Background: Peritoneal metastasis (PM) is currently treated with the complex procedure of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS_HIPEC). This procedure presents high morbidity and mortality rates, but they have only been examined in the immediate post-operative period. The aim of our study is to present, describe and analyze the post-operative events, secondary to a cytoreductive surgery and HIPEC procedure that occurs after the patients' discharge from the hospital. Patients and methods: We examine retrospectively 219 patients who were discharged from our hospital from the initial 230 patients with PM, who were operated on from August 2005 to August 2015 and underwent CRS and HIPEC. Complications are investigated from the patient's discharge date until the 90th post-operative day, and are categorized with the Clavien-Dindo classification. Results: We identified 17 patients (7.8%) who developed late complications. No major differences in patient characteristics were identified between this group of 17 patients and the rest, apart from a slightly higher PCI (23.5 vs. 22.3). Mean length of stay at the re-admission was 11.7 days. 5 of the patients (29.4%) had to be re-operated on, whereas we found a mortality of 11.8% (2/17 patients). The most common complications involved abdominal abscesses (17.6%), ureteral strictures (17.6%) and enterocutaneous fistulae (17.6%). Conclusion: Our study highlights the late complications following CRS plus HIPEC procedures, that occur after the patient's discharge from the hospital, an issue that has not been investigated thoroughly yet and may have serious impact on the post-operative quality of life. The role of adjuvant chemotherapy following CRS and HIPEC procedures in the onset of such complications appears to be important and needs further investigation.

Background. Peritoneal carcinomatosis (PC) is associated with a poor prognosis. Cytoreductive surgery (CRS) and HIPEC play an important role in well-selected patients with PC. The aim of the study is to present the differences in the intraoperative parameters in patients who received HIPEC in two different manners, open versus closed abdomen. Patients and Methods. The population includes 105 patients with peritoneal carcinomatosis from colorectal, gastric, and ovarian cancer, sarcoma, mesothelioma, and pseudomyxoma peritonei. Group A(n=60)received HIPEC using the open technique and Group B(n=45)received HIPEC with the closed technique. The main end points were morbidity, mortality, and overall hospital stay. Results. There were two postoperative deaths (3.3%) in the open group versus no deaths in the closed group. Twenty-two patients in the open group (55%) had grade III-IV complications versus 18 patients in the closed group (40%). There are more stable intraoperative conditions in the closed abdomen HIPEC in CVP, pulse rate, and systolic pressure parameters. Conclusions. Both methods are equal in the HIPEC procedures. Perhaps the closed method is the method of choice for frail patients due to more stable hemodynamic parameters.

AIM:To determine if cholecystectomy and liver's round ligament removal is a necessary step during cytoreductive surgery (CRS) and HIPEC METHODS: This was a retrospective observational study based on records from 180 patients treated in our center from 2005 to 2014. All patients have been offered CRS and HIPEC for peritoneal pseudomixoma (20 patients), peritoneal mesothelioma (7 patients), peritoneal carcinomatosis from ovarian cancer (66 patients), colorectal cancer (42 patients), gastric cancer (10 patients), mucinous adenocarcinoma of the appendix (28), and other abdominal malignancies (7 patients). We performed a cholecystectomy and we removed the round ligament of the liver in all patients, even if there wasn't a macroscopic tumor infiltration of the above anatomical structures. We reviewed the histological reports of all 180 patients.RESULTS:Patients with peritoneal carcinomatosis from mucinous adenocarcinoma of the appendix were treated more aggressively, due to the macroscopic appearance of the disease. Histologic report show no evidence of metastases at the round ligament of the liver in 21, 4% of the patients that were treated with CRS although it was estimated to be involved based on the macroscopic examination at the time of surgery. Tumor involvement of the gallbladder was overestimated, macroscopically, at the same patients in 25% of the cases. In patients with peritoneal carcinomatosis from ovarian cancer, macroscopic appearance of the gallbladder may be delusive. In 25% of the above patients there was a microscopic tumor involvement of the gallbladder, although there was not macroscopic evidence of the disease.CONCLUSION:More extended cytoreductive surgery is needed in case of peritoneal carcinimatosis from ovarian cancer. In case of PC from mucinous adenocarcinoma of the appendix, it's difficult to calculate the extent of the disease and avoid unnecessary surgical excisions. More data is needed to confirm the above.KEY WORDS:Cytoreductive surgery, Gallbladder, HIPEC, Peritoneal carcinomatosis, Round ligament of the liver.

Purpose: Cytoreductive surgery (CS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the proper treatment for resectable peritoneal carcinomatosis (PC). The aim of this study was to evaluate the postoperative course and long-term outcome of repeat CS (reCS) plus repeat HIPEC (reHIPEC) in patients with recurrent disease, after primary CS plus primary HIPEC.Methods: From 2004 to 2012 85 patients were subjected to primary CS + HIPEC. Fourteen of those patients developed recurrent PC and were subjected to reCS+reHIPEC during the same time period. Eligibility criteria included limited extent of the peritoneal disease, and interval of more than 12 months from the primary CS+HIPEC. The origins of the tumors were ovarian cancer (n=7) colorectal cancer (n=3), pseudomyxoma peritonei (n=3), and uterine sarcoma (n=1).Results: At second laparotomy, mean peritoneal cancer index (PCI) was 5.3 +/- 2.8. Among the 14 procedures, HIPEC was used in all patients. The postoperative mortality was 0% and grade 3-4 postoperative complications occurred in 4 patients. The overall 1-, 2- and 3-year overall survival rate was 90, 40 and 30%, respectively.Conclusion: ReCS+reHIPEC is feasible and yields an accepted survival in highly selected patients.

A high prevalence of undernutrition has been recorded in hospital patients. The aim of our study was to investigate the prevalence of malnourished patients in a Greek district hospital.

Background/Aims: Pseudomyxoma peritonei syndrome (PMP) may be associated with slow "benign" or malignant process. However, the natural history of this disease is slow progression to death. Its treatment is variable and controversial. In this current study we have compared the patients with Pseudomyxoma peritonei syndrome with recurrences due to the cell entrapment hypothesis. Methodology: Data were derived from a database of patients with PMP treated at our hospitals from 2004 to 2009. All patients had undergone various surgical operations prior to referral to our institutions for definitive treatment. All patients had recurrences in special sites due to entrapment of malignant cells. Results: There are 6 patients, four men and two women. The initial clinical presentation of the disease was hernia in one, appendicitis in three and ovarian mass in one. The mean time from the initial operation to be definitive management was 23.5 months with an average of 1.83 operations per patient. After cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) the mean survival was 31 months with minimal recurrences and only 0.3 operations per patient. Conclusions: Our data suggest that the patients should be referred to a center with a peritoneal surface malignancy program after the PM P diagnosis as soon as possible. Incomplete debulking procedures and minimal invasive operations promote uncontrollable intra-abdominal tumor growth due to tumor cell entrapment and the tendency of PMP to grow at wound sites.

PURPOSEOvarian cancer is the leading cause of death from gynecological cancer. The current treatment of this type of cancer consists of cytoreductive surgery (CRS) and systemic chemotherapy. The aim of this study was to examine if the hyperthermic intraoperative chemotherapy (HIPEC) is an alternative modality to treat this category of patients along with a second attempt of surgical resection and second or third line systemic chemotherapy.METHODSForty-eight patients suffering from advanced ovarian cancer (FIGO stages III and IV) who recurred after initial treatment with conservative or debulking surgery and systemic chemotherapy were included in this study. Twenty-four patients (group A) were treated with CRS followed by HIPEC and then systemic chemotherapy. Due to various reasons the remaining 24 patients (group B) were treated with CRS and systemic chemotherapy alone.RESULTSThe median survival for group A was 19.4 months vs. 11.2 months in group B (p <0.05). One-year survival was 85% in group A vs. 35% in group B (p <0.05). The 3-year survival rate was 50% in group A vs. 18%. in group B (p <0.01). The resection status was found to be a significant predictor of overall survival (p <0.05). Patients with peritoneal cancer index (PCI) score < 15 appeared also to have longer survival.CONCLUSIONThe use of HIPEC along with the extent of the disease and the extent of cytoreduction play an important role in the survival of patients with a recurrence in an initially advanced ovarian cancer.

The aim of our study was to describe a case of ileocolic intussusception due to caecum cancer in a very young patient and the difficulties in the diagnosis.

Conclusively, studies on the possible beneficial effect of specific types of food or of adding supplements like calcium and vitamin D to the daily diet have somewhat equivocal results. It is not possible to conclude with certainty whether a low fat diet with increased fibre, fruit and vegetables has a particular benefit in preventing colon cancer. The same applies to the effect of calcium and vitamins C and D.

OBJECTIVE:The isolated use of Doppler-guided haemorrhoidal artery ligation (DGHAL) may fail for advanced haemorrhoids (HR; grades III and IV). Suture haemorrhoidopexy (SHP) and mucopexy by rectoanal repair (RAR) result in haemorrhoidal lifting and fixation. A prospective evaluation was performed to evaluate the results of DGHAL combined with adjunctive procedures. METHOD:The study included 147 patients with HR (male patients: 102; grade III: 95, grade IV: 52) presenting with bleeding (73%) and prolapse (62%). RESULTS:More ligations were required for grade IV than grade III HR (10.7 + 2.8 vs 8.6 + 2.2, P < 0.001). SHP (28 patients) and RAR (18 patients) at 1-4 positions were deemed necessary in 46 (31%) patients. Minimal (muco-)cutaneous excision (MMCE) was added in 23 patients. SHP/RAR was applied more frequently in grade IV HR (60%vs 16%, P < 0.001). In patients not having MMCE, SHP/RAR was added in 57% of grade IV cases (P < 0.001). Complications included residual prolapse (10; two second surgery), bleeding (15; two second DGHAL), thrombosis (four), fissure (three) and fistula (one). Analgesia was required not at all, up to 1-3 days, 4-7 days and >7 days by 30%, 31%, 16% and 14% of the patients, respectively. SHP/RAR was associated with greater discomfort (17%vs 6%, P < 0.001). No differences were found between SHP and RAR. At an average follow-up of 15 months, 96% of patients were asymptomatic and 95% were satisfied. CONCLUSIONS:DGHAL with the selective application of SHP/RAR is a safe and effective technique for advanced grade HR.

The objectives of this retrospective study were to investigate the incidence, risk factors, and clinical significance of incidental parathyroidectomy during thyroidectomy. In this study, there were 315 patients who underwent thyroidectomy between 1996 and 2006. All the operations were performed by a single experienced surgeon (J.S.). Pathology reports on all specimens were reviewed and information regarding patient demographics, diagnosis, operative details, and postoperative complications were collected. A total of 315 thyroidectomies were performed: 101 total thyroidectomies (32.1%) and 214 subtotal thyroidectomies (67.9%). Two hundred and eighty patients were operated on for benign disease (88.9%) and 35 for malignant disease (11.1%). Incidental parathyroidectomy was identified in 32 cases (10.2%). Preoperative diagnosis of malignant disease (P = 0.009) and duration of the disease (P = 0.001) were significant predictors of incidental parathyroidectomy. Incidental parathyroidectomy was significantly correlated with postoperative hypoparathyroidism (P = 0.03). Transient postoperative hypoparathyroidism occurred in 18 cases (6%) and permanent in three cases (1%). The duration of the disease was the sole significant predictor of postoperative hypoparathyroidism (P < 0.001). Incidental parathyroidectomy seems to be the result of the use of extensive surgical procedures. The preoperative diagnosis of malignant disease and the delay of the operation, which leads to a more advanced thyroid disease, make the use of extensive surgical procedures necessary.

BACKGROUND/AIMS:The aim of this study is to evaluate the results of intraoperative and postoperative parameters in patients presenting peritoneal carcinomatosis in which we performed cytoreductive surgery (CS) and hyperthermic introperitoneal chemotherapy (HIPEC). PATIENTS AND METHODS:The population included 55 patients with peritoneal carcinomatosis from colorectal origin in 19, gastric in 6, ovarian in 23, sarcomas in 5 and pseudomyxoma peritonei in 2. The peritoneal cancer index (PCI) which directly reflected the volume of the peritoneal disease in our study ranged from 3-29 (median 19,7). The main endpoints were morbidity, mortality, completeness of cytoreduction, survival rates and main intraoperative characteristics. RESULTS:The CS was considered as CCo (no residual disease) in 85% of patients. The mean survival in the patients with complete cytoreduction was 19 months versus 9,8 m in patients with incomplete cytoreduction (p < 0.05). The PCI was one of the most important factors concerning the long-term survival. Patients with PCI < 16 had better survival than these with PCI > 16 (11,8 vs 6,4 m p < 0.05). There are many intraoperative and postoperatives parameters with interesting results which predicts the postoperative outcome but not the long-term survival. The mortality rate was 3.6% (2 patients), twenty-two patients (41.5%) presented one or more complications. Actuarial 5 year survival was 52%. CONCLUSION:Interactive CS + HIPEC is on effective treatment strategy in PC patients.

INTRODUCTION:Patients with resection of stomach and especially with Billroth II reconstruction (gastro jejunal anastomosis), are more likely to develop afferent loop syndrome which is a rare complication. When the afferent part is obstructed, biliary and pancreatic secretions accumulate and cause the distention of this part. In the case of a complete obstruction (rare), there is a high risk developing necrosis and perforation. This complication has been reported once in the literature.CASE PRESENTATION:A 54-year-old Greek male had undergone a pancreato-duodenectomy (Whipple procedure) one year earlier due to a pancreatic adenocarcinoma. Approximately 10 months after the initial operation, the patient started having episodes of cholangitis (fever, jaundice) and abdominal pain. This condition progressively worsened and the suspicion of local recurrence or stenosis of the biliary-jejunal anastomosis was discussed. A few days before his admission the patient developed signs of septic cholangitis.CONCLUSION:Our case demonstrates a rare complication with serious clinical manifestation of the afferent loop syndrome. This advanced form of afferent loop syndrome led to the development of huge enterobiliary reflux, which had a serious clinical manifestation as cholangitis and systemic sepsis, due to bacterial overgrowth, which usually present in the afferent loop. The diagnosis is difficult and the interventional radiology gives all the details to support the therapeutic decision making. A variety of factors can contribute to its development including adhesions, kinking and angulation of the loop, stenosis of gastro-jejunal anastomosis and internal herniation. In order to decompress the afferent loop dilatation due to adhesions, a lateral-lateral jejunal anastomosis was performed between the afferent loop and a small bowel loop.

International Journal of DermatologyVolume 48, Issue 4 p. 440-441 Isolated cutaneous cryptococcosis in an immunocompromised patient cured without antifungals Anastasios C. Datsis MD, PhD, Anastasios C. Datsis MD, PhD Messologi and Patras, GreeceSearch for more papers by this authorAgeliki Tsintoni MD, Ageliki Tsintoni MD Messologi and Patras, GreeceSearch for more papers by this authorArgyro Tasoula MD, Argyro Tasoula MD Messologi and Patras, GreeceSearch for more papers by this authorNikolaos Roupas MD, Nikolaos Roupas MD Messologi and Patras, GreeceSearch for more papers by this authorHarisios Trahalios MD, Harisios Trahalios MD Messologi and Patras, GreeceSearch for more papers by this authorMarkos Marangos MD, PhD, Markos Marangos MD, PhD Messologi and Patras, GreeceSearch for more papers by this authorPantelis Leonardos MD, PhD, Pantelis Leonardos MD, PhD Messologi and Patras, GreeceSearch for more papers by this authorJohn Spiliotis MD, PhD, John Spiliotis MD, PhD Messologi and Patras, GreeceSearch for more papers by this author Anastasios C. Datsis MD, PhD, Anastasios C. Datsis MD, PhD Messologi and Patras, GreeceSearch for more papers by this authorAgeliki Tsintoni MD, Ageliki Tsintoni MD Messologi and Patras, GreeceSearch for more papers by this authorArgyro Tasoula MD, Argyro Tasoula MD Messologi and Patras, GreeceSearch for more papers by this authorNikolaos Roupas MD, Nikolaos Roupas MD Messologi and Patras, GreeceSearch for more papers by this authorHarisios Trahalios MD, Harisios Trahalios MD Messologi and Patras, GreeceSearch for more papers by this authorMarkos Marangos MD, PhD, Markos Marangos MD, PhD Messologi and Patras, GreeceSearch for more papers by this authorPantelis Leonardos MD, PhD, Pantelis Leonardos MD, PhD Messologi and Patras, GreeceSearch for more papers by this authorJohn Spiliotis MD, PhD, John Spiliotis MD, PhD Messologi and Patras, GreeceSearch for more papers by this author First published: 19 March 2009 https://doi.org/10.1111/j.1365-4632.2009.03787.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume48, Issue4April 2009Pages 440-441 RelatedInformation

PURPOSE:Peritoneal carcinomatosis (PC), which has been regarded as a lethal condition, may now be treated, achieving a long-term disease-free survival with cytoreductive surgery by treating macroscopic tumor seeding and hyperthermic intraperitoneal chemotherapy (HIPEC) by treating residual microscopic disease. The purpose of this study was to analyse the morbidity and mortality of this procedure.METHODS:A total of 39 consecutive patients were included in this retrospective study. After complete resection of the PC, HIPEC was performed via the coliseum technique. The chemotherapeutic agents used depended on the tumors' histology.RESULTS:Postoperative mortality and morbidity rates were 5.1%% (2/39) and 43.5% (17/39), respectively. The most frequent complications were pulmonary complications (31%), gastrointestinal fistulas (20%), hematologic toxicity (16%) and postoperative bleeding (11%). Statistical correlations were evidenced between morbidity and PC index (p<0.004), duration of surgery (p<0.001) and blood loss (p<0.001).CONCLUSION:This approach has resulted in a relatively high but acceptable percent of adverse events considering the expected advantage for survival.

Objective: The aim of the present study was to evaluate the role of age on different types of liver surgery. Methodology: Between 2002 and 2007, 50 patients underwent a variety of liver surgical procedures due to primary or metastatic tumours. Of these, 24 were 70 years old or older, and 26 patients were younger than 70 years old at the time of the operation. Results: Among the patients included in the study, 22 underwent radiofrequency ablation. Another 11 underwent non‐anatomical liver resection. The remaining 17 patients underwent liver resection, with more than three segments resected. The type of procedure, duration of operation, estimated blood loss, and postoperative death and morbidity rates were not significantly different between the two groups. The mean survival of patients that underwent radiofrequency ablation or non‐anatomical resection was not significantly different between the two groups. However, in the patients in which liver resection was performed, mean survival was significantly greater in the younger group. Conclusions: These results indicate that hepatic resection is a safe and feasible procedure in elderly patients. The postoperative outcome in this age group is comparable of that of younger patients.

PURPOSE:To report our preliminary experience in the combined treatment of peritoneal carcinomatosis (PC) using cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC).PATIENTS AND METHODS:This prospective study included patients with PC from gynaecological, gastric and colon cancer, treated in two centers. Cytoreductive surgery included the peritonectomy procedures described by Jacquet and Sugarbaker as well as multivisceral resections in order to achieve a complete macroscopical cancer eradication. The HIPEC that followed was performed via the open abdomen technique.RESULTS:Twenty-four patients (3 men and 21 women, mean age 60 years) were treated. Twelve patients had PC from ovarian cancer, 7 from colon, 3 from gastric and 2 from uterine cancer. The mean duration of the procedure was 7.83 h (range 5 -12.30). Macroscopically, complete cytoreduction (CC) was achieved in 18 (75%) patients. Two (8.3%) patients died in the first 30 days. The overall morbidity was 42% and 2 patients were reoperated. The mean follow up was 22 months (range 3-36). The overall 1-year survival was 59.1%; concerning the gynaecological cancers it was 53.8% (mean survival 11.7 months) and for gastrointestinal cancers it was 44.4% (mean survival 9.5 months).CONCLUSION:Our preliminary data suggest that the combined treatment of cytoreduction plus HIPEC for PC is associated with acceptable mortality and morbidity and offers an improved survival in these patients. An optimal patient selection and establishment of experienced centres are of paramount importance.

Sir, Isolated supraglottic stenosis is a very uncommon condition and is rarely discussed in the literature. Although most reports are referred to the paediatric population, we recently encountered the problem of supraglottic stenosis in a 78-year-old female patient with acute suppurative cholecystitis, who was operated urgently a few hours after her admission. The unexpected extensive supraglottic stenosis made intubation impossible. After several ineffective attempts for intubation, an urgent tracheotomy was performed in order to ventilate the patient and complete the operation. The patient had an uneventful postoperative recovery from the suppurative cholecystitis. On the 5th post-operative day, direct flexible laryngoscopy was performed, which revealed bilateral hypertrophy of the arytenoid folds with the epiglottis being fixed on them. The glottis was inspected macroscopically with a paediatric inoptic laryngoscope and appeared to be normal. The patient had no previous history of prolonged intubation, external cervical trauma, chemical burn, gastroesophageal reflux, post-infectious fibrous scar formation or irradiation; conditions that have been associated with upper airway stenosis (1–3). She had undertaken five operations in the past, without any technical problems during tracheal intubation. Additionally, a work up for autoimmune disorders was negative. Fifteen days after the abdominal operation, the patient underwent a trans-oral carbon dioxide laser resection of the arytenoids folds and epiglottis adhesiolysis, a procedure we can describe as supraglottoplasty. We preferred this kind of minimal surgery in order to avoid the serious complications of the supraglottic laryngectomy. In a previous report of 82 patients with chronic laryngeal stenosis, the authors criticized the extensive nature of supraglottic laryngectomy in the management of benign lesions (4). The endotracheal tube was removed four and a half months after the operation, being afraid of the possibility of restenosis as described in another patient with supraglottic stenosis who underwent trans-oral carbon dioxide laser supraglottic laryngectomy (5). Before the removal of the tube, we performed a flexible laryngoscopy, which revealed a 5–10% lessening of the airway orifice, comparatively to the airway caliber that we created after the resection of the arytenoids folds. Nevertheless this final orifice had at least the double diameter than the pre-operative one, permitting a normal respiratory function. The patient has remained asymptomatic in an excellent condition until now. Conclusively, an unsuspected benign isolated supraglottic stenosis can be a serious problem during an emergency general surgery operation. Unsuccessful intubation attempts may result in edema and complete airway obstruction, requiring an urgent tracheostomy in order to complete the operation. The endotracheal tube should remain on site until the definitive repair of the stenosis. A conservative surgery, such as supraglottoplasty, is preferred from a supraglottic laryngectomy because it has the same long-term results with fewer complications.