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Background: Patients with colon cancer may present at multiple different stages of the disease process. Many patients can be cured of colon cancer as a result of a simple surgical procedure usually performed by minimally invasive techniques. However, there are a variable number of patients, estimated at approximately 10%, who have a more advanced disease. If these patients are treated by the current conventional standard of care, the likelihood for treatment failure is extremely high. Methods: These are not patients with known disseminated disease but patients who are at high risk of recurrent disease unless special treatments are initiated preoperatively and intraoperatively. The identification of these patients is by (1) a high-quality CT scan, (2) tumor markers found preoperatively, (3) colonoscopic findings, and (4) symptoms. Results: Patients identified as being at high risk require special preoperative treatments which include neoadjuvant chemotherapy. Intraoperative chemotherapy with HIPEC should occur as part of the treatment if peritoneal metastases are documented by biopsy. In the operating room, a thorough exploration of all possible occult peritoneal spaces for metastatic disease needs to be performed. A modified cytoreductive surgical procedure along with a colon resection is performed in order to minimize sites of occult peritoneal metastases. This includes the greater omentum, ovaries, and tubes in postmenopausal women. Peritonectomy is used to create a shroud around the tumor so that all peritoneum that has been in direct contact with the tumor surface is resected and is used as a barrier against tumor cell dissemination in the process of colon cancer resection. If peritoneal metastases are visualized at any site, HIPEC should be included as part of the treatment package. Conclusions: I am convinced that patients at high risk of recurrence will have an improved outcome with proper preoperative evaluation, preoperative neoadjuvant chemotherapy, and a revised intraoperative management strategy. [ABSTRACT FROM AUTHOR]

Abstract Background There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications. Methods A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1st International Congress of the World Society of Emergency Surgery and 9th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus. Recommendations In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay. NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended. Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained. Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

Abstract Background Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC. Methods The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced. Results Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B). Conclusions Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.

Abstract Background The incidence of cancer during pregnancy is approximately 1 in 1000. The most common types encountered during pregnancy are cervical, breast and ovarian. Epithelial tumors of the appendix on the other hand are rare and account for only approximately 1% of all colorectal neoplasms; the occurrence of this neoplasm during pregnancy is extremely rare. Case Presentation The medical history of a 30 year old woman diagnosed at 17 weeks gestation with an appendiceal mucinous tumor with large volume pseudomyxoma peritonei was presented. Her pregnancy was preserved and she had an early vaginal delivery of a healthy baby at 35 weeks. At 2 1/2 weeks postpartum the patient underwent extensive cytoreductive surgery and intraperitoneal chemotherapy. She remains disease-free 5 years after her initial diagnosis. A literature review of this clinical situation and a discussion of treatment plans were presented. Conclusion The management of an appendiceal tumor with pseudomyxoma peritonei diagnosed during pregnancy requires full knowledge of the natural history of this disease to achieve a balance of concern for maternal survival and fetal health.

Abstract Background Mucinous neoplasms within the abdomen may disseminate by direct extension through the diaphragm to involve the pleural space. Treatment of this condition is by parietal and visceral pleurectomy followed by hyperthermic intrapleural chemotherapy. Case presentation In this case report a patient developed persistent right upper lobe interstitial pneumonitis and progressive parenchymal fibrosis following intrapleural chemotherapy treatment with mitomycin C and doxrubicin. The condition persisted until death 28 months later. Death was from progressive intraabdominal disease with intestinal obstruction and sepsis associated with progressive pulmonary parenchymal disease. The right pleural space disease did not recur. Conclusion This manuscript is the first case report describing interstitial pneumonitis and lung fibrosis following intrapleural chemotherapy. Since pulmonary toxicity from chemotherapy is a dose-dependent phenomenon, dose reduction of intrapleural as compared to intraperitoneal hyperthermic chemotherapy may be necessary.

• Delayed leak from a ureter can occur following pelvic surgery. • Stenting the ureteral defect through the bladder or kidney is often unsuccessful. • A rendezvous procedure may be successful to reestablish ureteral continuity. • A sequence of collaborative efforts by urologist and interventional radiologist is required. Iatrogenic damage to the ureter as a result of an abdominal or pelvic surgical procedure is unusual. However, it does occur and the surgeon must be prepared to deal knowledgeably with the injury. Leaks that are recognized within the operating theater are managed, for the most part, at the same surgical procedure oftentimes with urologic consultation. A delayed leak presents unique problems in that direct access to the site of the leak is not possible except by a reoperative procedure. Delayed leaks present a clinical situation involving the urologist, interventional radiologist, as well as the surgeon. A patient who developed delayed urine leakage following a partial sacrectomy to remove recurrent mucinous appendiceal malignancy was studied. The leakage was controlled using a nephroureteral stent. Placement of the nephroureteral stent was made possible by the rendezvous procedure. The sequence of procedures to reestablish ureteral continuity following a delayed leak are important in the successful placement of a nephroureteral stent. After establishing the site of the injury a percutaneous nephrostomy must be placed. Then, through the nephrostomy, a guidewire is placed in the ureter to be recovered and advanced into the bladder using a ureteroscope and grasping forceps. A nephroureteral stent is placed over the guidewire to bridge the gap and stent the ureteral defect. The rendezvous procedure can be successful a large percentage of the time with a delayed ureteral leakage. Successful recovery of a guidewire in the ureter by ureteroscopy requires a combined interventional radiology and urologic procedure. [ABSTRACT FROM AUTHOR]

Abstract The treatment of peritoneal surface malignancy mainly focuses on diffuse malignant peritoneal mesothelioma, pseudomyxoma peritonei from appendiceal cancer, and peritoneal dissemination from gastrointestinal and ovarian cancers. Cancer progression causes peritoneal implants to be distributed throughout the abdominopelvic cavity. These nodules plus the ascitic fluid result in abdominal distension. As the disease progresses, these tumors cause intestinal obstruction leading to debilitating symptoms and a greatly impaired quality of life. In the past, the prognosis of patients with peritoneal surface malignancy was regarded dismal and cure was not an option. Recently, cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has shown an improved survival in selected patients with this disease. To date, multiple different treatment regimens of perioperative intraperitoneal chemotherapy have been used. This review focuses on the perioperative intraperitoneal chemotherapy currently in use in conjunction with cytoreductive surgery for the treatment of peritoneal surface malignancy at the Washington Cancer Institute.

• Peritoneal metastases from colorectal cancer are lethal. • Cytoreductive surgery plus perioperative chemotherapy is a treatment option. • A perioperative FOLFOX regimen with intraperitoneal oxaliplatin was described. • The pharmacokinetic studies suggested efficacy. Colorectal cancer can disseminate malignant cells to the peritoneal surfaces which over time progress to peritoneal metastases. Management of this type of metastatic disease has been approached using a combined treatment that consists of cytoreductive surgery and perioperative chemotherapy. To optimize these treatments a more effective chemotherapy that is used as planned part of the surgical procedure is required. Pharmacologic studies to initiate a new perioperative chemotherapy treatment were modeled after the successful systemic treatments of metastatic colorectal cancer referred to as FOLFOX. A management plan that included all of the essential features of successful systemic chemotherapy was formulated. Pharmacokinetic studies of 5-fluorouracil given both intravenously and intraperitoneally and oxaliplatin given intraperitoneally were investigated. The compatibility of 5-fluorouracil and oxaliplatin was documented showing no degradation of either drug when they were mixed in-vitro over 24 h. The pharmacokinetic analysis of hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin showed cytotoxic concentrations for 120 min. In order to maximize oxaliplatin's effect, both intravenous bolus and continuous infusion 5-fluorouracil was combined with early postoperative intraperitoneal chemotherapy (EPIC). In total, 200 mg/m2 of oxaliplatin was combined with a minimum of 1600 mg of 5-fluorouracil over the 24 -h treatment plan. This perioperative FOLFOX treatment was completed in 2 patients and the clinical effectiveness as a result of this in-depth case reports was presented. Formal phase II studies, as a result of these pharmacokinetic and clinical investigations, have been initiated. [ABSTRACT FROM AUTHOR]

• Diverticuli are found throughout the gastrointestinal tract from esophagus to rectum. • In the jejunum diverticuli are most commonly proximal, multiple and asymptomatic. • A large solitary jejunal diverticulum caused life endangering midgut volvulus. • In the absence of timely surgical intervention the condition would have been fatal. Jejunal diverticula are a rare subtype of false diverticula found in the gastrointestinal tract. When present, they are usually multiple, in the proximal jejunum and asymptomatic. Rarely, they can cause acute complications that can develop into an acute abdomen requiring surgical intervention. We present the rare manifestation of a single jejunal diverticulum causing midgut volvulus and bowel ischemia. Early surgical intervention with small bowel derotation allowed complete recovery. Data regarding the case, operative intervention, and patient follow-up was prospectively accumulated with permission of the patient at an academic institution. All patient identifiers were removed. All research steps were performed under guidance outlined in the SCARE criteria. We present the case of a 78-year-old man who presented to our institution with an acute abdomen. CT imaging demonstrated a whirlpool sign without an obvious lead point. The patient was without prior surgical intervention. Urgent exploratory laparotomy revealed a midgut volvulus with associated bowel ischemia and impending infarction secondary to adhesive disease from a large single jejunal diverticulum. Derotation resulted in gradual recovery of bowel vascularity. Resection of the portion of the jejunum containing the diverticulum resulted in full clinical recovery of the patient. Complications of jejunal diverticula, although rare, should be considered as part of the differential diagnosis of an acute abdomen of unknown etiology. Urgent surgical intervention was required to avoid a potential catastrophic outcome. [ABSTRACT FROM AUTHOR]

• Determine metastases as hematogenous, lymphatic or transcoelomic. • In the past splenic metastases was assumed to be hematogenous. • Splenic metastases may occur in the absence of hematogenous dissemination. • Gastrointestinal or gynecologic splenic metastases are likely implants. Metastases from gastrointestinal and gynecologic malignancy may occur through lymphatic channels, through venules of the cancer or into the peritoneal space. The metastatic process involves lymphatic, hematogenous or transcoelomic dissemination. Two patients with splenic metastases are presented. Their clinical course is presented in an attempt to identify the route of cancer dissemination to the spleen. Lymphatic, hematogenous, or transcoelomic patterns of cancer dissemination are possible. Transcoelomic cancer dissemination into the peritoneal space results in peritoneal metastases. In a woman with ovarian cancer peritoneal metastases, a large lesion within the parenchyma of the spleen was described. This disease was present at multiple other sites as peritoneal metastases but no hematogenous or lymphatic metastases. A second patient with mucinous appendiceal neoplasm with peritoneal metastases was studied. Hematogenous metastases from this malignancy is extremely rare and lymphatic metastases were not present at the time of right colon resection. After studying these two patients, our hypothesis is that splenic metastases result from transcoelomic dissemination to the splenic hilum or splenic notches with progression of disease into the parenchyma of the spleen. When oncologists are considering aggressive local-regional treatments for peritoneal metastases important patient management decisions are influenced by the presence versus absence of hematogenous metastases. We suggest that the presence of splenic metastases does not indicate systemic (hematogenous) or lymphatic metastatic process but an extension of peritoneal metastases at the hilum of the spleen or within splenic notches deep into the parenchyma of the spleen. [ABSTRACT FROM AUTHOR]

• 0.5 % of appendectomy specimens show neuroendocrine and 0.5 % show epithelial malignancy. • In 2 patients these two malignancies were in the same appendectomy specimen. • Patients peritoneal metastases occurred from the mucinous epithelial malignancy only. • Rather than routine right hemicolectomy, radical appendectomy is suggested. Although uncommon, neoplasms of the appendix do exist. The two most common types are neuroendocrine tumors and mucinous appendiceal neoplasms. In two patients unusual gross and microscopic findings in an appendectomy specimen were recorded. Special immunocytochemistry studies were used to determine the histologic type of the tumors in the appendix. The clinical features and histopathology of two patients who had both a neuroendocrine tumor and a low grade appendiceal mucinous neoplasm in the same appendectomy specimen were described. Possibilities for the causation and treatment of this unusual condition were discussed. The incidence of this double malignancy was estimated at 2.5 in 1000 appendectomy specimens. Although extremely unusual, a neuroendocrine tumor and a mucinous appendiceal neoplasm can exist in the same appendix. This condition is reported in two young patients. [ABSTRACT FROM AUTHOR]

• Sarcomatosis is the progression of visible malignant nodules on peritoneal surfaces. • Long-term disease-free survival is unusual if high grade sarcomatosis is treated by CRS and HIPEC. • In two patients prolonged disease-free survival has been observed with complete resection of low grade disease plus HIPEC. • The lack of deep tissue invasion with low grade sarcoma may account for the long-term success of CRS and HIPEC. Sarcomatosis results from the dissemination of cells from an abdominal or pelvic primary sarcoma to the peritoneal surfaces. In most patients this is a lethal condition. The clinical and radiologic features of two patients with sarcomatosis were reviewed. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) were used for treatment. Current status of these two patients was available. These two patients had a large extent of disease. In one, a myxoid sarcoma filled the pelvis. In another, all quadrants of the abdomen and pelvis were involved by peritoneal metastases from a uterine leiomyosarcoma. The grade of these two tumors was moderate and low. Surgical resection of all sarcomatosis was performed and this was followed by HIPEC. Clinical and radiologic follow-up at 37 and 58 months after complete cytoreduction show no evidence of disease. An effort to identify patients with sarcomatosis who are predicted to have a complete cytoreduction should occur when these patients are evaluated. Patients with a complete resection and a sarcoma-specific HIPEC may have prolonged disease-free survival. No other treatments for these patients have been described. [ABSTRACT FROM AUTHOR]

• The goal of cancer surgery is complete removal and absolute containment of the malignant process. • Laparoscopy performed with cancer cells within the peritoneal space may cause cancer progression within trochar sites. • This unintended adverse consequence of laparoscopy may be reduced by limiting trochar sites to the midline. • Prospective data regarding the incidence of trochar site disease is not available but it does continue to occur. Cancer surgery has as its goal complete clearance and absolute containment of the malignant disease as it is being resected. Any aspect of the procedure which allows the escapes of malignant cells may result in disease recurrence. The patient presented to an emergency room with left-sided abdominal pain. Pelvic sonogram suggested the diagnosis of a ruptured left ovarian cyst. A uterine biopsy showed high grade serous carcinoma. Definitive treatment of the primary ovarian cancer wasen bloc laparoscopic resection of her uterus, Fallopian tube and ovaries. CT showed port site recurrence in both right and left upper abdominal trochar sites. The right-sided port site recurrence was through the fascia just lateral to the right rectus muscle and was small. A much larger port site metastases was present at the right trochar site that was through the left rectus muscle. The incidence of midline and lateral port site recurrence after laparoscopy for diagnosis or resection of ovarian cancer has not been determined. Limitation of trochar sites to the midline may reduce the extent of abdominal wall disease spread. [ABSTRACT FROM AUTHOR]

• A margin of resection for an advanced right colon cancer is the second portion of the duodenum. • Recurrence of right colon cancer may involve the anterior aspect of the duodenum. • Resection of the duodenum may occur without resection of the ampulla of Vater. • Reimplantation of the ampulla of Vater into the proximal jejunum was accomplished without adverse events. Local or regional recurrence of colon or rectal cancer frequently occurs if there is a positive margin of resection or spillage of cancer cells during the operation. The clinical course of a patient with right colon cancer recurrent within the resection site and on the anterior aspect of the duodenum was reviewed. Resection of recurrent right colon cancer was accomplished by subtotal duodenectomy. Reconstruction was with jejunal advancement and reimplantation of the ampulla of Vater. No postoperative complications occurred and palliation was excellent. Prevention of recurrent right colon cancer is an import consideration for primary resection. However, if this duodenum is involved by recurrence, techniques for resection exist. [ABSTRACT FROM AUTHOR]

• For long-term benefit to result from cytoreductive surgery, all visible disease must be removed. • Peritoneal metastases obscured from visible detection by the surgeon will not be resected. • Peritoneal tunnels in the inguinal and porta hepatis regions were identified. • For optimal cytoreduction, peritoneal tunnels must be opened and tumor resected. Peritoneal metastases from gastrointestinal cancer can be treated by a combination of surgery to remove visible evidence of disease and perioperative intraperitoneal chemotherapy to eradicate microscopic disease. Complete cytoreduction is necessary for long-term benefit. Two sites for incomplete cytoreduction because tumor is hidden from visual inspection were identified. Patients who developed recurrence at these anatomic sites were studied. A peritoneal tunnel along a patent processus vaginalis allowed tumor to be sequestered along the inguinal canal in a female patient. A peritoneal tunnel beneath a hepatic bridge over the round ligament obscured mucinous tumor in a male patient. Peritoneal tunnels in the inguinal region or at the porta hepatis should be opened by surgical dissection so that all foci of peritoneal metastases are removed at a complete cytoreductive surgery and these sites treated with chemotherapy. [ABSTRACT FROM AUTHOR]

• Meckel's diverticulum is an outpouching of the distal small bowel. • This diverticulum may contain ectopic gastric epithelium which can become malignant. • A patient with gastric cancer with peritoneal metastases had the cancer origin in a Meckel's diverticulum. • Systemic cancer chemotherapy followed by cytoreductive surgery provided 4 years of disease-free survival. Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, resulting from incomplete obliteration of the omphalomesenteric duct in early fetal development. The diverticulum frequently contains ectopic gastrointestinal epithelial tissue, most commonly gastric or pancreatic. Adenocarcinoma can arise from either of these epithelia but is extremely rare, with less than 50 cases reported in the world literature. In a patient with peritoneal metastases from ectopic gastric mucosae in a Meckel's diverticulum a multidisciplinary treatment plan was initiated. Diagnosis was evident from study of the resected specimen of small bowel in a patient with acute abdominal pain. A multiagent chemotherapy regimen using oxaliplatin, mitomycin C, doxorubicin, and capecitabine (O-Max) resulted in a clinical and radiologic response. A second surgery with extensive sampling of tissues from the abdomen and pelvis confirmed a complete response to systemic chemotherapy. At four years from onset of disease the patient has no evidence of recurrence. Peritoneal metastases from malignant degeneration of ectopic gastric epithelium in a Meckel's diverticulum was reported. Multidisciplinary treatments were beneficial. [ABSTRACT FROM AUTHOR]

Highlights • Morbidly obese patients do get cancer and require laparotomy for resection of the malignancy. • Sleeve gastrectomy can follow a successful oncologic intervention with minimal increase in morbidity and mortality. • Doing the oncologic procedure, HIPEC, and then sleeve gastrectomy helps prevent tumor seeding at the gastric staple line. • Patient satisfaction is high with a favorable prognosis expected from a simultaneous oncologic and bariatric intervention. Abstract Introduction Morbidly obese patients may require a laparotomy to resect a malignancy. In some patients the cancer resection can be combined with the bariatric procedure to concomitantly treat both diseases. Presentation of case A morbidly obese patient with peritoneal metastases from an appendiceal mucinous neoplasm was evaluated and definitively treated with Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC), at the same time the patient was treated for morbid obesity with sleeve gastrectomy and removal of a previous laparoscopic adjustable gastric banding (LAGB). Discussion The clinical features and treatments of a cancer patient who underwent a combined surgical oncologic and bariatric procedure is presented. A second-look cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) preceded a sleeve gastrectomy. At the time of surgical exploration the prognosis from an oncologic perspective was acceptable. The near total gastric resection was performed without complications. Conclusions With short term follow-up, this patient's outcome was favorable suggesting that surgical oncologic and bariatric procedures can be combined. Further, clinical investigations are indicated in this common clinical setting. [ABSTRACT FROM AUTHOR]