysed in relation to surgical staging procedures.

Results: In total, 138 patients were included, of whom 32 had undergone a surgical staging procedure before CRS-HIPEC. Median overall survival in the surgical staging group was 1.89 years and in the non-staging group 3.07 years (p=0.060). In the surgical staging group, eight patients developed abdominal wall recurrences (25 %) compared with three (3 %) in the non-staged group. Eight staged patients (25 %) were considered inoperable at definite surgery (open-close). PCI score (p<0.001) was higher at definite surgery in patients who had undergone a staging laparoscopy. Factors associated with shorter overall survival in multivariate analysis were: open and close, PCI ≥21 and presence of signet ring cells. However, a staging procedure was not associated with a shorter overall survival.

Conclusions: Surgical staging procedures is a valuable assessment of inoperability, though at the expense of more frequent abdominal wall recurrences. Imaging-based strategies may provide useful insights into whether surgical staging is the most effective approach for patient selection.

Objectives: This study aims to evaluate the clinical impact of introducing an Enhanced Recovery After Surgery (ERAS) protocol in the management of patients undergoing cytoreductive surgery (CRS), with or without hyperthermic intraperitoneal chemotherapy (HIPEC). By addressing a population at high risk of postoperative complications and delayed recovery, the study seeks to determine whether ERAS can improve short-term outcomes, optimize perioperative care, and promote faster and safer recovery in a standardized, evidence-based manner across multiple centers.

Methods: The EPICH study is a multicenter, prospective, interventional trial conducted across 20 centers in Italy. A total of 300 patients undergoing CRS±HIPEC will be enrolled in two sequential phases: standard perioperative care followed by ERAS protocol implementation. The primary endpoint is the mean hospital length of stay (LOS). Secondary endpoints include postoperative complications, ICU admission, readmission rates, bowel function recovery, mortality, and patient-reported quality of recovery. The ERAS protocol includes prehabilitation, anemia and nutritional optimization, intraoperative fluid and pain management, and early mobilization and oral feeding. Data will be analyzed using random-effects linear models to account for center-level variation and confounding factors.

Results: Preliminary evidence suggests that the ERAS protocol may help reduce mean hospital LOS, postoperative complications, and ICU stays, as well as support faster bowel recovery and improved patient-reported outcomes-findings that this study seeks to validate.

Conclusions: The EPICH study could provide robust evidence supporting the adoption of ERAS as the standard of care for patients undergoing CRS±HIPEC, with potential benefits in terms of improved recovery, reduced complications, and decreased healthcare resource utilization.

Objectives: Synchronous peritoneal metastasis (PM) represents an advanced stage of colorectal cancer (CRC), indicating extensive tumor spread. Visceral adipose tissue (VAT) has been linked to cancer development and progression. This study aims to explore the relationship between VAT and occult synchronous PM in CRC patients before surgery.

Methods: We enrolled 681 CRC patients, with 419 in the primary cohort (356 non-metastatic and 63 with PM) and 262 in the validation cohort (239 non-metastatic and 23 with PM). Clinical characteristics and laboratory measurements were collected prior to surgery. Adipose and muscle tissues were delineated on preoperative contrast-enhanced computed tomography (CT) images. The association between visceral adipose tissue and synchronous PM was assessed using univariate and multivariate logistic regression analyses.

Results: In the primary cohort, 419 patients were diagnosed with CRC, with 63 presenting with PM. Patients with PM had higher visceral adipose tissue index (VATI) levels compared to those without PM. Additionally, there was a trend towards increased PM incidence with elevated VATI. Multivariate logistic regression analysis confirmed that higher VATI was independently associated with PM. These findings were consistent in the validation cohort.

Conclusions: VATI is an independent risk factor for occult synchronous PM in patients with CRC.

Objectives: This explorative porcine study investigated the immediate postoperative response of inflammatory protein markers and ischemic metabolites in peritoneal abdominal wall tissue during and after hyperthermic intraperitoneal chemotherapy (HIPEC) assessed by microdialysis.

Methods: Eight cancer-free female pigs underwent imitation cytoreductive surgery (CRS) followed by HIPEC (90 min) using a carboplatin dosage of 800 mg/m². A subperitoneal microdialysis catheter was placed in the abdominal wall to sample inflammatory protein markers and ischemic metabolites. During and after HIPEC, dialysates and blood samples were collected over 8 h. Inflammatory protein expression levels were quantified using Proximity Extension Assay (Olink Target 96 Inflammation panel). In addition, concentrations of ischemic metabolites were quantified using a CMA600 microdialysis analyzer.

Results: An immediate response of 27 proteins, including proteins from the TNF family, early inflammatory chemokines, pro- and anti-inflammatory proteins, was found within the first 30 min after HIPEC initiation. This was followed by a modest and relatively constant inflammatory response. Glycerol concentrations tended to decrease during the sampling period, while glucose showed more stable levels. Constant hyperlactatemia exceeding the plasma levels was seen during and after HIPEC, with no significant tissue ischemia as indicated by the lactate/pyruvate ratios.

Conclusions: In a porcine model, CRS with HIPEC leads to an immediate and relatively constant increased inflammatory and ischemic peritoneal tissue short-time response. The explorative findings contribute to the debate on the value of HIPEC in combination with CRS and call for future studies to further investigate the inflammatory and metabolic tissue responses.

Objectives: Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is a novel surgical technique for patients with peritoneal metastases not amenable to curative treatment. PIPAC delivers pressurised aerosolised chemotherapy using a hyperbaric capnoperitonem established laparoscopically. This study sought to investigate the feasibility and safety of PIPAC in an Australian population.

Methods: We undertook a cohort analysis of prospectively-collected data on patients undergoing PIPAC across two Australian hospitals. Participants were planned to have three PIPAC procedures, each 6 weeks apart. Study outcomes included post-operative complications including 30-day mortality, length of stay (LOS) and patient quality of life (EORTC QLQ-C30 scores).

Results: 18 patients underwent 50 completed procedures. 13 patients had two or more PIPACs. The most common primary malignancy was colorectal cancer (n=8), followed by gastric cancer (n=4), appendiceal cancer (n=4) and mesothelioma (n=2). One grade four but no grade five complications occurred, with zero 30-day mortality. Median LOS was 1 day. Mean EORTC QLQ-C30 score increased from 47.8 at baseline to 53 post second PIPAC. Due to the heterogeneity of our cohort, survival analysis and statistical comparisons were unable to be made.

Conclusion: PIPAC is feasible, safe and well tolerated in an Australian population with a lack of severe complications and zero 30 day mortality. Due to the small number of patients and the heterogeneity of our study's sample, it was not possible to perform survival analysis. The study is nonetheless valuable as the first investigation of implementation of PIPAC in Australia.

Objectives: The main prognostic factor for peritoneal metastasis (PM) is the complete resection of the disease during cytoreductive surgery. Accurate patient selection is therefore essential for determining eligibility for this type of surgery. The peritoneal carcinomatosis index (PCI) is a widely used tool for assessing the extent of carcinomatosis. This study aimed to evaluate the inter-observer reproducibility of PCI assessments via laparoscopy and identify factors influencing this reproducibility.

Methods: Between November 2020 and November 2022, 25 laparoscopic PCI assessment videos were reviewed by six surgeons from two centers. The total PCI score, regional PCI scores, and the number of visualized PCI areas were recorded. Inter-observer concordance was analyzed.

Results: The median PCI score was 12 out of 39 (range 0-39), and the median number of visualized PCI regions was 10 out of 13 (range 1-13). The intraclass correlation coefficient (ICC) for the total PCI score was 0.846 (95 % CI 0.738, 0.927). A history of abdominal surgery significantly impacted PCI assessment reproducibility (p=0.029).

Conclusions: This study found a high inter-observer concordance in laparoscopic PCI assessments. Previous abdominal surgery negatively affected reproducibility, highlighting a challenge in evaluating the PCI in these patients.