Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard treatment for pseudomyxoma peritonei (PMP), and complete cytoreduction remains essential for prognosis. While gastrectomy has traditionally represented a major threshold of surgical aggressiveness, the functional impact of increasingly extensive perigastric dissection is not well defined. We retrospectively analyzed 110 consecutive patients who underwent CRS and HIPEC for appendiceal PMP between 2016 and 2024. Perigastric procedures were categorized into five Gastric Cytoreductive Levels (GCLs) based on the extent of vascular sacrifice. Postoperative gastrointestinal recovery was compared among stomach-preserving procedures (GCL1–4), whereas morbidity and oncologic outcomes were evaluated across all five groups. Independent predictors of delayed oral refeeding were assessed through multivariable logistic regression, and a predictive nomogram was developed. Gastrointestinal recovery worsened with increasing extent of stomach-preserving perigastric dissection. Patients in GCL4 experienced delayed oral intake, longer dependence on parenteral nutrition, and prolonged hospitalization compared with those undergoing less extensive procedures; nasogastric tube removal was also delayed. Major morbidity, 30 day mortality, and long-term survival were similar across all groups. Female sex, longer operative duration, and GCL4 independently predicted delayed oral refeeding. The nomogram demonstrated good discrimination and calibration. Increasingly extensive perigastric cytoreduction is associated with impaired postoperative gastric recovery while maintaining acceptable morbidity and oncologic outcomes. The predictive nomogram—although exploratory—may help to anticipate postoperative nutritional needs and support tailored recovery strategies after extensive CRS and HIPEC for PMP.

BACKGROUND:Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is widely adopted as the principal treatment for selected patients with pseudomyxoma peritonei from low-grade appendiceal mucinous neoplasms. Prognostic uncertainty persists in patients with a very high peritoneal tumor burden. This study assessed predictors of survival in the overall cohort and explored whether established prognostic factors remain applicable in patients with super-extended disease and a very high Peritoneal Cancer Index (PCI). METHODS:Consecutive patients with pseudomyxoma peritonei from low-grade appendiceal mucinous neoplasms who underwent cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy were retrospectively analyzed. Survival analyses were performed in the overall cohort. An exploratory threshold analysis identified the most discriminative cut-off for the PCI. In the super-extended PCI subgroup, compartmental disease saturation and additional complexity-enhancing resections were assessed. Restricted mean survival time at 36 months was estimated with bootstrap CIs. RESULTS:A total of 73 patients were included. In the overall cohort, a higher PCI and incomplete cytoreduction independently predicted poorer overall survival; a higher PCI, incomplete cytoreduction, and intraoperative complications predicted worse disease-free/progression-free survival. The optimal prognostic threshold was PCI 30. Among the 20 patients with a PCI greater than 30, the prognostic discrimination of PCI and completeness of cytoreduction attenuated, whereas supramesocolic complexity-enhancing resections were associated with poorer overall survival and reduced restricted mean survival time at 36 months. CONCLUSION:Beyond a PCI of 30, global burden metrics become less informative. Outcomes appear to be more closely linked to disease topography, particularly in cases of extensive supramesocolic compartment involvement. This may identify a distinct high-risk phenotype.

BACKGROUND:Pancreatic ductal adenocarcinoma (PDAC) is among the most aggressive malignancies, and peritoneal metastases (PM) represent the second most common site of dissemination, carrying a particularly poor prognosis. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is an emerging locoregional approach for intraperitoneal drug delivery. However, its role in PDAC-related PM remains poorly defined. METHODS:This retrospective, multicentric study based on the ISSPP registry included patients with PM from PDAC treated with PIPAC from the International Society for the Study of Pleura and Peritoneum (ISSPP) registry. Outcome measures were safety, reason for stopping PIPAC, overall survival (OS), treatment response and prognostic factors for suvival at the time of the first PIPAC. RESULTS:One hundred fifty six patients were treated with 350 PIPAC procedures in 6 centers. Three or more PIPAC were completed in 55 (35.2%) patients. No major surgical complications (Clavien-Dindo ≥3) occurred; grade 3-4 adverse events (CTCAE v5.0) were recorded in 10 of 350 procedures (2.9%), and 30-day mortality was 3.8% per patient (6/156), in all cases due to disease progression. The main reason for discontinuation were disease progression and poor general conditions in 77 (49.35%) and 10 (6.41%) patients respectively. Median OS was 19 months from diagnosis and 9 months from PIPAC1. Survival analysis from PM diagnosis based on intraperitoneal drug choice showed a median OS of 15 months in patients with cisplatin and doxorubicin and 23 months with nab-paclitaxel (p = 0.027). Multivariable ananlysis showed that an higher Peritoneal Cancer Index (PCI) at PIPAC1 (p = 0.008) was associated with worse survival, whereas the use of intraperitoneal nabpaclitaxel (p = 0.004). After a 120 days landmark analysis accounting for immortal-time bias, completion of ≥3 PIPAC procedures remained independently associated with survival (adjusted p = 0.005) CONCLUSION: PIPAC appears to be a safe treatment option for patients with PM from PDAC, with a low rate of major complications, however its feasibility is limited, as only about one third completed ≥3 procedures. In this multicentric cohort a hypothesis generating survival signal and histological response were observed, particularly with nab-paclitaxel-based regimens. Prospective studies are needed to validate PIPAC for palliative treatment of PM of pancreatic origin.

Anastomotic leakage (AL) is a major complication in colorectal surgery, particularly following rectal cancer surgery, necessitating effective prevention strategies. The increasing frequency of colorectal resections and anastomoses during cytoreductive surgery (CRS) for peritoneal carcinomatosis further complicates this issue owing to the diverse patient populations with varied tumor distributions and surgical complexities. This study aims to assess and compare AL incidence and associated risk factors across conventional colorectal cancer surgery (CRC), gastrointestinal CRS (GI-CRS), and ovarian CRS (OC-CRS), with a secondary focus on evaluating the role of protective ostomies. A retrospective analysis was performed on 1324 patients undergoing CRC, GI-CRS, and OC-CRS between January 2015 and December 2022. Multivariate analysis was utilized to identify preoperative, intraoperative, and postoperative variables as potential AL risk factors. The overall AL rate was 3.0

Introduction Hyperthermic intraperitoneal chemotherapy (HIPEC) is a current treatment option for peritoneal carcinosis (PC) after cytoreductive surgery (CRS). Genital skin alterations are rare complications reported variously after HIPEC using Mitomycin-C. Presentation of case A 42-year-old man with a diagnosis of stage IV colorectal cancer underwent CRS and HIPEC using mitomycin-C. On postoperative day 75, he developed scrotal wall necrosis not responding to any medical treatment. After he underwent surgery to remove the necrotic tissue and primarily suture the scrotal wound with success. Discussion Genital skins disorders are rarely drugs-related effects and few cases after HIPEC using Mitomycin-C are reported in literature. The most accepted hypothesis to explain the occurrence of scrotal ulcers after CRS and HIPEC is the extravasation reaction to Mitomycin-C that inhibits wound healing and induces skin necrosis. Conclusion Correct diagnosis and immediate surgical debridement are the preferable management.

Purpose//objectives: A disproportionate incidence's increase of rectal cancer in patients younger than 50 years of age. The ESMO and NCCN recommendations are not age-specific and the literature is poor and conflicting. We decided to examine patients with rectal cancer treated in our centre in the last 15 years with curative neoadjuvant radiochemotherapy comparing outcomes in the two groups under and over 55 years old. Materials/methods: 788 rectal cancer patients were enrolled in this monocentric retrospective observational study (523 =>55 years and 265 < 55). All patients received neoadjuvant chemoradiation treatment. R statistical software v.4.1.3 was used for the entire analysis. The outcomes were death, local recurrence, and new distant metastases. Survival analysis was performed using the Kaplan-Meier method and the Log-rank was used to compare the two groups. Results: All patients were classified in different risk groups, according to the ESMO 2017 rectal cancer clinical practice guidelines. 88 % of patients under 55 years old at the diagnosis belonged to the bad or advanced risk groups with an equal division. In patients over 55 years old, there was a clear dominance of the advanced risk class (62 % of the total). In multivariate analysis, OS and DFS decrease with increasing age and ESMO risk group. The other variables in multivariate were not significant. For Both OS, DFS and MFS, the curves separated significantly at 55 years of age, with a prevalence of metastasis development in the older group. Conclusion: Elderly patients have a prevalence of advanced disease. Younger patients seem having a better OS at 3 and 5 years. ESMO risk group and age were the only variables affecting OS and DFS. Young patients have better MFS and DFS at 2 and 5 years than patients older than 55 years. The addition of oxaliplatin to fluoropyrimidinebased neoadjuvant chemotherapy resulted not significant in both groups.

OBJECTIVE:Assessemnet of anastomotic leak rates following recto-sigmoid resection in advanced ovarian cancer surgery after implementing a restrictive stoma policy. Secondary objectives include identifying predictive factors for stoma creation, analyzing anastomotic leak management, and perioperative outcomes. SUMMARY BACKGROUND DATA:Recto-sigmoid resection is essential in advanced ovarian cancer treatment but carries risks like anastomotic dehiscence. The role of protective stomas remains uncertain, highlighting the need for targeted strategies. METHODS:This retrospective study includes data from 722 patients who underwent recto-sigmoid resection between January-2020 and December-2023 at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. Patients were classified under liberal (2020-2021) or restrictive (2022-2023) stoma policies. The liberal approach relied on general surgeon preference without predefined criteria, while the restrictive policy introduced a systematic evaluation of risk factors by the gynecologic oncologist and the general surgeon in the surgical team before proceeding with ostomy creation. RESULTS:The restrictive policy significantly reduced stoma rates from 38.8 % to 11.1 % (p < 0.001) without increasing anastomotic leaks (stable at 2.5 %, p = 1.000). Predictive factors for stoma included multiple bowel resections, inferior mesenteric artery closure, low anastomosis, and residual tumor. Patients with stomas experienced more severe postoperative complications (p = 0.007), prolonged hospital stays (p < 0.001), and delayed chemotherapy (p = 0.018). No differences in anastomotic leak management were recorded among patients with and without ostomy. CONCLUSIONS:A restrictive stoma policy reduced ostomy rates without affecting leak rates or mortality, supporting individualized surgical decision-making in ovarian cancer. Prospective studies are needed to clarify risk factors for leaks and validate the necessity of protective stomas.

BACKGROUND:Metastatic colorectal cancer (mCRC) remains a leading cause of cancer-related mortality. While metastasectomy could improve survival in selected patients, the role of repeated resections in oligorecurrent disease is less defined. METHODS:We retrospectively analyzed patients with mCRC treated at Fondazione Policlinico Universitario Agostino Gemelli-IRCCS (Rome, Italy) between 2010 and 2024. Eligible patients underwent ≥2 resections of metastatic lesions. Disease-free survival after second metastasectomy (DFS2) and overall survival (OS) were the coprimary end points. Prognostic factors were tested with Cox regression, and a composite risk score (Fondazione Policlinico Gemelli Risk Score [FPGRiskScore]) was developed. RESULTS:Among 1586 patients with mCRC, 396 (24.9%) received at least one metastatic surgery and 143 (9%) underwent ≥2 metastasectomies. Median DFS2 was 8.2 months (95% confidence interval [CI]: 7.3-13.1), and 5-years OS rate was 73.1% (95% CI: 64.5-83.0); after a median follow-up from the last metastasectomy of 34.3 months, 49/143 patients (34.2%) were relapse-free and median DFS after the second surgery of the metastases from the last surgery was 13.1 months (95% CI: 9.1-17.5). Patients stratified by FPGRiskScore (disease-free interval [DFI] from the first metastasectomy ≤ vs. >12 months, metastatic burden ≤ vs >5 cm, RAS/BRAF status, and Eastern Cooperative Oncology Group Performance Status [ECOG PS] scale 0 vs. ≥1) showed distinct outcomes: low-risk patients achieved a median DFS2 of 18.4 months and 5-years OS of 87.6%, compared with 7.8 months/72.0% in intermediate-risk and 4.9 months/55.3% in high-risk group. CONCLUSIONS:Repeated metastasectomy offers substantial survival benefit in selected patients with oligorecurrent mCRC, with long-term disease control achievable in a subset. Prognostic stratification incorporating clinical and molecular features (FPGRiskScore) may refine patient selection and guide multidisciplinary management.

The aim of this study was to evaluate the safety and feasibility of totally intracorporeal colorectal anastomosis (TICA) in patients undergoing colorectal resection for the treatment of deep endometriosis (DE) affecting the bowel. Between January 2021 and August 2024, 33 consecutive patients with DE treated with segmental colorectal resection were enrolled. In 30 patients, TICA was performed. Demographic, operative, and postoperative data were collected retrospectively. The mean distance between the endometriotic nodule and the anal verge was 11.5 (7–18) cm. The mean operative time was 282.83 (190–512) minutes. No major intraoperative complications occurred. Three (10

Background: RPS are rare tumors requiring complex surgery. The impact of postoperative complications on long-term outcomes is still debated. This study aimed to identify predictors of severe complications and assess their influence on overall survival (OS) and disease-free survival (DFS). Methods: We retrospectively analyzed 61 patients who underwent curative surgery for primary RPS between 2013 and 2023 at a tertiary cancer center. Patients with pelvic or recurrent sarcomas were excluded. Severe complications were defined as Clavien–Dindo (CD) grade ≥ 3A. Cox regression and Fine–Gray competing risk models were used for OS and DFS, respectively. Sarculator and P-POSSUM scores were included in multivariable models. Results: Severe complications occurred in 14.8% of patients; 30-day mortality was 1.6%. Predictive factors for complications included longer operative time, gastric resection, intraoperative complications, and transfusions. In multivariable analysis, Sarculator was significantly associated with both DFS (HR 0.97; p = 0.004) and OS (HR 0.97; p = 0.008). The P-POSSUM mortality score predicted OS (HR 1.12; p = 0.002). Severe complications were not independently associated with DFS or OS. Conclusions: In this cohort, severe complications did not impact long-term oncological outcomes. Prognostic tools such as Sarculator and P-POSSUM may enhance risk stratification in RPS surgery. Prospective validation is warranted.

Background: Since 2011, Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) has emerged as a promising treatment option for patients with peritoneal surface malignancies (PSM) who are not eligible for cytoreductive surgery (CRS). Repeated minimal-invasive treatment is one of the key features and the current empirical standard treatment (ST) consists of at least three administrations over about three months. However, many patients are unable to complete the full course, limiting the potential benefits of PIPAC. Method: This retrospective, single-center study assessed the completion rate of ST and identified the main causes and predictive factors for discontinuation. This study also evaluated the feasibility, safety, and efficacy of PIPAC and investigated whether improved patient selection over the years has resulted in better oncological outcomes. Result: Data from 168 patients treated with PIPAC between January 2017 and March 2023 for a total of 336 procedures showed that only 29% completed ST. Multivariate analysis identified ascites >500 mL and a prior history of bowel obstruction as significant predictors of discontinuation. Conclusions: Patients with radiological or clinical signs of obstruction should not be considered for PIPAC treatment, and ascites increases the risk of incomplete treatment. Larger studies are eagerly awaited to corroborate these findings and refine the selection criteria by disease entity.

ObjectiveSurgical management of bowel endometriosis is still controversial. Recently, many authors have pointed out the potential benefits of preserving the superior rectal artery, thus ensuring better perfusion of the anastomosis. The aim of this study was to evaluate the complication rate and functional outcomes of a bowel resection technique for deep endometriosis (DE) involving a nerve- and vascular-sparing approach. MethodsA single-center retrospective study was conducted by enrolling patients who underwent segmental resection of the rectus sigmoid for DE in our department between September 2019 and April 2022. Intraoperative and postoperative complications were recorded for each woman, and functional outcomes relating to the pelvic organs were assessed using validated questionnaires (Knowles-Eccersley-Scott-Symptom [KESS] questionnaire and Gastro-Intestinal Quality of Life Index [GIQLI] for bowel function, Bristol Female Lower Urinary Tract Symptoms [BFLUTS] for urinary function, and Female Sexual Function Index [FSFI] for sexual function). These were evaluated preoperatively and postoperatively after 6 months from surgery. ResultsSixty-one patients were enrolled. No patients had Clavien-Dindo grade 3 or 4 complications, there were no rectovaginal fistulas or ureteral lesions, and in no cases was it necessary to reoperate. Temporary bladder voiding deficits were reported in 8.2% of patients, which were treated with self-catheterizations, always resolving within 45 days of surgery. Gastrointestinal function evaluated by KESS and GIQLI improved significantly after surgery, whereas sexual function appeared to worsen, although without reaching the level of statistically significant validity. ConclusionOur vascular- and nerve-sparing segmental bowel resection technique for DE had a low intraoperative and postoperative complication rate and produced an improvement in gastrointestinal function after surgery.

Background: Peritoneal carcinomatosis is one of deadliest metastatic patterns of gastric cancer, being associated with a median overall survival (OS) of 4 months. Up to now, palliative systemic chemotherapy (pSC) has been the only recommended treatment. The aim of this study is to evaluate a potential survival benefit after CRS + HIPEC compared to pSC. Methods: A systematic review was conducted according to the PRISMA guidelines in March 2024. Manuscripts reporting patients with peritoneal carcinomatosis from gastric cancer treated with CRS + HIPEC were included. A meta-analysis was performed, comparing the survival results between the CRS + HIPEC and pSC groups, and the primary outcome was the comparison in terms of OS. We performed random-effects meta-analysis of odds ratios (ORs). We assessed heterogeneity using the Q2 statistic. Results: Out of the 24 papers included, 1369 patients underwent CRS + HIPEC, with a median OS range of 9.8–28.2 months; and 103 patients underwent pSC, with a median OS range of 4.9–8 months. CRS + HIPEC was associated with significantly increased survival compared to palliative systemic chemotherapy (−1.8954 (95% CI: −2.5761 to −1.2146; p < 0.001). Conclusions: CRS + HIPEC could provide survival advantages in gastric cancer peritoneal metastasis compared to pSC.