Stefano Scaringi

Iterative Cytoreductive Surgery Associated With Hyperthermic Intraperitoneal Chemotherapy for Treatment of Peritoneal Carcinomatosis of Colorectal Origin With or Without Liver Metastases

Introduction:The aim of this study was to evaluate the results of an aggressive strategy in patients presenting peritoneal carcinomatosis (PC) from colorectal cancer with or without liver metastases (LMs) treated with cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Patients and Methods:The population included 43 patients who had 54 CS+HIPEC for colorectal PC from 1996 to 2006. Sixteen patients (37%) presented LMs. Eleven patients (25%) presented occlusion at the time of PC diagnosis. Ascites was present in 12 patients (28%). Seventy-seven percent of the patients were Gilly 3 (diffuse nodules, 5–20 mm) and Gilly 4 (diffuse nodules>20 mm). The main endpoints were morbidity, mortality, completeness of cancer resection (CCR), and actuarial survival rates. Results:The CS was considered as CCR-0 (no residual nodules) or CCR-1 (residual nodules <5 mm) in 30 patients (70%). Iterative procedures were performed in 26% of patients. Three patients had prior to CS + HIPEC, 10 had concomitant minor liver resection, and 3 had differed liver resections (2 right hepatectomies) 2 months after CS + HIPEC. The mortality rate was 2.3% (1 patient). Seventeen patients (39%) presented one or multiple complications (per procedure morbidity = 31%). Complications included deep abscess (n = 6), wound infection (n = 5), pleural effusion (n = 5), digestive fistula (n = 4), delayed gastric emptying syndrome (n = 4), and renal failure (n = 3). Two patients (3.6%) were reoperated. The median survival was 38.4 months (CI, 32.8–43.9). Actuarial 2- and 4-year survival rates were 72% and 44%, respectively. The survival rates were not significantly different between patients who had CS + HIPEC for PC alone (including the primary resection) versus those who had associated LMs resection (median survival, 35.3 versus 36.0 months, P = 0.73). Conclusion:Iterative CS + HIPEC is an effective treatment in PC from colorectal cancer. The presence of resectable LMs associated with PC does not contraindicate the prospect of an oncologic treatment in these patients.

Advanced gastric cancer with or without peritoneal carcinomatosis treated with hyperthermic intraperitoneal chemotherapy: a single western center experience.

INTRODUCTIONnThe aim of this article was to evaluate the role of hyperthermic intraperitoneal chemotherapy (HIPEC), associated or not to cytoreductive surgery (CS) in the treatment of different stages of advanced gastric cancer (AGC).nnnPATIENTS AND METHODSnThirty seven patients with AGC who underwent 43 HIPEC from June 1992 to February 2007 were included. HIPEC used Mitomycin-C and Cisplatin for 60-90 min at 41-43 degrees C intra-abdominal temperature. The main endpoints were long-term survivals, morbidity and mortality rates.nnnRESULTSnEleven patients had no demonstrable sign of PC and constituted the Prophylactic-group, while 26 patients had macroscopic PC (PC-group). Five patients were Gilly 1 or 2 (nodules <0.5 cm) and 21 Gilly 3 or 4 (nodules >or=0.5 cm). In the PC-group a complete curative CS was achieved before HIPEC in 8 (PC-curative subgroup) and a palliative HIPEC in 18 patients (PC-palliative subgroup). The overall 30-days mortality was 5% (2 patients). Two patients in the Prophylactic group died within 6 months after hospital discharge (overall mortality 11%). The estimated risk of death per procedure was 9%. Ten patients (27%) presented one or more complications. The median survival was 23.4 months in the Prophylactic group, and 6.6 months in the PC-group (p<0.05). The median survival in the PC-curative subgroup was 15 vs 3.9 months in the PC-palliative subgroup (p=0.007). The median survival according to Gilly classification was significantly different (Gilly 1&2 vs Gilly 3&4, 15 vs 4 months respectively, p=0.014). The global recurrence rates between the Prophylactic group and the PC-curative subgroup at 2years were 36% vs 50% respectively. The median delay to recurrence was 18.5 vs 9.7 months respectively.nnnCONCLUSIONnHIPEC might be useful to improve the survival in selected patients with ACG only when a complete cytoreduction can be achieved. Despite encouraging data, prospective studies, based on larger cohorts of patients are required to assess the role of this procedure as a prophylactic treatment in patients with AGC.

Age as a Predictive Factor of Testosterone Improvement in Male Patients After Bariatric Surgery: Preliminary Results of a Monocentric Prospective Study

BackgroundMale obesity can be associated with symptomatic alterations in sex hormones resulting in hypogonadism and impaired fertility. Surgical-induced weight loss can improve the sex hormone profile in men. The aim of the present study is to evaluate the levels of sex hormones in obese males before and after 6xa0months from bariatric surgery. Possible mechanisms and clinical implications are also discussed.MethodsWe evaluated levels of serum total testosterone (TT), sex hormone-binding globulin (SHBG), calculated free testosterone (cFT), follicular-stimulating hormone (FSH), luteinizing hormone (LH), and total estradiol (E2) in 20 male patients at the baseline and 6xa0months after bariatric surgery.ResultsMedian [interquartile range] age at the time of surgery was 40.5 [27.2–46.7] years with a median [interquartile range] BMI of 43.6 [40.9–48.7] kg/m2. The median baseline levels of TT, SHBG, cFT, LH, and FSH were reduced; levels of E2 were elevated. At 6xa0months from surgery, the median BMI dropped to 34.8 [31.7–40.5]u2009kg/m2, TT, SHBG, cFT, LH, and FSH increased, while levels of E2 decreased. The improvement in the sex hormone profile was more evident in younger patients, with a statistically significant difference in cFT following surgery and in the raise of TT and cFT between the groups of patients below and above 35xa0years. At multivariate analysis, the age was the best predictive factor of the postoperative variations of TT.ConclusionsThese preliminary results confirm the general improvement in sex hormone profile in obese men after bariatric surgery and introduce the age as a possible contributing factor to this improvement.

Lésions précancéreuses de la vésicule biliaire

This Mini-review summarizes the epidemiology, predisposing and pre-cancerous conditions related to carcinoma of the gallbladder. In 75% of cases, gallbladder cancer is a cholangiocarcinoma, usually presenting in a late and advanced stage, and it carries one of the worst prognoses of all GI malignancies. Early stage disease is usually discovered incidentally by the pathologist in a gallbladder specimen removed for calculous cholecystitis. It occurs three times more frequently in women than in men and invasive forms usually occur after the age of 60. Incidence varies with geographic location. Besides genetic and geographic factors, the presence of one or more large gallstones is a major risk factor. Gallbladder polyps larger than 1.5 cm. (especially solitary sessile hypoechogenic polyps) are associated with a 50% risk of malignancy. Choledochal cysts and other variations of the biliopancreatic junction are also associated with high risk; cancer may occur at a much younger age in these patients and in the absence of gallstones. Porcelain gallbladder is a risk factor, particularly when there is calcification of the gallbladder mucosa. Chronic gallbladder infection has been implicated as a risk factor for malignant degeneration. Finally, cancer of both the gallbladder and the bile ducts is more frequent in patients suffering from primary biliary cirrhosis.

Syndrome fissuraire d'un pseudoanévrisme de l'artère gastroduodénale au contact d'un faux-kyste pancréatique : une complication rare mais grave de la pancréatite chronique

Most pseudoaneurysms (PsA) of the peripancreatic arteries cause direct erosion of the arterial wall from pancreatic enzymes that are usually in contact with or in a pseudocyst (PC). Rupturing is a rare and serious complication (90% mortality if untreated). We report the case of a 56-year-old patient with chronic alcoholic pancreatitis who developed a cephaloisthmic PC, complicated with a PsA of the gastroduodenal artery revealed by pain and deglobulization associated with cholestasis. After a diagnostic scan, emergency selective arteriography with coil embolization was performed. Five days later, hemorrhage recurred and a cephalic duodenopancreatectomy was performed. PsA of the gastroduodenal artery occur in the first 10 years of chronic pancreatitis. They are revealed by abdominal pains and/or gastrointestinal hemorrhage or shock from rupture. A scan with arterial reconstruction provides diagnosis. Arteriography is the most sensitive technique to locate the aneurysm and its branches and to perform selective embolization with coils. The failure rate is between 0 and 23%. Surgical treatment (elective ligation of the artery or partial pancreatic excision) should be limited to when embolisation fails and/or recurrent hemorrhage.

Anévrisme des artères pancréatico-duodénales

Anevrisme des arteres pancreatico-duodenales G. Virzi, A. Joudinaud du Passage, S. Scaringi, E. Facchiano, C. Leroy, Y. Flamant, S. Msika, R. Kianmanesh L’âge moyen au moment du diagnostic est de 50xa0ans. Le mode de revelation est fait de douleurs abdominales, d’un etat de choc, d’une hemorragie digestive, d’une douleur biliaire, d’un ictere ou d’une anemie aigue. Plus rarement, ces anevrismes sont reveles fortuitement sur l’imagerie. La rupture d’un anevrisme des arteres pancreatico-duodenales est une complication grave avec un taux de mortalite elevee. Dans ces conditions, le diagnostic de rupture d’un anevrisme des arteres pancreatico-duodenales est une urgence therapeutique. L’embolisation arterielle est le traitement de choix, et la chirurgie doit etre reservee aux echecs de l’embolisation. Nous rapportons le cas d’une patiente qui a ete traitee avec succes par embolisation arterielle, mais qui a pose un probleme diagnostique et therapeutique.