Francesco Fleres

The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the treatment of ovarian cancer relapse

Nowadays the standard clinical management for advanced epithelial ovarian cancer is constituted by primary cytoreductive surgery associated to adjuvant systemic chemotherapy. Even if this first-line chemotherapy shows a high rate of complete responses, the disease recurrences occur especially in stage-III patients. Actually an option for this subset of patients is represented by secondary cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy that represents a promising therapy, having shown positive results in terms of median overall survival, progression free survival and overall survival. However, a much more research is still required especially by prospective randomised trials to improve outcomes in recurrent ovarian cancer.

Giant retroperitoneal liposarcoma: Case report and review of the literature

Highlights • The origin from perirenal fat is very uncommon.• The occurrence of hematogenous metastasis is a rare finding at the time of diagnosis.• The undifferentiated and pleomorphic type are neoplasm with high grade of malignancy.• In case of diagnostic doubt and in presence of recurrence, magnetic resonance imaging (MRI) may be useful because can identifying in a reliable manner the satellite localizations of the main lesion.• The complete surgical (R0) resection represents the only possibility of radical treatment.• Following surgical resection, the 50–100% of liposarcomas recur from residual tissue, which is the primary cause of death.• Percutaneous biopsy has low accuracy in the diagnosis of retroperitoneal dedifferentiated liposarcoma (DDLS).

Wernicke encephalopathy as rare complication of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Highlights • Peritoneal carcinomatosis (PC) of gastric origin is a frequent event even in the early phase of the disease.• This is the first case, to our knowledge, of Wernicke Encephalopathy (WE) complicating CRS plus HIPEC used as treatment of peritoneal carcinomatosis of gastric origin.• WE is an uncommon neurological disorder characterized by a classical triad of symptoms: ataxia, ocular motor cranial neuropathies and changes in consciousness.• A deficiency of thiamine is responsible for the WE syndrome.• The application of Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) gives encouraging results.• A deficiency of thiamine is responsible for the WE syndrome.

Reply to “The incidence of cisplatin nephrotoxicity post hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery”

We read an article by Hakeam, Breakiet, Azzam, Nadeem, and Amin, with interest and would like to congratulate the authors for the effort that they have put in a field so challenging. Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is, in fact, a promising approach to treat peritoneal surface malignancies, but it is characterized by high morbidity and mortality. In literature it is reported that a major morbidity rate ranges from 12% to 57% in highvolume centres; the mortality incidence ranges from 0.9% to 11%. The short-term outcome is related to surgery, but also to chemoperfusion. We agree with the conclusions made by the authors, confirming, on the basis of our experience, that nephrotoxicity can complicate HIPEC, above all if it is performed using cisplatin. As this topic has not yet been fully elucidated, we measured the plasma level of cisplatin before, during and after HIPEC, in order to identify the period within which there is the higher risk of toxicity linked to the intraperitoneal chemotherapy. Our experience had demonstrated that the peak of serum level of cisplatin is reached during the perfusion; until the 4th post-operative (p.o.) day high levels remain and, in 7th p.o. day, the value returns to that before the intervention. At the light of these considerations, we retain that, for 4 days after the procedure, is necessary to ensure the hyperhydration, and the infusion of albumin and of fresh frozen plasma, in order to dilute the effective quantity of circulating cisplatin, to increase the proportion of albuminbound cisplatin, and to maintain a normal blood volume and perfusion.

Rectal perforation by inadvertent ingestion of a blister pack: A case report and review of literature

The accidental ingestion of a foreign body (FB) is a relatively common condition. In the present study, we report a peculiar case of rectal perforation, the first to our knowledge, caused by the inadvertent ingestion of a blister pill pack. The aim of this report is to illustrate the difficulties of the case from a diagnostic and therapeutic viewpoint as well as its unusual presentation. A 75-year-old woman, mentally impaired, arrived at our emergency department in critical condition. The computed tomography scan revealed a substantial abdominopelvic peritoneal effusion and free perigastric air. The patient was therefore submitted to an urgent exploratory laparotomy; a 2-cm long, full-thickness lesion was identified in the anterior distal part of the intraperitoneal rectum. Hence, we performed a Hartmann’s procedure. Because of her critical condition, the patient was eventually transferred to the Intensive Care Unit, where she died after 10 d, showing no surgical complication. The ingestion of FBs is usually treated with observation or endoscopic removal. Less than 1% of FBs are likely to cause an intestinal perforation. The intestinal perforation resulting from the unintentional ingestion of an FB is often a difficult challenge when it comes to treatment, due to its late diagnosis and the patients’ deteriorated clinical condition.

Therapeutic strategies for jejunal diverticulitis: our experience and a review of the recent literature

The jejunoileal diverticulosis is an uncommon entity, which affects elderly people, and its complications can be fatal due to delayed diagnosis. The disease often presents with non-specific symptoms like intermittent abdominal pain, dyspepsia, bloating or abdominal fullness and constipation. Complications of jejunal diverticulosis include perforation, acute intestinal obstruction and diverticular bleeding. Nowadays the mortality was reduced because of the improvement of the diagnostic, pharmaceutical and surgical protocols, but preoperative diagnosis of jejunal diverticulitis is still rarely made. We report two cases of elderly patients presenting with acute abdominal pain and fever. Both underwent to an exploratory laparotomy, which revealed multiple jejunal diverticula. In both cases intestinal resections with primary anastomosis was performed. There are different therapeutic approaches depending on the severity of the disease and the general clinical condition of the patient. We also discussed about the various therapeutic strategies.

How to do: technique of liver hanging maneuver—step by step

In 2001, Belghiti et al. described a technique called “liver hanging maneuver” (LHM): consisting in lifting the liver during parenchymal transection by a tape passed between the anterior surface of inferior vena cava (IVC) and the liver. In this manner surgeons achieve the effective vascular control especially for the deeper parenchymal transection and a guidance of the direction of anatomic parenchymal transection. LHM can be performed due to the existence of a longitudinal avascular and virtual space between anteriorly the posterior face of liver and posteriorly the anterior face of IVC. We use this method, which is adopted routinely by the Reims Team, and is it similar to the one described by Belghiti with some peculiarities: it is a combined bidirectional up and down (or cranio-caudal) approach. We show step by step how to perform a safety LHM. We adopted a dissection of the avascular space using: (I) smooth and gently movements; (II) hydro-dissection; (III) 14 Fr nasogastric tube. We think our video can help surgeons especially junior surgeons to understand better LHM and maybe to reproduce it more facility, reducing any risks correlated to this maneuver.

Cystic lymphangioma of the pancreas: a hard diagnostic challenge between pancreatic cystic lesions—review of recent literature

Lymphangiomas are rare congenital benign tumors arising from the lymphatic system. The incidence of this disease in the pancreas is extremely rare, accounting for less than 1% of these tumors. Before introducing the review we reported a case of a 67-year-old woman with cystic lymphangioma of the pancreas. We reported the radiological investigations carried out preoperatively and the treatment performed. The review tries to identify the features described in literature of the pancreatic lymphangioma. We have performed a PubMed research of the world literature between January 1st 2000, to November 31st 2017, using the keywords [Lymphangioma pancreas], [diagnosis], [CT lymphangioma] and [MRI lymphangioma]. We have found 158 articles, of which about 100 were case reports. Based on our search criteria, we have identified 31 pancreatic lymphangioma in literature reporting their imaging characteristics. According to our report and to several authors in literature the diagnosis of cystic pancreatic lymphangioma should be considered as a differential diagnosis of pancreatic cystic lesions (PCLs). The role of imaging exams (CT and MRI) can help to identify and suspect this possibility of diagnosis. The endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) can have a potential role to reach the correct diagnosis.

Uterine large cell neuroendocrine carcinoma with unusual colonic metastasis

1Department of Human Pathology of Adult and Evolutive Age “Gaetano Barresi”, Section of Anatomic Pathology, University of Messina, 98125 Messina, Italy. 2Student in Medicine and Surgery, University of Messina, 98125 Messina, Italy. 3Department of Human Pathology of Adult and Evolutive Age “Gaetano Barresi”, Section of General Surgery, University of Messina, Azienda Ospedaliera Universitaria “Policlinico Gaetano Martino”, 98125 Messina, Italy.

Evaluation of cisplatin plasma levels in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

ABSTRACT Introduction Peritoneal surface malignancies have long been regarded as incurable, however, they can be treated with cytoreductive surgery in addition to hyperthermic intraperitoneal chemotherapy. This approach is associated with an increase in morbidity and mortality, unless hyperhydration is provided in a timely manner. Methods Cisplatin (CDDP) is the most widely used chemotherapeutic agent. Plasma levels of cisplatin (CDDP), a widely used chemotherapeutic agent, were measured before, during, and after the procedure. This was done in order to identify the window of highest risk as a function of drug concentrations, assuming a dose-dependent effect. Results Plasma levels of CDDP peak during perfusion. The concentration remains high until the 4th post-operative day and returns to pre-operative levels by the 7th post-operative day. Conclusions Our findings suggest that ensuring hyperhydration as well as infusing albumin and fresh frozen plasma may be of particular value for at least the first 4 days after the procedure.