PURPOSE:Peritoneal spread of neoplastic diseases is considered a fatal condition with a dismal prognosis. Few therapeutic options were offered to these patients and surgery had only palliative character. However, advances in surgical techniques and new drugs development, have changed the management of this terminal stage disease. Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC), has been proposed as a promising alternative to palliative surgery and systemic chemotherapy, since 1980s. Many changes through all these years have refined the technique and standardized indications and limits.METHODS:A retrospective study was performed in our medical records, of all patients treated with CRS and HIPEC since 2006. Survival, complications and prognostic factors were studied in a total of 632 patients.RESULTS:Female patients were 419 and males were 213. Mean age was 52.6 years. Peritoneal metastases secondary to colorectal cancer were the most frequent treated disease (87 patients), whereas hepatobilliary-pancreatic neoplastic diseases and sarcomas were the less frequent causes of peritoneal carcinomatosis. Patients with peritoneal metastases from ovarian cancer, treated with systemic chemotherapy and then received interval cytoreductive surgery with HIPEC, were the largest group that are still alive (43%), while only 35% of patients with hepatobilliary-pancreatic cancer and peritoneal disease are alive at present. Gender, age, peritoneal cancer index (PCI), completeness of cytoreduction score (CCs), and number of complications were important prognostic factors of overall survival.CONCLUSIONS:Peritoneal carcinomatosis is still considered a final stage disease with a poor prognosis. The confinement of the neoplastic disease in the peritoneal cavity has led to the development of local therapies with promising results. CRS and HIPEC have evolved significantly over the past several years and are at the present the most valuable treatment in highly selected patients with peritoneal carcinomatosis.

PURPOSE:To identify the role of systemic chemotherapy in the management of appendiceal malignancies.METHODS:Over a 10-year period (2005 -2014), 52 patients with appendiceal neoplasms were treated at our Peritoneal Surface Malignancy Unit [14 (26.9%) disseminated peritoneal adenomucinosis (DPAM), 30 (57.7%) peritoneal mucinous carcinomatosis of appendiceal origin (PMCA) and 8 (15.4%) PMCA-I]. All patients (100%) underwent cytoreductive surgery (CRS) & hyperthermic intraperitoneal chemotherapy (HIPEC), while 20 (38.5%) of them also received perioperative systemic chemotherapy.RESULTS:Mean peritoneal cancer index (PCI) was 23.6. Completeness of cytoreduction score (CC-S) was: CC-0 in 26 patients (50%), CC-1 in 20 patients (38.5%) and CC-2 in 6 patients (11.5%). High grade malignancy was reported in 27 patients (51.9%) and low grade malignancy in 25 patients (48.1%). More than half of the patients developed recurrence (n=36, 69.2%), while death was reported in 40.4% (n=21). Median overall survival (OS) in all histologic groups was 24 months for patients who received perioperative systemic chemotherapy and 14 months for patients who did not (p=0.048). Median disease free survival (DFS) in all histologic groups was 19 months for patients who received perioperative systemic chemotherapy and 10 months for patients who did not (p=0.034).CONCLUSION:We suggest that perioperative systemic chemotherapy serves as a helpful therapeutic tool in the management of peritoneal mucinous appendiceal carcinomas treated with cytoreductive surgery & HIPEC.

PURPOSE:Peritoneal metastasis (PM) is nowadays treated with the complex procedure of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy (CRS+HIPEC). Given the fact that the procedure presents high morbidity and mortality rates, admitting patients to the Intensive Care Unit (ICU) seems inevitable. In our study, we have tried to determine the factors that indicate when admission in the ICU is necessary.METHODS:We retrospectively analyzed 230 patients (140 females, 90 males) with PM, who were operated on from November 2005 until October 2015, and underwent CRS+HIPEC. The patients were divided into two groups, based on whether they were extubated after the operation or not, thus being admitted to the ICU. We also distinguished a group of patients who, after the initial extubation, had to be re-intubated and transferred to the ICU. We assessed morbidity and mortality rates for each of the aforementioned groups, along with the complications developed in each case (thoracic, gastrointestinal, renal).RESULTS:We found that morbidity and mortality rates in both examined groups were approximately similar; the course changed when a complication occurred, and this increased mortality, especially if the onset of the symptoms was delayed. Also, these rates were much worse for the group that had to be re-intubated and transferred to the ICU.CONCLUSIONS:On the whole, we conclude that the decision of immediate admission to the ICU post-operatively is hard, as it depends on multiple factors; therefore, the use of an easy predictive method is not realistic and a more individualized and patient-to-patient approach is preferable.

To study hormonal system disturbances in adult multiple trauma patients (MTPs) without traumatic brain injury (TBI) in the two distinctive post-traumatic phases and to reveal prognostic parameters of clinical outcome.

PURPOSE:The aim of this study was to explore the natural course of peritoneal carcinomatosis (PC) in patients who are not fit to undergo cytoreductive (CRS) surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).METHODS:Over an 8-year period (2006-2013) 320 patients were excluded from CRS and HIPEC at our center. Exclusion criteria were: (a) age >75 years; (b) ASA score ≥ 3; (c) extraperitoneal disease; (d) massive disease involvement of the small bowel; (e) disease involvement of the hepatic pedicle or the pancreas; (f) invasion of retroperitoneal space; (g) more than two stenoses of the small bowel. Another 130 patients underwent CRS and HIPEC.RESULTS:In the HIPEC group (N=130), the mean overall survival was 26.2±11.7 months, while from the non- HIPEC group (N=320), 200 patients underwent palliative surgery, with a mean overall survival of 11.7±8.3 months. Only 120 patients received palliative chemotherapy with a mean overall survival of 7.2±4.3 months.CONCLUSION:Our study suggests that, in patients unfit to undergo CRS & HIPEC, an exploratory laparotomy and palliative surgery should be performed, offering a survival benefit and improved quality of life.

Gastrointestinal Stromal tumors (GIST) are the most common sarcomas of the gastrointestinal tract, with transformation typically driven by activating mutations of cKIT and less commonly platelet-derived growth factor receptor alpha (PDGFRA). Successful targeting of tyrosine-protein kinase Kit with imatinib, a tyrosine kinase inhibitor, has had a major impact in the survival of patients with GIST in both the adjuvant and metastatic setting. A recent modification of treatment guidelines for patients with localized, high-risk GIST extended the adjuvant treatment duration from 1 year to 3 years. In this paper, we review the clinical data of patients with GIST treated in the Oncology Outpatient Unit of “Attikon” University Hospital and aim to assess which patients are eligible for prolongation of adjuvant imatinib therapy as currently suggested by treatment recommendations.

PURPOSE:The development of digestice fistulas is a complication of gastrointestinal operations during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). In this article we present the incidence, management and outcome of enterocutaneous digestive fistulas after CRS and HIPEC.METHODS:Over the past 10 years (2005-2014), 184 patients with peritoneal carcinomatosis underwent CRS and HIPEC. HIPEC was administered in the operating room immediately after CRS, but in 48 (26%) patients this happened before the formation of intestinal anastomosis or repair of seromuscular tears, using the open (coliseum) technique; in the remaining 137 (74%) patients the anastomoses were performed before HIPEC. All patients were operated on by the same surgical team.RESULTS:Of the 185 patients 16 (8.6%) developed an enterocutaneous digestive fistula. Spontaneous fistula closure was observed in 14 (87.5%) patients. The median duration of spontaneous closure was 18 days (range 9-56). Reoperation was needed in 2 (12.5%) patients. There were 2 (12.5%) deaths.CONCLUSION:CRS and HIPEC is a well-known treatment modality for peritoneal carcinomatosis. The incidence of digestive fistulas is increased a little compared to that of conventional digestive surgery.

To evaluate thyroid axis TA hormone disturbances in adult multi-trauma patients (AMTP) without traumatic brain injury (TBI) and to correlate the results with other clinical and laboratory components of patient’s post-traumatic course.

To study plasma B-type natriuretic peptide BNP) variation in adult multi-trauma patients and to correlate BNP levels with the class of haemorrhagic shock and the amount of fluids received during resuscitation.

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.

Laparoscopic cholecystectomy is the method of choice in treatment of gallstone disease. Comparative costs of laparoscopic cholecystectomy and open cholecystectomy remain unclear. The main benefits of laparoscopic surgery include the period of short recovery, fewer days off work, less post-operative pain and better aesthetic outcome. The aim of this study was to estimate the cost and effectiveness of laparoscopic cholecystectomy versus classical open cholecystectomy from the payers’ perspective.

Chylous peritonitis is the acute accumulation of intestinal lymph (chyle) in the peritoneal cavity that presents with symptoms and signs of acute abdomen. Generally idiopathic, it represents a rare cause of acute surgical abdomen. The diagnosis is usually made at laparotomy, since there are no distinctive features to suspect this entity preoperatively.

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.

BACKGROUND:The aim of this study was to evaluate the risk factors of wound dehiscence and determine which of them can be reverted.METHODS:We retrospectively analyzed 3500 laparotomies. Age over 75 years, diagnosis of cancer, chronic obstructive pulmonary disease, malnutrition, sepsis, obesity, anemia, diabetes, use of steroids, tobacco use and previous administration of chemotherapy or radiotherapy were identified as risk factorsRESULTS:Fifteen of these patients developed wound dehiscence. Emergency laparotomy was performed in 9 of these patients. Patients who had more than 7 risk factors died.CONCLUSION:It is important for the surgeon to know that wound healing demands oxygen consumption, normoglycemia and absence of toxic or septic factors, which reduces collagen synthesis and oxidative killing mechanisms of neutrophils. Also the type of abdominal closure may plays an important role. The tension free closure is recommended and a continuous closure is preferable. Preoperative assessment so as to identify and remove, if possible, these risk factors is essential, in order to minimize the incidence of wound dehiscence, which has a high death rate.

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.

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.