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Background Cytoreductive surgery (CRS) for the management of peritoneal carcinomatosis (PC) can involve significant blood loss which necessitates the transfusion of blood products. This poses a particular challenge in the Jehovah's Witnesses population whose beliefs do not permit the transfusion of blood products or blood-related derivatives. This report describes the experience of one institution performing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC) for PC in Jehovah's Witnesses and perioperative management strategies employed to avoid blood transfusion. Methods A review of literature and prospectively collated data of Jehovah's Witnesses patients who underwent extensive CRS for PC and HIPEC for PC. Results Four patients had CRS and HIPEC for PC. The median PC index score was 11 and complete cytoreduction was achieved in all cases. Primary tumours were ovarian (n = 1), colorectal (n = 2) and neuroendocrine tumour of gastrointestinal origin (n = 1). The median difference between preoperative and postoperative haemoglobin was 38 g/L (23-43 g/L). Strategies included acute normovolumaeic haemodilution and autotransfusion within a closed circuit, autotransfusion from cell salvage and provisions for possible use of a haemoglobin based oxygen carrier. Ancillary measures identified and implemented to minimize transfusion dependence included, but were not limited to, preoperative iron infusion, perioperative acute haemodilution and cell salvage, administration of tranexamic acid, prothrombinex and use of paediatric tubes for venepuncture. Conclusion The review suggests CRS and HIPEC for extensive PC can be done safely in circumstances where transfusion of allogenic blood products is not permitted.

Peritoneal metastasis (PM) following primary resection of colorectal cancer is common. The combined use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy has significantly improved the survival outcome of patients with colorectal PM (CRPM). Diagnosing and treating early PM is essential as its extent is correlated with poorer outcomes. There are two novel therapies - second-look surgery and synchronous hyperthermic intraperitoneal chemotherapy - that are proposed to prophylactically treat or intervene early in the disease process to reduce the incidence and adverse outcomes associated with PM. These strategies are limited to patients at high risk of developing CRPM, including those that had synchronous PM or ovarian metastases resected at primary tumour removal, or a perforated primary tumour. The data on advanced primary tumour (T4) as a prognostic factor for PM after primary resection suggest that T4a tumours are prognostically worse than T4b. This literature review outlines the evidence, feasibility and safety regarding the pre-emptive treatments, as well as the relevance of T4a tumours as a risk factor for metachronous CRPM.

Background Combined cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) has been considered as a standard approach for peritoneal surface malignancy. This study aims to assess the learning curve of this combined approach. Methods Prospectively collected data of our first 800 consecutive patients treated by CRS and PIC between January 1996 and July 2014 were retrospectively reviewed. Eight hundred patients were divided into two groups and eight groups for comparison. A significant difference was defined as P < 0.05. Results A significant increase in the rate of the completeness of cytoreduction (CC) score-0 from 74.0% to 83.0% was seen with a reduction in rates of other CC scores. Also, there was a decreasing trend in mean blood transfusion units. The rate of viscus perforation, fistula formation and small bowel obstruction was significantly lower in the recent 400 patients. However, there was a significant increase in the incidence of deep venous thrombosis and pulmonary embolism. There was an improvement in the 5-year survival rate for patients with colorectal cancer, pseudomyxoma peritonei and mesothelioma. Conclusion Our findings demonstrate a learning curve associated with the combined approach of CRS and PIC. With adequate experience, CRS and PIC can be safely performed with acceptable mortality and morbidity.

Background Treatment of peritoneal metastases (PM) and liver metastases (LM) from colon cancer remains controversial. LM has been viewed as exclusion criterion for cytoreductive surgery (CRS) on the basis that such spread represents systemic disease. CRS and intraperitoneal chemotherapy (IPC) has gained increasing recognition as a treatment modality for selected patients with colon cancer and PM. This study analyses results of CRS and IPC for colon cancer and synchronous resection for treatment of LM and PM. Methods Seventy-eight patients with PM/LM colon cancer were analysed. Forty-two patients with PM were treated for disease limited to the peritoneum (A), and 36 patients received treatment for both PM and LM (B). Overall survival (OS), disease-free survival (DFS), morbidity, mortality and recurrence were compared. Results Median OS and DFS was 32.8 and 13.5 months. The median OS for A and B were 45.5 and 24.4 months respectively. Within B patients, 18 had a peritoneal carcinomatosis index (PCI) >7 and >3 LM and median survival of 21.8 months compared with 18 patients with PCI ≤7 and LM ≤3 with median survival of 38.4 months. Median DFS for A and B were 17.7 and 8.5 months respectively. Twenty-seven in total experienced major complications following surgery. Sixty-one patients recurred. Of A, 71.4% recurred compared with B at 86.1%. Conclusion While our study is limited, it has demonstrated encouraging evidence that long-term survival outcomes can be achieved in this small but significant number of patients treated by CRS/IPC and additional synchronous liver resection with no significant increase in morbidity when compared with CRS/IPC alone.

Background Peritoneal carcinomatosis (PC) results from the secondary spread of many intraabdominal tumour types, such as colorectal malignancy (colorectal cancer, CRC), disseminated peritoneal adenomucinosis (DPAM), appendiceal cancer, ovarian carcinoma, sarcoma or from the occurrence of primary peritoneal disease such as peritoneal mesothelioma. The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has seen improvements in survival in selected cases of these cancers. Methods Between 1996 and 2014, a prospective database of 675 patients was created for the peritonectomy unit at our hospital. In total, 827 peritonectomy procedures (including redo CRS) were performed for the major subgroups of PC: DPAM 220; appendiceal cancer (peritoneal mucinous adenocarcinoma (PMCA)) 191; CRC 234; diffuse malignant peritoneal mesothelioma (DMPM) 73 and others 109. There were 152 redo-peritonectomy procedures within the total mentioned earlier (CRC 26; DPAM 58; DMPM 18; appendix 40; other 10). Results The 5-year survivals for DPAM and PMCA were 80% and 42% respectively. The 5-year survivals for appendiceal cancer with peritoneal cancer index (PCI) 20 were 60, 57 and 37% respectively (P = 0.09). The 2- and 5-year survivals for CRC were 56 and 24% respectively. The 5-year survivals for PCI 0–5, 6–10, 11–15 and >15 were 59, 15, 7 and 0% respectively (P = 0.000). The 5-year survival for DMPM with PCI 20 were 100, 55 and 39% respectively (P = 0.01). Conclusion CRS in combination with HIPEC provides a chance of long-term survival in selected cases of PC when compared with systemic therapy alone.

Peritoneal metastasis (PM) following primary resection of colorectal cancer is common. The combined use of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy has significantly improved the survival outcome of patients with colorectal PM (CRPM). Diagnosing and treating early PM is essential as its extent is correlated with poorer outcomes. There are two novel therapies - second-look surgery and synchronous hyperthermic intraperitoneal chemotherapy - that are proposed to prophylactically treat or intervene early in the disease process to reduce the incidence and adverse outcomes associated with PM. These strategies are limited to patients at high risk of developing CRPM, including those that had synchronous PM or ovarian metastases resected at primary tumour removal, or a perforated primary tumour. The data on advanced primary tumour (T4) as a prognostic factor for PM after primary resection suggest that T4a tumours are prognostically worse than T4b. This literature review outlines the evidence, feasibility and safety regarding the pre-emptive treatments, as well as the relevance of T4a tumours as a risk factor for metachronous CRPM.

There is now a considerable body of published evidence supporting the use of a multimodal approach consisting of cytoreductive surgery (CS) and heated intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal metastases (PM) arising from selected gastrointestinal tract malignancies. In the absence of systemic metastases, it is thought that disease confined to the peritoneum may be eradicated through optimum cytoreduction. This review critically evaluates the current body of published evidence for the use of CS/HIPEC in the treatment of advanced colorectal, appendiceal and gastric cancer. Although its role remains less defined in patients with gastric PM, current evidence provides a compelling argument for its use in PM of colorectal and appendiceal origin. With a low mortality and acceptable morbidity rate, CS/HIPEC may offer hope of long-term survival and cure in a defined group of patients with this disease.

Background: Nephron-sparing surgery has become an acceptable alternative to radical nephrectomy in the treatment of renal tumours. Control of intraoperative blood loss can be an important challenge during partial nephrectomy. InLine radiofrequency ablation (ILRFA) device has shown promising results of significant reduction of intraoperative blood loss in liver resection. In this study, we tested ILRFA-assisted partial nephrectomy in a porcine model. Methods: Eight landrace pigs were used in this study. Every pig underwent 2–3 partial nephrectomies. The proposed line of parenchymal incision was circumferentially scored with a diathermy. Then, ILRFA was deployed into this resection plane. After complete coagulation, the resection was then simply carried out using the scalpel. For the control resection, we used diathermy to transect the other pole, further sutures were then used to secure the residual bleeding. Results: The ILRFA deployments were set to 3 cm power algorithm. The average radiofrequency ablation coagulation time was 5 min. The mean intraoperative blood loss 35 ± 7 mL in the ILRFA and 152 ± 94 mL in the control, a 77.0% reduction (P = 0.024). The mean blood loss per centimetre of resection area was 2.09 ± 1.41 mL/cm2 in the ILRFA compared with 12.79 ± 1.68 mL/cm2 in controls; the reduction was 79.0% (P = 0.019). Conclusion: Our study indicates that ILRFA for partial nephrectomy in a porcine model is effective in reducing blood loss. Precoagulation before parenchymal transection appears to be a valid concept in nephron-sparing surgery.

Background: Renal injury accounts for 10% of all abdominal trauma. Low-grade renal injuries can be managed without surgery. However, patients with grade IV or grade V injuries may require nephrectomy. In this study, InLine radiofrequency ablation device (ILRFA), which we developed for liver surgery was tested in the animal model of simulated renal injury. Methods: A grade IV renal injury was induced in eight landrace pigs. Then treatment with ILRFA was compared to conventional diathermy and suture; totally 24 surgeries were carried out (12 ILRFA vs 12 control). Results: No massive bleeding occurred and no animal died during the experiments. Immediately after surgery, the pigs were given euthanasia. The average of RFA coagulation time was 3.5 min. The mean intraoperative blood loss was 42 ± 16 mL in the ILRFA and 195 ± 58 mL in the control, a 78.5% reduction (P

Background: In liver surgery, the increase in advancement of laparoscopic equipment has allowed the feasibility and safety of complex laparoscopic liver resection. However, blood loss and the potential risk of gas embolism seem to be the main obstacles. In this study, we successfully used the InLine radiofrquency ablation (RFA) device to carry out laparoscopic hand-assisted liver resection in pigs. Methods: Under general anaesthesia with tracheal intubation, pigs underwent InLine RFA-assisted laparoscopic liver resection. After installation of Hand Port and trocars, the InLine RFA device was introduced through Hand Port system and inserted into the premarked resection line. Then the generator was turned on and the power was applied according to the power setting. The resection was finally carried out using diathermy or stapler. For the control group, resection was simply carried out by diathermy or stapler. Results: Eight Landrace pigs underwent 23 liver resections. Blood loss was reduced significantly in the InLine group (P

Combined cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) has been considered as a standard approach for peritoneal surface malignancy. This study aims to assess the learning curve of this combined approach.Prospectively collected data of our first 800 consecutive patients treated by CRS and PIC between January 1996 and July 2014 were retrospectively reviewed. Eight hundred patients were divided into two groups and eight groups for comparison. A significant difference was defined as P0.05.A significant increase in the rate of the completeness of cytoreduction (CC) score-0 from 74.0% to 83.0% was seen with a reduction in rates of other CC scores. Also, there was a decreasing trend in mean blood transfusion units. The rate of viscus perforation, fistula formation and small bowel obstruction was significantly lower in the recent 400 patients. However, there was a significant increase in the incidence of deep venous thrombosis and pulmonary embolism. There was an improvement in the 5-year survival rate for patients with colorectal cancer, pseudomyxoma peritonei and mesothelioma.Our findings demonstrate a learning curve associated with the combined approach of CRS and PIC. With adequate experience, CRS and PIC can be safely performed with acceptable mortality and morbidity.

Treatment of peritoneal metastases (PM) and liver metastases (LM) from colon cancer remains controversial. LM has been viewed as exclusion criterion for cytoreductive surgery (CRS) on the basis that such spread represents systemic disease. CRS and intraperitoneal chemotherapy (IPC) has gained increasing recognition as a treatment modality for selected patients with colon cancer and PM. This study analyses results of CRS and IPC for colon cancer and synchronous resection for treatment of LM and PM.Seventy-eight patients with PM/LM colon cancer were analysed. Forty-two patients with PM were treated for disease limited to the peritoneum (A), and 36 patients received treatment for both PM and LM (B). Overall survival (OS), disease-free survival (DFS), morbidity, mortality and recurrence were compared.Median OS and DFS was 32.8 and 13.5 months. The median OS for A and B were 45.5 and 24.4 months respectively. Within B patients, 18 had a peritoneal carcinomatosis index (PCI)7 and3 LM and median survival of 21.8 months compared with 18 patients with PCI ≤7 and LM ≤3 with median survival of 38.4 months. Median DFS for A and B were 17.7 and 8.5 months respectively. Twenty-seven in total experienced major complications following surgery. Sixty-one patients recurred. Of A, 71.4% recurred compared with B at 86.1%.While our study is limited, it has demonstrated encouraging evidence that long-term survival outcomes can be achieved in this small but significant number of patients treated by CRS/IPC and additional synchronous liver resection with no significant increase in morbidity when compared with CRS/IPC alone.

Peritoneal carcinomatosis (PC) results from the secondary spread of many intraabdominal tumour types, such as colorectal malignancy (colorectal cancer, CRC), disseminated peritoneal adenomucinosis (DPAM), appendiceal cancer, ovarian carcinoma, sarcoma or from the occurrence of primary peritoneal disease such as peritoneal mesothelioma. The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has seen improvements in survival in selected cases of these cancers.Between 1996 and 2014, a prospective database of 675 patients was created for the peritonectomy unit at our hospital. In total, 827 peritonectomy procedures (including redo CRS) were performed for the major subgroups of PC: DPAM 220; appendiceal cancer (peritoneal mucinous adenocarcinoma (PMCA)) 191; CRC 234; diffuse malignant peritoneal mesothelioma (DMPM) 73 and others 109. There were 152 redo-peritonectomy procedures within the total mentioned earlier (CRC 26; DPAM 58; DMPM 18; appendix 40; other 10).The 5-year survivals for DPAM and PMCA were 80% and 42% respectively. The 5-year survivals for appendiceal cancer with peritoneal cancer index (PCI)10, 10-20 and20 were 60, 57 and 37% respectively (P = 0.09). The 2- and 5-year survivals for CRC were 56 and 24% respectively. The 5-year survivals for PCI 0-5, 6-10, 11-15 and15 were 59, 15, 7 and 0% respectively (P = 0.000). The 5-year survival for DMPM with PCI10, 10-20 and20 were 100, 55 and 39% respectively (P = 0.01).CRS in combination with HIPEC provides a chance of long-term survival in selected cases of PC when compared with systemic therapy alone.

Background: This study aims to assess the survival of patients who underwent peritonectomy, to assess the morbidity and mortality associated with the procedure and to review the published reports on the survival of patients with peritoneal spread of colorectal cancer (CRC). Methods: Peritonectomy involves resection of all visible peritoneal tumour and is followed by heated intraperitoneal chemotherapy. Peritonectomy with heated intraperitoneal chemotherapy is associated with a 3-year survival of 30–50% in patients with low peritoneal cancer index (PCI) with peritoneal carcinomatosis from CRC. There are approximately 1000 patients in phase 2 studies and a large survival advantage was shown in a randomized control trial. We have carried out over 100 peritonectomy procedures. This study describes 22 patients with peritoneal spread of gastrointestinal cancer treated with peritonectomy between 1996 and March 2005. Twenty of these patients had primary colorectal cancer and two patients had primary small bowel cancer. Results: Of the 22 patients who underwent peritonectomy, 8 patients are now deceased. The median follow up is now 16.1 months. At 12 months, the survival was 61.5% and at 24 months the survival was 46.1%, which are creditable results comparable with the world published reports. We found that those patients with all macroscopic residual tumour removed at the end of the procedure (completeness of cancer resection, CCR O) had improved 24-month survival compared with patients in whom there was incomplete tumour resection (53.3% survival vs 22.2%, respectively, P = 0.024). Patients with a PCI score less than 13 had better survival (P = 0.0003). Conclusions: Peritonectomy for peritoneal carcinomatosis from CRC offers patients improved survival. Our results are consistent with the published data with respect to improved survival in patients with low PCI and complete cytoreduction.

Background: 1α,25-dihydroxyvitamin D3 (1,25[OH]2D3) has been shown to inhibit the proliferation of various cancer cells including colon, prostate, melanoma, osteosarcoma and breast cancer. Methods: The human hepatoma cell line (HepG2) was cultured with 1,25(OH)2D3 or one of two analogues EB1089 or CB1093 for various durations. Cellular proliferation was measured by uptake of [3H]thymidine, and cell numbers were determined by trypan blue exclusion counting. Results: 1,25(OH)2D3, EB1089 and CB1093 all inhibited proliferation of HepG2 by up to 90% after 5 days of treatment, compared to the untreated controls. Decreased proliferation was associated with an approximately 50% reduction in cell numbers at concentrations of up to 10–10 mol/L after 5 days of treatment with 1,25(OH)2D3. Cell proliferation rapidly recovered in cultures treated with lower concentrations of 1,25(OH)2D3 (10–10 and 10–11 mol/L) when 1,25(OH)2D3 was removed from the cultures by placing cells in serum containing medium without 1,25(OH)2D3. When HepG2 cells were treated with 10–8 mol/L 1,25(OH)2D3 for 5 weeks, there was still significant inhibition of proliferation, although at week 5 there was 66% inhibition compared to 93% at the end of week 1. Conclusions: 1,25(OH)2D3, EB1089 and CB1093 all significantly inhibit the proliferation of HepG2 hepatoblastoma cells, with EB1089 being the most potent at lower concentrations. Inhibition can be maintained for at least 4 weeks, but is reversed after removal of vitamin D3.

BACKGROUND: An involved or inadequate (< 1 cm) resection margin is associated with a high rate of local tumour recurrence and reduced survival rates after liver resection for colorectal metastases. This paper assesses whether or not hepatic cryotherapy of the resection edge is suitable to improve local disease control. METHODS: From April 1990 to May 1997, we performed cryotherapy of the resection edge in 44 patients after liver resection for colo rectal liver metastases with an involved or inadequate resection margin. The reasons for performing edge cryotherapy instead of extension of resection were: proximity of hepatic veins or portal sheath (n = 12); avoidance of extended left or right hemihepatectomy (n = 15); inadequate liver tissue reserve after resection (n = 16); and patient unfit to undergo further major resection (n = 1). Histological examination showed the resection margin to be involved in 24 patients and close (< 1 cm) in 20 patients. RESULTS: Two patients died after surgery. Morbidity consisted of intra-abdominal collections (n = 6), postoperative bleeding (n = 1), wound infection (n = 1) and transient liver failure (n = 1). At a median follow-up of 19 months, 16 patients are alive and disease-free, 26 patients developed recurrence and 15 of them died. Nineteen patients developed recurrence which involved the liver but only five of these were at the resection edge. Median overall and liver disease-free survival was 33 and 23 months, respectively. CONCLUSIONS: Cryotherapy of the resection edge after resection of colorectal liver metastases with involved or inadequate resection margins considerably improves local disease control and may allow a greater proportion of patients with liver metastases to undergo potentially curative treatment.

Background: The present study reviews the nature of upper gastrointestinal complications of hepatic arterial chemoperfusion at a tertiary referral centre for the treatment of hepatic malignancy. Methods: The patients involved in the present study all had major upper gastrointestinal (GI) haemorrhage and were undergoing hepatic arterial chemoperfusion. Results: Eight patients had major upper GI haemorrhage. Three of these patients were not referred for surgical management, and all three patients died. The five patients who were admitted or transferred to our unit and who underwent surgery all survived. Conclusions: These complications are probably caused by extravasation of 5-fluorouracil (5-FU) following thrombosis of the gastroduodenal artery. The resulting cavity may perforate into the hepatic artery, portal vein, duodenum or biliary tree. Surgeons and oncologists should be aware of these complications. If upper abdominal pain occurs, chemoperfusion should cease immediately and an urgent investigation, which may include catheter angiography, gastroscopy and computed tomography (CT) scanning. should be carried out to exclude an hepatic artery pseudo-aneurysm.

Pancreatitis is a well recognised but rare complication following liver resection. The precise aetiology is not well understood and the clinical diagnosis may frequently be obscured by the postoperative state. Postoperative pancreatitis has a high mortality rate and should always be considered in patients who unexpectantly deteriorate postoperatively. We present three fatal cases of pancreatitis following liver resection. The literature is reviewed to elucidate common factors in patients who develop postoperative pancreatitis.

Fifty per cent of patients with colorectal cancer develop hepatic metastases but only a minority are candidates for potentially curative surgical resection. Hepatic artery chemotherapy (HAC) has been used to treat patients with non-resectable metastases confined to the liver. Although response rates to HAC have been shown to be higher than response rates to systemic chemotherapy, the advantage in terms of survival has been debated. Furthermore, HAC requires surgical catheter placement which adds to the cost and morbidity of treatment. There have now been eight prospective randomized trials of HAC vs intravenous chemotherapy and/or supportive therapy. The present paper analyses the results of these trials with particular reference to survival. Surgical morbidity, treatment-related toxicity and cost are also discussed.

Fifty consecutive patients undergoing resection of colorectal cancer were randomized to either receive cimetidine at a dose of 400 mg bd for a minimum of 5 pre-operative days, then intravenously for 2 postoperative days, or to act as controls. Baseline immune function was determined in all patients by in vitro testing of lymphocyte proliferation (LP) in response to mitogen, skin testing for cell mediated immunity (CMI) and measurement of lymphocyte subsets. Immune function was retested in both groups on the second postoperative day. In control patients the mean postoperative LP value was 41% of pre-operative levels (P < 0.0001) and the mean CMI reduced to 29% (P < 0.0001). Patients treated with cimetidine had no significant fall in these parameters. Numbers of T and natural killer (NK) cells fell after surgery in both groups, and B cell numbers were maintained in the cimetidine group. It is concluded that cimetidine reduces the immunosuppression that follows colonic resection.

A synthetic prostaglandin E1 (PGE1) analogue, misoprostol, was investigated for its effects on the growth of colon cancer in two in vivo models. Human colon cancer cell lines C170, LIM2412 and LIM2405 were grown as subcutaneous xenografts on T-lymphocyte deficient ARC(s) nu/nu mice. Tumour volumes were found to be significantly inhibited compared with control in misoprostol-treated animals with two cell lines. C170 was inhibited by 70.5% (P = 0.0001) and LIM2412 by 68.2% (P = 0.01). LIM2405 was inhibited by 33% (P = 0.14) which was not significantly different from the control. In a second experiment, colon cancers were induced in Sprague-Dawley rats using 1,2 dimethyl-hydrazine (DMH). After 10 weeks of treatment, rats were randomized to receive a 5 week course of 20 micrograms/kg per day of oral misoprostol. Misoprostol-treated rats were found to have a similar tumour incidence and staging compared with control animals. Oral administration of misoprostol has an inhibitory effect on early tumour growth of some colonic cancers, but not on established tumours.

Five approaches to postal faecal occult blood test (FOBT) were compared in a population sample of 966 subjects collected from three general practitioner patient lists in Southern Sydney. The highest compliance rate (59.8%) was achieved by a method using a general practitioner letter, with no dietary restrictions with FOBT. This was also the least expensive method. Compliance rates can be affected by incorrect address information and screenees not considering themselves to be current patients. An explanation from the family doctor addressed personally to the patient with an enclosed FOBT kit can achieve high compliance rates.

Background: Preoperative scanning for hepatic colorectal metastases surgery remains a challenge, especially in the age of preoperative chemotherapy, which has marked biochemical and physical effects on the liver. Integrated fluoro-deoxyglucose positron emission tomography and computed tomography (FDG-PET/CT) has applications for detecting extrahepatic disease. The aim of the present study was to investigate FDG-PET/CT as a preoperative planning tool for detecting liver lesions in patients with and without preoperative chemotherapy. Methods: Patients who had resection of hepatic colorectal metastases between January 2004 and June 2006 were included. Patients were divided into those who received preoperative chemotherapy and those who did not. Malignant hepatic lesions found on each scan were compared with those found on histopathology, intraoperative examination and/or intraoperative ultrasound. Accurate scans (scan lesions corresponded to true lesions), false positives (scan lesions detected at least one non-lesion) and false negatives (scan lesions missed at least one true lesions) were recorded. Results were also compared on a per lesion basis. Results: A total of 21 patients had preoperative FDG-PET/CT scans with preoperative chemotherapy and 53 without. Accurate tests were six (29%) for the chemotherapy group versus 28 (53%) for the non-chemotherapy group (P= 0.06). Notably, there were 11 (52%) underestimations in the chemotherapy group versus 18 (34%) in the non-chemotherapy group. A total of 1.7 lesions were missed per patient in the chemotherapy group versus 0.7 in those who did not receive chemotherapy. Conclusion: Preoperative assessment with FDG-PET/CT is not useful for hepatic colorectal metastases, particularly when preoperative chemotherapy is used, with a trend towards underestimation of lesions.

Background: Hepatic artery chemotherapy (HAC) and cryoablation are treatments for unresectable liver metastases from colorectal carcinomas. Our centre has previously published data that describe survival statistics of patients after each of these treatments. It has also been established that serial serum carcinoembryonic antigen (CEA) concentrations may be used to monitor disease progress, and that the magnitude of fall is prognostic for both treatments. The pattern of fall of CEA following cryotherapy and regional chemotherapy has not previously been compared. Methods: In this study, we examined 26 HAC patients and 24 cryotherapy patients. Results: The mean percentage of the pre-treatment CEA concentration for the HAC group was 60.5% at 50 days and 29.4% at 150 days, and for the cryotherapy group 24.9% at 50 days and 24.3% at 150 days. Calculating the difference between means revealed a significantly different mean fall in the cryotherapy group at 50 days (P 0.1) which was not significant. In patients who responded to hepatic artery chemotherapy, the eventual CEA fall was very similar in magnitude. Conclusions: The pattern of fall of CEA differs in these two treatments.

Background: Peritoneal dissemination of malignancy is usually considered incurable. The purpose of the present study was to evaluate the efficacy of intraperitoneal chemohyperthermia and cytoreductive surgery. Methods: The present article is a retrospective review of prospectively recorded data in 60 patients who underwent 71 peritonectomy procedures between January 1996 and May 2004. Hospital records, a database and department notes were studied. Conditions treated were pseudomyxoma peritoneii (PMP) and appendiceal cancer (23), mesothelioma (7), colorectal cancer (CRC, 15), ovarian cancer (6) and other forms of malignancy (9). Following cytoreductive surgery, early postoperative intraperitoneal chemotherapy (EPIC) was given in 47 procedures, five with added i.v. mitomycin C. In 34 procedures, heated intraperitoneal chemotherapy (HIPEC) was administered. A policy change was made from intravenous to intraperitoneal mitomycin C chemotherapy in December 2001. Peritoneal cancer index (PCI) was calculated for all procedures. Results: Of the procedures, 23 had PCI ≤ 10, 37 had PCI of 11–20, and 11 had PCI > 20. The median operation time was 9 h. Blood units transfused and length of hospital stay have declined. Mortality was 4/60 patients (6.7%), caused by pancytopenia and sepsis. Morbidity occurred in 28/71 procedures. The 3-year survival rate for the HIPEC group was 71% compared with 28% for the no HIPEC group. In the complete excision group, the 3-year survival rate was 52% compared with 13% for the incomplete excision group. The 3-year survival rate for PMP and appendiceal cancer was 74%. The 2-year survival rate for ovarian cancer was 67%, mesothelioma 57%, and CRC 50%, respectively. Conclusions: Morbidity is significantly associated with duration of surgery and units of blood transfused. Our findings are consistent with the international experience in patients treated with combined peritonectomy and HIPEC.

Background: Whilst gastrin has been found to be trophic for some colorectal cancer cell lines, and gastrin receptor antagonists are able to block this phenomenon, their potency has been modest. Methods: The effect of a new, potent and selective CCK B receptor antagonist, CI-988 on the growth of LoVo, a human colon cancer cell line both in virro and in vivo was investigated. Results: Basal growth of LoVo in vitro was inhibited by up to 58.93 ± 7.30% with concentrations of CI-988 as low as 1 × 10--11 mol/L whereas the addition of gastrin (G17) at 0.5 nmol/L had no effect. LoVo was also grown in vivo for 10 days in nude mice subsequently treated with CI-988 at 10 mg/kg per day orally for 20 days. CI-988 inhibited the growth of xenografts by 53%. Conclusion: This was the first study in cancer with this potent gastrin receptor antagonist, (21–988. The results suggest that CI-988 may be of use in inhibiting the growth of colorectal cancer.

Introduction: Liver resection is widely used in the treatment of primary and secondary liver tumours. One of several important factors associated with mortality both in cirrhotic and non-cirrhotic patients after liver resection is operative blood loss. We evaluated the use of a prototype radiofrequency ablation probe to treat the transection plane prior to liver resection in the sheep model. Methods: In-line radiofrequency ablation (RFA) was performed on the liver using a prototype device consisting of 11 electrodes mounted on a 8-cm base. The RITA 1500 generator was used for power delivery. Ultrasonic aspirator (UA) and clamp resection were performed on the liver of sheep with and without in-line RFA. The blood loss was measured by weighing swabs. Results: A total of 26 liver resections were performed. The mean (SD) blood loss with UA resection was 0.032 g (0.011) versus 0.005 (0.005) g without and with prior in-line RFA, respectively (P = 0.001). The mean (SD) blood loss with clamp resection was 0.087 (0.10) g versus 0.01 (0.008) without and with in-line RFA, respectively (P = 0.155). Conclusion: In-line RFA makes liver resection easier with minimal blood loss and may make cirrhotic liver resection easier with minimal blood loss. This is likely to improve the operative safety of liver resection.

Serum carcinoembryonic antigen (CEA) levels in 33 Australian patients with hepatic metastases from colorectal cancer were measured before and after treatment with hepatic cryotherapy and intra-arterial chemotherapy. Pre-operative and monthly postoperative CEA measurements were made and the lowest postoperative reading was recorded as a percentage fall from the pre-operative level. There was a highly significant association between the maximum percentage fall in CEA and survival. A 50% increase in the maximum percentage fall in CEA level was associated with one-tenth the risk of death (95% CI RR 0.03 to 0.32, Cox regression). It is estimated that an increase in the maximum percentage fall in CEA of 50% from 25 to 75% was associated with an increase in the median survival from 240 days to over 2 years.

Purpose The study reported our experience with first 100 consecutive patients who underwent radiofrequency ablation (RFA) of their unresectable malignant lung tumours. Methodology From Nov 2000 to Dec 2006, the clinical and treatment-related information regarding the 100 consecutive patients (58 males, mean age of 65 years) with 240 lung tumours treated by RFA were collected prospectively and reviewed retrospectively. RFA was performed under CT guidance with local anaesthetics and conscious sedation. The patients were followed up with chest CT at regular intervals. Results Five patients had primary lung carcinoma while the remaining patients had pulmonary metastases from extra-thoracic malignancies, with colorectal cancer being the most common primary site (70%). The mean number of pulmonary lesions ablated was 2.4 per patient; the mean size of lesion was 2.2 cm in diameter. Nineteen patients had repeat RFA for recurrent or residual pulmonary disease. There was no post-procedural mortality and the overall morbidity rate was 42%. The most common complication was pneumothorax, which occurred in of 31% of procedures (n = 39/127) with only 20 (16%) requiring chest tube placement. After a median follow-up of 24 months (range 1 to 70 months), 72% of RFA treated lesions did not progress. The overall median disease-free interval was 13 months, with 1-, 3- and 5-year disease-free survival of 55%, 22% and 7% respectively. The overall median survival was 34 months with 1-, 3- and 5-year-survival of 85%, 49% and 33% respectively. Conclusion Percutaneous RFA is an emerging therapy with promising results when surgical resection of pulmonary malignancy cannot be performed.

Purpose This systematic review aims to assess the safety and efficacy of radiofrequency ablation(RFA) for pulmonary malignancies. Methodology Searches for relevant literature on RFA for lung tumours prior to Nov 2006 were performed in six electronic databases. Application of predetermined inclusion and exclusion criteria, quality assessment and data extraction were independently performed for all retrieved studies. Results were synthesized through tabulation and combined with a narrative review. Results Sixteen relevant studies on lung RFA with more than 10 patients that reported rates of morbidity, mortality, complete tumour ablation, local recurrence or survival were identified for this review. All included studies were level 4 evidence case series with median follow-up periods ranging from 9–24 months. The overall post-procedural morbidity rates ranged from 15–76% and mortality rates ranged from 0–5%. The most common complications were pneumothoraces occurring at 9–61 % of procedures. The rates of complete tumour necrosis achieved by RFA ranged from 38–98% while the rates of local recurrence from previously ablated lesions ranged from 2–38%. The overall median progression free interval ranged from 13 to 26 months. The overall median survival from the time of lung RFA, ranged from 8.6–33 months, with 1, 2 and 3 year survival of 71–85%, 55–65% and 38–46%, respectively. Conclusion The available evidence for radiofrequency ablation of primary and metastatic lung tumours is very limited. Surgical resection should remain the standard of care when feasible. Radiofrequency ablation, however, is safe and appears to have a promising role in the treatment of unresectable lung tumours.

Purpose: Peritoneal carcinomtosis (PC) is uniformly regard ed as a terminal disease with a median survival of 1–6 months and few treatment options. As improved understanding of tumour biology evolved, PC is increasingly recognized as locoregional disease. The aim of this study to report our experience with our 208 consecutive patients with peritoneal carcinomatosis treated by cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC). Methodology: From January 1997 to September 2008, the clinical and treatment-related data of 208 patients with PC were entered into a prospective database. The CRS was performed using peritonectomy procedures and the IPC was performed using Mitomycin C for gastrointestinal tumours with Cisplatin and Doxorubicin added for peritoneal mesothelioma at 42 deg Celsius via the Coliseum technique. Results: The median follow-up period was 36 months (Range: 1–89 months). The hospital mortality was 3%. The overall morbidity rate was 43% with grade 1 and 2 mortality in 75 patients, grade 3 complications in 49 patients and grade 4 complications in 24 patients. The overall median survival was 82 months with 1-, 3- and 5- year actuarial survival of 85%, 70% and 70% respectively. The median survival rates for pseudomxyma peritonei (n = 102), colorectal carcinoma (n = 53) and peritoneal mesothelioma (n = 25) were 82, 30 and 30 months respectively. Conclusion: CRS and IPC for PC can be performed with acceptable mortality and morbidity as for other major gastrointestinal surgeries with satisfactory long term survival results.

Background: Cytoreductive Surgery (CRS) combined with peri-operative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with pseudomyxoma peritonei (PMP). This treatment modality was associated with relatively high rates of peri-operative morbidity and mortality in the past. This study evaluates the clinical and treatment-related risk factors for peri-operative morbidity and mortality in PMP patients who underwent CRS and PIC. Methods: One hundred and thirty-six consecutive CRS and PIC procedures for PMP were evaluated. The association of twenty-four clinical and treatment-related risk factors with grades III and IV/V morbidity were assessed by univariate and multivariate analysis. Results: The mortality rate was 4%. The grades III and IV morbidity rates were 21% and 23%, respectively. Multivariate analysis showed 2 significant risk factors for grade IV/V morbidity: ASA > 3 (p = 0.008) and an operation length > 10 hours (p < 0.001). Conclusions: Patients with extensive comorbidity who undergo a long cytoreductive procedure are at a particularly high risk of a severe adverse event. Preoperative evaluation of patients is necessary to improve peri-operative outcome.

Purpose: Peritoneal mesothelioma is a rare malignancy regarded as a preterminal condition with few therapeutic options. The aim of this study is to report the results of 25 patients with diffuse peritoneal mesothelioma treated with cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC). Methodology: From 1999 to 2008, the clinical and treatment-related data of 25 patients with primary peritoneal mesothelioma who underwent CRS and IPC were reviewed from a prospective database. The CRS was performed by using peritonectomy procedures and the IPC was performed using Cisplatin, Mitomycin C at 42 degrees Celsius for 90 minutes by using the Coliseum technique. Results: The peri-operative mortality rate was 4%. The morbidity rates were was 36%, with grade 1 and 2 complications in 9 patients, grade 3 complications in 7 patients and grade 4 complications in 4 patients. The median follow-up was 15 months (range: 1–89 months). The overall patient median survival after cytoreduction and peri-operative intraperitoneal chemotherapy was 30 months. The 1-, 2- and 3- year actuarial survival was 77%, 61% and 49% respectively. On univariate analyses, the histopathology subtype (p = 0.007) and completeness of cytoreduction (p = 0.013) were identified to be significant prognostic factors for overall patient survival. Conclusion: CRS and IPC for diffuse peritoneal mesothelioma can be performed safely with acceptable morbidity and mortality rates. Compared to historical controls, CRS and IPC have demonstrated improved survival in selected patients. The completeness of cytoreduction and histological subtype were demonstrated to be the major determinants of survival.

Purpose Pre-operative scanning for hepatic colorectal metastases surgery remains a challenge, especially in the age of neo-adjuvant chemo, which has marked biochemical & physical effects on the liver. We investigated helical CT and CT portography as pre-op planning tools. Methodology All patients who had resection of hepatic colorectal metastases between Jan 2004 and June 2006 were included. Patients were divided into those who received neo-adjuvant chemo and those who did not. The number of malignant hepatic lesions found on each scan was compared with those found on histopathology & intra-op ultrasound/examination. Accurate scans (scan lesions = true lesions), over-estimations (scan lesions > true lesions) and under-estimations (scan lesions

Purpose Pre-op scanning for hepatic colorectal metastases surgery remains a challenge, especially in the age of neo-adjuvant chemotherapy, which has marked biochemical and physical effects on the liver. FDG-PET has clear applications for detecting extrahepatic disease. We investigated FDG-PET as a pre-op planning tool for detecting lesions in patients with and without neo-adjuvant chemotherapy. Methodology All patients who had resection of hepatic colorectal metastases between Jan 2004 and June 2006 were included. Patients were divided into those who received neo-adjuvant chemotherapy and those who did not. The number of malignant hepatic lesions found on each scan was compared with those found on histopathology, intra-operative examination and/or intra-operative ultrasound. Accurate scans (scan lesions = true lesions), over-estimations (scan lesions > true lesions) and under-estimations (scan lesions

Purpose Australia has the highest incidence of mesothelioma worldwide. Compared with traditional treatments using systemic chemotherapy, the combined cytoreductive surgery (CRS) with perioperative intraperitoneal chemotherapy (PIC) has shown improved survival. Methodology Fifteen consecutive patients with peritoneal mesothelioma underwent CRS and PIC at the St. George Hospital, Sydney. Clinical and treatment-related data were prospectively collected and reported. The morbidity and mortality rates and overall median survival were evaluated to assess the safety and efficacy of CRS and PIC in the treatment of peritoneal mesothelioma. Results There were 10 male and 5 female patients. The median age was 55 years old (range 35–72). The median follow-up was 12 months (range 6–50). Thirteen patients were surveyed regarding asbestos exposure, in which 7 reported a definite asbestos exposure, 3 reported working in high risk occupations and 3 reported minimal exposure risk. The mean operating duration was 9.6 hours. Rate of re-operation was 7% and mean hospital stay was 23 days. The morbidity and mortality rates were 36% and 7% respectively, with an overall median survival of 86 months (range 1–86). The 1-, 2- and 3-year survivals were 80%, 69% and 55% respectively. Conclusion CRS combined with PIC is a treatment option for peritoneal mesothelioma that confers improved survival, when compared with historical controls using systemic chemotherapy.

Purpose The purpose of this series was to evaluate the prognostic features for local progression in non-surgical candidates after undergoing percutaneous RFA of lung tumours. Methodology From Nov 2000, a total of 233 lung neoplasms (9 primary) in 95 patients (56 males, mean age of 66 years) with a mininum follow-up of 6 months were included in this study. The primary end point was local progression free interval defined from the time of RFA intervention. Local progression was defined as tumour recurrence of previously RFA treated site/s. Univariate and multivariate analysis were performed to identify significant prognostic parameters for post-ablative tumour recurrence. Results The mean number of tumours ablated per patient was 2.5 while the mean diametre of tumours was 2.2 cm. After a median follow up period of 24 months (range: 6–54 months), 32% of ablated tumours recurred. The overall median local progression free interval was 20 months (range 3–54 months) with 1, 2 and 3 year local progression free survival of 82%, 74% and 68% respectively. Univariate analysis of lesion characteristics identified size (p = 0.0002), hilar location (p = 0.0141), proximity to bronchus (p = 0.009) and vessel (p = 0.001), number of ablations required per lesion (p = 0.0052) and post-ablation and tumour volume ratio (p = 0.0002) as statistically significant prognostic factors for tumour recurrence. Multivariate analysis identified size of lung tumours >3 cm (p = 0.07) as an independent risk factor for local progression. Conclusion Percutaneous lung RFA may play a useful role as a local therapy in non-surgical candidates with pulmonary neoplasms. However, the efficacy of local control may be restricted to lesions smaller than 3 cm.

Purpose The objectives of this report were to critically evaluate the efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy (peritonectomy) for patients with peritoneal carcinomatosis from colorectal carcinoma. Methodology Forty patients with histologically confirmed peritoneal dissemination from colorectal cancer underwent peritonectomy at the St George Hospital, Sydney. All clinical and treatment-related data were prospectively collected. Perioperative and survival results were analysed by intention-to-treat principle. Results The mean age at the time of surgery was 54 (S.D. = 14) years. There were 25 male patients. Three, 20 and 17 patients had well-, moderately- and poorly-differentiated tumours. The mean peritoneal cancer index was 12 (S.D. = 9). The mean operation duration was 7 (S.D. = 4) hours. The mean ICU, HDU and overall hospital stay was 1 (S.D. = 0.5), 5 (S.D. = 8) and 28 (S.D. = 34) days, respectively. Seventeen patients (42%) had moderate morbidity and required interventional procedures for resolution. Six patients (15%) had severe morbidity and required returning to ICU or operating theatre for management. There was no operative death. After a median follow-up of 12 months since peritonectomy, the overall median survival was 30 months (range 1 to 46), with 1- and 2-year survival of 67% and 61%, respectively. Conclusions Peritonectomy is a treatment option for selected patients with peritoneal carcinomatosis from colorectal carcinoma.

Purpose Intraoperative blood loss during liver resection remains a major concern due to association with higher postoperative complications. The InLine RFA device (ILRFA) (Resect Medical Inc® Fremont CA) has achieved promising results in liver surgery with minimal blood loss and no increase of postoperative complications. In this multicentre controlled study, 108 patients undergoing liver resection were investigated. Methodology 108 liver resections were performed in 4 medical centres, consisting of 54 ILRFA and 54 ultrasonic Surgical Aspirator (USA) transection as the control group. Pringle manoeuvre was applied only when required. Blood loss was measured from sponge weights and suction bottle contents. Results The type of liver resection was very similar in both groups. Median number of RFA deployments was 3 (1–12) with a median coagulation time of 9 (3–36) minutes. Median operation blood loss was 165 ± 20 ml (5–675 ml) in the ILRFA and 654 +/−83 ml (80–3600 ml) in the control, a 74.8% reduction (P