Right-Sided Pneumothorax Associated with Pneumoperitoneum Subsequent to Transverse Colon Perforation: Case Report

Pneumothorax can be spontaneous or secondary to a pre-existing disorder or trauma. Pneumothorax associated with pneumoperitoneum without thoraco-abdominal communication is a rare event poorly described in the literature. We report the case of a 73-year-old patient undergoing abdominal debulking surgery for advanced stage ovarian cancer complicated by a pneumoperitoneum and a right-sided pneumothorax without hernia or evidence of diaphragmatic trauma. Several physio-pathological hypotheses have been suggested, including a potential COVID-19 infection without clear etiology. Our case report emphasizes the possible association of pneumothorax with pneumoperitoneum related to a colon perforation without visible diaphragmatic or mediastinal defects.

Second-look surgery plus hyperthermic intraperitoneal chemotherapy versus surveillance in patients at high risk of developing colorectal peritoneal metastases (PROPHYLOCHIP-PRODIGE 15): a randomised, phase 3 study

BACKGROUND

Diagnosis and treatment of colorectal peritoneal metastases at an early stage, before the onset of signs, could improve patient survival. We aimed to compare the survival benefit of systematic second-look surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC), with surveillance, in patients at high risk of developing colorectal peritoneal metastases.

METHODS

We did an open-label, randomised, phase 3 study in 23 hospitals in France. Eligible patients were aged 18-70 years and had a primary colorectal cancer with synchronous and localised colorectal peritoneal metastases removed during tumour resection, resected ovarian metastases, or a perforated tumour. Patients were randomly assigned (1:1) to surveillance or second-look surgery plus oxaliplatin-HIPEC (oxaliplatin 460 mg/m², or oxaliplatin 300 mg/m² plus irinotecan 200 mg/m², plus intravenous fluorouracil 400 mg/m²), or mitomycin-HIPEC (mitomycin 35 mg/m²) alone in case of neuropathy, after 6 months of adjuvant systemic chemotherapy with no signs of disease recurrence. Randomisation was done via a web-based system, with stratification by treatment centre, nodal status, and risk factors for colorectal peritoneal metastases. Second-look surgery consisted of a complete exploration of the abdominal cavity via xyphopubic incision, and resection of all peritoneal implants if resectable. Surveillance after resection of colorectal cancer was done according to the French Guidelines. The primary outcome was 3-year disease-free survival, defined as the time from randomisation to peritoneal or distant disease recurrence, or death from any cause, whichever occurred first, analysed by intention to treat. Surgical complications were assessed in the second-look surgery group only. This study was registered at ClinicalTrials.gov, NCT01226394.

FINDINGS

Between June 11, 2010, and March 31, 2015, 150 patients were recruited and randomly assigned to a treatment group (75 per group). After a median follow-up of 50·8 months (IQR 47·0-54·8), 3-year disease-free survival was 53% (95% CI 41-64) in the surveillance group versus 44% (33-56) in the second-look surgery group (hazard ratio 0·97, 95% CI 0·61-1·56). No treatment-related deaths were reported. 29 (41%) of 71 patients in the second-look surgery group had grade 3-4 complications. The most common grade 3-4 complications were intra-abdominal adverse events (haemorrhage, digestive leakage) in 12 (23%) of 71 patients and haematological adverse events in 13 (18%) of 71 patients.

INTERPRETATION

Systematic second-look surgery plus oxaliplatin-HIPEC did not improve disease-free survival compared with standard surveillance. Currently, essential surveillance of patients at high risk of developing colorectal peritoneal metastases appears to be adequate and effective in terms of survival outcomes.

FUNDING

French National Cancer Institute.

A UNICANCER phase III trial of hyperthermic intra-peritoneal chemotherapy (HIPEC) for colorectal peritoneal carcinomatosis (PC): PRODIGE 7

LBA3503

Background: Promising results have been obtained during the last decade using cytoreductive surgery (CRS) plus HIPEC for selected patients with colorectal PC who are amenable to complete macroscopic resection. This is the first trial to evaluate the specific role of HIPEC, after CRS, for the treatment of PC of colorectal origin. Methods: Prodige 7 is a randomized phase III, multicenter trial. Patients with histologically proven and isolated PC, peritoneal cancer index (PCI) ≤25 were eligible. Randomization (1:1) was stratified by center, complete macroscopic resection (R0/1 vs R2), and neoadjuvant systemic chemotherapy. Patients were treated with CRS plus HIPEC with oxaliplatin or CRS alone, in association with systemic chemotherapy. The primary endpoint was the overall survival (OS). Secondary endpoints were relapse-free survival (RFS) and toxicity. 264 patients were required to show a gain in median OS from 30 to 48 months (HR = 0.625) with a two-sided α = 0,046 and 80% power. Results: 265 patients from 17 centers were included between February 2008 and January 2014: 132 in Arm without HIPEC and 133 in Arm with HIPEC. The median age was 60 years (range: 30-74). Baseline characteristics were well balanced. The overall post-operative mortality rate was 1.5% and was not different between the two arms. The morbidity rates did not differ statistically at 30 days. At 60 days, the grade 3-5 morbidity rate was significantly higher with HIPEC (24.1% vs. 13.6%, p= 0.030). After a median follow up of 63.8 months (95% CI: 58.9-69.8), the median OS was 41.2 months (95% CI 35.1-49.7) in the non-HIPEC Arm and 41.7 months (95% CI: 36.2-52.8) in the HIPEC Arm, HR = 1.00 (95% CI: 0.73-1.37) p = 0.995. The median RFS was 11.1 months (95% CI: 9-12.7) in non-HIPEC Arm and 13.1 months (95% CI: 12.1-15.7) in HIPEC Arm, HR = 0.90 (95% CI: 0.69-1.90) (p = 0.486), whilst the 1-year RFS rates were 46.1% in non-HIPEC Arm and 59 % in the HIPEC Arm. Conclusions: The therapeutic curative management of PC from colorectal cancer by CRS shows satisfactory survival results. While the addition of HIPEC with oxaliplatin does not influence the OS. Clinical trial information: NCT00769405.

The Challenging Diagnosis of Non-Community-Acquired Pneumonia in Non-Mechanically Ventilated Subjects: Value of Microbiological Investigation

BACKGROUND

Early recognition and an attempt at obtaining microbiological documentation are recommended in patients with non-community-acquired pneumonia (NCAP), whether hospital-acquired (HAP) or health care-associated (HCAP). We aimed to characterize the clinical features and microbial etiologies of NCAP to assess the impact of microbiological investigation on their management.

METHODS

This was a prospective 1-y study in a university hospital with 141 non-mechanically ventilated subjects suspected of having HAP (n = 110) or HCAP (n = 31).

RESULTS

Clinical criteria alone poorly identified pneumonia (misdiagnosis in 50% of cases). Microbiological confirmation was achievable in 80 subjects (57%). Among 79 microorganisms isolated, 28 were multidrug-resistant aerobic Gram-negative bacilli and group III Enterobacteriaceae and 6 were methicillin-resistant Staphylococcus aureus. Multidrug-resistant aerobic Gram-negative bacilli accounted for one third of the microorganisms in early-onset HAP and for 50% in late-onset HAP. Methicillin-resistant S. aureus was most often recovered from subjects with HCAP. Inappropriate empirical antibiotics were administered to 36% of subjects with confirmed pneumonia. Forty subjects were admitted to the ICU, 13 (33%) of whom died. Overall, 39 subjects (28%) died in the hospital.

CONCLUSIONS

Integrating the microbiological investigation in the complex clinical diagnostic workup of patients suspected of having NCAP is mandatory. Respiratory tract specimens should be obtained whenever possible for appropriate management.

Prophylactic laparoscopic cholecystectomy in adult sickle cell disease patients with cholelithiasis: A prospective cohort study

INTRODUCTION

Prophylactic laparoscopic cholecystectomy remains controversial and has been discussed for selected subgroups of patients with asymptomatic cholelithiasis who are at high risk of developing complications such as chronic haemolytic conditions. Cholelithiasis is a frequent condition for patients with sickle cell disease (SCD). Complications from cholelithiasis may dramatically increase morbidity for these patients. Our objective was to evaluate the effectiveness of prophylactic cholecystectomy in SCD patients with asymptomatic gallbladder stones.

METHODS

From January 2000 to June 2014, we performed 103 laparoscopic cholecystectomies on SCD patients. Fifty-two patients had asymptomatic cholelithiasis. The asymptomatic patients were prospectively enrolled in this study, and all underwent a prophylactic cholecystectomy with an intraoperative cholangiography. The symptomatic patients were retrospectively studied. Upon admission, all patients were administered specific perioperative management including intravenous hydration, antibiotic prophylaxis, oxygenation, and intravenous painkillers, as well as the subcutaneous administration of low-molecular-weight heparin. During the same period, 51 patients with SCD underwent a cholecystectomy for symptomatic cholelithiasis. We compared these 2 groups in terms of postoperative mortality, morbidity, and hospital stay.

RESULTS

There were no postoperative deaths or injuries to the bile ducts in either group. In the asymptomatic group, we observed 6 postoperative complications (11.5%), and in the symptomatic group, there were 13 (25.5%) postoperative complications.

DISCUSSION

Regarding the SCD complications, we observed 1 case (2%) of acute chest syndrome in an asymptomatic cholelithiasis patient, while there were 3 cases (6%) in the symptomatic group. Vaso-occlusive crisis was observed in 1 patient (2%) with asymptomatic cholelithiasis, and in 4 patients (8%) in the other group. The mean hospital stay averaged 5.8 (4-17) days for prophylactic cholecystectomy and 7.96 (4-18) days for the comparative symptomatic group.

CONCLUSIONS

Postoperative complications related to SCD were less frequent for asymptomatic patients who had a laparoscopic prophylactic cholecystectomy. This intervention, if performed with perioperative specific management, is safe and helps avoid emergency operations for acute complications including cholecystitis, choledocholithiasis, and cholangitis. For SCD patients, a prophylactic cholecystectomy reduces hospital stays.

Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): A French multicentric survey

BACKGROUND

Over the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision.

METHODS

A survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE).

RESULTS

Thirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), "open" abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs.

CONCLUSION

Protocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

Development and validation of a simple reversed-phase high-performance liquid chromatography method for the determination of testosterone in serum of males

An isocratic high-performance liquid chromatographic method with detection at 234 nm was developed, optimized and validated for the determination of testosterone in human serum. Propylparaben was used as internal standard. A Hypersil BDS RP-C18 column (150 mmx4.6 mm, 5 microm), was equilibrated with a mobile phase composed of acetonitrile and water (35:65, v/v) and having a flow rate of 1 ml/min. The elution time for testosterone and internal standard was approximately 11.6 and 9.9 min, respectively. Calibration curves of testosterone in serum were linear in the concentration range of 1-20 ng/ml. Limits of detection and quantification in serum were 0.4 and 1.1 ng/ml, respectively. Recovery was greater than 92%. Intra- and inter-day relative standard deviation for testosterone in serum was less than 2.1 and 3.9%, respectively. This method was applied to the determination of testosterone serum levels of 12 healthy males and data were correlated with data obtained using a radioimmunoassay method.

Genetic factors and the founder effect explain familial MS in Sardinia

OBJECTIVE

To estimate the presence of familial aggregation and determine the contribution of genetic factors to familial clustering of MS in patients coming from Sardinia, a Mediterranean island considered a genetically homogeneous, isolated area having high disease incidence and prevalence.

METHODS

Recurrence risk in siblings of 901 Sardinian patients and factors influencing risk (patient and sibling sex, patient age at onset, sibling birth cohort, and presence of affected relatives other than siblings) were examined. The presence of distant familial relationships among patients was evaluated by tracing the extended pedigrees of all patients with MS born in one Sardinian village.

RESULTS

Twenty-three brothers and 36 sisters of the 2,971 siblings were affected with MS. Recurrence risk was greater in siblings of index patients with onset age less than 30 years (p < 0.01, increased risk 2.33 times) and having a relative with MS other than a sibling or parent (p < 0.01, increased risk 2.90 times). Pedigree analysis of patients from the village of L. showed that all 11 patients descended from 3 pairs of ancestors, whereas no cases occurred in the remaining 2,346 inhabitants. In descendants from the 3 couples, MS prevalence was dramatically greater than the regional average and 1.5 times greater than that observed in siblings of affected cases.

CONCLUSIONS

Data from this study indicate that MS familial aggregation in Sardinians is influenced by genetic factors and that founder effect and the isolation of Sardinia can be considered causes of the enrichment of "etiologic" MS genes.

[Pleuro-pneumo-phreno-pericardiectomy with pericardial and diaphragmatic plasty]

Aim of the paper is to evaluate 43 extrapleural pneumonectomy performed from 1988 to May 2000. Criteria for extrapleural pneumonectomy were pleural biopsy by thoracoscopy, potentially completely resectable unilateral disease by computed tomography and predicted postresection forced expiratory volume >1,3 L/sec. The resections regarded 33 pleural mesothelioma, 9 pleural lung-carcinosis and 1 pleural melanoma effusion. The perioperative mortality rate was 2,2% (1 death) and morbidity 21,4%.

[Video-thoracoscopic sympathectomy in the treatment of Raynaud's disease and palmar hyperhidrosis]

BACKGROUND AND AIM

Raynaud's syndrome is a clinical entity characterised by episodic vascular spasm, digital ischemia in response to cold or emotional stimuli and hyperhidrosis. Many patients suffering from Raynaud's syndrome are successfully treated using medical therapy alone. Those patients who do not respond to medical treatment undergo surgery but the indications continue to be a source of controversy. A modern approach to thoracic sympathectomy requires a video-assisted technique. The aim of this study is to attempt to use mini-invasive type surgery to treat Raynaud's disease and hyperhidrosis in order to evaluate the real efficacy of thoracic sympathectomy in a large number of patients. The results of this method were compared for the two different pathologies in question.

METHODS

The methodology used by this study is based on instrumental and clinical tests performed before and after surgery on treated patients using a comparative criterion and with a minimum 5-year follow-up. The pre- and postoperative diagnostic tests were performed by the vascular surgery laboratory and using a C.W. Doppler and a reflected light photoplethysmograph. Capillaroscopy and laboratory evaluations relating to secondary Raynaud's disease were carried out by internist type structures. The patients enrolled in the study responded to the following criteria: primary Raynaud's disease, palmar hyperhidrosis and associated syndromes. The population came from a mixed sociodemographic background, albeit within a strictly regional zone (Sardinia). A total of 42 patients were studied. The surgical technique used consisted of the ablation of thoracic ganglia from the 2nd to the 4th.

RESULTS

The results showed a resolution of symptoms in 95% of patients treated for hyperhidrosis, whereas a 50% recidivation rate was observed in patients with Raynaud's disease alone, although symptoms were less intense. The results for Raynaud's disease were more disappointing, but it is important to remember that surgery is the ultimate choice for cases with advanced lesions which do not respond to medical treatment. Under these circumstances, the possibility of halting the evolution of the pathology represents an auspicious achievement.

CONCLUSIONS

The authors affirm that mini-invasive surgical treatment of hyperhidrosis was resolutive during a mean follow-up of 3 years. It therefore represents a valid method which causes minimum esthetic damage to the patient and the greatest functional benefit. The postoperative period is short (about 3 days) and free of major complications. There is virtually no post-surgical pain.

[Videolaparoscopic treatment of biliary lithiasis. Evolution of our experience]

Videolaparoscopic cholecystectomy is considered the treatment of choice for simple cholelithiasis. Now many surgeons consider the laparscopic procedure usable also in the complicated biliary lithiasis like acute cholecystitis and choledocholithiasis. The authors report their recent experience of the laparoscopic treatment of biliary lithiasis, regarding 221 non-selected patients (69% symptomatic cholelithiasis, 20% chronic cholecystitis, 4.5% acute cholecystitis, 4.5% coledocolithiasis, 2% hydrops). The diagnostic-therapeutic protocol and the results are described and compared with the beginning of their experience, when they treated only symptomatic gallbladder stone disease, and with the reports of the literature. The authors concluded that the laparoscopic procedure is a good chance for the surgeon in the treatment of all cases of benign biliary disease. But, in particular for patients with choledocholithiasis, he has be able to know all the diagnostic and therapeutic possibilities, to choose the best in every single case.

Therapy of migraine by modulating dopamine hypersensitivity: its effect on mood and pain

Clinical and pharmacological evidences support the hypothesis of a hypersensitivity of dopamine (DA) receptors in migraine patients. The aim of our single-blind and placebo-controlled study is to evaluate the presence of this hypersensitivity and to desensitize the DA system with apomorphine, a classical DA receptor agonist. We studied six patients suffering from migraine without aura resistant to the prophylactic treatment and with high frequency of attacks. In these patients, we first tested individual sensitivity by a single i.m. low dose of apomorphine to assess the lowest effective dose to be administered s.c. in continuous infusion without side-effects. We used the response of growth hormone (GH) to apomorphine as a marker of DA2-receptor function. Clinical evaluation, blood pressure and heart rate were recorded before placebo or apomorphine administration and monitored every 15 min for 1 h after each injection. The treatment consisted of the continuous subcutaneous infusion of apomorphine for three weeks at the dosage previously assessed by the test. No difference in blood pressure and heart rate was found during test and treatment. The treatment was effective in reducing the frequency and the severity of migraine attacks.

Dopamine hypersensitivity in migraine: role in apomorphine syncope

There is some evidence supporting a potential role of hypersensitivity of the dopaminergic system in the pathogenesis of migraine. In this case report, we describe a syncopal episode in a patient with migraine without aura after the administration of a very low dose of apomorphine, a classical agonist of dopaminergic receptors. The absence of cardiovascular risk factors in this patient suggests that the clinical event might have been caused by hypersensitivity of the dopaminergic system.

Corticotropin-releasing hormone stimulates adenylyl cyclase activity in the retinas of different animal species

In the present study we investigated the presence of corticotropin-releasing hormone (CRH)-stimulated adenylyl cyclase activity in the retinas of different animal species. CRH significantly stimulated adenylyl cyclase activity in homogenates of calf, pig, rabbit and guinea pig retinas. The stimulatory effects were concentration-dependent with half-maximal responses occurring at 20-30 nM CRH. The enzyme activities increased by 37-80% at the maximal concentration of CRH (1 microM). On the other hand, adenylyl cyclase activities of chicken and pigeon retinas were poorly stimulated by CRH. In calf, pig and rabbit retinas, the CRH effect was completely antagonized by the CRH receptor antagonist alpha-helical CRH 9-41 and required the presence of GTP. The stimulatory response elicited by CRH was also found to be not additive with that produced by either vasoactive intestinal peptide or dopamine. These results provide evidence for the presence in retinas of different animal species of functional CRH receptors, an important criterion for the classification of CRH as a retinal neurotransmitter.