Diaphragmatic Resection Research Articles

Upper-Abdominal Cytoreduction for Advanced Ovarian Cancer—Therapeutic Rationale, Surgical Anatomy and Techniques of Cytoreduction

Cytoreductive surgery (CRS) is the cornerstone of treating advanced ovarian cancer. Approximately 60–70% of patients with advanced ovarian cancer will have involvement in the upper abdomen or the supracolic compartment of the abdominal cavity. Though the involvement of this region results in poorer survival compared, complete cytoreduction benefits overall survival, making upper-abdominal cytoreduction an essential component of CRS for advanced ovarian cancer. The upper abdomen constitutes several vital organs and large blood vessels draped with the parietal or visceral peritoneum, common sites of disease in ovarian cancer. A surgeon treating advanced ovarian cancer should be well versed in upper-abdominal cytoreduction techniques, including diaphragmatic peritonectomy and diaphragm resection, lesser omentectomy, splenectomy with or without distal pancreatectomy, liver resection, cholecystectomy, and suprarenal retroperitoneal lymphadenectomy. Other procedures such as clearance of the periportal region, Glisson’s capsulectomy, clearance of the superior recess of the lesser sac, and Morrison’s pouch are essential as these regions are often involved in ovarian cancer. This manuscript covers the surgical anatomy of the upper abdomen, the techniques and therapeutic rationale of upper-abdominal cytoreduction, and specific measures for perioperative management of these patients. The main focus is the description of various peritonectomies and regional lymphadenectomies.

Successful Surgical Treatment of Stage IVB Immature Teratoma Involving the Liver and Thoracic Cavity, With Combination Chemotherapy: A Case Report

Introduction Immature teratomas are very rare tumors, representing only 1% of ovarian cancers. Distant metastases to the liver effect late disease manifestation, rendering chemotherapy the only viable option. Case presentation Here, we report the successful surgical management of stage IVB immature teratoma after cisplatin-based chemotherapy. A 20-year-old woman presented with a huge abdominal palpable mass and dyspnea. Postoperative pathology confirmed immature teratoma with metastases to the liver, diaphragm, and thoracic cavity (stage IVB). The patient underwent right hemihepatectomy, diaphragm resection, thoracic mass resection, and diaphragm repair using aortic artificial graft. She did not receive postoperative adjuvant chemotherapy. After the complete surgical resection of the tumor, the patient had no recurrence during the 44-month follow-up period. Conclusion No established treatment modalities have been developed for further treatment, once the first-line combination chemotherapy achieves unfavorable results in stage IVB immature teratoma. Surgical resection may offer hope for excellent disease control in this dismal stage. To obtain best possible outcomes, coordinated care between oncologists and general surgeons is required.

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.

Primary spindle cell tumor originating from the liver that was difficult to diagnose

BackgroundIt has been reported that hepatocellular carcinoma (HCC) with spindle cell tumor accounts for 1.8% of all HCCs, but spindle cell tumors that do not show an obvious conventional HCC are extremely rare. In this report, we describe a case of resection of a primary spindle cell tumor of the liver that was difficult to diagnose.Case presentationA 75-year-old man presented with fever and right chest pain. He was suspected of a giant primary diaphragmatic tumor of extrahepatic origin by imaging studies. The preoperative differential diagnosis included benign masses such as myxoid sarcoma and schwannoma, and we planned a diaphragmatic resection. Intraoperatively, however, dissection of the tumor from the liver was not possible, requiring an extended right posterior segmentectomy with combined resection of the diaphragm. The patient had a good postoperative course and 1 year has passed since the surgery with no recurrence. The pathology showed that the mass was located just below the hepatic capsule/parenchymal region and was adherent to the diaphragm, but there was no continuity. The morphology suggested a low-grade mesenchymal tumor such as a solitary fibrous tumor and perivascular epithelioid cell tumor, but immunostaining was negative, making the diagnosis difficult. Although some areas of high proliferative activity were observed, finally, the diagnosis of primary spindle cell tumor of the liver with smooth muscle differentiation was made based on the positive results of muscle markers such as αSMA, desmin, and h-caldesmon.ConclusionsSpindle cell tumor arising from the liver is so rare that preoperative and pathological diagnosis is often difficult to reach. Although further studies are needed to elucidate and better understand this uncommon clinical entity, we consider that complete resection is necessary for the above case, which may contribute to long-term survival.

Hypophosphatemia Is Associated With Postoperative Morbidity After Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy: A Retrospective Study.

Hypophosphatemia following surgery is associated with a higher rate of postoperative complications; however, the significance of postoperative hypophosphatemia after cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) is unknown. A prospectively maintained database was queried for all patients who underwent CRS/HIPEC for any histology at the Mount Sinai Health System. The perioperative serum phosphate levels, postoperative complications, and comorbidities were compared between patients with or without major complications. From 2007 to 2018, 327 patients underwent CRS/HIPEC. Most of the patients had low phosphate levels on postoperative day (POD) 2, reaching a median nadir of 2.3mg/dL on POD 3. Patients with major complications had significantly lower levels of serum phosphate on POD 5-7 compared with patients without complications, with median serum phosphate 2.2mg/dL (IQR 1.9-2.4) versus 2.7mg/dL, (IQR 2.3-3), P<0.01. Hypophosphatemia on POD 5-7 was also more frequent in patients who developed an anastomotic leak, with median serum phosphate 2.2mg/dL (IQR 1.9-2.6) versus 2.8mg/dL (IQR 2.2-3.2), P=0.001. On multivariate analysis, the number of organs resected at surgery, diaphragm resection, postoperative intensive care unit stay, and serum phosphate level <2.4mg/dL on POD 5-7 were independently associated with a major complication after CRS/HIPEC. Following CRS/HIPEC, POD 5-7 hypophosphatemia is associated with severe postoperative complications and anastomotic leak.

Postoperative Respiratory Failure Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy is Associated with Volume of Intraoperative Crystalloid Administration and Worse Survival.

Postoperative respiratory failure (PRF) is associated with increased morbidity after surgery. This retrospective study explores preoperative and perioperative risk factors associated with PRF in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) and the resultant impact on survival. We identified all patients who underwent CRS/HIPEC at our institution between 2007 and 2017. PRF was defined as mechanical ventilation for more than 48h after surgery or reintubation not related to an additional procedure within the first 30 days postoperatively. The relationship between clinicopathologic variables and PRF was examined using Kaplan-Meier log-rank survival analysis and multivariable Cox regression models with 90-day, 1-year and 5-year overall survival (OS). Overall, 314 patients underwent CRS/HIPEC, of whom 24 patients (7.6%) developed PRF. On univariable analysis, chronic obstructive pulmonary disease (COPD) was the only preoperative risk factor associated with PRF (p=0.049). Of the intraoperative risk factors, diaphragmatic resection (p=0.008), Peritoneal Cancer Index (PCI) > 20 (p<0.001), and volume of intraoperative crystalloid (p<0.001) were all associated with PRF. On multivariable Cox regression, only intraoperative crystalloid was significantly associated with PRF (p<0.001), with a volume above 5.3L (area under the curve [AUC] 0.77) having a high predictive accuracy for PRF.Five-year OS was significantly decreased in patients with PRF (30.2% vs. 52.6%, hazard ratio 2.6, 95% confidence interval 1.5-4.4; p<0.001). Liberal intraoperative crystalloid volume resuscitation is a potential independent, modifiable intraoperative risk factor for PRF following CRS/HIPEC that may contribute to decreased long-term OS.

How to perform complete resection of peritoneal carcinomatosis nodules infiltrating the diaphragm without opening the pleural cavity in patients with advanced-stage ovarian cancers

Patients with advanced-stage ovarian cancer frequently present with peritoneal carcinomatosis, and a diaphragmatic involvement is observed in about 40% of cases. The goal of treatment includes complete surgical cytoreduction associated with systemic chemotherapy. Complete diaphragmatic cytoreduction is a crucial step and plays a major role in the overall survival of these patients. Deep infiltrating peritoneal carcinomatosis nodules are treated with diaphragmatic full-thickness resections, but these procedures involve opening the pleural cavity and are associated with a high rate of postoperative complications, such as pleural effusion and pneumothorax. A chest drain is often required, causing significant discomfort for the patients and potentially being an additional source of complications.In this study, we present a novel surgical technique to perform diaphragmatic resections using a linear stapler without opening the pleural cavity or needing a chest drain.

Hyperthermic intraperitoneal chemotherapy does not increase risk of major complication or failure to rescue in cytoreductive surgery.

Failure to rescue (FTR) is defined as death after a major complication. We evaluated FTR after cytoreductive surgery (CRS) with and without hyperthermic intraperitoneal chemotherapy (HIPEC). The ACS NSQIP database 2005-2018 was reviewed for all cases of CRS. Propensity score matching was used to compare outcomes between those undergoing CRS alone and those undergoing CRS/HIPEC. Patients were matched on age, sex, ascites, diabetes, hypertension and resection of liver, pancreas, colon/rectum, diaphragm, stomach, small bowel, and/or spleen. Thirty nine thousand one hundred and twenty-six patients underwent CRS; 38,387 underwent CRS alone; 739 underwent CRS/HIPEC. After matching there were 726 patients in each arm. Patients undergoing CRS/HIPEC had higher risk of reintubation (25 [3.4%] vs. 13 [1.8%] p = 0.049), urinary tract infection UTI (44 [6.1%] vs. 25 [3.4%] p = 0.019) and sepsis (73 [10.1%] vs. 44 [6.1%] p = 0.005). Patients in the CRS arm required more transfusions (229 [31.5%] vs. 176 [24.2%] p = 0.002). There was no significant difference in FTR between the CRS and CRS/HIPEC groups (11 [4.0%] vs. 6 [2.3%] p = 0.258), nor in the pooled incidence of major complications (275 [37.9%] vs. 262 [36.1%] p = 0.48). CRS/HIPEC is associated with increased rates of reintubation, UTI, and sepsis while CRS alone was associated with increased transfusion. However, the addition HIPEC to CRS did not increase the risk of pooled major complication or FTR.

Cardiophrenic and costophrenic lymph node resection via subxiphoid approach only

When enlarged cardiophrenic lymph nodes (CPLN) are resected the impact on survival is still uncertain, but resection contributes to accurate staging and complete gross resection in advanced ovarian cancer. CPLN resection can be performed via video-assisted thoracic surgery or transabdominally through the subxiphoid or transdiaphragmatic routes. The subxiphoid approach is used to reach the prepericardiac nodes located in the anterior mediastinum. The transdiaphragmatic route is used to remove the costophrenic and supradiaphragmatic paracaval lymph nodes located in the middle and posterior mediastinum, respectively. However, the transdiaphragmatic approach necessitates diaphragm opening and, in most cases, liver mobilization. Costophrenic nodes can be resected through the subxiphoid route in appropriate patients without opening the diaphragm. Thus, the subxiphoid approach may be preferred to remove the costophrenic lymph nodes, in cases in whom diaphragm resection is not anticipated, and especially when the resection procedure is planned to include the prepericardiac nodes. In this video article, we present the method of resecting both prepericardiac and costophrenic lymph nodes using only the subxiphoid approach in a case of advanced ovarian cancer. The subxiphoid virtual space between the pericardium and diaphragm was developed. The observed and palpated CPLNs were dissected and excised from the prepericardiac and right latero-cardiac spaces. Thereafter, diaphragm peritoneum beneath the right costophrenic nodes was dissected. After identifying any enlarged costophrenic nodes by palpation, the sternal and costal diaphragmatic attachments were incised and the right latero-cardiac space was extended. When the single enlarged node was reached, it was grasped and pulled with curved-ring forceps and ultimately resected.

A Case Report of Primary Malignant Pulmonary Melanoma.

We operated on primary malignant melanoma of the lung, attaching the pericardium, diaphragm, and parietal pleura. A 48-year-old female was admitted to our hospital because of persistent dyspnea and cough. A preoperative computed tomography of the chest revealed 3 lesions in the right lung and a mass on the diaphragm between the right lung’s lower lobe and heart. A middle lobectomy was performed. The mass on the diaphragm had invaded the diaphragm and pericardium strictly. With a pericardiectomy and a diaphragmatic resection, the mass was removed in an en-bloc manner. Adjuvant chemotherapy was started 1 month after surgery and consisted of 5 days course of iv injection of cisplatin (90 mg/kg). The follow-up period was 5 years and uneventful. For primary pulmonary melanoma, even if it has intrapulmonary metastases, surgery and adjuvant chemotherapy can provide uneventful survival for more than 5 years.

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.

Postoperative pulmonary complications and outcomes in cytoreductive surgery for ovarian cancer: a propensity-matched analysis

ObjectivesTo assess the prevalence of postoperative pulmonary complications (PPCs), the perioperative factors associated with PPCs, and the association of PPCs with postoperative outcomes in ovarian cancer patients undergoing cytoreductive surgery.MethodsA retrospective analysis was conducted on patients who underwent cytoreductive surgery in our hospital, between September 2017 and January 2021, and patient medical records were reviewed to collect relevant clinical information. Univariable and multivariable analyses were used to identify significant risk factors for PPCs. Analysis of the association of PPCs with postoperative outcomes, mortality and 30-day readmission, was undertaken utilizing propensity score-matched controls and multivariable logistic regression model.ResultsFinal analysis was performed with 268 ovarian cancer patients after cytoreductive surgery, among whom the incidence of PPCs was 26.9%, and the most frequent pulmonary complication was pleural effusion. According to the multivariate analysis, the intraoperative fluid infusion volume (L) (odds ratio (OR) 1.34; 95% confidence intervals (CI) 1.01–1.77; P = 0.040), diameter size of diaphragmatic resection (cm) (OR 1.16; 95% CI 1.06–1.28; P = 0.002), and surgical complexity scores (OR 1.26; 95% CI 1.13–1.42; P < 0.001) were significantly associated with the development of PPCs. The multivariable logistic regression analyses with propensity-matched controls demonstrated that the occurrence of PPCs significantly increased the risk of 30-day readmission (OR 6.01; 95% CI 1.12–32.40; P = 0.037) and did not significantly affect inpatient mortality.ConclusionOvarian cancer patients undergoing cytoreductive surgery, especially those with diaphragmatic resection or higher surgical complexity scores, represent a high-risk population for PPCs. In addition, goal-directed fluid therapy is vital to reducing the occurrence of PPCs in patients at risk. PPCs were not associated with in-hospital mortality but were significantly associated with an increased risk of 30-day readmission after cytoreductive surgery.

Under Pressure: A Rare Case Of Right Ventricular Failure In Setting Of Large Mediastinal Mass

<h3>Introduction</h3> Large mediastinal tumors are rare and have a wide spectrum of presentations. Herein we present a case of right ventricular failure in the setting of a large anterior mediastinal chondrosarcoma. <h3>Case presentation</h3> 32 year old male with no known significant past medical history presented with one week of severe cough and chest pain. CT scan showed a large anterior mediastinal mass (9.3 × 12.4 × 13.6 cms), and biopsy was consistent with chondrosarcoma. Three weeks later, patient underwent complete surgical resection of mass along with partial chest wall, pericardium and diaphragm resection and reconstruction. Postoperative echocardiogram (TTE) showed severe right ventricular (RV) dysfunction and severe tricuspid regurgitation. Pulmonary Hypertension and Right heart failure service was consulted for further evaluation. <h3>Decision making</h3> Review of postoperative TTE showed no signs of pulmonary hypertension (systolic notching, septal flattening, RV hypertrophy). Review of preop TTE showed distal 2/3 of RV obscured by mediastinal mass and basal 1/3 RV hypokinetic. Review of chest CT from one month prior to surgery revealed large anterior mediastinal mass severely compressing distal third of RV along with significant right atrial enlargement. Two possible hypotheses for RV failure were contemplated at this point. 1. Chronic compression of right ventricle leading to severe geometric distortion/increased wall tension of non-compressed RV segments leading to myocardial dysfunction. 2. Acute surgical injury or chronic compression of right coronary artery leading to infarct and scar. Patient was diuresed and TTE done on postoperative day 5 showed significant improvement in RV size/function. Repeat TTE done on postoperative day 30 showed further improvement in RV size/function. These findings suggest direct myocardial compression as a more likely etiology of RV failure as opposed to infarct. <h3>Conclusion</h3> This case presents a rare case of large mediastinal mass causing right ventricular dysfunction by compression. This case also illustrates the importance of multimodality imaging (TTE and CT) in the evaluation of RV failure.

Cardiophrenic and costophrenic lymph node resection via subxiphoid approach only

Even the resection's impact of enlarged cardiophrenic lymph nodes (CPLN) on survival still uncertain, it contributes to accurate staging and complete gross resection in advanced ovarian cancer. CPLN resection can be performed via video-assisted thoracic surgery or transabdominally through the subxiphoid or transdiaphragmatic routes. The subxiphoid approach is utilized to reach the prepericardiac nodes located in the anterior mediastinum. The transdiaphragmatic route is used to remove the costophrenic and supradiaphragmatic paracaval lymph nodes located in the middle and posterior mediastinum, respectively. Transdiaphragmatic approach necessitates diaphragm opening and, in most cases, liver mobilization. However, costophrenic nodes can be resected through the subxiphoid route in appropriate patients without opening the diaphragm. Thus, the subxiphoid approach can be firstly preferred to remove the costophrenic lymph nodes, in cases whose diaphragm resection is not anticipated, and especially when the resection procedure is planned to include the prepericardiac nodes. In this video article, we present the method of resecting both prepericardiac and costophrenic lymph nodes through the subxiphoid approach in an advanced ovarian cancer case. The subxiphoid virtual space between the pericardium and diaphragm was developed. The observed and palpated CPLNs were dissected and excised from the prepericardiac and right latero-cardiac spaces. Thereafter, diaphragm peritoneum beneath the right costophrenic nodes was dissected. After determining the enlarged costophrenic node by palpation, the sternal and costal diaphragmatic attachments were incised and the right latero-cardiac space was extended. When the node was reached, it was grasped and pulled with curved-ring forceps and ultimately resected.

Invited Commentary: Stapled Diaphragmatic Resection in Cytoreductive Surgery with Intraperitoneal Chemotherapy: A Potential Solution to a Difficult Scenario.

Invited Commentary: Stapled Diaphragmatic Resection in Cytoreductive Surgery with Intraperitoneal Chemotherapy: A Potential Solution to a Difficult Scenario.

Stapled Full-Thickness Diaphragm Resection: A Novel Approach to Diaphragmatic Resection in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy.

Full-thickness diaphragm resection (FT-DR) during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is sometimes required to achieve a complete cytoreduction. It is conventionally performed with electrocautery with primary repair or mesh repair. FT-DR using a linear cutting stapler is a novel technique that avoids entry to the chest cavity and minimizes the use of electrocautery on the diaphragm. We performed an institutional retrospective review of a prospectively maintained database of 145 patients who underwent CRS-HIPEC between 2013 and 2019. Patients were divided into the Conventional or Stapled group based on the FT-DR approach indicated in the operative report. Of the 145 patients who underwent CRS-HIPEC, 27 underwent FT-DR, with 63% (n = 17) in the Stapled group. There were no significant demographic or oncologic differences between the 2 groups. Patients in the Stapled group underwent tube thoracostomy (13.3% vs 60%; p = 0.008), were diagnosed with pneumonia (12% vs 50%; p = 0.04), required reintubation (6% vs 40%; p = 0.03), and required mechanical ventilation more than 48 hours (6% vs 50%; p = 0.02) less frequently than the Conventional group. There was no difference in pleural recurrence between the 2 groups (Conventional 20% vs Stapled 12%, p = 0.56). Stapled full-thickness diaphragm resection is a novel approach to achieving a complete cytoreduction that excludes the pleural cavity, minimizes diaphragm manipulation, and is associated with improved postoperative pulmonary outcomes in patients undergoing CRS-HIPEC.

En Bloc Diaphragmatic Resection for Hepatocellular Carcinoma with Diaphragmatic Invasion, a Propensity Score Matched Analysis

Aim: This study aimed to evaluate the impact of en bloc diaphragmatic resection (DR) in patients with hepatocellular carcinoma(HCC). Method: Patients who received DR at the time of hepatectomy for HCC between 1997 to 2017 were retrospectively identified on a prospectively maintained database. Outcomes were compared to HCC patients without DR using propensity score matching(PSM) of 1:4 by controlling for alpha-fetoprotein levels and UICC staging. Results: During study period, 1744 patients received hepatectomy for HCC. Amongst them, 122 had en bloc DR, with 38 showing diaphragmatic invasion on histopathology. The diaphragm was repaired either primarily(n=112) or by mesh repair(n=10). Patients who required DR were more symptomatic on presentation, with higher AFP levels, larger tumour size, and more advanced UICC staging(P<0.001). After PSM, 122 patients with DR were matched to 488 patients without DR. Patients in the DR group were more likely to require major hepatectomy(87.7% vs. 73.6%, P=0.001), with higher risk of developing pulmonary complications(27.1% vs. 19.1%, P=0.007) and severe complication(27% vs. 14.1%, P=0.001). There was no difference in pathological UICC staging, but patients with DR were more likely to develop extrahepatic metastasis(21.3% vs. 12.7%, P=0.102). 5-year OS were 28.1% and 39.2%(P=0.009), while 5-year DFS were 17.9% and 23.4%(P=0.251) for the DR and non-DR groups respectively. Preoperative albumin, AFP, UICC stage, involved resection margin and the need for ICU support were associated with poor DFS but DR was not prognostic. Conclusion: HCC with diaphragmatic invasion was associated with poor tumor pathology and higher risk of postoperative pulmonary complications.

Diaphragmatic resection and liver mobilization during surgery for advanced ovarian cancer

Diaphragmatic resection and liver mobilization during surgery for advanced ovarian cancer