Diaphragmatic Stripping Research Articles

Does neoadjuvant chemotherapy reduce surgical complexity in patients with advanced-stage epithelial ovarian cancer?

BackgroundThis study aimed to determine the effect of neoadjuvant chemotherapy (NACT) on the complex surgical procedures required in addition to staging surgery for the need to achieve a residual tumor 1 cm or less in a population of stage IIIC–IV epithelial ovarian cancer patients.MethodsPatients were referred for NACT if preoperative imaging and/or intraoperative evaluation confirmed that it was not possible to achieve a residual tumor size of 1 cm or less with cytoreductive surgery or if the patient had a poor performance status and a high American Society of Anesthesiologists (ASA) score. Surgical complexity was defined as complex or non-complex.ResultsOne hundred and twenty-six patients with stage IIIC–IV ovarian cancer were included in the study. Primary cytoreductive surgery was performed in 67 patients, and interval cytoreductive surgery was performed in 59 patients after NACT. At least one complex surgery was performed in 74.6% of the patients in the primary cytoreductive surgery group and in 61% of the patients in the NACT group, with no statistically significant difference between the groups. However, the NACT group showed significantly decreased rates of low-rectal resection, diaphragmatic peritoneal stripping, and peritonectomy.ConclusionsThe analyses showed no reduction in the requirement for at least one complex surgical procedure in the group of patients who underwent NACT. Nevertheless, this group exhibited a significant decrease in low-rectal resection, diaphragmatic peritoneal stripping, and peritonectomy due to their effectiveness in reducing peritoneal disease.

Diaphragmatic stripping in epithelial ovarian cancer at first diagnosis: Impact on morbidity and survival outcomes

ObjectivesDiaphragmatic stripping is a standard procedure that is performed in a significant proportion of patients undergoing surgical cytoreduction for advanced ovarian cancer. The objective of the present study is to evaluate morbidity and survival outcomes among patients offered diaphragmatic surgery for primary diagnosed optimally resected ovarian cancer. Study designWe conducted a retrospective cohort study, identifying patients that were offered surgery between 2016 and 2021 for primary diagnosis of ovarian cancer. Cases that had diaphragmatic stripping or partial diaphragmatic resection were selected and compared to cases that did not require this procedure. Kaplan-Meier and Cox-regression analyses were applied to evaluate survival outcomes. ResultsOverall, 61 patients that had diaphragmatic stripping were identified. Severe postoperative complications (Clavien-Dindo 3 + ) were noted in 19 patients (31 %). Survival analyses denoted that the stage of the disease at the time of diagnosis, as well as the timing of the surgical procedure (PDS vs IDS) and the completion of tumor debulking were factors that significantly affected the recurrence free and overall survival of patients. Severe postoperative morbidity was a significant predictor of the overall survival. Multivariate cox-regression analysis that was adjusted for the stage of the disease revealed that preoperative pleural effusion, optimal (compared to complete) tumor resection and the occurrence of postoperative complications significantly affected the overall survival of patients. Compared to patients that did not have diaphragmatic surgery, patients submitted to diaphragmatic stripping or resection had improved progression free and overall survival rates, irrespective of the stage of the disease at diagnosis or the adequacy of resection status. ConclusionsDiaphragmatic surgery is feasible in advanced ovarian cancer patients with acceptable morbidity that mainly refers to postoperative pleural effusion. Its positive impact on patients‘ survival requires further investigation.

Exploring the Potential Role of Upper Abdominal Peritonectomy in Advanced Ovarian Cancer Cytoreductive Surgery Using Explainable Artificial Intelligence.

The Surgical Complexity Score (SCS) has been widely used to describe the surgical effort during advanced stage epithelial ovarian cancer (EOC) cytoreduction. Referring to a variety of multi-visceral resections, it best combines the numbers with the complexity of the sub-procedures. Nevertheless, not all potential surgical procedures are described by this score. Lately, the European Society for Gynaecological Oncology (ESGO) has established standard outcome quality indicators pertinent to achieving complete cytoreduction (CC0). There is a need to define what weight all these surgical sub-procedures comprising CC0 would be given. Prospectively collected data from 560 surgically cytoreduced advanced stage EOC patients were analysed at a UK tertiary referral centre.We adapted the structured ESGO ovarian cancer report template. We employed the eXtreme Gradient Boosting (XGBoost) algorithm to model a long list of surgical sub-procedures. We applied the Shapley Additive explanations (SHAP) framework to provide global (cohort) explainability. We used Cox regression for survival analysis and constructed Kaplan-Meier curves. The XGBoost model predicted CC0 with an acceptable accuracy (area under curve [AUC] = 0.70; 95% confidence interval [CI] = 0.63-0.76). Visual quantification of the feature importance for the prediction of CC0 identified upper abdominal peritonectomy (UAP) as the most important feature, followed by regional lymphadenectomies. The UAP best correlated with bladder peritonectomy and diaphragmatic stripping (Pearson's correlations > 0.5). Clear inflection points were shown by pelvic and para-aortic lymph node dissection and ileocecal resection/right hemicolectomy, which increased the probability for CC0. When UAP was solely added to a composite model comprising of engineered features, it substantially enhanced its predictive value (AUC = 0.80, CI = 0.75-0.84). The UAP was predictive of poorer progression-free survival (HR = 1.76, CI 1.14-2.70, P: 0.01) but not overall survival (HR = 1.06, CI 0.56-1.99, P: 0.86). The SCS did not have significant survival impact. Machine Learning allows for operational feature selection by weighting the relative importance of those surgical sub-procedures that appear to be more predictive of CC0. Our study identifies UAP as the most important procedural predictor of CC0 in surgically cytoreduced advanced-stage EOC women. The classification model presented here can potentially be trained with a larger number of samples to generate a robust digital surgical reference in high output tertiary centres. The upper abdominal quadrants should be thoroughly inspected to ensure that CC0 is achievable.

Neo-adjuvant chemotherapy does not reduce surgical complexity nor the accuracy of intra-operative visual assessment of disease in advanced ovarian cancer

AimCompare the surgical complexity and histological accuracy of visual inspection of disease in patients undergoing primary debulking (PDS) versus delayed debulking surgery (DDS) following neo-adjuvant chemotherapy (NACT) for advanced ovarian cancer (AOC). Materials and methodsAll patients undergoing PDS or DDS for stage III / IV AOC at a UK cancer centre between January 2014–October 2021 were included. Retrospective data was collected accessing an electronic gynaecological oncology database, operation and histology records. Comparative frequencies of surgical procedures performed were calculated for primary versus delayed cohorts; and correlation between intra-operative suspicion of disease and specimen histology at PDS and DDS compared. ResultsN=232. PDS was performed in 45.3% and DDS in 54.7% of patients; achieving complete cytoreduction in 77.2%. Appendicectomy, pelvic and para-aortic nodal dissection were undertaken significantly more often at primary surgery; whilst right diaphragm stripping, pelvic peritonectomy, splenectomy and cholecystectomy were more likely following NACT. We found no variation in bowel resection rates between cohorts. For the majority of specimens, there was no difference in correlation between intra-operative suspicion of disease and final histopathology – with a significantly lower positive predictive value for visual assessment demonstrated only for liver capsule and pelvic peritoneum at DDS. ConclusionNACT does not appear to reduce the complexity of surgery, including rates of bowel resection; nor accuracy of intra-operative visual assessment of disease. We therefore caution against both deferring to NACT to facilitate less radical delayed debulking; and any presumption that macroscopically abnormal tissue at DDS may represent inert post-NACT ‘burn-out’, mitigating indication for excision. We instead suggest reservation of the neo-adjuvant pathway for patients with poor PS and radiologically-confirmed surgical stopping points; and advocate equivalent and maximal cytoreductive effort to remove all visibly abnormal tissue in both the upfront and delayed surgical settings.

Surgical Anatomy of the Liver-Significance in Ovarian Cancer Surgery.

Ovarian cancer is the leading cause of death among all gynecological malignancies. Most patients present with an advanced stage of the disease. The routes of spread in ovarian cancer include peritoneal dissemination, direct invasion, and lymphatic or hematogenous spread, with peritoneal and lymphatic spread being the most common among them. The flow direction of the peritoneal fluid makes the right subphrenic space a target site for peritoneal metastases, and the most frequently affected anatomical area in advanced cases is the right upper quadrant. Complete cytoreduction with no macroscopically visible disease is the most important prognostic factor. We reviewed published clinical anatomy reports associated with surgery of the liver in cases of advanced ovarian cancer. The disease could disseminate anatomical areas, where complex surgery is required-Morrison's pouch, the liver surface, or porta hepatis. The aim of the present article is to emphasize and delineate the gross anatomy of the liver and its surgical application for oncogynecologists. Moreover, the association between the gross and microscopic anatomy of the liver is discussed. Additionally, the vascular supply and variations of the liver are clearly described. Oncogynecologists performing liver mobilization, diaphragmatic stripping, and porta hepatis dissection must have a thorough knowledge of liver anatomy, including morphology, variations, functional status, potential diagnostic imaging mistakes, and anatomical limits of dissection.

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.

8482 An Unusual Presentation of Granulomatous Peritonitis Following Cystectomy for Mature Teratoma

<h3>Study Objective</h3> To highlight granulomatous peritonitis as a potential complication of cyst content spillage during laparoscopic ovarian cystectomy for mature teratoma. To describe the first known case of granulomatous peritonitis infiltrating the right hemidiaphragm, leading to right-sided pneumonia and requiring a partial diaphragmatic resection. To review prevention and treatment strategies of granulomatous peritonitis following ovarian cystectomy for mature cystic teratoma. <h3>Design</h3> Case report. <h3>Setting</h3> Community hospital. <h3>Patients or Participants</h3> 1 patient. <h3>Interventions</h3> Surgical intervention consisting of extensive resection of disease, including laparoscopy converted to midline laparotomy, left salpingo-oopherectomy, omentectomy, partial bladder cystectomy, liver wedge resection, diaphragm stripping, partial resection of diaphragm, mesenteric nodule resection, appendectomy, repair of both large and small bowel; as well as resection of anterior abdominal wall disease. <h3>Measurements and Main Results</h3> Pathology demonstrated recurrent mature cystic teratoma, abundant hair fragments and associated foreign body type granulomatous reaction. The patient was asymptomatic at 9 months after surgical intervention. <h3>Conclusion</h3> Awareness of granulomatous peritonitis, and the potential extent of disease, as a complication of dermoid cyst rupture is paramount. Cyst content spillage is often challenging to avoid, and copious irrigation is advised if spillage occurs - yet may still not successfully prevent peritonitis. Route of cystectomy should be carefully considered to minimize risk of spillage. Ultimately, maintaining an index of suspicion for this diagnosis when a patient presents with vague or unusual symptoms following laparoscopic cystectomy for mature dermoid may expedite appropriate care, which may include extensive surgical resection.

8811 Diaphragmatic Endometriosis: Anatomopathology and Correlation with Surgical Technique in 230 Patients Treated in a Referral Center

<h3>Study Objective</h3> To define a decision-making algorithm for Diaphragmatic Endometriosis (DE) surgical treatment correlating laparoscopic appearance of endometriotic implants with their histopatological counterpart. <h3>Design</h3> All the cases of DE surgically treated in Our Department, from January 2004 to January 2021, were analyzed in a retrospective chart review. <h3>Setting</h3> DE lesions were correlated to intraoperative findings (morphology, localization, side of the diaphragm, diameter, depth of infiltration and number) and classified according to their histopathological features as: •"Foci": bidimensional superficial peritoneal lesions, generally ≤ 1 cm diameter. •"Plaques": thin fibrotic lesions, thickening the diaphragmatic peritoneum with no muscular infiltration, > 1cm diameter. •"Nodules": solid, tridimensional implants, associated with partial or full-thickness infiltration of underneath muscle layers and generally > 1cm diameter. <h3>Patients or Participants</h3> Two hundred -thirty patients were collected. <h3>Interventions</h3> The histopathologic revision of all the specimens enabled us to select a different laparoscopic surgical approach, for each lesion, as the following: <h3>Measurements and Main Results</h3> •Argon Beam Coagulator (ABC) and/or Diathermocoagulation (DTC) for diaphragmatic foci; •Diaphragmatic stripping is indicated for endometriotic plaques •Nodulectomy is the right choice for endometriotic nodules, with the need of partial or full-thickness diaphragmatic resection according to the entity of muscular involvement. <h3>Conclusion</h3> A safe eradication of the implants requires a standardization of the surgical technique based on the knowledge of laparoscopic and histopathologic characteristics of lesions, thus avoiding intra- and post-operative morbidities.

Stapled diaphragm resection: A new approach to diaphragmatic cytoreductive surgery for advanced-stage ovarian cancer

ObjectiveTo evaluate a novel technique for diaphragmatic full-thickness resection (DFTR) using a vascular stapler to perform cytoreductive surgeries in patients with advanced ovarian cancer. Study DesignSingle-center retrospective analysis of consecutive patients with advanced-stage ovarian cancer undergoing stapled diaphragmatic full-thickness resections (S-DFTRs) as part of cytoreductive surgeries between January 2018 and June 2022, according to the IDEAL recommendations. ResultsFifteen patients underwent cytoreductive surgeries with S-DFTRs. The median operative time was 300 (114–547) minutes. Cytoreduction was considered complete in all cases. All S-DFTRs were performed on the right diaphragm. Concomitant left diaphragmatic peritoneal stripping was performed in 5 cases (33.3%) and was associated with a conventional DFTR in 1 case (6.7%). Prophylactic intraoperative tube thoracostomy was never required. Four patients (26.7%) were admitted to the intensive care unit. Pleural effusion was observed in 9 patients (60.0%), and 4 (26.7%) required a postoperative pigtail catheter thoracostomy. Three patients (20.0%) required catheter placement on the right hemithorax (ipsilaterally to the S-DFTR) and 2 patients (13.3%) required catheters on the left hemithorax (contralaterally to the S-DFTR). Pneumothorax requiring tube thoracostomy was observed in 1 case (6.7%) on the left hemithorax (contralaterally to the S-DFTR). Pulmonary embolism and pneumonia were both observed once (6.7%). The median hospitalization length was 14 (5–36) days. During the follow-up, 6 patients (40.0%) had a recurrence, but none involved the pleura or the diaphragm. According to the IDEAL classification, this study could be ranked as stage 2a (development). ConclusionsThis technique appears to be a fast and safe method for performing diaphragmatic cytoreductive surgeries and could reduce postoperative complications.

Survival of patients with stage IV high-grade serous ovarian cancer treated with intraperitoneal versus intravenous platinumbased chemotherapy (501)

Survival of patients with stage IV high-grade serous ovarian cancer treated with intraperitoneal versus intravenous platinumbased chemotherapy (501)

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.

410 The application of j-plasma in the excision of diaphragmatic lesions as part of complete cytoreduction in patients with advanced ovarian cancer

Introduction: The objective of this study was to investigate the safety and treatment efficacy of J-Plasma in cases of advanced Epithelial Ovarian Cancer with upper abdominal involvement undergoing peritoneal and diaphragmatic stripping. Methods: A retrospective review of a prospectively maintained database of patients who had diaphragmatic stripping with the use of J-Plasma® from January 2016 to September 2019, due to peritoneal dissemination for advanced stage ovarian cancer (FIGO stage ≥III) was performed.

Multiquadrant Robotic Assisted Primary Cytoreduction for Stage III C Ovarian Cancer Part I Complete Omentectomy Right Diaphragm Stripping

<h3>Study Objective</h3> To demonstrate Part I of multi-quadrant robotic assisted abdominal primary cytoreductive surgery for Stage IIIC epithelial ovarian cancer. <h3>Design</h3> A prospective single patient underwent robotic assisted cytoreductive surgery. Docking time for pelvic and abdominal dissection was recorded. The multiple procedures that patient underwent was recorded for operative time along with intraoperative complications and postoperative complication, estimated blood loss, and length of hospitalization. <h3>Setting</h3> Tertiary hospital. <h3>Patients or Participants</h3> Patient is a 56-year-old female presents with abdominal pain. CT scan showed no ascites soft tissue mass in the right hepatic gutter omental mass with minimal pelvic fluid and pelvic mass. CA 125 was 533. <h3>Interventions</h3> Robotic Xi. <h3>Measurements and Main Results</h3> The abdominal docking time was 2 minutes and 30 seconds. The pelvic docking time which was the time from de-docking after completion of abdominal dissection to rotating the boom to re-docking for pelvic dissection was 5 minutes and 30 seconds. Total operative time for both pelvic and abdominal dissection was 246 minutes. The operative time for right diaphragm peritonectomy 30 minutes and resection of omental caking with complete omentectomy was 68 minutes. The pelvic dissection which consisted of en bloc modified posterior exenteration procedure with total intracorporal sigmoid rectal anastomosis was 126 minutes. A complete cytoreductive surgery with no gross residual was achieved. EBL 200 cc and length of hospitalization was 4 days. There was no intraoperative or postoperative complication. <h3>Conclusion</h3> Robotic assisted multi-quadrant surgery is feasible to achieve upper abdominal, abdominal and pelvic procedures to achieve an optimal cytoreductive surgery for stage IIIc ovarian cancer.

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.

Robotic transthoracic diaphragmatic hernia repair.

Robotic transthoracic diaphragmatic hernia repair.

Is preoperative CA-125 level a predictor of cytoreduction in carcinoma ovary?

Optimal cyto-reduction of advanced EOC has profound impact on the survival and prognosis of patients3. Suboptimal cyto-reduction of advanced ovarian cancer is related to initial tumor bulk which indirectly correlates with serum CA125 levels. Can assessment of level of CA 125 in pre-opererative period predict optimal cyto-reduction is the aim of the study. The mean age of the 70 patients in this study was 49.9 years (SD- 11.75, Range: 21-69 years). Fourty four (63%) had stage III-?V disease. Sixty five (93%) patients had papillary serous ovarian cancer. The serum CA125 levels ranged from 6- 5300 U/ml with median pre-operative serum CA-125 level for all the patients being 259 U/ml (IQR- 682.98U/ml). The level was elevated (>35 U/ml) in 49% of patients with stage ?-? compared with 93% of patients with stage ? or ?V disease. Optimal tumor cyto-reduction was obtained in 61/70 cases (87%) of total patients and in 35/44 (80%) of patients with stage III-?V disease. Diaphragmatic stripping, appendecetomy, recto-sigmoid resection and anastomosis, pelvic peritonectomy, peritoneal stripping/ debulking of peritoneal disease, hemi-colectomy, ileo colic anastomosis and partial nephrectomy. Most of our patients were in intermediate surgical complexity category with a score between 4-7. In 9 patients all belonging to advanced stage, sub-optimal cyto-reduction was done due to multiple co-morbidities, multiple mesenteric lymphnode involvement, multiple small bowel and liver parenchymal deposits and patient not willing for colostomy. An ROC curve analysis showed threshold value of CA125 of 411U/ml. With a cut-off of 411U/ml, 97% of total patients with CA125 levels lower than 411U/ml were able to undergo optimal cyto-reduction. Also, in 76% of patients with CA125 level more than 411U/ml optimal cyto-reduction could be achieved. When only advanced stages (stage III-IV) were considered, with a cut-off of 411U/ml, 88% of patients with CA125 levels lower than 411U/ml were able to undergo op

Radical Surgical Procedures in Advanced Ovarian Cancer and Differences Between Primary and Interval Debulking Surgery.

We aimed to identify differences in cytoreduction rates and procedures performed in patients with advanced ovarian cancer undergoing primary (PDS) or interval debulking surgery (IDS). Data were collected prospectively on 110 consecutive patients from June 2016 to Mar 2020. Forty-nine patients (44.5%) underwent diaphragmatic peritonectomy (34 in PDS and 15 in IDS, p=0.005), while 38 (34.5%) underwent large bowel resection (29 in PDS and 9 in IDS, p<0.001). Complete cytoreduction was achieved in 39 patients in PDS and 29 in IDS (65% vs. 58%, p=0.22). Longer operations with more blood loss and extended hospital stay were performed in the PDS group. Ten patients (9.1%) experienced severe complications and in eight patients (7.2%) chemotherapy was delayed. More bowel resections and diaphragmatic stripping were performed in the PDS group. End surgical results were similar between groups, with a trend for more complete cytoreduction in PDS.

Diaphragmatic Endometriosis: Classification of Lesions in a Retrospective Series of 150 Patients Treated by Minimally-Invasive Surgery in a Single Third-Level Referral Center.

Study Objective To create a classification of diaphragmatic endometriosis (DE) in order to better select the surgical treatment of endometriotic nodules, depending on their size and localization. Design All the patients treated for deep infiltrating endometriosis (DIE) with DE between January 2004 and December 2018 were retrospectively reviewed. All the patients underwent surgery by laparoscopic approach or video-assisted thoracoscopic surgery (VATS). Diaphragmatic lesions were classified in three groups according to size, shape and depth of muscular infiltration. Setting Department of Obstetrics & Gynecology, and Thoracic Surgery, IRCCS Sacro Cuore Don Calabria Hospital – Negrar (Verona), Italy. Patients or Participants 150 patients with DE were identified. Interventions 128 patients were treated by laparoscopy, 21 by VATS and 1 of them had VATS combined with laparoscopy. Measurements and Main Results Patients were divided into 3 groups, according to the proposed classification. The first group of 99 patients (66%) included those with superficial lesions ≤ 1 cm. These lesions were called ‘foci' and were treated by diathermocoagulation (DTC) or argon laser vaporization. The second group included 17 patients (11,3%) with lesions called ‘plaques', bigger than 1cm, bidimensional and caused thickening of the involved tissue, without deep infiltration of the muscular layer of the diaphragm. These lesions were usually removed by diaphragmatic stripping. In the last group, the lesions were called ‘nodules', they were larger than 10 mm, and with deep infiltration of the diaphragm These nodules were observed in 34 patients (22,6%) and were removed by laparoscopic excision with diaphragmatic resection or by VATS. Conclusion Diaphragmatic nodules can be easily classified in one of the proposed groups. Considering this classification, different methods of surgical treatments of DE can be chosen, in order to allow a total and safe removal of the lesions, with low complications rate and a significant improvement of patients' symptoms.

Long term survival and perioperative propensity score matched outcomes of diaphragmatic resections compared to stripping in cytoreductive surgery + intra-peritoneal chemotherapy

ObjectivesTo assess the impact of short and long term outcomes of diaphragm resection and repair in cyto-reductive surgery (CRS) and intra-peritoneal chemotherapy (IPC). Methods1230 consecutive CRS/IPC procedures were performed between 1996 and 2018 in Sydney, Australia. Among these, 652 underwent diaphragmatic intervention. The analysis was preformed according to histological subtype. First diaphragm interventions were compared to non-diaphragmatic CRS. Secondly, diaphragm resection was compared to diaphragm stripping. Overall survival and recurrence free survival was assessed based on histological diagnosis. ResultsThere were no differences between the resection and stripping groups for the colorectal cohort. For mesothelioma, increased incidences of pleural effusions in the resection group were noted (63% vs.28%, p = 0.017). In HAMNs, the resection group was associated with increased reoperations (42% vs. 15%, p = 0.03) and in hospital death (16.7% vs. 0.6%, p = 0.012). Resection in LAMNs were linked with increased transfusion requirements (9 vs. 6, p = 0.01), reoperation (39% vs. 23%, p = 0.05) and prolonged length of stay (34 days vs. 25 days, p = 0.02).There were no differences in overall survival and recurrence free survival in colorectal cancer. Median overall survival was decreased in mesothelioma by 20 months. In LAMNs the median survival was significantly decreased for the resection group. Similarly, the resection group had a 4-month earlier recurrence. ConclusionWe conclude that diaphragm interventions are an essential part of CRS. They are associated with increased perioperative morbidity. This morbidity is not attributable to whether the patient underwent diaphragm stripping or resection. However in mesothelioma and LAMNs, requiring diaphragm resection is likely to be an indicator for tumor aggression.

Resection of hepatic metastasis as a part of ultra-radical surgery for epithelial ovarian cancer- a single institution experience

Introduction: Studies of metastatic patterns in patients with epithelial ovarian cancer have shown that nearly one-half of the patients had hepatic metastases at the time of death. We report our single institution experience in approaching liver metastases from epithelial ovarian cancer. Method: Patients with epithelial ovarian cancer operated in our center between January 2012 and April 2018 were enrolled in the study. Patients who underwent liver resection for metastases from ovarian cancer at the time of cytoreductive surgery were included in the study. Relevant demographic, clinical and pathological data were collected and analyzed. Result: 34/329 (12.59%) patients underwent liver resection. 8/34 underwent primary cytoreductive surgery, 24/34 interval cytoreductive surgery and 2/34 secondary cytoreductive surgery. 26 patients had single while 8 had multiple hepatic metastases. Synchronous resections during surgery most commonly included retroperitoneal lymphadenectomy (n=30), peritonectomy (n=17), diaphragmatic stripping (n=11), resection of bladder deposits (n=9) and bowel resection (n=5). Less commonly done were resection of deposits over rectosigmoid, caecum, appendix, mesentery, ureter and gall bladder. Splenectomy and distal pancreatectomy were each done in 2 patients. The completeness of the cytoreductive score achieved was 0-1 in all patients who underwent liver resection. On histopathology, 16 patients (47.06%) showed response to chemotherapy while 18 patients (52.94%) still had a viable disease. None of the patients experienced liver-related complications. On follow-up, 28 patients were disease-free, 4 had recurrences in sites other than the liver. 2 patients had expired due to non-hepatic causes. The median 3-year survival is 17.3% in liver resection cohort and 29.8% in those without liver resection. Conclusion: Complete cytoreduction is the most important factor for achieving a meaningful survival in advanced ovarian cancer. If technically feasible, hepatic resections can be undertaken with acceptable morbidity and mortality for the treatment of ovarian cancer.