Biomedical subjects
Publications and source records attributed to J Esquivel.
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Peritoneal surface malignancy can arise from pseudomyxoma peritonei, gastrointestinal carcinoma, abdomino-pelvic sarcoma and peritoneal mesothelioma. In the past, only palliative treatments were offered and the results were poor. We have proposed a new concept in managing patients with peritoneal surface malignancy. It involves an aggressive combined treatment modality of cytoreduction and perioperative intraperitoneal chemotherapy. The results are promising for patients with pseudomyxoma peritonei, peritoneal mesothelioma and well-selected patients with invasive peritoneal surface malignancies. The success in such comprehensive treatment depends on tumor biology, patient's co-morbidities, the completeness of cytoreduction, the efficacy of intraperitoneal chemotherapy administration and the surgeon's experience. The importance of patient selection is emphasized. The rationales and the outline of the current management strategies are described. Large phase II studies have demonstrated the marked survival advantage in this aggressive approach to peritoneal surface malignancy.
INTRODUCTION: Pseudomyxoma peritonei syndrome is a rare disease that causes extensive accumulation of non-invasive mucinous tumour and mucinous fluid throughout the abdomen and pelvis. The primary tumour is a perforated appendiceal adenoma or mucinous adenocarcinoma. In patients with an open processus vaginalis or other peritoneal defect, the adenomatous epithelial cells may accumulate within the hernia sac, causing mucoid fluid to be present at the time of hernia repair. MATERIALS AND METHODS: From February 1991 to September 1997, the diagnosis of pseudomyxoma peritonei syndrome was established in 20 patients in whom mucoid material was found in a hernia sac during a hernia repair. Clinical features of these patients were critically evaluated using the completeness of cytoreduction as an endpoint. RESULTS: The treatments delivered at the time of hernia repair had no impact on the outcome. A lack of interim events vs the use of interim treatments between hernia repair and definitive cytoreduction was significant in relation to a complete vs incomplete cytoreduction. Non-aggressive histology and an interval of less than 1 year was statistically significantly associated with a favourable outcome from surgical intervention. CONCLUSION: When mucoid fluid is encountered at the time of a hernia repair, recovery of that fluid and the hernia sac for histologic study is important. When adenomatous epithelial cells are present, a CT scan should be performed to look for the typical distribution of mucinous tumour and fluid that suggests the pseudomyxoma peritonei syndrome. If the diagnosis can be confirmed, referral to a centre experienced in the treatment of this rare disease is suggested.
Prevalence studies generally find nosocomial urinary tract infections to be the most common type of nosocomial infection, accounting for between 21% and 45% of all HAIs. The main risk factor appears to be the presence of a urinary catheter, with an estimated 80% of these infections being associated with their use. This paper describes a model which quantifies the extent of the burden of these infections in terms of the number of patients affected and the costs incurred by the hospital sector; and identifies the potential benefits of the routine use of silver alloy coated catheters, as a means of reducing the incidence of this type of infection. An illustrative model of the annual costs and benefits associated with the routine use of this intervention in adult, non-day case patients admitted to the medical and surgical specialties of NHS hospitals throughout England is presented. The results suggest that a 14.6% reduction in the incidence of urinary tract infections in catheterized medical patients, and a 11.4% reduction in catheterized surgical patients, would cover the cost of the intervention. Any further reduction in incidence would result in net positive benefits.
OBJECTIVE: To establish selection criteria for reoperation in patients with peritoneal dissemination from appendiceal malignancy. SUMMARY BACKGROUND DATA: The outcome of patients with mucinous appendiceal neoplasms with peritoneal surface dissemination has changed as a result of a better understanding of the clinical and pathologic features of this disease. This knowledge, combined with aggressive strategies for the use of perioperative intraperitoneal chemotherapy and peritonectomy procedures, has resulted in long-term disease-free survival in many of these patients. However, some of the patients develop progressive disease, and a question regarding additional surgery is appropriate. A critical analysis of the results of second-look surgery should assist in the management of patients with recurrent peritoneal surface dissemination of an appendiceal neoplasm. METHODS: Three hundred twenty-one patients with epithelial peritoneal surface malignancy of appendiceal origin underwent surgery during a 12-year period. Ninety-eight of these patients (30.5%) underwent a second-look procedure. A database of selected clinical features regarding these 98 patients was gathered from the clinical records. A critical statistical analysis of these clinical features and their prognostic impact was performed using survival as an endpoint. All patients were managed by a treatment regimen that used cytoreductive surgery and intraperitoneal chemotherapy. RESULTS: The overall 5-year survival rate of these 98 patients was 73.6%. This compared favorably with a 68% survival rate of 223 patients who did not undergo reoperation. Survival based on the number of cytoreductive surgeries and the free interval between them showed no significant difference. Patients who had second-look surgery with bowel obstruction as a symptom and those in whom the amount of tumor was increased or minimally decreased at the first and second cytoreductions had a significantly inferior 5-year survival rate. A complete second cytoreduction was associated with an improved 5-year survival rate. CONCLUSIONS: Follow-up of patients treated for peritoneal dissemination from neoplasms of appendiceal origin is indicated. Selected patients in whom recurrence develops are candidates for repeat cytoreductive surgery plus intraperitoneal chemotherapy with curative intent.
BACKGROUND: Pseudomyxoma peritonei syndrome is a rare disease arising from perforation of an adenoma of the appendix. The syndrome is characterized by progressive accumulation of mucinous fluid and tumor within the abdomen and pelvis. Although this tumor is only superficially invasive and does not metastasize, it is a fatal disease. Extra-abdominal spread of pseudomyxoma peritonei is a rare occurrence, with few reports in the medical literature. This review focuses on pleural extension of mucinous tumor in patients with pseudomyxoma peritonei syndrome. METHODS: From December 1983 to April 1999, all patients who underwent cytoreductive surgery for pseudomyxoma peritonei syndrome were assessed for pleural involvement at the time of the presentation or follow-up. Clinical information on these patients, including chest computed tomographic scan, was retrospectively reviewed. The mechanisms of extension of mucinous tumor from peritoneal cavity to pleural surface and the results of treatment were of special interest. RESULTS: Twenty-three of 426 patients (5.4%) showed pleural extension of pseudomyxoma peritonei syndrome. In four patients (17%), extension into the chest occurred before cytoreductive surgery. In 18 patients, the pleural space was entered during a subdiaphragmatic peritonectomy; and, in 12 patients, extension of disease from peritoneal to pleural space occurred. In six patients (26%), surgical interventions were required to excise tumor that had invaded the hemidiaphragm; and, in the six other patients (26%), there was a minor penetration during subphrenic peritonectomy, which was closed immediately. Finally, in seven patients (30%), the mechanism of spread was unknown. Twelve patients were treated for pleural thoracotomy. Eight patients had an attempt to completely eradicate pleural mucinous tumor, and five patients are currently disease free in the chest (22%); four of these five had intrapleural cytoreduction plus intrapleural chemotherapy. The median survival for all 23 patients is 55 months. CONCLUSION: Pleural spread of pseudomyxoma peritonei syndrome may be a direct result of cytoreductive surgery and the subphrenic peritonectomy procedure. In some patients, dissecting mucinous tumor may infiltrate through the diaphragm and result in pleural extension. Pleural extension of pseudomyxoma peritonei syndrome carries a poor prognosis. Intrapleural chemotherapy combined with cytoreductive surgery may be of considerable value in treatment and prevention of disease dissemination; it should be considered when pleural extension of mucinous tumor is feared or confirmed at the time of cytoreductive surgery.
BACKGROUND: Heated intraoperative intraperitoneal chemotherapy achieves high peritoneal concentrations with limited systemic absorption and has become an important tool in the management of patients with peritoneal carcinomatosis from low-grade malignancies such as pseudomyxoma peritonei and in selected cases of high-grade tumors such as colon adenocarcinoma. When the closed abdomen technique is used, its perioperative toxicity seems to be related to the hemodynamic and cardiac function changes associated with increased body temperature and increased intra-abdominal pressure. METHODS: Hemodynamic and cardiac function variables during heated intraoperative intraperitoneal chemotherapy, using an open abdomen "coliseum technique," were measured in 15 patients with the use of a noninvasive esophageal Doppler monitor. RESULTS: The hemodynamic and cardiac function changes were characterized by an increased heart rate, increased cardiac output and decreased systemic vascular resistance associated with an increased body temperature, and decreased effective circulating volume with the urinary output tending to decrease as the therapy progressed. CONCLUSION: Heated intraoperative intraperitoneal chemotherapy with the open abdomen coliseum technique induces a hyperdynamic circulatory state with an increased intravenous fluid requirement and avoids changes because of increased intra-abdominal pressure. Hemodynamic and cardiac stability, as documented by normal blood pressure and adequate urinary output, can be achieved by liberal intravenous fluids, titrated to frequent urinary output determination.
BACKGROUND: Pseudomyxoma peritonei syndrome is characterized by a gradual expansion of mucoid tumour and fluid at specific sites within abdominopelvic regions as a result of a perforated appendiceal adenoma. The aim was to analyse the presenting symptoms and signs of patients with this condition. METHODS: Of 410 patients with appendiceal tumours 217 had the diagnosis of pseudomyxoma peritonei syndrome with histological confirmation. A retrospective review of the clinical characteristics that determine presentation was performed. RESULTS: Overall, suspected acute appendicitis was the most common presentation (27 per cent). For women the diagnosis was most commonly made while being evaluated for an ovarian mass (39 per cent). Increasing abdominal girth was the second most common presentation overall (23 per cent). Thirty patients (14 per cent) presented with new-onset hernia, of which the majority (26) were inguinal hernias. CONCLUSION: Consideration of appendicitis, increased abdominal girth, ovarian mass and new-onset hernia as caused by this syndrome may facilitate diagnosis and definitive treatment.
BACKGROUND: Peritoneal carcinomatosis from gastrointestinal cancers is a fatal diagnosis without special combined surgical and chemotherapy interventions. Guidelines for cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) by using the Coliseum technique have been developed to treat patients with peritoneal carcinomatosis and other peritoneal surface malignancies. The purpose of this study was to analyze the morbidity and mortality of patients undergoing cytoreductive surgery and HIIC by using mitomycin C. METHODS: Data were prospectively recorded on 183 patients who underwent 200 cytoreductive surgeries with HIIC between November 1994 and June 1998. Seventeen of the 183 patients returned for a second-look surgery plus HIIC. All HIIC administrations occurred after cytoreduction and used continuous manual separation of intra-abdominal structures to optimize drug and heat distribution. Origins of the tumors were as follows: appendix (150 patients), colon (20 patients), stomach (7 patients), pancreas (2 patients), small bowel (1 patient), rectum (1 patient), gallbladder (1 patient), and peritoneal papillary serous carcinoma (1 patient). Morbidity was organized into 20 categories that were graded 0 to IV by the National Cancer Institute's Common Toxicity Criteria. In an attempt to identify patient characteristics that may predispose to complications, each morbidity variable was analyzed for an association with the 25 clinical variables recorded. RESULTS: Combined grade III/IV morbidity was 27.0%. Complications observed included the following: peripancreatitis (6.0%), fistula (4.5%), postoperative bleeding (4.5%), and hematological toxicity (4.0%). Morbidity was statistically linked with the following clinical variables: duration of surgery (P < .0001), the number of peritonectomy procedures and resections (P < .0001), and the number of suture lines (P = .0078). No HIIC variables were statistically associated with the presence of grade III or grade IV morbidity. Treatment-related mortality was 1.5%. CONCLUSIONS: HIIC may be applied to select patients with peritoneal carcinomatosis from gastrointestinal malignancies with 27.0% major morbidity and 1.5% treatment-related mortality. The frequency of complications was associated with the extent of the surgical procedure and not with variables associated with the delivery of heated intraoperative intraperitoneal chemotherapy. The technique has shown an acceptable frequency of adverse events to be tested in phase III adjuvant trials.
Peritoneal carcinomatosis occurs in about 10% of patients with colon cancer. Patients with progressive disease develop complications, with a median survival of 9 months. Our goal is to present a new quantitative scoring system by which to evaluate patients with peritoneal carcinomatosis. The Peritoneal Cancer Index and Completeness of Cytoreduction Score represent quantitative and prognostic indicators that permit the creation of a clinical pathway. Based on the scores, patients can undergo systemic chemotherapy, exploratory laparotomy or cytoreductive surgery. If there is a complete cytoreduction, perioperative intraperitoneal chemotherapy is given and these patients are considered potential long-term survivors.
OBJECTIVE: To assess the clinical significance of portal vein gas (PVG) demonstrated by computed tomography (CT). DESIGN: Review of medical records. SETTING: Three network-affiliated hospitals providing both primary community-based and tertiary services. METHODS: Review of diagnosis, clinical circumstances, and significance of PVG in 7 patients detected by CT during a 3-year period in 3 affiliated hospitals. RESULTS: Four of 7 patients underwent laparotomy; 1 patient refused surgery. Two patients were treated with intravenous antibiotics only and had uneventful clinical courses. Of the 3 patients who died, 1 refused and 2 underwent laparotomy. CONCLUSIONS: This series indicates that more sensitive imaging and more widespread use of endoscopic retrograde cholangiopancreatography, colonoscopy, and liver transplantation have changed the clinical presentation of PVG; PVG may be found in various clinical settings that do not mandate laparotomy; and the significance of PVG must be derived from the clinical context of the individual patient.
Cardiovascular disease is the leading cause of death in patients undergoing maintenance dialysis. This study was undertaken to evaluate the lipid abnormalities and body composition by bioelectrical impedance in patients receiving continuous ambulatory peritoneal dialysis (CAPD). The patients were between the ages of 28 and 77 and had been on dialysis for periods ranging from 6-48 months. Body composition studies performed by electrical impedance showed that the CAPD patients generally had elevated levels of body fat. Most of these patients had waist-to-hip fat ratios of more than 1.0, and lean tissue was decreased. Serum chemistries showed that most of the patients had albumin levels less than 3.5 g/dL. The most frequent lipid abnormalities found were: hypertriglyceridemia; hypercholesterolemia; decreased HDL levels; elevated cholesterol/HDL and apoproteins (Apo B/A-1); and elevated lipoprotein [Lp(a)] levels. Cardiovascular disease was prevalent in the patients studied. Ten had a positive history of angina, with three documented myocardial infarction and two documented cardiovascular disease. In conclusion, standard CAPD treatment may increase the risk of cardiovascular disease.
BACKGROUND: Peritoneal carcinomatosis has been regarded as a uniformly lethal clinical entity. Recently, dose-intensive treatments combining cytoreductive surgery and intraperitoneal chemotherapy have resulted in long-term survival in selected patients. METHODS: This article reports the morbidity and mortality associated with this new treatment strategy in 45 consecutive treatments of 43 patients with peritoneal carcinomatosis treated during an 18-month interval. RESULTS: The duration of median postoperative ileus was 21 days, and increased age of the patient and extent of cytoreduction caused an increased incidence of ileus. Twenty-one complications occurred in 17 patients (37.7%). Complications related to enteric function included fistula (n = 4), bile leak (n = 1), pancreatitis (n = 1), and anastomotic disruption (n = 1). There were two early and two late episodes of postoperative bleeding requiring reoperation. Six patients had pneumonia and one had deep vein thrombosis. There were no deaths. Six of the seven complications related to enteric function occurred in patients who had undergone induction intraperitoneal chemotherapy before cytoreductive surgery plus early postoperative intraperitoneal chemotherapy. CONCLUSIONS: As a result of these findings, induction intraperitoneal chemotherapy is only recommended for patients with low-volume intraabdominal cancer. In most patients surgical removal of peritoneal carcinomatosis before intraperitoneal chemotherapy is recommended. Because of the significant morbidity related to treatment of peritoneal carcinomatosis, careful patient selection and favorable long-term results of treatment are required.
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Contraception with lynestrenol-mestranol (Lyndiol) was studied in 332 Mexican women during a period of two and one-half years. Side effects were minimal or transient. No pregnancies occurred in those who took the medication according to instructions. The women were followed with yearly pelvic examinations and Papanicolaou smears, serial endometrial biopsies and extensive studies of blood, liver and glandular function. Complete ophthalmological studies were done on 30 patients. No clinical or laboratory evidence of harmful effects could be demonstrated. Return to ovulation (using pregnanediol excretion and endometrial biopsies as parameters) occurred in all of 22 women studied in the first three post-treatment cycles. Eight posttreatment pregnancies and the resulting offspring were normal. The first post-treatment cycle, as with other oral contraceptives, was unpredictable and tended to be prolonged. It varied in length from 22 to 60 days.
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Rosai-Dorfman Disease is a histiocytic proliferative disorder which primarily affects lymph nodes. Extranodal involvement occurs in about one half of the patients and the head and neck area represents the region most commonly involved. We present the case of a 48 year-old female who was found with a pancreatic mass during evaluation for abdominal pain. She underwent a distal pancreatectomy and splenectomy. Her pathology showed sinus histiocytosis with massive lymphadenopathy (SHML) involving the pancreas and lymph nodes and focally the spleen. The histiocytes characteristically contained one or more viable lymphocytes in the cytoplasm. The lymphocytes had penetrated the cytoplasm in a process known as "emperipolesis", where the lymphocytes continued to have free movement in the histiocyte. The histiocytic cells were positive with S-100 protein and CD68. Rosai-Dorfman Disease (SHML) can affect the peripancreatic lymph nodes with possible secondary pancreatic involvement and present as a pancreatic mass.