P-100 ANATOMICAL STUDY ON THE PREPERITONEAL FAT DISTRIBUTION IN EXTENDED RETROMUSCULAR PREPERITONEAL DISSECTION: FROM THE FATTY TRIANGLE TO THE FATTY TRIDENT

Aim

Extended retromuscular dissection performed for abdominal wall reconstruction in complex abdominal wall repair has progressively exposed the anatomy between the peritoneal layer and abdominal wall muscles. This study aimed to assess the morphology and distribution of preperitoneal fat in a cadaveric model.

Material and methods

Thirty frozen cadaver torsos were dissected by posterior component separation. The shape of the preperitoneal fat was identified, and the dimensions and more significant distances were calculated.

Results

The results showed that the preperitoneal fat resembles a trident, exists along the midline under the linea alba, and expands in the epigastric area into a rhomboid shape. The fatty triangle was found to be a part of this rhomboid. The mean rhomboid area was 35 cm2. Caudally, the midline preperitoneal fat widened under the arcuate line to reach the Retzius space. Laterally, the Bogros space communicated the root of the trident with the paracolic gutters, Toldt's fascia, and pararenal fats, forming the lateral prong of the trident. The mean width of the midline prong at the umbilicus was 2.8 cm. It was easier to tear the peritoneum outside the area reinforced by the fatty trident.

Conclusions

The concept of preperitoneal fatty trident may be of practical assistance to perform various hernia procedures, from the simple ventral hernia repair to the more complex preperitoneal ventral repair or posterior component separation techniques. The consistency of this layer allows us to follow our plane between the peritoneum and muscle layers to extend the preperitoneal dissection.

V-018 PREOPERATIVE OPTIMIZATION AND POSTERIOR COMPONENT SEPARATION WITH INTRAOPERATIVE MONITORING OF RECTUS MUSCLE INERVATION FOR LOSS OF DOMAIN INCISIONAL HERNIA

Aim

The importance of an appropriate patient optimization (botulin toxin and pneumoperitoneum) and adequate surgical technique is highlighted.The possibility of intraoperative monitoring of the nerves that may be injured during posterior component separation is explained

Material and methods

We present a 74 years old man, past smoker, with history of hypertension, steatohepatitis and chronic bronchopathy

Results

This is a disastrous but unfortunately not so uncommon story of a failed repair of a simple umbilical hernia with 3 previous unsuccessful attempts of repair with and without mesh. After the last surgery the patient developed a giant incisional hernia with loss of domain. Optimization consisted of improving nutritional status, respiratory physiotherapy, botulin toxin and pneumoperitoneum. The surgery was made using previous skin scar. After dissecting the retrorectus space, a posterior component separation was made with the aid of monitoring the nerves that come to innervate the rectus abdominis. An overextended overlapped was obtained. A patch of absorbable mesh was used to completely close the peritoneum. A combination of absorbable and permanent synthetic mesh was used as giant reinforcement of the visceral sac. The only points of fixation were the Cooper Ligaments. The patient had a satisfactory recovery without complications and was discharged on the 8th postoperative day.

Conclusions

Loss of domain incisional hernias is a real surgical challenge. The combination of a good preoperative strategy (preoperative neumoperitoneum) and surgical technique (TAR and pannniculectomy) gives a great opportunity to solve very complex cases of incisional hernia.

V-007 LESSONS LEARNED DURING THE ABDOMINAL WALL RECONSUTRCTION FOR A MULTIRECURRENT LUMBAR HERNIA AFTER BONE GRAFT HARVESTING

The best approach for lateral incisional hernia is not known. Among these difficult hernias, those arising from iliac crest harvesting can be particularly challenging. The objective of this video is to illustrate the surgical approach of a multirecurrent case with the need of adding a posterior component separation

A 70 years old woman with 2 previous attempts of repair was referred to our center. With the patient in a 45 degrees lateral decubitus, a posterior lumbar approach was initiated through the previous scar. The retromuscular preperitoneal plane was accessed with difficulty due to previous meshes in the subdiaphragmatic, iliac and posterior areas. A big tear on the medial peritoneum changed our plan to add a posterior component separation. As we did not want to enlarge the lumbar incision to denervate more the lateral abdominal wall, we decided to make an accessory midline incision. Probably, an ETEP approach could have been better even before making the posterior incision. Once the retromuscular plane was dissected, the hole in the peritoneum could be closed. The reconstructive phase consisted in making a taco configuration using the combination of a permanent and absorbable mesh.

We have learned from this case, that an eTEP dissection of the retromuscular plane could have helped to avoid the accessory midline incision. It is also important to consider the potential iatrogenic denervation we could add in case of enlargement of the incision.

NF-kappa B is required for the development of tumor spheroids

Tumor cells cultured in three-dimensional models provide a more realistic and biologically meaningful analysis of the initial phases of cancer development and drug resistance. Several studies have demonstrated that culture of cancer cells in three dimensions induces cellular resistance to a variety of anti-neoplastic drugs by poorly understood mechanisms. The role of the transcription factor NF-kappaB and inhibitors of apoptosis proteins (IAPs) in the onset and development of drug resistance during tumor spheroid growth has not been established. In this work, we found a significant increase in the activity and expression of NF-kappaB and its downstream target XIAP (X-linked IAP) in cancer cells grown as multi-cellular tumor spheroids. Blocking XIAP expression with RNA interference markedly increased the sensitivity of cancer tumor spheroid cells toward anti-neoplastic drugs, indicating a role for IAPs in establishing drug resistance. In turn, inhibition of NF-kappaB by negative dominants suppressed spheroid formation, whereas overexpression of the upstream kinase IkappaBKbeta increased their growth and resistance. The present data suggested that NF-kappaB and its downstream target XIAP were essential for the growth and drug resistance of small avascular tumor.

Second malignancy risk associated with treatment of Hodgkin's lymphoma: meta-analysis of the randomised trials

BACKGROUND

Despite several investigations, second malignancy risks (SMR) following radiotherapy alone (RT), chemotherapy alone (CT) and combined chemoradiotherapy (CRT) for Hodgkin's lymphoma (HL) remain controversial.

PATIENTS AND METHODS

We sought individual patient data from randomised trials comparing RT versus CRT, CT versus CRT, RT versus CT or involved-field (IF) versus extended-field (EF) RT for untreated HL. Overall SMR (including effects of salvage treatment) were compared using Peto's method.

RESULTS

Data for between 53% and 69% of patients were obtained for the four comparisons. (i) RT versus CRT (15 trials, 3343 patients): SMR were lower with CRT than with RT as initial treatment (odds ratio (OR) = 0.78, 95% confidence interval (CI) = 0.62-0.98 and P = 0.03). (ii) CT versus CRT (16 trials, 2861 patients): SMR were marginally higher with CRT than with CT as initial treatment (OR = 1.38, CI 1.00-1.89 and P = 0.05). (iii) IF-RT versus EF-RT (19 trials, 3221 patients): no significant difference in SMR (P = 0.28) although more breast cancers occurred with EF-RT (P = 0.04 and OR = 3.25).

CONCLUSIONS

Administration of CT in addition to RT as initial therapy for HL decreases overall SMR by reducing relapse and need for salvage therapy. Administration of RT additional to CT marginally increases overall SMR in advanced stages. Breast cancer risk (but not SMR in general) was substantially higher after EF-RT. Caution is needed in applying these findings to current therapies.

Meta-Analysis to Evaluate the Role of Interferon in Follicular Lymphoma

Purpose

To determine whether interferon (IFN) -α2, when given with or following chemotherapy, influences response rate, remission duration, and survival in newly diagnosed patients with follicular lymphoma.

Patients and Methods

Ten phase III studies evaluating the role of IFN-α2 in 1,922 newly diagnosed patients with follicular lymphoma were analyzed. Updated individual patient data were used to perform meta-analyses for response, survival, and remission duration.

Results

The addition of IFN-α2 to initial chemotherapy did not significantly influence response rate. An overall meta-analysis for survival showed a significant difference in favor of IFN-α2, but also showed significant heterogeneity between studies. Further analyses were carried out in order to explain this heterogeneity, and to define the circumstances in which IFN-α2 prolonged survival. The survival advantage was seen when IFN-α2 was given: (1) in conjunction with relatively intensive initial chemotherapy (2P = .00005), (2) at a dose ≥ 5 million units (2P = .000002), (3) at a cumulative dose ≥ 36 million units per month (2P = .000008), and (4) with chemotherapy rather than as maintenance therapy (P = .004). With regard to remission duration, there was also a significant difference in favor of IFN-α2, irrespective of the intensity of chemotherapy used, IFN dose, or whether IFN was given as a maintenance strategy or with chemotherapy.

Conclusion

When given in the context of relatively intensive initial chemotherapy, and at a dose ≥ 5 million units (≥ 36 × 106 units per month), IFN-α2 prolongs survival and remission duration in patients with follicular lymphoma.

A prospective clinical trial comparing chemotherapy, radiotherapy and combined therapy in the treatment of early stage Hodgkin's disease with bulky disease

We performed a randomized clinical trial to assess the usefulness and toxicity of combined therapy compared with chemotherapy and radiotherapy in the treatment of early stage Hodgkin's disease with bulky disease as an adverse prognostic factor. Three-hundred and seven patients were enrolled into the study. They were randomized to receive either radiotherapy (extended field, generally mantle, 3500 cGy), or chemotherapy (adriamycin, bleomicin, vinblastine and dacarbazine: ABVD, 6 monthly) cycles or combined therapy (three cycles of ABVD, followed by irradiation therapy and three more cycles of chemotherapy). The median follow-up duration from start of treatment was 11.4 years. Complete response rates were similar in the three arms: 83% for radiotherapy (95% confidence interval [CI] 67-92%), 80% for chemotherapy (CI 69-88%) and 87% for combined therapy (CI 74-94%). However, disease-free survival and overall survival were better in the patients treated with combined therapy. At 12 years 76% (CI 51-93%) of the patients treated with combined therapy remained alive in the first complete remission compared with 42% (CI 26-61%) in patients treated with radiotherapy and 48% (CI 31-57%) in patients who had received chemotherapy alone (P < 0.01). Improvement in overall survival was also evident at 12 years: 88% (CI 59-93%) in those who had received combined therapy, compared with 53% (CI 36-67%) in the radiotherapy arm and 59% (CI 35-67%) in the chemotherapy group. Acute toxicity was more frequent in patients treated with combined therapy, but no death related treatment was observed in the three groups. Late toxicity was similar in the three treatment groups. Combined therapy with extended field radiotherapy and six cycles of chemotherapy is an effective treatment of patients with early stage bulky Hodgkin's disease compared with chemotherapy or radiotherapy alone.

Cranioplasty: cosmetic or therapeutic?

Cranioplasty is among the oldest surgical procedures. Trauma, infections, tumors and compression caused by brain edema are some of the reasons for the removal of bone. The indications for cranioplasty after resolution of the primary process that led to the bone defect were never well defined, and many were the "cosmetic" indications for cranioplasty. However, there are many theories suggesting that an underlying physiological alteration may occur which may require the correction of the bone defect; many patients improve after surgery. We discuss the physiopathological basis of the "syndrome of the trephined" and try to achieve a better understanding of the present status of cranioplasty and its possible therapeutic role.

Interferon alpha 2b as maintenance therapy in low grade malignant lymphoma improves duration of remission and survival

We assessed the efficacy and toxicity of interferon alpha 2b (IFN) as maintenance therapy in patients with low grade malignant lymphoma. Between March 1986 and December 1989, 98 patients with low-grade malignant lymphoma in complete remission after conventional chemotherapy were randomly assigned to received IFN, 5.0 MU three times a week for one year, as maintenance therapy (n = 48), or to receive no treatment (control group, n = 50). In March 1994, the median duration of response had not yet been reached in the patients treated with IFN compared to 46 months in the control group. At 9-years 62% of the patients in the IFN arm remain in first complete remission compared to only 25% in the control group (p <.001). In addition, the median duration of survival has not yet been reached in either the IFN arm compared to 74 months in the control group (p <.001). Quality of life was excellent in both groups and severe side effects secondary to IFN treatment were not observed. All patients completed the planned dose of IFN. We conclude that IFN as maintenance therapy in low-grade malignant lymphoma is an excellent therapeutic option because it improves the duration of remission and survival without producing severe side effects or reducing the quality of life.

Angiocentric T-cell lymphoma of the nose, paranasal sinuses and hard palate

Sixty-five cases of malignant lymphoma of the nose, paranasal sinuses and hard palate were retrospectively analysed to identify the presence or absence of angiocentric lesions. We observed that the 23 patients with angiocentric lesions had a worse prognosis with a shorter duration of response and also a shorter duration of survival, compared with 42 cases of malignant lymphoma of the same anatomical region but without angiocentric lesions. Patients with angiocentric lymphoma were associated with other bad prognostic factors such as elevated levels of lactic dehydrogenase and beta 2 microglobulin, local bone destruction and lymphopenia. Immunophenotyping studies showed that most patients with angiocentric lesions had T cell lymphomas (18 of 23, 78 per cent). We believe that patients with angiocentric T cell lymphomas of the nose, paranasal sinuses and hard palate represent a distinctive clinico-pathological entity with different clinical presentation and outcome. Patients with angiocentric T cell lymphomas had frequent relapse at extranodal sites and combined therapy should be considered as the initial therapeutic approach.

[Ferritin in the cerebrospinal fluid as an early indicator of neuromeningeal involvement in patients with malignant lymphoma]

In order to evaluate whether cerebrospinal fluid (CSF) ferritin could be useful to determine early infiltration of central nervous system (CNS) in patients with malignant lymphoma, the ferritin concentration was measured in 30 previously untreated patients with malignant lymphoma without evidence of neurologic infiltration. Six patients showed elevation of CNS ferritin 2 to 6 months after clinical and cytologic diagnosis of CNS involvement was confirmed. Twenty-four patients with normal CSF ferritin did not show involvement of CNS 6 to 23 months after the study was done. Measurement of CNS ferritin appears to be important in the early detection of CNS involvement of malignant lymphoma and should be included in the clinical evaluation to detect patients at high-risk to develop this complication and prophylaxis could be done to avoid it.

Treatment of adult acute lymphoblastic leukemia with adriamycin, vincristine, and prednisone

At the present time, it is possible to achieve up to a 95% complete remission in childhood acute lymphoblastic leukemia, using the combination of vincristine and prednisone. Nevertheless, it has not been possible to reproduce these results in the adult. For this reason, a third drug, in this case adriamycin in a low dose, was added to the vincristine-prednisone combination in the treatment of adult acute lymphoblastic leukemia (ALL). Complete remission was achieved in 45 of the 50 patients (90%). The median duration of remission was 23 months and the median survival time in this group was 31 months. The complications were minimal and the tolerance was good. From the point of view of our results and others reported in the literature, we consider that the combination of vincristine, prednisone, and adriamycin is a useful method for induction of remission of adult ALL.

Treatment of acute leukemia during pregnancy: presentation of nine cases

The hematologic and obstetric problems of nine pregnant patients with acute leukemia are analyzed. Seven patients received chemotherapy during various trimesters of pregnancy, four during the first 10 weeks, and there was no evidence of congenital malformations in any of their offspring. Six of nine babies are alive and healthy with a normal growth 2 months to 15 years after birth, one child was stillborn, and two children died 21 and 90 days after birth. These results were compared with others in the literature and the conclusions are that pregnancy is not a contraindication for treatment of acute leukemia, that cytotoxic drugs may not cause congenital malformations, and that the management of pregnant patients with acute leukemia should be carefully planned.

Acquired von Willebrand's syndrome during autoimmune disorder

A case with evidence of acquired von Willebrand's syndrome associated with systemic lupus erythmatosus and Sjögren's syndrome is described. The patient, who had no family history of bleeding, presented a haemorrhagic diathesis of recent origin, the bleeding time was prolonged, procoagulant Factor-VIII and von Willebrand factor levels were low and platelet aggregation was decreased with different concentrations of Ristocetin. No improvement was seen after the tranfusion of cryoprecipitates, and there was no increase in procoagulant Factor-VIII. Clinical improvement resulted after treatment with corticosteroids, and later, the laboratory abnormalities characteristic of von Willebrand's disease became normal. The level of procoagulant factor-VIII reached the very high level of 810%.

Adriamycin and splenectomy in the treatment of histiocytic medullary reticulosis

Histiocytic medullary reticulosis (HMR) is a rare, malignant disorder with unsatisfactory response to various chemotherapeutic agents that have been used up to the present time. The purpose of this communication is to describe the first patient with this disease in whom an immediate, complete remission was obtained using only adriamycin. Four months after institution of this treatment, a staging laparotomy and splenectomy revealed residual disease in the spleen only. Adriamycin was continued as the sole agent, to the full calculated dose, followed by maintenance therapy consisting of cyclophosphamide. The patient continues to be in complete remission 35 months after diagnosis was established.