Diaphragmatic Disease Research Articles

The application of pringle manoeuvre, type three liver mobilisation, full thickness diaphragmatic resection with primary closure technique and peritonectomy in the management of advanced ovarian malignancy.

We present an educational technique for the safe completion of complete cytoreduction of diaphragmatic disease for the management of advanced ovarian malignancy. We demonstrated these steps with attention to anatomical landmarks and surgical approaches, considering intraoperative and postoperative morbidity and mortality. We present the case of a 49-year-old female patient diagnosed with suspected stage 3C ovarian malignancy following diagnostic laparoscopy. We demonstrate the surgical application of the Pringle maneuver, type 3 liver mobilization, and full-thickness diaphragmatic resection. This was completed with a primary closure technique, with integrity ensured through the performance of an air test and Valsalva maneuver. Final histology confirmed a serous borderline tumor with invasive implants within a port site nodule (stage 4A). This technique affirms the essential skills in gynecological oncology training and details a challenging case requiring advanced surgical skills and knowledge, with specific consideration for intraoperative multidisciplinary decision-making.

Do surgeons overestimate diaphragmatic peritoneal disease in interval debulking surgery of ovarian cancer?

IntroductionCytoreductive surgery is a key point in ovarian cancer treatment. Substantial morbidity may be consecutive to this major radical surgery. However, the objective of no residual tumor (CC-0) had demonstrated its clear improvement of prognosis. Could macroscopically-driven interval debulking surgery (IDS) overestimate active cancer cells and be unnecessarily morbid? Materials and methodsThis retrospective cohort study was conducted in Center Leon Berard Cancer Center between 2000 and 2018. We included women with advanced epithelial ovarian cancer who received neoadjuvant chemotherapy and underwent an IDS including resection of peritoneal metastases on the diaphragmatic domes. The primary endpoint was the pathological outcome of peritoneal resections of diaphragmatic domes. ResultsPeritoneal resections of diaphragmatic domes consisted of 117 patients. 75 patients required resection of nodules from the right cupola only, 2 patients from the left cupola only, and 40 patients bilaterally. Pathological analysis of the diaphragmatic domes found that 84.6% of samples demonstrated the presence of malignant cells, and only 12.8% found no tumor involvement. Pathology analysis could not be performed for 3 patients (2.6%) (vaporization). ConclusionSurgical evaluation after neoadjuvant chemotherapy in ovarian cancer does not often overestimate peritoneal involvement by active carcinomatosis. Potential surgical morbidity due to peritoneal resection in IDS is admissible.

DIAPHRAGMATIC MOBILITY, DISEASE SEVERITY, AND EXERCISE TOLERANCE IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Airflow obstruction in patients with Chronic Obstructive Pulmonary Disease represents the main disabling factor, in a progressive and irreversible manner. Respiratory muscle dysfunction correlates with disease mortality and morbidity and reduces the patient's tolerance to exercise and quality of life. Thus, this study aimed to evaluate diaphragmatic mobility, disease severity, and exercise tolerance in patients with COPD. Methods: The study included clinically stable patients diagnosed with COPD according to the GOLD 2019 guidelines. We excluded patients who had disease exacerbation during the study or in the last two months preceding the study those who were unable to perform any of the study assessments due to lack of understanding or cooperation, and those who had clinical intercurrences of cardiorespiratory and, or musculoskeletal nature during the assessments. The diaphragmatic mobility was measured by ultrasound, curvilinear transducer (1-5Mhz). The 6-minute walk test (6MWT) was performed according to the guidelines suggested by the American Thoracic Society. We used the COPD Assessment Test (CAT) and the modified Borg scale to assess the patient's quality of life and the degree of dyspnea, respectively. Results: Sixty-six patients were included and classified into three groups: mild COPD (n=16), moderate COPD (n=30), and severe/very severe COPD (n=20). The mean age of the patients was 63.7 ± 9.4 years, 53% were female, and the mean BMI was 27.6 ± 5.5 kg/m². Diaphragmatic mobility did not correlate with the distance walked on the 6MWT (p=0.8), CAT scores (p=0.2), and disease severity (p=0.9). It also did not correlate with other clinical and functional variables such as heart and respiratory rate, blood pressure peripheral oxygen saturation (SpO2), and Borg scores. Conclusion: In our study, diaphragmatic mobility measurements seem unable to identify disease severity and to correlate with other clinical and functional parameters.

Shear wave elastography of the diaphragm in acute exacerbation of chronic obstructive pulmonary disease: A prospective observational study.

Patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are prone to diaphragmatic dysfunction. However, dynamic assessment of diaphragmatic function is complex and difficult, and whether the assessment of diaphragmatic function can reflect clinical indicators such as lung function in AECOPD patients remains unclear. We studied diaphragm stiffness and diaphragm stiffening rate (DSR) in AECOPD patients with acute exacerbations ≥ 2 times within 1 year and their correlation with clinical data, the diaphragmatic thickening fraction (DTF), lung function, and blood gas values. In total, 112 AECOPD patients in group C and Group D who had acute exacerbations ≥ 2 times within 1 year in the Global Initiative for Chronic Obstructive Lung Disease Guideline A (low risk, few symptoms), B (low risk, many symptoms), C (High risk, few symptoms), D (High risk, many symptoms) grouping system were included in the study. Their general clinical data, chronic obstructive pulmonary disease assessment test (CAT), modified medical research council (mMRC), number of acute exacerbations in 1 year, DTF, lung function, and blood gas analysis were collected. The diaphragm shear wave elasticity at functional residual capacity (DsweFRC) and DSR were measured by ultrasound. The DsweFRC and DSR of Group D were higher than those of Group C (P < .05). DsweFRC, DSR were negatively correlated with DTF, forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and FEV1/FVC (r ranged from -0.293 to -0.697, all P < .05), and positively correlated with CAT score, mMRC score, and arterial carbon dioxide pressure (r ranged from 0.274 to 0.462, all P < .05) in both groups; the correlation coefficients of DsweFRC, DSR and DTF, FEV1/FVC in group D were greater than those in group C. There was no correlation between DsweFRC, DSR and arterial oxygen partial pressure in both groups (P > .05). The DsweFRC, DSR increased with the number of acute exacerbations per year in both groups. We found that diaphragmatic stiffness in AECOPD patients increased with the number of acute exacerbations within 1 year, correlated with DTF, CAT, mMRC, lung function, and arterial carbon dioxide pressure and provides a simple and practical method for dynamically assessing diaphragmatic function and disease severity in AECOPD patients.

Using a machine learning algorithm to predict outcome of primary cytoreductive surgery in advanced ovarian cancer.

To develop a machine learning (ML) algorithm to predict outcome of primary cytoreductive surgery (PCS) in patients with advanced ovarian cancer (AOC) METHODS: This retrospective cohort study included patients with AOC undergoing PCS between January 2017 and February 2021. Using radiologic criteria, patient factors (age, CA-125, performance status, BRCA) and surgical complexity scores, we trained a random forest model to predict the dichotomous outcome of optimal cytoreduction (<1 cm) and no gross residual (RD = 0 mm) using JMP-Pro 15 (SAS). This model is available at https://ipm-ml.ccm.sickkids.ca. One hundred and fifty-one patients underwent PCS and randomly assigned to train (n = 92), validate (n = 30), or test (n = 29) the model. The median age was 58 (27-83). Patients with suboptimal cytoreduction were more likely to have an Eastern Cooperative Oncology Group 3-4 (11% vs. 0.75%, p = 0.004), lower albumin (38 vs. 41,p = 0.02), and higher CA125 (1126 vs. 388,p = 0.012) than patients with optimal cytoreduction (n = 133). There were no significant differences in age, histology, stage, or BRCA status between groups. The bootstrap random forest model had AUCs of 99.8% (training), 89.6%(validation), and 89.0% (test). The top fivecontributors were CA125, albumin, diaphragmatic disease, age, and ascites. For RD = 0 mm, the AUCs were 94.4%, 52%, and 84%, respectively. Our ML algorithm demonstrated high accuracy in predicting optimal cytoreduction in patients with AOC selected for PCS and may assist decision-making.

Diaphragmatic endometriosis: robotic approaches and techniques

To present different approaches used in the surgical management of diaphragmatic endometriosis using the Davinci Robotic system. A video article presenting patient positioning, port placement, and surgical techniques used in robotic excision of diaphragmatic endometriosis with concomitant pelvic disease. Endometriosis center. Patients undergoing excision of diaphragmatic endometriosis. Systematic robotic approach to excise diaphragmatic lesions depending on the depth of invasion. The advantages and disadvantages of the lithotomy and the lateral decubitus approach were reviewed. Ports placements are illustrated according to the chosen approach. Diaphragmatic peritoneal stripping, diaphragmatic shaving, and diaphragmatic excision are different techniques used according to the depth of invasion. N/A. The choice of approach between the lithotomy position and the left lateral decubitus position depend on the extent of the diaphragmatic disease and the presence of concomitant pelvic lesions. Despite the lack of high-quality evidence, the advantages of the robotic system may improve the outcomes in such difficult cases in comparison with conventional laparoscopy.

8880 Recurrent Endometriosis-Associated Massive Hemorrhagic Ascites: A Case Report and Literature Review

<h3>Study Objective</h3> To discuss the presentation, pathophysiology, and management of large-volume endometriosis-related ascites. <h3>Design</h3> Case report and literature review. <h3>Setting</h3> University-based teaching hospital. <h3>Patients or Participants</h3> A 31-year-old with cyclic pelvic pain presented with new-onset hemorrhagic ascites up to 6L in volume requiring recurrent paracentesis. <h3>Interventions</h3> Initial ultrasound imaging (Figure 1) revealed large volume ascites, normal uterus, and normal ovaries. Computed tomography scan revealed a large amount of ascites with a normal-appearing liver. Paracentesis revealed hemosiderin laden macrophages and no evidence of malignancy or bacterial growth. The patient's medical and hepatologic workup was unremarkable. After undergoing two additional paracentesis procedures, she underwent diagnostic laparoscopy and peritoneal biopsies. Findings included stage 4 endometriosis with posterior cul-de-sac disease, right adnexal and large bowel disease, and diaphragmatic disease (Figure 2). <h3>Measurements and Main Results</h3> The patient was started on high-dose oral progestins postoperatively. Thereafter, she noted symptom improvement and less frequent paracentesis, but stopped therapy due to side effects. She was started on Elagolix and add-back therapy with no recurrence of ascites over one month of follow-up. Large-volume endometriosis-associated ascites is rare, usually recurrent, and thought to be due to massive ovarian transudate plus altered lymphatic drainage¹. Symptoms may mimic those of an ovarian malignancy. Associated CA-125 levels vary and do not correlate with the presence of ascites^2,3. Additionally, 38% of patients present with pleural effusion². Suppressive therapy with gonadotropin-releasing hormone (GnRH) agonists temporarily prevents ascites recurrence, but medical management regimens and outcomes vary^1,3,4. Surgical management of endometriosis without bilateral salpingo-oophorectomy (BSO) is associated with a recurrence rate of over 50%, while BSO is curative¹. <h3>Conclusion</h3> Clinicians should consider endometriosis in the workup for patients presenting with pelvic pain and recurrent large-volume hemorrhagic ascites after ruling out ovarian malignancy. Suppressive therapy with high-dose progestins or GnRH agonists/antagonists may improve symptoms and reduce the risk of recurrent ascites, but rigorous studies are lacking.

961 Surgery for Stage IVA Metastatic Thymoma Found Incidentally Post-COVID-19

Abstract Background Thymic epithelial tumours (TET) are rare thoracic cancers with reported annual incidence of 1.3–3.2 per million. TETs are histologically classified as thymomas or thymic carcinomas. Thymomas are slow-growing tumours that comprise the majority of lesions found in the anterior mediastinum. They can be associated with autoimmune disorders such as Myasthenia Gravis. Contrast CT is the standard for diagnosis. Surgery is treatment of choice depending on resectability of the tumour. The Masaoka-Koga staging system is correlated with overall survival and is utilised post-surgical resection to guide adjuvant treatment. Case Presentation A 50-year-old male presented with cough, shortness of breath, myalgia, sore throat, and reduced sense of smell that was diagnosed as COVID-19. CT chest and abdomen showed a large heterogeneous mediastinal mass (11cm) invading the innominate vein and left upper lobe with two left pleural deposits, and diaphragmatic disease. CT biopsy confirmed thymoma. MDT recommended surgery due to patient age and resectability of tumour with post-operative chemotherapy. The sites of disease necessitated a left thoracotomy and median sternotomy. The pleural and diaphragmatic deposits were resected, followed by left upper lobe anatomical dissection enbloc with invaded pericardium, phrenic and vagus nerve, followed by median sternotomy to resect the thymic mass along with the innominate vein. Final staging was stage IVA thymoma (B2 and B3) (T3N0M1aR0). A CT scan at 1 year showed no recurrence despite patient declining adjuvant chemotherapy. Conclusion Surgical resection is a viable treatment option for patients with stage IVA thymoma who present with resectable primary and metastatic disease.

Using a machine learning algorithm to predict outcome of cytoreduction in advanced ovarian cancer (079)

Using a machine learning algorithm to predict outcome of cytoreduction in advanced ovarian cancer (079)

What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival

IntroductionOur paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined. Materials and methodsRetrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed. Results42.6% of patients had radiologically ‘positive’ CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes. ConclusionRadiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume – in particular, heralding upper abdominal disease – and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.

Application of J-Plasma in the excision of diaphragmatic lesions as part of complete cytoreduction in patients with advanced ovarian cancer.

For the resection of diaphragmatic disease in patients with advanced ovarian cancer (OC), a plethora of ablative methods have been utilized. The present study aimed to present preliminary data on the use of J-Plasma in OC with diaphragmatic involvement via a retrospective review of patients who had diaphragmatic stripping with of J-Plasma® from January 2016 to September 2020. A total of 12 patients (median age, 65 years) were analyzed. Median operative time was 240 min while median estimated blood loss was 400 ml. Median operative time for diaphragmatic resection was 25 min. During a median follow-up of 12 months, two recurrences were noted while none of the patients died of the disease. Median disease free survival was 12 months. Overall, the preliminary outcomes of the present study indicated that J-Plasma could be safely used in diaphragmatic resection and it was associated with low rates of short-term morbidity. However, further studies are warranted to reach to safe conclusions.

Ultrasound of the chest and mediastinum in children, interventions and artefacts. WFUMB review paper (part 3).

Ultrasound (US) is an ideal diagnostic tool for paediatric patients owning to its high spatial and temporal resolution, realtime imaging, and lack of ionizing radiation and bedside availability. The lack of superficial adipose tissue and favourable acoustic windows in children makes US the first line of investigation for evaluation of pleural and chest wall abnormalities.In the first part of the topic the technical requirements were explained and the use of ultrasound in the lung and pleura in paediatric patients were discussed. In the second part lung parenchymal diseases with their subpleural consolidations are reflected. In the third part, the use of ultrasound for chest wall, mediastinum, diaphragmatic diseases, trachea, interventions and artifacts in paediatric patients are summarized.

Perioperative management of diaphragmatic diseases in neonates and infants

Diaphragmatic diseases(DD) in neonates and infants are rare surgical cases involving the cardiopulmonary and digestive system, complicating perioperative management. The study aims to describe the clinical presentations, radiological imaging, anesthesia and surgical technique of three types of DD; congenital diaphragmatic hernia(CDH), hiatal hernia (HH) and eventration of the diaphragm(ED). This was single-center case series in a tertiary referral and teaching hospital from July to August 2021. Three patients were presented, a 13 days old neonate with CDH, a one-month-old infant with HH and a two-month-old infant with ED. An institutional review board was obtained, and the PROCESS guidelines were used in writing. Main clinical presentation was respiratory distress and vomiting since birth. Radiological imaging was essential to diagnose each case. CDH had more cardiopulmonary complications and more extended post-operative care in intensive care during the perioperative period. DD is a differential diagnosis in early-onset respiratory distress in neonates and infants with recurring infections and trouble feeding. Radiological examination is crucial in the diagnosis, and surgical treatment is favorable. CDH remains the most severe form of DD.

Systematization of Laparoscopic Surgery for Deep Endometriosis

Study Objective The objective of the study is to show that a qualified team and the systematization of the surgical technique help to decrease the number of complications in laparoscopic surgery for deep endometriosis. Design Retrospective cohort during the period between 2017 to 2020. Setting Laparoscopic operating room with patient in semi-gynecological position. Patients or Participants 355 women with deep endometriosis. Interventions Surgeries were performed by the same team, with the same systematization. In all cases were performed cavity review, oophoroplasty and ovarian fixation, ureterolysis, hypogastric nerves identification and bowel disease treatment, and endometrial nodules exeresis. Postoperative complications, hospitalization time, fistulas, etc. were evaluated. Measurements and Main Results Of all the 355 surgery patients of the group, 86,98% had bowel disease, 40,82% had urinary tract disease, 24,85% ovary disease, 1,77% diaphragmatic disease, 3,55% parametrium injuries, concurrent or not. A percentage of 15,97% hysterectomies were performed, out of the total of 355 patients. The techniques used to treat bowel disease were rectosigmoidectomy in 15,38% of the cases, shaving in 39,05% of the cases, circular stapling in 14,79% of the cases, appendectomy in 17,15% of the cases, and right colectomy in 0,59% of the cases. Only one protective colostomy was performed in one of the cases (0,59%) due to the height of the wound when compared to the anal verge, and no drains were used in any of the cases. The average hospitalization time was 3 days (2 to 10), and no blood transfusions were required. On postoperative, there were 0,59% of cases with rectovaginal fistulas and 0,59% of cases with intestinal perforation. Conclusion The data showcased in our group review showed that deep endometriosis surgery is a high complexity procedure and should be performed by surgeons with a comprehensive experience in anatomy, together with multidisciplinary surgeons and systematizing the surgery technique, to achieve better results. The objective of the study is to show that a qualified team and the systematization of the surgical technique help to decrease the number of complications in laparoscopic surgery for deep endometriosis. Retrospective cohort during the period between 2017 to 2020. Laparoscopic operating room with patient in semi-gynecological position. 355 women with deep endometriosis. Surgeries were performed by the same team, with the same systematization. In all cases were performed cavity review, oophoroplasty and ovarian fixation, ureterolysis, hypogastric nerves identification and bowel disease treatment, and endometrial nodules exeresis. Postoperative complications, hospitalization time, fistulas, etc. were evaluated. Of all the 355 surgery patients of the group, 86,98% had bowel disease, 40,82% had urinary tract disease, 24,85% ovary disease, 1,77% diaphragmatic disease, 3,55% parametrium injuries, concurrent or not. A percentage of 15,97% hysterectomies were performed, out of the total of 355 patients. The techniques used to treat bowel disease were rectosigmoidectomy in 15,38% of the cases, shaving in 39,05% of the cases, circular stapling in 14,79% of the cases, appendectomy in 17,15% of the cases, and right colectomy in 0,59% of the cases. Only one protective colostomy was performed in one of the cases (0,59%) due to the height of the wound when compared to the anal verge, and no drains were used in any of the cases. The average hospitalization time was 3 days (2 to 10), and no blood transfusions were required. On postoperative, there were 0,59% of cases with rectovaginal fistulas and 0,59% of cases with intestinal perforation. The data showcased in our group review showed that deep endometriosis surgery is a high complexity procedure and should be performed by surgeons with a comprehensive experience in anatomy, together with multidisciplinary surgeons and systematizing the surgery technique, to achieve better results.

Near Infrared Imaging with Indocyanine Green for Resection of Diaphragmatic Endometriosis

Study Objective To describe the key principles of successful extra pelvic endometriosis excision, highlighting diaphragmatic endometriosis, and the potential role of indocyanine green and near infrared imaging. Design Case Report. Setting Multidisciplinary surgical case at an academic institution using robotic and near infrared technology. Patients or Participants Thirty-three-year-old para zero with chronic pelvic pain and laparoscopically proven stage IV endometriosis, new onset right shoulder pain and known diaphragmatic disease. Interventions Preoperative MRI followed by robotic-assisted laparoscopic diaphragmatic endometriosis excision using near infrared technology. Measurements and Main Results Complete excision of endometriosis was achieved with resolution of patient's pain. Conclusion Successful diaphragmatic endometriosis excision requires appropriate pre-operative imaging, coordination of a multidisciplinary team, and can be aided by the use of indocyanine green and near infrared imaging. To describe the key principles of successful extra pelvic endometriosis excision, highlighting diaphragmatic endometriosis, and the potential role of indocyanine green and near infrared imaging. Case Report. Multidisciplinary surgical case at an academic institution using robotic and near infrared technology. Thirty-three-year-old para zero with chronic pelvic pain and laparoscopically proven stage IV endometriosis, new onset right shoulder pain and known diaphragmatic disease. Preoperative MRI followed by robotic-assisted laparoscopic diaphragmatic endometriosis excision using near infrared technology. Complete excision of endometriosis was achieved with resolution of patient's pain. Successful diaphragmatic endometriosis excision requires appropriate pre-operative imaging, coordination of a multidisciplinary team, and can be aided by the use of indocyanine green and near infrared imaging.

Complications and Outcomes of Diaphragm Surgeries in Epithelial Ovarian Malignancies.

To achieve optimal debulking, cytoreductive surgery often involves diaphragm stripping. We describe our complications and survival outcomes after diaphragm surgery in epithelial ovarian cancer. A retrospective analysis on patients with advanced stage epithelial ovarian cancer between January 2012 and September 2019. The details of the diaphragmatic resections and stripping and their complications were looked into. During the study period, 616 patients with epithelial ovarian cancers were operated of which, 81 (13.2%) had diaphragm surgery. The majority underwent diaphragm stripping (60%) while 33% had resection and 7% cases had diaphragmatic nodule excision. Optimal debulking was achieved in 89% of cases. The complexity of surgery was intermediate in 64% of patients and complex in 33% as per Aletti's scoring. Mean operating time was 300min (SD113). Moderate to severe pleural effusion was seen in 26 (32. %) patients necessitating pleural tapping in 16% and single lumen pleurex catheter insertion in 11%. Median recurrence-free and overall survival were 22 (95% CI 16.9-27) and 32months (95% CI 25.5-38) respectively. Diaphragm stripping and resection is an important step in achieving optimal debulking of advanced and recurrent ovarian cancer. Diaphragmatic disease clearance is a necessary skill to be acquired by the gynaecologic oncology surgeons. Choosing the patients correctly and anticipation of complications can reduce morbidity and mortality.

Splenectomy and Distal Pancreaticosplenectomy: Surgical Anatomy and Technique Specific to Advanced Ovarian Cancer.

Ovarian cancer is one of the most aggressive malignancies in women and usually presents at an advanced stage. Complete tumor debulking and platinum sensitivity are the two important determinants of survival in ovarian cancer. Upper abdominal surgery with bowel resections and peritonectomy are usually needed to achieve optimal cytoreduction. Splenic disease in the form of diaphragmatic peritoneal disease or omental caking at the splenic hilum is not infrequent. Around 1-2% of these require distal pancreaticosplenectomy (DPS) and the decision to perform DPS versus splenectomy should be made early in the intraoperative period to prevent unnecessary hilar dissection and bleeding. We hereby describe the surgical anatomy of the spleen and pancreas and point of technique of splenectomy and DPS specific to advanced ovarian cancers.

HL-024: Case Report: Re-Challenging with Pembrolizumab for a Case of Hodgkin Lymphoma with no Transplant with Multiple Relapses

In classical Hodgkin lymphoma (cHl), characterized by the overexpression of PDL1 and PDL2, there is a benefit from novel therapeutic strategy for the relapsed refractory disease, and has been approved by the FDA. A 44-year-old female patient presented in 2007 with diffuse enlarged lymph nodes. Biopsy showed a classical nodular sclerosis HL; stage IV according to the Ann Arbor classification system. She received 6 cycles of chemotherapy ABVD regimen (doxorubicin 25 mg/m2, bleomycin 10 IU/m2, vinblastine 6 mg/m2 IV, dacarbazine 375 mg/m2), leading to complete remission. Upon follow-up, end of 2008, PET-CT showed a relapse. Three cycles of chemotherapy ICE protocol were administered (cisplatin 20 mg/m2 day 1-3, etoposide 75 mg/m2 day 1-3, ifosfamide 1200 mg/m2 day 1-3, mesna 1600 mg/m2 day 1-3). PET-CT showed a complete remission, but the patient refused to have an autologous transplant due to financial difficulties. Early 2017, PET-CT showed a recurrence of disease. Treatment with the anti-CD30 antibody brentuximab vedotin 1.8 mg/kg with bendamustine 100 mg/m2 q3 weeks given for 3 cycles resulted in partial response. We continued the treatment for 3 more cycles with a complete remission. An autologous HSCT was not performed, and she continued the follow up for 1 year. December 2017 a Pet CT scan showed a new relapse, initiation of pembrolizumab 200 mg q3 weeks for 1 year with a partial response on Pet-Ct. November 2018 for financial issues, pembrolizumab was stopped (treatment not approved). A new PET-CT in April 2019 showed a progression of supra and infra diaphragmatic LNs and bone marrow disease. Re-challenging strategy, the patient was re-treated with pembrolizumab 200 mg Q3W, with evidence of disease progression in October 2019, suggesting a pseudo progression. A new PET-CT in January 2020 showed a persistent stable disease. Treatment was continued and new PET-CT in April 2020 showed a stable partial response. In summary, re-treatment with pembrolizumab is still active for non-transplanted recurrent HL with multiple previous relapses treated with pembrolizumab.

Hernia diafragmática derecha complicada tras hepatectomía. Presentación de un cuadro oclusivo

Traumatic diaphragmatic hernia is an infrequent form of diaphragmatic disease. We present the case of a complicated right diaphragmatic hernia after right hepatectomy.

Tozzi classification of diaphragmatic surgery in patients with stage IIIC-IV ovarian cancer based on surgical findings and complexity.

ObjectiveTo introduce a systematic classification of diaphragmatic surgery in patients with ovarian cancer based on disease spread and surgical complexity.MethodsFor all consecutive patients who underwent diaphragmatic surgery during Visceral-Peritoneal debulking (VPD) in the period 2009–2017, we extracted: initial surgical finding, extent of liver mobilization and type of procedure. Combining these features, we aimed to classify the surgical procedures necessary to tackle different presentation of diaphragmatic disease. We also report histology, intra- and post-operative specific complication rate based on the classification.ResultsA total of 170 patients were included in this study, 110 (64.7%) had a peritonectomy, while 60 (35.3%) had a full thickness resection with pleurectomy. We identified 3 types of surgical procedures. Type I treated 28 out of 170 patients (16.5%) who only had anterior diaphragm disease, needed no liver mobilization, included peritonectomy and had no morbidity recorded. Type II pertained to 105 out of 170 patients (61.7%) who had anterior and posterior disease, needed partial and sometimes full liver mobilization, had a mix of peritonectomy and full thickness resection, and experienced 10% specific morbidity. Type III included 37 out of 170 patients (21.7%) who needed full mobilization of the liver, always had full thickness resection, and suffered 30% specific morbidity.ConclusionDiaphragmatic surgery can be classified in 3 types. The adoption of this classification can facilitate standardization of the surgery, comparison of data and define the expertise required. Finally, this classification can be a benchmark to establish the training required to treat diaphragmatic disease.