Perioperative morbidity and quality of life in long-term survivors following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Improved prognosis can be achieved in selected patients with peritoneal carcinomatosis (PC) by major surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). METHOD: Sixty seven patients with PC were operated with the aim of complete macroscopical cytoreduction followed by HIPEC (using cisplatin, mitomycin or mitoxantrone). Quality of life was assessed with the EORTC QLQ-C30 questionnaire. RESULTS: The patients had a variety of primary tumours, including appendix carcinomas (22/67). Mean operating time was 7 hours and complete cytoreduction was achieved in 58% of the patients. Overall morbidity was 34%. Post-operative mortality was 4.5%. The mean score for global health status of long-term survivors (20 questionnaires/25 patients) was 62.6 (73.3 for the control population, p=0.07). Functional status, particularly the role (56.4) and the social functioning (53.9) were impaired. CONCLUSION: Cytoreductive surgery combined with HIPEC is associated with an increased morbidity and mortality. Complications are predominantly related to major surgery. Following this aggressive treatment, survivors may achieve a satisfactory quality of life.     

Intraoperative (hypertherme) intraperitoneale Chemotherapie—Überlegungen und Aspekte zum sicheren intra- und postoperativen Umgang mit Zytostatika

The application of open intraoperative intraperitoneal chemotherapy following cytoreductive surgery for the treatment of pseudomyxoma peritonei or peritoneal carcinomatosis requires safety precautions for the medical and non-medical personnel. In agreement with already existing rules, precautions were established which result in an optimum of safety. These concern the preparation of the cytostatic drugs, the application in the operating room as well as personal precautions intra- and postoperatively. After the establishment of theses recommendations, 22 patients were treated with open intraperitoneal chemotherapy in 1.5 years without any severe accidents. Therefore, a safe intraoperative use of cytotoxic drugs is possible. At the moment, the indication for such an approach may be given in peritoneal carcinomatosis from appendix, colon or ovarian cancer. In the future, an adjuvant application in other gastrointestinal malignancies (e.g. T3/T4 gastric carcinoma) may be considered.     

Surgical strategy in aortoesophageal fistulae: endovascular stentgrafts and in situ repair of the aorta with cryopreserved homografts

OBJECTIVE: The surgical treatment of aortoesophageal fistulae (AEF) has a high morbidity and mortality rate. We report our experience with the sequential use of endovascular thoracic stentgrafts and cryopreserved aortic homografts for in situ repair of the descending thoracic aorta. METHODS: In a 7-year period, 6 patients with AEF were treated at our center. After primary endovascular repair in all cases, 4 patients subsequently underwent in situ repair of the descending thoracic aorta with cryopreserved homografts. Long-term antibiotic therapy was given in all cases. Recent clinical status and radiologic findings on follow-up studies of each patient were analyzed. The mean follow-up time was 35 months (range, 2-76). RESULTS: Endovascular stentgraft repair was technically successful in all cases. Two patients were not candidates for open surgical repair because of their medical condition; they both died within 8 weeks after discharge from the hospital, 1 from recurrent septic episodes, and the other from upper gastrointestinal bleeding. One of 4 patients who had undergone open surgical repair died 1 year later from upper gastrointestinal bleeding that occurred presumably due to an infectious degeneration of the homograft after secondary infection with a methacillin-resistant Staphyloccocus aureus. In 1 case persistent paraplegia and in another case persistent renal failure occurred. CONCLUSION: The use of cryopreserved homografts is a valuable alternative to in situ repair with prosthetic vascular grafts or extra-anatomic reconstructions in the surgical treatment of AEF. Endovascular stentgraft placement plays a role as a bridging procedure in emergency situations.     

Rare diaphragmatic complications following cytoreductive surgery and HIPEC: report of two cases

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been proven to be an effective treatment modality for selected patients with peritoneal surface malignancies. The most common surgical complications after CRS and HIPEC are anastomotic leakage, intestinal obstruction and peripancreatitis. This case report presents two patients with early and late postoperative diaphragmatic hernia after CRS and HIPEC. One patient that initially had pseudomyxoma peritonei complained of persistent chest pain and dyspeptic disorder after peritonectomy and HIPEC and underwent reoperation due to a left diaphragmatic hernia containing the splenocolic flexure. The other patient had gastric cancer and peritoneal carcinomatosis and developed anastomotic leakage of the transverse colon anastomosis and pleural empyema. Stripping of the diaphragm is often performed during CRS, sometimes combined with diaphragmatic resection. A herniation through a diaphragmatic defect is rarely diagnosed during either the early or late postoperative period. Direct suture of the defect or closure with synthetic or biological tissue are possible surgical techniques for repair with a good prognosis.     

The quality of oral anticoagulation before,during and after a period of patient self-management

The study analyzes the quality of anticoagulation during a 3-year follow-up on patients who were treated by an anticoagulation clinic (ACS) for 1 year (Phase I), performed weekly self-management of anticoagulation (PSM) after a specific training for another year (Phase II) and finally returned to be treated by the anticoagulation clinic (ACS) for a third year (Phase III). The mean fraction of INR values within therapeutic target range was higher in Phase II (0.69 +/- 0, 11) compared to Phases I (0.40 +/- 0.20) and III (0.56 +/- 0.18; p < 0.05). Time spent in therapeutic target range was higher in Phase II (0.70 +/- 0.10) compared to Phases I (0.43 +/- 0.25) and III (0.60 +/- 0.17; p < 0.05). Mean square deviation from target value was lower in Phase II (0.39 +/- 0.17) compared to Phases I (0.81 +/- 0.44) and III (0.64 +/- 0.39, p = 0.05). Thus, the quality of anticoagulation during Phase II (PSM) was significantly better compared to Phases I (ACS) and III (ACS) in all endpoints tested. This shows that the quality of oral anticoagulation deteriorates again if patient self-management is stopped and patients return to conventional treatment. Furthermore, the quality of anticoagulation was better in Phase III (post-PSM) compared with Phase I (pre-PSM) although the type of treatment was identical in both phases (ACS). This suggests that the increased patient empowerment and enhanced compliance acquired during PSM (Phase II) might have a positive impact on the quality of anticoagulation, even when patients return to the conventional treatment (ACS).     

Fatal sepsis in an AIDS patient during therapy for Pneumocystis carinii pneumonia

The case of a patient with a newly diagnosed HIV infection and Pneumocystis carinii pneumonia is presented. Despite treatment with high-dose trimethoprim/sulfamethoxazole (TMP/SMX) and prednisone with initial improvement, the patient acutely deteriorated with severe acidosis and died on the 4th day of hospitalization. Cryptococcus neoformans grew the next day in broncheoalveolar lavage (BAL) and blood culture. As simultaneous presence of more than one opportunistic infection can occur in these patients, systematic workup for other common opportunistic infections must be performed. Received: October 12, 2000 · Revision accepted: December 8, 2001 R. J. Piso (corresponding author)     

Kyphoplastie und Vertebroplastie bei osteoporotischen Wirbelkörperkompressionsfrakturen

Background

We evaluated the efficacy and safety of kyphoplasty and vertebroplasty using the data presented in recently published papers with respect to pain relief, function, complication rate, and incidence of new vertebral fractures.

Methods

Detailed searches for English-language and German-language articles published between 2002 and 2009 were performed in a number of electronic databases. Because of the large number of case series, we considered only systematic reviews and controlled studies. The internal validity of reviews and studies was judged by two authors independently. Data extraction was performed by one author, and extracted data were checked for completeness and correctness by a second author.

Results

A total of eight systematic reviews, primarily summarizing results from case series, and 11 controlled studies, two of which were randomized controlled trials (RCTs), were included. Both kyphoplasty and vertebroplasty significantly reduce pain in the majority of patients and can lead to short-term and possibly long-term improvement of function. Kyphoplasty induces fewer clinically relevant complications than vertebroplasty does, and there is presently stronger evidence for its efficacy compared with vertebroplasty. There is inconclusive evidence about the risk of new fractures after kyphoplasty and vertebroplasty.

Conclusion

Both procedures seem to be equally effective, but kyphoplasty is safer than vertebroplasty. New results, specifically from RCTs comparing the two procedures, are needed to provide more definitive data.     

Safety of Gastric Resections During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis

Background  Cytoreductive surgery (CRS) including gastric resection combined with hyperthermic intraperitoneal chemotherapy (HIPEC) can improve the prognosis of selected patients with peritoneal surface malignancies. Perioperative morbidity of this aggressive treatment strategy is high; however, overall mortality can be low in specialized centers. The aim of this study was to assess the safety of gastric resections with anastomosis during CRS and HIPEC. Methods  Between 2005 and 2008, 204 patients underwent CRS and HIPEC at our tertiary referral centre. Of these, 37 procedures (male/female 24/13, median age 55 years) included gastric resections. The clinical data of all patients were introduced into a database and analyzed with respect to the morbidity associated with the gastric resections. Results  Of all patients included, 16 had pseudomyxoma peritonei, 11 gastric carcinoma, 4 ovarian carcinoma, 3 malignant peritoneal mesothelioma, and 3 colon carcinoma. Twenty-seven patients had previous surgery (n = 22) and/or systemic chemotherapy (n = 18). Fifteen total gastrectomies, 3 subtotal gastrectomies, 12 distal gastrectomies, and 7 gastric wedge resections were performed during CRS. The overall postoperative morbidity was 45%; main surgical complications were pancreatitis (n = 6), abdominal abscess (n = 4), bile leakage (n = 2), and digestive fistula (leakage of ileorectostomy and small bowel perforation) (n = 2). However, no complications occurred at the site of the esophageal anastomosis (n = 15), gastric anastomosis (n = 15) or gastric suture (n = 7). No patient died postoperatively during the hospitalization period. Conclusions  CRS in combination with HIPEC is associated with high postoperative morbidity; however, anastomosis following total or subtotal gastrectomy is safe in experienced centers. No leakages related to gastric resections occurred in this high-risk patient group. Pompiliu Piso and Przemyslaw Slowik have contributed equally to this study.     

Self-management of oral anticoagulation in the elderly: rationale, design, baselines and oral anticoagulation control after one year of follow-up. A randomized controlled trial

Self-management is safe and reliable in patients with long-term oral anticoagulation (OAC). However, no study has yet assessed the safety and efficacy of OAC self-management in elderly patients with major thromboembolic and haemorrhagic complications as primary outcomes. In this multi-centre, open, randomised controlled trial, patients aged 60 years or more were randomised into the self-management group (SMG) (N = 99) or routine care group (RCG) (N = 96). We describe the rationale, design, baseline characteristics and interim analyses of oral anticoagulation control quality within the first year of follow-up. The medians of the squared international normalised ratio (INR) value deviations after six and 12 months were significantly lower in the SMG with medians of 0.16 and 0.16 compared to the RCG with medians of 0.25 and 0.25. The percentage of time within target range and the percentage of INR measurements within target range were significantly higher in the SMG versus the RCG within the first six months (medians 71% vs. 58% and 69% vs. 57%), and during the second six months of the study (75% vs. 67% and 72% vs. 57%). The numbers of all thromboembolic events requiring hospitalisation, major bleeding events, and deaths were similar in both groups. These preliminary results suggest that self-management of oral anticoagulation is safe and feasible for elderly patients willing to participate in a structured training programme.