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BackgroundWhile parenchymal hepatic metastases were previously considered a contraindication to cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), liver resection (LR) is increasingly performed with CRS/HIPEC.MethodsPatients from the US HIPEC Collaborative (2000-2017) with invasive appendiceal or colorectal adenocarcinoma undergoing primary, curative intent CRS/HIPEC with CC0-1 resection were included. LR was defined as a formal parenchymal resection. Primary endpoints were postoperative complications and overall survival (OS).ResultsA total of 658 patients were included. About 83 (15%) underwent LR of colorectal (58%) or invasive appendiceal (42%) metastases. LR patients had more complications (81% vs. 60%; p = .001), greater number of complications (2.3 vs. 1.5; p < .001) per patient and required more reoperations (22% vs. 11%; p = .007) and readmissions (39% vs. 25%; p = .014) than non-LR patients. LR patients had decreased OS (2-year OS 62% vs. 79%, p < .001), even when accounting for peritoneal carcinomatosis index and histology type. Preoperative factors associated with decreased OS on multivariable analysis in LR patients included age < 60 years (HR, 3.61; 95% CI, 1.10-11.81), colorectal histology (HR, 3.84; 95% CI, 1.69-12.65), and multiple liver tumors (HR, 3.45; 95% CI, 1.21-9.85) (all p < .05). When assigning one point for each factor, there was an incremental decrease in 2-year survival as the risk score increased from 0 to 3 (0: 100%; 1: 91%; 2: 58%; 3: 0%).ConclusionsAs CRS/HIPEC + LR has become more common, we created a simple risk score to stratify patients considered for CRS/HIPEC + LR. These data aid in striking the balance between an increased perioperative complication profile with the potential for improvement in OS.

Livers from donation after circulatory death (DCD) donors are an increasingly more common source of organs for transplantation. While there are few high-level studies in the field of DCD liver transplantation, clinical practice has undergone progressive changes during the past decade, in particular due to mounting use of postmortem normothermic regional perfusion (NRP). In Spain, uncontrolled DCD has been performed since the late 1980s/early 1990s, while controlled DCD was implemented nationally in 2012. Since 2012, the rise in DCD liver transplant activity in Spain has been considerable, and the great majority of DCD livers transplanted in Spain today are recovered with NRP. A panel of the Spanish Liver Transplantation Society was convened in 2018 to evaluate current evidence and accumulated experience in DCD liver transplantation, in particular addressing issues related to DCD liver evaluation, acceptance criteria, and recovery as well as recipient selection and postoperative management. This panel has created a series of consensus statements for the standard of practice in Spain and has published these statements with the hope they might help guide other groups interested in implementing new forms of DCD liver transplantation and/or introducing NRP into their clinical practices.

Livers from donation after circulatory death (DCD) donors are an increasingly more common source of organs for transplantation. While there are few high-level studies in the field of DCD liver transplantation, clinical practice has undergone progressive changes during the past decade, in particular due to mounting use of postmortem normothermic regional perfusion (NRP). In Spain, uncontrolled DCD has been performed since the late 1980s/early 1990s, while controlled DCD was implemented nationally in 2012. Since 2012, the rise in DCD liver transplant activity in Spain has been considerable, and the great majority of DCD livers transplanted in Spain today are recovered with NRP. A panel of the Spanish Liver Transplantation Society was convened in 2018 to evaluate current evidence and accumulated experience in DCD liver transplantation, in particular addressing issues related to DCD liver evaluation, acceptance criteria, and recovery as well as recipient selection and postoperative management. This panel has created a series of consensus statements for the standard of practice in Spain and has published these statements with the hope they might help guide other groups interested in implementing new forms of DCD liver transplantation and/or introducing NRP into their clinical practices.

Livers from donation after circulatory death (DCD) donors are an increasingly more common source of organs for transplantation. While there are few high-level studies in the field of DCD liver transplantation, clinical practice has undergone progressive changes during the past decade, in particular due to mounting use of postmortem normothermic regional perfusion (NRP). In Spain, uncontrolled DCD has been performed since the late 1980s/early 1990s, while controlled DCD was implemented nationally in 2012. Since 2012, the rise in DCD liver transplant activity in Spain has been considerable, and the great majority of DCD livers transplanted in Spain today are recovered with NRP. A panel of the Spanish Liver Transplantation Society was convened in 2018 to evaluate current evidence and accumulated experience in DCD liver transplantation, in particular addressing issues related to DCD liver evaluation, acceptance criteria, and recovery as well as recipient selection and postoperative management. This panel has created a series of consensus statements for the standard of practice in Spain and has published these statements with the hope they might help guide other groups interested in implementing new forms of DCD liver transplantation and/or introducing NRP into their clinical practices.

Introduction The role of systemic chemotherapy (SC) in the management of metastatic appendiceal adenocarcinomas is not defined. Methods We perform an observational study of patients treated of peritoneal metastases from appendiceal neoplasm between June 2004 and December 2017. They were referred to our hospital for CRS HIPEC. Systemic Chemotherapy regimens were decided by the referring oncologist. We analyze PCI, CC, and use of SC. Overall survival and progression free survival were compared attending to histologic subtype (high- and low-grade adenocarcinomas) and the use of SC. Results 60 patients were included, 26 were male, median age 63 years (26-81). Median follow-up of 38 months [2-155]. The predominant histologic subtype was mucinous adenocarcinoma (58/60), 1 was colonic type, and 1 adenocarcinoid with signet ring cells. Four patients had extraperitoneal metastases, 2 hepatic metastases (1 with high-grade mucinous adenocarcinoma and 1 with colonic adenocarcinoma), and 2 in the low-grade group developed parenchymal lung disease. Three patients died in the postoperative period. Systemic chemotherapy was administered in 26 patients/57. No difference were observed in the OS and PFS regardless the use of SC in the high- and in the lo-grade groups. Conclusions The use of SC in low-grade mucinous adenocarcinoma subtype is not supported by our results, and there is no literature date supporting it neither. Palliative SC in high-grade patients deserves of clinical trials for been accepted as standard of care, when benefits are not clearly established by evidence and toxicities are not negligible., Introducción El papel de la quimioterapia sistémica (SC) en el tratamiento de los adenocarcinomas apendiculares metastásicos no está definido. Métodos Realizamos un estudio observacional de pacientes tratados con metástasis peritoneales de neoplasma apendicular entre junio de 2004 y diciembre de 2017. Fueron remitidos a nuestro hospital para HIPEC de CRS. Los regímenes de quimioterapia sistémica fueron decididos por el oncólogo referente. Analizamos PCI, CC, y uso de SC. La supervivencia global y la supervivencia libre de progresión se compararon atendiendo al subtipo histológico (adenocarcinomas de grado alto y bajo) y al uso de SC. Resultados Se incluyeron 60 pacientes, 26 eran hombres, mediana de edad 63 años (26-81). Mediana de seguimiento de 38 meses [2-155]. El subtipo histológico predominante fue el adenocarcinoma mucinoso (58/60), 1 fue de tipo colónico y 1 adenocarcinoide con células en anillo de sello. Cuatro pacientes tuvieron metástasis extraperitoneales, 2 metástasis hepáticas (1 con adenocarcinoma mucinoso de alto grado y 1 con adenocarcinoma de colon) y 2 en el grupo de bajo grado desarrollaron enfermedad pulmonar parenquimatosa. Tres pacientes fallecieron en el postoperatorio. Se administró quimioterapia sistémica en 26 pacientes / 57. No se observaron diferencias en el sistema operativo y PFS, independientemente del uso de SC en los grupos de grado alto y alto. Conclusiones El uso de SC en el subtipo de adenocarcinoma mucinoso de bajo grado no está respaldado por nuestros resultados, y no hay datos publicados que lo respalden. El SC paliativo en pacientes de alto grado merece los ensayos clínicos por haber sido aceptado como estándar de atención, cuando los beneficios no están claramente establecidos por la evidencia y las toxicidades no son despreciables.

BackgroundPatient selection for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is critically important to optimizing outcomes. There is currently no literature regarding the safety of CRS/HIPEC in patients with cirrhosis. The aim of this case series is to report the outcomes of three patients with well-compensated cirrhosis who underwent CRS/HIPEC.MethodsPatients were identified from a prospectively maintained peritoneal surface malignancy database. Patient, tumor, and operative-related details were recorded as short-term postoperative outcomes. Results were analyzed using descriptive statistics.ResultsAll patients had well-compensated (Child-Pugh Class A) cirrhosis and Eastern Cooperative Oncology Group (ECOG) performance status of 0. One patient had preoperative evidence of portal hypertension. All safely underwent CRS/HIPEC with completeness of cytoreduction (CC) scores of 0. The postoperative morbidity profile was unique, but all complications were manageable and resulted in full recovery to preoperative baseline status.ConclusionsPatient selection for CRS/HIPEC is critical for optimization of short- and long-term outcomes. This small series suggests that well-compensated cirrhosis should not be an absolute contraindication to CRS/HIPEC.

BackgroundPatient selection for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is critically important to optimizing outcomes. There is currently no literature regarding the safety of CRS/HIPEC in patients with cirrhosis. The aim of this case series is to report the outcomes of three patients with well-compensated cirrhosis who underwent CRS/HIPEC.MethodsPatients were identified from a prospectively maintained peritoneal surface malignancy database. Patient, tumor, and operative-related details were recorded as short-term postoperative outcomes. Results were analyzed using descriptive statistics.ResultsAll patients had well-compensated (Child-Pugh Class A) cirrhosis and Eastern Cooperative Oncology Group (ECOG) performance status of 0. One patient had preoperative evidence of portal hypertension. All safely underwent CRS/HIPEC with completeness of cytoreduction (CC) scores of 0. The postoperative morbidity profile was unique, but all complications were manageable and resulted in full recovery to preoperative baseline status.ConclusionsPatient selection for CRS/HIPEC is critical for optimization of short- and long-term outcomes. This small series suggests that well-compensated cirrhosis should not be an absolute contraindication to CRS/HIPEC.

BackgroundCytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has an emerging role in the treatment of peritoneal malignancies. The CRS-HIPEC approach has known treatment-related toxicities. This study sought to determine the predictors of major postoperative complications after CRS-HIPEC in a high-volume center.MethodsFrom a single-institution database, this study investigated complications experienced by patients undergoing CRS-HIPEC. Multiple preoperative and operative factors were analyzed for their ability to predict 60-day Clavien grade 3 and greater (major) complications by logistic regression. A predictive model was created from preoperative factors using multivariate logistic regression. The model was tested by Akaike's information criterion, the Hosmer and Lemeshow Goodness-of-Fit Test, the receiver operating characteristic, and the Youden Index.ResultsThe study evaluated 247 patients undergoing CRS-HIPEC. The primary tumor site was the appendix in 166 cases (67.2 %), the colorectal area in 51 cases (20.6 %), the peritoneum (mesothelioma) in 22 cases (8.9 %), the ovary in 5 cases (2 %), and the small bowel in 3 cases (1.2 %). The median peritoneal cancer index was 14 (range 0-29), and 235 patients (95.1 %) had a complete (CC-0/1) cytoreduction. Major complications occurred for 41 patients (16.6 %), classified as grade 3 in 33 cases (13.4 %), grade 4 in 5 cases (2 %), and grade 5 (deaths) in 3 cases (1.2 %). The factors predictive of major complications in the multivariate analysis were a Charlson Comorbidity Index (CCI) score higher than 0 [odds ratio (OR), 2.505; p = 0.035], presence of preoperative symptoms (OR 1.951; p = 0.064), and prior resection status [no resection or prior CRS-HIPEC (OR 2.087) vs. prior resection without CRS-HIPEC (OR 3.209); p = 0.046]. These variables were used to create a tool predictive of postoperative complications.ConclusionPresence of symptoms, CCI, a

ImportanceHyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery have been shown to benefit selected patients with peritoneal carcinomatosis. However, these procedures are associated with high morbidity and mortality. Available data investigating the outcomes of HIPEC are mostly limited to single-center studies. To date, there have been few large-scale studies investigating the postoperative outcomes of HIPEC.ObjectiveTo determine the associated 30-day morbidity and mortality of cytoreductive surgery-HIPEC in the treatment of metastatic and primary peritoneal cancer in American College of Surgeons National Surgical Quality Improvement Program centers.Design, setting, and participantsA retrospective review of HIPEC cases performed for primary and metastatic peritoneal cancer diagnoses was conducted. The cytoreductive surgical procedures were sampled, and disease processes were identified. Patient demographics, intraoperative occurrences, and postoperative complications were reviewed from the American College of Surgeons National Surgical Quality Improvement Program from 2005-2011.Main outcomes and measuresThirty-day mortality and morbidity.ResultsOf the cancers identified among the 694 sampled cases, 14% of patients had appendiceal cancer, 11% had primary peritoneal cancer, and 8% had colorectal cancer. The American Society of Anesthesiologists classification was 3 for 70% of patients. The average operative time was 7.6 hours, with 15% of patients requiring intraoperative transfusions. Postoperative bleeding (17%), septic shock (16%), pulmonary complications (15%), and organ-space infections (9%) were the most prevalent postoperative complications. The average length of stay was 13 days, with a 30-day readmission rate of 11%. The rate of reoperation was 10%, with an overall mortality rate of 2%.Conclusions and relevanceAmerican College of Surgeons National Surgical Quality Improvement Program hospitals performing HIPEC have acceptable rates of mo

ImportanceHyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery have been shown to benefit selected patients with peritoneal carcinomatosis. However, these procedures are associated with high morbidity and mortality. Available data investigating the outcomes of HIPEC are mostly limited to single-center studies. To date, there have been few large-scale studies investigating the postoperative outcomes of HIPEC.ObjectiveTo determine the associated 30-day morbidity and mortality of cytoreductive surgery-HIPEC in the treatment of metastatic and primary peritoneal cancer in American College of Surgeons National Surgical Quality Improvement Program centers.Design, setting, and participantsA retrospective review of HIPEC cases performed for primary and metastatic peritoneal cancer diagnoses was conducted. The cytoreductive surgical procedures were sampled, and disease processes were identified. Patient demographics, intraoperative occurrences, and postoperative complications were reviewed from the American College of Surgeons National Surgical Quality Improvement Program from 2005-2011.Main outcomes and measuresThirty-day mortality and morbidity.ResultsOf the cancers identified among the 694 sampled cases, 14% of patients had appendiceal cancer, 11% had primary peritoneal cancer, and 8% had colorectal cancer. The American Society of Anesthesiologists classification was 3 for 70% of patients. The average operative time was 7.6 hours, with 15% of patients requiring intraoperative transfusions. Postoperative bleeding (17%), septic shock (16%), pulmonary complications (15%), and organ-space infections (9%) were the most prevalent postoperative complications. The average length of stay was 13 days, with a 30-day readmission rate of 11%. The rate of reoperation was 10%, with an overall mortality rate of 2%.Conclusions and relevanceAmerican College of Surgeons National Surgical Quality Improvement Program hospitals performing HIPEC have acceptable rates of mo

Purpose: Isolated limb perfusion (ILP) with hyperthermia is an effective treatment for in-transit metastases of malignant melanoma in the extremities. Preclinical studies have shown that hyperthermia may induce an immunogenic death of tumour cells. We therefore decided to study whether ILP may induce tumour-specific immune responses in the clinical setting. Method: The number of Melan-A/Mart-1 specific CD8+ T cells, as well as other phenotypically different immune cells, was recorded in peripheral blood in 12 HLA-A2+ patients with in-transit metastases undergoing hyperthermic ILP with melphalan. Results: All patients underwent ILP without any complication and with an overall response rate of 83%. No substantial changes in the number of circulating T-cells, B-cells, NK-cells or monocytes were observed during follow-up. Four out of 12 patients showed an elevation of Melan-A+ CD8+ T-cells 4 weeks after ILP. Conclusion: We here report our preliminary observations that a small increase in tumour-specific T-cells could be seen in a subpopulation of patients after ILP. However, much more work is necessary to fully delineate the systemic immune response to hyperthermic ILP.

[No abstract available]