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Despite advances in modern surgery, congenital heart disease remains a medical challenge and major cause of infant mortality. Valved conduits are routinely used to surgically correct blood flow in hearts with congenital malformations by connecting the right ventricle to the pulmonary artery (RV-PA). This review explores the current range of RV-PA conduits and describes their strengths and disadvantages. Homografts and xenografts are currently the primary treatment modalities, however both graft types have limited biocompatibility and durability, and present a disease transmission risk. Structural deterioration of a replaced valve can lead to pulmonary valve stenosis and/or regurgitation. Moreover, as current RV-PA conduits are of a fixed size, multiple subsequent operations are required to upsize a valved conduit over a patient's lifetime. We assess emerging biomaterials and tissue engineering techniques with a view to replicating the features of native tissues, including matching the durability and elasticity required for normal fluid flow dynamics. The benefits and limitations of incorporating cellular elements within the biomaterial are also discussed. Present review demonstrates that an alignment of medical and engineering disciplines will be ultimately required to produce a biocompatible and high-functioning artificial conduit. [ABSTRACT FROM AUTHOR]

Introduction: We report the largest series to date on the safety and efficacy of yttrium-90 (90Y) radioembolization for the treatment of unresectable, chemorefractory colorectal cancer liver metastases (CRCLM). Methods: A total of 302 patients underwent resin-based 90Y radioembolization for unresectable, chemorefractory CRCLM between 2006 and 2013 in Sydney, Australia. All patients were followed up with imaging studies at regular intervals until death. Radiologic response was evaluated with the response criteria in solid tumors criteria. Clinical toxicities were prospectively recorded. Survival was calculated by the Kaplan-Meier method, and potential prognostic variables were identified on univariate and multivariate analysis. Results: Median follow-up in the complete cohort was 7.2 months (range 0.2-72.8), and the median survival after 90Y radioembolization was 10.5 months with a 24-month survival of 21 %. On imaging follow-up of 293 patients who were followed up beyond 2 months, complete response to treatment was observed in 2 patients (1 %), partial response in 111 (38 %), stable disease in 96 (33 %), and progressive disease in 84 (29 %). Four factors were independently associated with a poorer prognosis: extensive tumor volume, number of previous lines of chemotherapy, poor radiological response to treatment, and low preoperative hemoglobin. One hundred fifteen (38 %) developed clinical toxicity after treatment; most complications were minor (grade I/II) and resolved without active intervention. Conclusions: 90Y radioembolization is a safe and effective treatment for unresectable, chemorefractory CRCLM. [ABSTRACT FROM AUTHOR]

Introduction: The management of unresectable, chemorefractory colorectal cancer liver metastases (CRCLM) is a clinical dilemma. Yttrium-90 (Y90) radioembolization is a potentially safe and effective treatment for patients with CRCLM who have failed conventional chemotherapy regimens. Methods: A systematic review of clinical studies before November 2012 was performed to examine the radiological response, overall survival and progression-free survival of patients who underwent Y90 radioembolization of unresectable CRCLM refractory to systemic therapy. The secondary objectives were to evaluate the safety profile of this treatment and identify prognostic factors for overall survival. Results: Twenty studies comprising 979 patients were examined. Patients had failed a median of 3 lines of chemotherapy (range 2-5). After treatment, the average reported value of patients with complete radiological response, partial response and stable disease was 0 % (range 0-6 %), 31 % (range 0-73 %) and 40.5 % (range 17-76 %), respectively. The median time to intra-hepatic progression was 9 months (range 6-16). The median overall survival was 12 months (range 8.3-36). The overall acute toxicity rate ranged from 11 to 100 % (median 40.5 %). Most cases of acute toxicity were mild (Grade I or II) (median 39 %; range 7-100 %) which resolved without intervention. The number of previous lines of chemotherapy (≥3), poor radiological response to treatment, extra-hepatic disease and extensive liver disease (≥25 %) were the factors most commonly associated with poorer overall survival. Conclusion: Y90 radioembolization is a safe and effective treatment of CRCLM in the salvage setting and should be more widely utilized. [ABSTRACT FROM AUTHOR]

Introduction: There are a paucity of data on the treatment of unresectable, chemoresistant breast cancer liver metastases (BRCLM) with yttrium-90 (Y90) radioembolization. Methods: Forty patients underwent resin-based Y90 radioembolization for unresectable, chemoresistant BRCLM between 2006 and 2012 in a single institution. All patients were followed up with imaging studies at regular intervals as clinically indicated until death. Radiologic response was evaluated with the Response Criteria in Solid Tumors criteria. Clinical toxicities were prospectively recorded as per the National Cancer Institute Common Toxicity Criteria. Survival was calculated by the Kaplan-Meier method and potential prognostic variables were identified on univariate and multivariate analysis. Results: Follow-up was complete in all patients. The median follow-up was 11.2 (range 0.6-30.5) months and the median survival after Y90 radioembolization was 13.6 months, with a 24-month survival of 39 %. On imaging follow-up of 38 patients who survived beyond 1 month of treatment, a complete response (CR) to treatment was observed in two patients (5 %), partial response (PR) in 10 patients (26 %), stable disease (SD) in 15 patients (39 %), and progressive disease (PD) in 11 patients (29 %). Two factors were associated with an improved survival on multivariate analysis: CR/PR to treatment (vs. SD vs. PD; p < 0.001) and chemotherapy after radioembolization (vs. no chemotherapy; p = 0.004). Sixteen patients (40 %) developed clinical toxicity after treatment; all complications were minor grade I/II and resolved without active intervention. Conclusion: This study provides supportive evidence of the safety and efficacy on Y90 radioembolization for the treatment of unresectable, chemoresistant BRCLM. Further prospective investigation is required to assess the suitability of this treatment in this population. [ABSTRACT FROM AUTHOR]

Introduction: Only 15% of patients with colorectal liver metastases (CLM) are candidates for curative hepatectomy at time of diagnosis, limited by anatomical location and tumor burden. Ablative therapies may extend this. This study reports a single institution's long-term experience with hepatic cryotherapy for advanced CLM. Methods: Between April 1990 and June 2009, 304 patients were curatively treated with cryotherapy. Survival was estimated by Kaplan-Meier method. Prognostic factors for survivals were determined by using univariate and multivariate analyses. Results: A total of 293 patients were included into analysis. The median number of lesions treated per patient was three (range, 1-13). The median overall survival was 29 (range, 3-220) months. The 1-, 3-, 5-, and 10-year survivals were 87%, 41.8%, 24.2%, and 13.3%, respectively. A total of 161 patients developed intrahepatic recurrences: cryosite (23%); edge recurrence (14%); and within the liver remnant (78%). The median disease-free survival (DFS) was 9 (range, 1-220) months. The 1-, 3-, 5-, and 10-year DFS rates were 37.9%, 17.2%, 13.4%, and 10.8%, respectively. Univariate analysis identified four factors that significantly affect survival: node-positive primary tumor ( p = 0.001), preoperative CEA level ( p < 0.001), number of lesions ( p < 0.001), and use of neoadjuvant chemotherapy ( p < 0.001). However, only primary tumor nodal status was independently prognostic (hazards ratio = 2.023; 95% confidence interval, 1.444-2.835; p < 0.001). Conclusions: Hepatic cryotherapy seems to be a safe and effective ablative technique for the treatment of colorectal liver metastases and may offer long-term survival in otherwise unresectable disease. [ABSTRACT FROM AUTHOR]

Background: This study evaluates the accuracy of computed tomography (CT) scoring of the peritoneal cancer index (PCI) and examines its association with surgical morbidity and outcomes in pseudomyxoma peritonei. Methods: Forty-seven patients with pseudomyxoma peritonei had preoperative evaluation of CT scans and were treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy. Their radiological PCI and intraoperative PCI were scored for determination of accuracy and for correlation with morbidity and outcomes. Results: Accuracy in detecting peritoneal lesions regardless of size ranged from 51% to 85% in the abdominopelvic regions and 21% to 25% in the small intestinal regions. The sensitivity of CT detection of peritoneal implants ranged from 67% to 84% in the abdominopelvic regions and from 56% to 57% in the small intestinal regions. The specificity of CT detection of peritoneal lesions was 100% in all regions. Preoperative CT identification of larger peritoneal lesions in the right upper quadrant ( P = 0.016), epigastrium ( P = 0.003), left upper quadrant ( P = 0.019), proximal jejunum ( P = 0.022), distal jejunum ( P = 0.022), and proximal ileum ( P = 0.022) predicted development of severe complications. Similarly, larger peritoneal lesions in the right upper quadrant ( P = 0.039), epigastrium ( P = 0.024), right flank ( P = 0.005), and right lower quadrant ( P = 0.034) were negatively associated with disease-free survival, and the right upper quadrant ( P = 0.037) was negatively associated with overall survival. Conclusions: Preoperative CT scan depicting extensive upper abdominal and small bowel disease predicts the presence of severe complications after cytoreduction. Extensive disease in the right upper quadrant seems to be associated with a poorer survival outcome. [ABSTRACT FROM AUTHOR]

Background: To evaluate the role of modern systemic therapies and its role as palliative or curative therapy for patients with colorectal peritoneal carcinomatosis with an emphasis on patient selection with the colorectal Peritoneal Surface Disease Severity Score (PSDSS). Methods: From three specialized treatment centers, patients with colorectal peritoneal carcinomatosis were identified between December 1988 to December 2009 to receive best supportive care, standard, or modern systemic therapies. Intent was classified as palliative or curative (if treated by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy). Patients were stratified according to the PSDSS. Survival was estimated by the Kaplan-Meier method. Results: Palliative and curative treatment achieved a median survival of 9 (95% confidence interval [95% CI] 5.9-12.8) and 38 (95% CI 30.2-45.2) months, respectively ( P < 0.001). The type of chemotherapy in the palliative and curative group influenced outcome ( P < 0.001, P = 0.011, respectively). In the palliative group, PSDSS I/II had a median survival of 24 (95% CI 15.6-32.6) and PSDSS III/IV had a median survival of 6 (95% CI 4.9-8.0) months ( P < 0.001). In the curative group, PSDSS I/II had a median survival of 49 (95% CI 40.0-58.3) and PSDSS III/IV had a median survival of 31 (95% CI 20.4-40.9) months ( P = 0.002). Conclusions: Modern systemic therapies were associated with improved outcome in patients with colorectal peritoneal carcinomatosis treated systemically alone or with cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. Preoperative evaluation with the PSDSS may improve patient selection and optimize outcomes. [ABSTRACT FROM AUTHOR]

Background: Surgical cytoreduction and intraperitoneal chemotherapy is increasingly accepted as an effective treatment modality for mucinous appendiceal neoplasm. For the majority of patients with low-grade histology, outcomes have been encouraging. The survival of patients with neoplasms of malignant character is protracted and this study was designed to evaluate the effectiveness of this surgical strategy on outcomes. Methods: Forty-six consecutive patients with mucinous and nonmucinous appendiceal cancer with peritoneal dissemination were studied. Clinicopathological and treatment related factors were obtained from a prospective database. The study's end points of disease-free survival (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier method. Results: The median DFS and OS after cytoreduction were 20.5 and 56.4 months respectively. Five-year overall survival rate was 45%. Five independent factors associated with DFS and OS were identified through a multivariate analysis: age (DFS p = 0.001, OS p = 0.002), completeness of cytoreduction (DFS p = 0.001, OS p = 0.003), previous chemotherapy treatment (DFS p = 0.021), CA 199 levels (DFS p = 0.013), and tumor grade (OS p = 0.005). Conclusions: Cytoreductive surgery and intraperitoneal chemotherapy may achieve long-term survival in appendiceal malignancies with peritoneal dissemination for which the predictors of outcomes identified through this study may tailor the disease management to commit patients early toward this successful surgical strategy. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the role of radioembolization and systemic chemotherapy as a combined modality therapy for unresectable colorectal liver metastases. Patients and methods: Prospective database of a major yttrium-90 microsphere radioembolization treatment center in Sydney, Australia, that included 140 patients with unresectable colorectal liver metastases was analyzed. Tumor response, overall survival, treatment-related complications and an evaluation of its role as a combined modality therapy with systemic chemotherapy were performed. Results: One hundred and thirty-three patients (95%) had a single treatment, and seven patients (5%) had repeated treatments. Response following treatment was complete in two patients (1%), partial in 43 patients (31%), stable in 44 patients (31%), and 51 patients (37%) developed progressive disease. Combining chemotherapy with radioembolization was associated with a favorable treatment response ( P = 0.007). The median overall survival was 9 (95% CI 6.4-11.3) months with a 1-, 2-, and 3-year survival rate of 42, 22, and 20%, respectively. Primary tumor site ( P = 0.019), presence of extrahepatic disease ( P = 0.033), and a favorable treatment response ( P < 0.001) were identified as independent predictors for survival. Conclusion: Combined modality therapy appears to improve tumor response rates. Survival is influenced by tumor site, presence of extrahepatic disease, and response to therapy. Yttrium-90 microsphere radioembolization is safe and may best be combined with systemic chemotherapy for patients with unresectable colorectal liver metastases. [ABSTRACT FROM AUTHOR]

Background: Resection of hepatocellular carcinoma (HCC) is potentially curative; however, recurrence is common. To date, few or no effective adjuvant therapies have been adequately investigated. This study evaluates the efficacy of adjuvant iodine-131-lipiodol after hepatic resection through the experience of a single-center hepatobiliary service of managing this disease. Patients and methods: All patients who underwent hepatic resection for HCC and received adjuvant iodine-131-lipiodol between January 1991 and August 2009 were selected for inclusion into the experimental group. A group composed of patients treated during the same time period without adjuvant iodine-131-lipiodol was identified through the unit's HCC surgery database for comparison. The endpoints of this study were disease-free survival and overall survival. Results: Forty-one patients who received adjuvant iodine-131-lipiodol after hepatic resection were compared with a matched group of 41 patients who underwent hepatic resection only. The median disease-free and overall survival were 24 versus 10 months ( P = 0.032) and 104 versus 19 months ( P = 0.001) in the experimental and control groups, respectively. Rates of intrahepatic-only recurrences (73 vs. 37%; P = 0.02) and surgical and nonsurgical treatments for recurrences (84 vs. 56%; P = 0.04) were higher in the experimental group compared to the control group. Conclusion: The finding of this study corroborates the current evidence from randomized and nonrandomized trials that adjuvant iodine-131-lipiodol improves disease-free and overall survival in patients with HCC after hepatic resection. The lengthened disease-free survival after adjuvant iodine-131-lipiodol allows for further disease-modifying treatments to improve the overall survival. [ABSTRACT FROM AUTHOR]

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with pseudomyxoma peritonei (PMP). However, this aggressive treatment modality has been consistently associated with variable rates of perioperative mortality between 0% and 18% and morbidity between 30% and 70%. This study evaluates the clinical and treatment-related risk factors for perioperative morbidity and mortality in PMP patients who underwent CRS and PIC. A total of 145 consecutive CRS and PIC procedures for PMP performed between January 1996 and March 2009 were evaluated. The association of 12 clinical and 20 treatment-related risk factors with grades III and IV/V morbidity were assessed by univariable and multivariable analysis. The mortality (grade V) rate was 3%. The morbidity rates of grades III and IV were 23% and 22%, respectively. Eight factors were associated with grade IV/V morbidity on univariable analysis: peritoneal cancer index ≥21 ( P = .034), ASA score ≥3 ( P = .003), operation duration ≥10 h ( P < .001), left upper quadrant peritonectomy procedure ( P = .037), colonic resection ( P = .012), ostomy ( P = .005), ileostomy ( P = .012), and transfusion ≥6 units ( p = 0.011). Multivariable analysis showed 2 significant risk factors for grade IV/V morbidity: ASA ≥ 3 ( P = .006) and an operation length ≥10 h ( P < .001). CRS and PIC has an acceptable rate of perioperative mortality and morbidity in selected patients with PMP. Patients with bulky disease who undergo a long operation are at a particularly high risk of a severe adverse event. [ABSTRACT FROM AUTHOR]

Cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) has improved survival in selected patients with peritoneal carcinomatosis. This study evaluates the morbidity of postoperative pancreatic fistula (PF) within the context of CRS and PIC. Two hundred seventy-one consecutive CRS and PIC procedures were evaluated. Diagnosis and classification of postoperative PF were performed according to the international study group on PF criteria. The associations between 8 clinical and 20 treatment-related factors with postoperative PF were determined by univariate and multivariate analysis. The management and clinical sequelae of postoperative PF were discussed. Seventeen patients (6.3%) developed postoperative PF. None of these patients died during their in-hospital stay. Multivariate analysis identified three independent risk factors for PF: transfusion of ≥6 units of blood ( P = 0.029), operation duration of ≥9 h ( P = 0.035), and splenectomy ( P = 0.020). Conservative management of PF was instituted in all 17 patients and was successful in 16 (94%). The overall time to PF closure was 26 (standard deviation 16) days after diagnosis. Although PF did not contribute to procedure-related mortality, it was associated with increased length of hospital stay ( P < 0.001). CRS and PIC presented an acceptable rate of PF that did not increase the procedure-related mortality. However, PF was associated with longer hospital stay. Most patients with PF were treated conservatively and did not require surgical intervention. [ABSTRACT FROM AUTHOR]

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with colorectal peritoneal carcinomatosis (CRPC). This treatment modality is associated with relatively high rates of perioperative morbidity and mortality. This study evaluated the clinical and treatment-related risk factors for perioperative morbidity and mortality in patients with CRPC who underwent CRS and PIC. Sixty-three consecutive patients who underwent CRS and PIC for CRPC were evaluated. Adverse events were rated from grades I to V with increasing severity. Clinical and treatment-related risk factors for grades III and IV/V morbidity were determined. There were no perioperative deaths (0%). The grades III and IV morbidity rates were 14 and 17%, respectively. A peritoneal cancer index >12 ( p = 0.019), transfusion >4 units ( p = 0.028), number of peritonectomy procedures >3 ( p = 0.013), left upper quadrant peritonectomy procedure ( p < 0.001), and number of primary colonic anastomosis >1 ( p = 0.004) were associated with grade IV morbidity on univariate analysis. Only left upper quadrant procedure was associated with grade IV morbidity on multivariate analysis ( p = 0.002). Only number of primary colonic anastomosis >1 ( p = 0.037) was associated with grade III morbidity on univariate analysis. This also was associated with grade III morbidity on multivariate analysis ( p = 0.028). CRS and PIC has an acceptable risk of perioperative morbidity in carefully selected patients with CRPC. Patients who require extensive surgery have the highest risk for a severe adverse event. Preoperative evaluation of patients is essential to improve perioperative outcome. [ABSTRACT FROM AUTHOR]