Diaphragmatic Resection Research Articles

A case of eventration of left diaphragm with improved pulmonary function by partial resection of diaphragm under VATS

A case of eventration of left diaphragm with improved pulmonary function by partial resection of diaphragm under VATS

Recurrence-Free Survival after Postoperative Hormone Therapy for Catamenial Pneumothorax.

Catamenial pneumothorax (CP) is a rare form of spontaneous pneumothorax that is linked to endometriosis; thus, it predominantly manifests in women of reproductive age. Considerable research has explored the potential benefits of postoperative hormone therapy following various surgical interventions. This study was performed to examine the clinical implications of postoperative hormone treatment in patients with CP. The study included patients who underwent surgical intervention for CP between November 2009 and February 2023. These procedures included wedge resection, diaphragm resection, and total pleural coverage. Recurrence-free survival was analyzed using the Kaplan-Meier log-rank test to assess the impact of hormone therapy. Additionally, Cox proportional hazards analysis was employed to identify risk factors associated with postoperative CP recurrence. The study included 41 patients, with a median age of 38.4 years. Among them, 27 individuals received hormone therapy, 8 of whom experienced recurrence during a median follow-up period of 1 year. Patients who received hormone therapy exhibited a lower rate of recurrence than those who did not; however, the difference was not statistically significant, likely due to the small sample size. Side effects of hormone therapy included depression (6.8%), excessive sweating (3.4%), and headache (3.4%). In the analysis of risk factors for postoperative recurrence, diaphragm resection emerged as a protective factor (hazard ratio, 0.16; 95% confidence interval, 0.03-0.77; p=0.022). Hormone treatment combined with surgery did not significantly impact recurrence in patients with CP. The application of diaphragm resection was the sole factor that displayed significance in preventing CP recurrence.

The key point of transsphenoidal surgery for infradiaphragmatic craniopharyngioma：Better sellar diaphragm resection

BackgroundCraniopharyngiomas have a high recurrence rate and a poor prognosis, and the key methods for reducing recurrences are unknown. The aim of this study was to explore the key points of microscopic or endoscopic transsphenoidal surgery used to treat infradiaphragmatic craniopharyngiomas. MethodsWe reviewed the medical records of patients with infradiaphragmatic craniopharyngiomas who were admitted to Peking Union Medical College Hospital between 2011 and 2018. ResultsWhen considering tumor location, all 34 patients had intrasellar tumors, with 19 of them exhibiting suprasellar extensions. Of the 34 patients, 24 patients underwent resection under the microscope and the remaining 10 patients underwent transsphenoidal endoscopic surgery. Gross total tumor resection was achieved in 16 patients. Twelve patients underwent invaded sellar diaphragm resection, while the remaining 22 patients were not. Cerebrospinal fluid leaks occurred during surgery in 18 patients. Visual acuity improved in two patients. After an average follow-up of 31.1 months, 13 patients experienced tumor recurrence. The short term recurrence rate in the sellar diaphragm resection group was significantly lower compared to the non-resected group (P < 0.001). Moreover, based on distinct surgical methods, the endoscope group displayed a reduced short term recurrence rate compared to the microscope group (P = 0.0048). ConclusionInvaded sellar diaphragm resection emerges as a pivotal maneuver in craniopharyngioma surgery, substantively influencing tumor recurrence. Capitalizing on the advantageous angled lens of endoscopes, surgeons can achieve heightened visualization. Significantly, the endoscopic approach exhibits a superior capacity to curtail recurrence, while effectively managing potential complications, when contrasted with the microscope group.

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.

Robotic-Assisted Laparoscopy Excision of a Severe Form of Diaphragmatic Endometriosis: A Retrospective Study of 60 Patients

To assess the feasibility, effectiveness, and safety of the robotic surgical approach in the treatment of severe diaphragmatic endometriosis (DE). Retrospective single-center study using data prospectively recorded in the Franco-European Multidisciplinary Institute of Endometriosis database and the National Observatory for Endometriosis database. Tertiary referral center. Endometriosis care center. Sixty consecutive patients undergoing robotic excision of severe DE from January 2020 to July 2023. Robotic excision of severe DE. Categorical and continuous variables were evaluated and compared using descriptive statistics. A p value of <.05 was considered statistically significant. Full-thickness diaphragmatic resection was performed in 76.7% of patients (46 of 60) and partial diaphragmatic muscle resection in 10% of cases (6 of 60). Peritoneal stripping technique was performed in 60% of patients (36 of 60), divided as follows: as the only technique in the case of extensive superficial diaphragmatic involvement in 13.3% of cases (8 of 60), in addition to full-thickness or partial diaphragmatic resection in the case of concomitant multiple foci in 46.7% of patients (28 of 60). Median operative time was 79.6 minutes with no statistically significative difference related to the surgeon performing surgery (p >.05). Intraoperative and postoperative complications occurred in 1.7% (1 of 60) and 6.6% of cases (4 of 60), respectively. Diaphragmatic hernia (Clavien-Dindo 3b) was the most common postoperative complication and required surgical repair in all cases. Median hospital stay was 24 hours. The rate of patients with complete recovery from DE symptoms has gradually increased during follow-up, reaching 89% after 12 months from surgery. In this case series, robotic treatment of severe DE in expert hands was feasible, effective, and safe.

ЛАПАРОСКОПИЧЕСКОЕ УДАЛЕНИЕ КИСТЫ ЗАБРЮШИННОГО ПРОСТРАНСТВА С РЕЗЕКЦИЕЙ И ПЛАСТИКОЙ ДИАФРАГМЫ

Background. Due to some challenges in diagnosis and surgical decision-making of retroperitoneal tumor-like masses, their treatment is regarded as a current issue in surgery. Objective. To demonstrate surgical treatment outcomes of a patient with a retroperitoneal tumor. Material and methods. The article presents our own clinical observation of a surgical removal of a tumor-like retroperitoneal tissue mass on the right with diaphragm resection as well as drainage of the pleural and abdominal cavities. Results. Based on laboratory and instrumental studies, the patient was clinically diagnosed with Chronic calculous cholecystitis as well as Parasitic cyst of the right liver lobe. A tumor-like posterolateral wall mass, about 5 cm in diameter, located retroperitoneally and associated with the right dome of the diaphragm was visualized intraoperatively. Laparoscopic removal of the mass within healthy tissues with resection and plastic of the right diaphragm dome was performed. The patient was discharged in a satisfactory condition, without complaints, for further outpatient follow-up by a surgeon at his place of residence. There were no repeated clinic visits or readmissions. Conclusions. The clinical observation indicating difficulty in diagnosis of retroperitoneal tumors in the preoperative period, it should be taken into consideration when planning surgery. When choosing a surgical treatment method, priority should be given to modern minimally invasive interventions, even in case of adjacent organs involvement.

Scoliosis After Resection of Primary Pediatric Chest Wall Tumors

BackgroundScoliosis is one of the long-term consequences of surgical resection of pediatric chest wall tumors. This study aimed to identify the risk factors associated with scoliosis development following the resection of chest wall tumors. MethodsRetrospective cohort study of 64 children who underwent resection of malignant chest wall tumors from 2009 to 2022. Univariate and multivariate analyses were used to investigate factors associated with scoliosis development. ResultsThe median age at the time of surgery was 7 years (range, 3–21), with 33 (51.6%) patients undergoing surgery before the age of 10 years. The most common histology was Ewing sarcoma (n = 57). A median of 3 (range, 1–5) contiguous ribs were resected. A total of 34 (53.1%) patients had anterior CWTs and 30 (46.9%) had posterior CWTs. Concomitant partial lung and diaphragmatic resection were performed in 12 patients (lung, n = 7; diaphragm, n = 5). Scoliosis convex towards the resection side developed in 21 (32.8%). The primary risk factors for scoliosis were resecting 3 or more ribs (OR 6.44) and resection of the posterior rib segment (OR 5.49). Patients with a tumor resection below 10 years old were not associated with a higher risk of scoliosis. ConclusionsScoliosis following resection of a primary malignant pediatric chest wall tumor is associated with resection involving three or more ribs and resection of the posterior rib sector. Type of StudyRetrospective observational. Level of EvidenceIV.

Blunt Trauma-Induced Diaphragmatic Hernia: Surgical Strategy and Outcomes

Blunt trauma-induced diaphragmatic hernia (DIH) is a rare but potentially life-threatening condition. Prompt diagnosis and management are crucial for successful outcomes. We present the case of a 40-year-old male who sustained blunt abdominal and chest trauma resulting in a left DIH with extensive gastrointestinal involvement. The patient underwent emergency laparotomy with primary repair of the diaphragmatic defect and resection of gangrenous stomach and bowel segments. Postoperatively, the patient recovered well and was discharged on day 14. Diagnosis of DIH relies on high clinical suspicion and radiological imaging, with CT scan being the modality of choice. Management involves surgical repair, either by primary closure or with the use of mesh, depending on the extent of the injury and presence of infection. Mortality rates are high in emergency repairs, especially when associated with bowel necrosis and perforation. This case highlights the importance of early recognition and timely intervention in DIH. Clinicians should maintain a high index of suspicion for DIH in patients presenting with a history of trauma and respiratory or abdominal symptoms. Improving awareness and understanding of abdominal injuries in trauma centers can help in early diagnosis and appropriate management, ultimately leading to better outcomes for patients with DIH.

Clinical application of endoscopic diaphragmotomy and dilation in a congenital duodenal diaphragm.

A congenital duodenal diaphragm (CDD) is a rare cause of duodenal obstruction in infants and children. The traditional approach to treatment has been surgical intervention either with excision and duodenoplasty or with bypass through a duodenoduodenostomy, which is invasive and carries the risk of anastomotic leakage. To summarize the key points of differential diagnosis and treatment of a CDD under gastroscopy and to evaluate its efficacy and safety. The clinical data of patients with a duodenal obstruction diagnosed and treated by gastroscopy in our hospital between January 2019 and December 2022 were retrospectively analyzed. The gastroscopic features of the CDD were summarized. The clinical outcomes of patients with CDD treated by gastroscopy were collected and investigated. A total of 13 children with a duodenal obstruction underwent a gastroscopic examination and/or treatment, and of these, 10 were diagnosed as having a CDD and 3 were finally diagnosed as having an annular pancreas. A dome-shaped structure during inspiration (9/10) and a guidewire that could be inserted through the opening into the distal lumen (6/10) were the gastroscopic features of the CDD, while the annular pancreas had none of these features. The 10 patients, 4 men and 6 women with the CDD, were treated through endoscopic diaphragmotomy and dilation. The age and weight at operation was 15 days to 7 years (M: 2.25 years) and 2.85-22 kg (M: 13.6 kg), respectively. A total of 11 endoscopic operations were performed in the 10 patients. The time of single operation was 15-55 min (M: 38 min). The patients did not experience complications such as bleeding, pneumoperitoneum, and duodenal papilla injury during the operation. Feeding was started 12-24 h after surgery, and the patients were discharged 2-10 days (M: 7 days) postoperatively. The patients were followed up for 3-36 months (M: 17 months), and none of them had a recurrence of vomiting. However, three showed a recurrence of stenosis in upper gastrointestinal imaging, one of whom underwent a partial diaphragm resection again 2 months after the primary treatment. A CDD can be confirmed by endoscopy based on its characteristic features. Endoscopic diaphragmotomy and balloon dilation are safe and effective, which can be a new option for minimally invasive treatment of a CDD.

Outcomes following minimally invasive approaches vs. open extended lobectomy for non-small cell lung cancer: a propensity-matched analysis of the National Cancer Database.

Traditional thoracotomy, an invasive surgical procedure, has been the standard approach for extended lobectomy in treating non-small cell lung cancer (NSCLC). However, minimally invasive surgery (MIS) has gained traction with advancements in surgical techniques. Despite this, the outcomes of extended lobectomy via a minimally invasive approach remain largely uncharted. Using the comprehensive National Cancer Database (NCDB), our research aimed to clarify the safety, feasibility, and efficacy of minimally invasive extended lobectomy in patients diagnosed with NSCLC. Our study encompassed a selection of patients with NSCLC who underwent extended lobectomy (defined as lobectomy or bilobectomy with chest wall, diaphragm or pericardial resection) between 2010 and 2014. Through propensity score matching (PSM), we ensured a balanced comparison between patients who underwent MIS and those who opted for the traditional open extended lobectomy. Both univariate and multivariate analyses were employed to discern whether the surgical approach had any significant impact on the prognosis of patients undergoing this specific procedure. Before PSM, our dataset included 3,934 patients. After 1:2 PSM, the MIS group included 683 cases, while the open group included 1,317 cases. One notable finding was the reduced average postoperative hospital stay for the MIS group at 7.15 days compared to the open group at 8.40 days (P<0.001). Furthermore, the 5-year survival rate was similar, with the MIS group at 53.1% and the open group at 51.3% (P=0.683). The results of our study suggest that MIS for extended lobectomy not only is safe and feasible but also is oncologically effective. However, it is imperative to note that these encouraging findings necessitate further validation through prospective studies to ascertain the full scope of benefits and potential risks associated with MIS.

Long-Term Outcome of Chest Wall and Diaphragm Repair with Biological Materials.

Chest wall and/or diaphragm reconstruction aims to preserve, restore, or improve respiratory function; conserve anatomical cavities; and upkeep postural and upper extremity support. This can be achieved by utilizing a wide range of different grafts made of synthetic, biological, autologous, or bioartificial materials. We aim to review our experience with decellularized bovine pericardium as graft in the past decade. We conducted a retrospective analysis of patients who underwent surgical chest wall and/or diaphragm repair with decellularized bovine pericardium between January 1, 2012 and January 13, 2022 at our institution. All records were screened for patient characteristics, intra-/postoperative complications, chest tube and analgesic therapy duration, length of hospital stay, presence or absence of redo procedures, as well as morbidity and 30-day mortality. We then looked for correlations between implanted graft size and postoperative complications and gathered further follow-up information at least 2 months after surgery. A total of 71 patients either underwent isolated chest wall (n = 51), diaphragm (n = 12), or pericardial (n = 4) resection and reconstruction or a combination thereof. No mortality was recorded within the first 30 days. Major morbidity occurred in 12 patients, comprising secondary respiratory failure requiring bronchoscopy and invasive ventilation in 8 patients and secondary infections and delayed wound healing requiring patch removal in 4 patients. There was no correlation between the extensiveness of the procedure and extubation timing (chi-squared test, p = 0.44) or onset of respiratory failure (p = 0.27). A previously demonstrated general viability of biological materials for various reconstructive procedures appears to be supported by our long-term results.

ASO Author Reflections: Which is the Better Choice for Patients with PC Who Underwent Diaphragm Resection: HIPEC or HITAC.

ASO Author Reflections: Which is the Better Choice for Patients with PC Who Underwent Diaphragm Resection: HIPEC or HITAC.

Outcomes Following Cytoreductive Surgery and Hyperthermic Intraoperative Thoraco-Abdominal Chemotherapy with Diaphragm Resection for Peritoneal Carcinomatosis: A Retrospective Cohort Study.

We aimed to evaluate the safety and efficacy of hyperthermic intraoperative thoraco-abdominal chemotherapy (HITAC) and cytoreductive surgery (CRS) for peritoneal carcinomatosis (PC) patients who underwent diaphragm resection. PC patients who underwent CRS with diaphragm resection were selected from a prospectively established database and were divided into hyperthermic intraperitoneal chemotherapy (HIPEC) and HITAC groups. The clinicopathological characteristics, treatment-related variables, perioperative adverse events (AEs), and survival outcomes were compared between the two groups. Of 1168 CRS + HIPEC/HITACs, 102 patients were enrolled-61 HITAC patients and 41 HIPEC patients. In the HITAC and HIPEC groups, the incidence of grade III-V AEs was 29.5% versus 34.1% (p = 0.621). The pleural progression rates were 13.2 versus 18.9% (p = 0.462) and the median overall survival (OS) was 50.5 versus 52.7 months (p = 0.958). Median time to progression (TTP) in thoracic disease was not reached. There was no significant difference in perioperative AEs, TTP, and OS for total patients and the completeness of cytoreduction (CC) score subgroups (p > 0.05). Age ≥ 60years (hazard ratio [HR] 4.162, p = 0.026) was an independent risk factor influencing pleural progression, and primary malignant peritoneal mesothelioma (MPM; HR 2.749, p = 0.016) and the presence of two or more serious AEs (SAEs; HR 7.294, p = 0.001) were independent risk factors influencing OS. HITAC can be performed in carefully selected PC patients who underwent diaphragm resection, with no worsening of the safety profile and a possible benefit for pleural progression. In those patients, age ≥ 60 years is associated with a shorter TTP of thoracic disease, while primary MPM and two or more perioperative SAEs are associated with worse OS.

Pulmonary metastasectomy for recurrent metastatic ovarian cancer.

The prognosis of patients with ovarian cancer with lung metastasis is poor; data on pulmonary metastasectomy for such patients are lacking. This study aimed to determine the safety and feasibility of pulmonary resection as part of cytoreductive surgery for recurrent metastatic ovarian cancer. Medical records of patients with ovarian cancer, who underwent pulmonary resection for lung metastasis in our hospital from April 2012 to February 2022, were retrospectively reviewed. Ten patients were included (median age, 53 years). Five patients had metastatic disease limited to the lungs. Additional surgeries included diaphragm resection, partial hepatectomy, para-aortic lymph node dissection, and cytoreduction. We achieved complete cytoreduction for all patients without severe complications, and the 30-day mortality was zero. After a median follow-up of 23 months, four of the patients experienced recurrence. One patient recurred 9 months after the operation and was lost to follow-up at 17 months, two died at 68 and 26 months respectively, one is alive with disease (23 months), and six are alive without recurrence, among whom two have survived for 56 and 124 months. Pulmonary resection for recurrent metastatic ovarian cancer seems safe and feasible, with long-term survival observed in certain patients. Pulmonary metastasectomy can be performed as part of the debulking surgery for selected patients with relapsed metastatic ovarian cancer. Both the patient lost to follow-up and the one who died at 26 months, had two lung metastatic nodules and did not receive postoperative chemotherapy, which might have led to relatively poor prognosis.

Liver metastasis composed of pure squamous cell carcinoma component from pancreatic pure ductal adenocarcinoma: a case report

BackgroundLiver metastasis of pure squamous cell carcinoma (SCC) from pancreatic ductal adenocarcinoma has not been previously reported.Case presentationA 66-year-old man underwent a computed tomography scan 3 years after surgery for pancreatic head cancer, and the scan revealed a mass lesion in the right lobe of the liver. A liver tumor biopsy was performed, and SCC was diagnosed. Whole sections of the pancreatic head cancer were re-evaluated, but no areas of SCC-like differentiation were identified. Although the pathology differed between the pancreas and liver, metastasis of adenosquamous carcinoma was considered. Three courses of gemcitabine plus nab-paclitaxel were administered to treat the liver metastasis of pancreatic cancer, but no response was attained. Therefore, primary SCC of the liver was considered and hepatic resection was performed. The tumor had invaded the diaphragm, and S5/6 partial hepatic resection with right diaphragm resection was performed. Pathological examination showed pure SCC of the liver, which differed from the pancreatic cancer. KRAS mutations were evaluated in the pancreatic and liver tumor specimens, and Q61R mutation was identified in both specimens. This pure SCC of the liver was diagnosed as metastasis from pancreatic cancer not by histology but by genetic analysis.ConclusionsThis is the first reported case of pure SCC liver metastasis from pancreatic cancer without a squamous cell component in the primary tumor. Evaluation of KRAS mutations in both specimens was useful for diagnosis.

473. PARACONDUIT HIATUS HERNIA AFTER OESOPHAGECTOMY: INCIDENCE, RISK FACTORS AND MANAGEMENT

Abstract Background Hiatus hernia after oesophagectomy is an uncommon but serious complication of oesophageal cancer surgery. With improving long-term oncologic outcomes, post oesophagectomy hiatus hernia is an increasingly recognised entity in oesophageal cancer survivorship. The aim of this study was to assess the incidence of and risk factors for paraconduit hiatus hernia (PHH), and to describe management approaches in a tertiary referral centre. Methods All patients undergoing oesophagectomy for cancer from 2008 to 2022 were included. Early PHH was defined as occurring within 3 months of index surgery, with all other PHH defined as late PHH. Surveillance computed tomography scans were undertaken among all disease-free patients to 5-years postoperatively. Kaplan Meier and Cox proportional hazards regression models were used to determine independent risk factors for PHH. Results 897 patients were studied. Early PHH occurred in 1.2%, and late PHH in 5.7% of patients. There was no late recurrence after early PHH. PHH was an asymptomatic radiologic finding in 45.5% of early and 84.3% of late cases. Median time to PHH was 15.7 months postoperatively. Nausea, abdominal pain and vomiting were the most common symptoms associated with PHH. Surgical intervention was required in 25.8% of cases, more commonly following early PHH (63.6%) as compared with late PHH (17.6%, P &amp;lt; 0.01). Operative approach (P &amp;lt; 0.001), extended resection of crura or diaphragm (P &amp;lt; 0.001) and male sex (P = 0.037) were associated with increased risk of hiatus hernia. Conclusion Paraconduit hiatus hernia is an uncommon complication after oncologic oesophagectomy. Surgical intervention is often required for patients with PHH presenting in the first three months after surgery, but a majority of patients with asymptomatic late PHH may be managed expectantly.

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.

Cytoreductive Surgery with HIPEC as Primary Treatment for Advanced Epithelial Ovarian Carcinoma: Upfront or Interval-ISPSM Collaborative Study.

Cytoreductive surgery with HIPEC has shown promising results in the interval setting of advanced epithelial ovarian cancer. Its role in upfront setting has not yet been established. All eligible patients underwent CRS-HIPEC as per institution protocol. Relevant data was collected prospectively in institutional HIPEC registry and analyzed retrospectively for the study period from February 2014 to February 2020. Out of 190 patients, 80 underwent CRS-HIPEC in upfront setting and 110 in interval setting. The median age was 54 ± 7.45years, upfront group had higher PCI (14.1 ± 8.75 vs. 9.6 ± 5.2. 2), and required longer duration of surgery (10.6 ± 1.73 vs. 8.4 ± 1.71h) had more blood loss (1025 ± 668.76 vs. 680 ± 302.23ml). The upfront group required more diaphragmatic resections, bowel resections, and multivisceral resections. The overall G3-G4 morbidity was comparable (25.4% vs. 27.3%), upfront group had more surgical morbidity (20% vs. 9.1%) whereas interval group had more medical morbidity, i.e., electrolyte imbalance and hematological. After a median follow-up of 43months, median DFS was 33months in the upfront vs. 30months in the interval group, p = 0.75, median OS was 46months interval group and was not yet achieved in upfront group.(p = 0.13). Four-year OS was 85% vs. 60%. In patients of advanced EOC upfront CRS HIPEC showed promising outcomes and trend towards better survival with similar morbidity and mortality. The upfront group had more surgical morbidity whereas interval group had more medical morbidity. Multiinstitutional randomized studies are needed to define patient selection and study morbidity patterns and compare the outcomes between CRS-HIPEC in the upfront and interval setting for advanced epithelial ovarian cancer.

Catamenial pneumothorax: Not only VATS diagnosis.

Catamenial pneumothorax (CP) is a rare type of spontaneous, recurring pneumothorax occurring in women, from the day before menstruation until 72 hours after its beginning. Conservative treatment is generally associated with recurrence of CP. Video-assisted thoracic surgery (VATS) approach allows not only to obtain diagnosis but also to guide definitive treatment of causing lesions, such as ectopic endometrial implants or diaphragmatic defects and fenestrations. We report our experience in VATS management of CP to focus on its role in CP. In this retrospective observational study, we collected data from women referred to our center for CP, from January 2019 to April 2022. All patients underwent VATS approach, with muscle-sparing thoracotomy when diaphragmatic fenestrations were detected, to perform selective diaphragmatic plication and/or partial diaphragmatic resection. Results were analyzed in terms of pneumothorax recurrence after surgical treatment. All patients were referred to gynecologists for medical therapy. Eight women (median age 36 years, range: 21-45), all with right side CP, were included; three already had pelvic endometriosis and two had already undergone lung apicectomy at other institutions. VATS allowed us to detect diaphragmatic fenestrations in seven patients (87.5%) and apical bullae in five (62.5%). Apicectomy was performed in five cases (62.5%), selective diaphragmatic plication in two (25%), and partial diaphragmatic resection in five (62.5%). Chemical pleurodesis with talc was performed in all to minimize the risk of recurrence. Pathological diagnosis of endometriosis on the resected diaphragm was achieved in five patients (62.5%). No recurrence occurred, except for one woman who stopped medical treatment for endometriosis. In the management of patients with CP, VATS should be recommended not only to obtain an explorative diagnosis of ectopic endometrial implants or diaphragmatic fenestrations but also to allow the most appropriate surgical treatment and obtain pathological specimens for confirmation and definitive diagnosis of thoracic endometriosis. Medical therapy to achieve ovarian rest is mandatory in the postoperative period and should not be discontinued.

Combined exploratory laparotomy, transpsoas, and thoracic approach to resection of a giant spinal ganglioneuroma: illustrative case.

Ganglioneuromas are rare peripheral nervous system tumors of neural crest origin. Most are often asymptomatic and incidentally found, but large tumors can cause mass effect. Herein, the authors report a case of a giant ganglioneuroma that arose from the lumbar foramina into the retroperitoneal and thoracic cavities. A 62-year-old female presented with low back pain, left lower extremity swelling, and increased sensation of an abdominal mass. Surgical treatment options were reviewed with the patient and coordinated care was planned by surgical oncological specialists. The patient opted for multistage exploratory laparotomy for abdominal mobilization, diaphragm resection, and en bloc resection with neuromonitoring. After surgery, the patient experienced significant improvement in symptoms. A combined surgical exposure involving gastrointestinal, thoracic, and neurological surgeons can be important in the safe resection of ganglioneuromas that span multiple body cavities. Hence, a thorough preoperative assessment could help plan surgery accordingly.