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PURPOSE: A valid comparison of immune function among different patients with different primary pathologies or even with different tumour burdens requires the common use of a reliable assessment of the patient's condition. The combined immuno-PCI system can translate a complex clinical situation into a simple point value to improve postoperative outcomes to assess the prognostic significance of combined immuno-PCI in peritoneal metastatic patients treated with cytoreductive surgery(CRS) and hyperthermic intraperitoneal chemotherapy(HIPEC). PATIENTS AND METHODS: Four hundred twenty-four patients from the prospectively maintained database of Dokuz Eylul University Peritoneal Surface Malignancy Center were retrospectively analysed. In addition to the demographic findings and the well-known clinicopathologic factors, several systemic inflammation-based prognostic scores, including the modified Glasgow prognostic score (mGPS), CRP-albumin ratio (CAR), neutrophil-lymphocyte ratio (NLR), neutrophil-thrombocyte ratio (NTR), and thrombocyte count, were all searched and stratified into scoring categories as prognostic determinants of surgical complications, final oncologic outcomes, recurrent disease, disease-free survival (DFS), and overall survival (OS). ROC analyses were performed, and cut-off values were obtained for all immune parameters by using the Youden index method. RESULTS: There were 314 (74%) women and 110 (26%) men. The median age was 56 (ranging from 18 to 86) years. The most frequent sites of peritoneal metastasis were colorectal (n = 204; 48%) and gynaecologic carcinomas (n = 187; 44%). Thirty-three patients (8%) had primary malignant peritoneal mesothelioma. The median follow-up was 37.8 (ranging from 1 to 124) months. The overall survival was 51.7%. The 1-year, 3-year, and 5-year survival rates were estimated as 80%, 48.4%, and 32.6%, respectively. PCI-CAR-NTR (1 to 3) (p < .001) scoring was an independent prognostic factor for DFS. In a Cox backwards regression analysis, anastomotic leak (p = .002), completeness of cytoreduction (p = .0014), number of organ resections (p = .002), lymph node involvement (p = .003), and PCI-CAR-NTR (1 to 3) scoring (p = .001) were found to be independently significant prognostic factors for overall survival. CONCLUSION: The PCI is a reliable and consistently valid prognostic factor to evaluate the tumour burden and tumour extent in patients treated with CRS/HIPEC. Staging the host by combining the PCI with an immunoscore may help to improve the outcomes of complications and overall survival in these complex cancer patients. The aggregate maximum immuno-PCI tool may be a better prognostic measure for outcome evaluation.

BACKGROUND: Gastrointestinal anastomotic leak (GAL) is a major cause of morbidity and mortality after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to determine the risk factors associated with GAL in peritoneal metastases (PM) surgery. METHODS: Patients who underwent CRS and HIPEC with gastrointestinal anastomosis were included. Charlson Comorbidity Index (CCI) and Eastern Cooperative Oncology Group (ECOG) performance status were used to assess preoperative condition of the patients. GAL was recorded as gastrointestinal extralumination diagnosed clinically, radiologicaly, or during reoperation. RESULTS: Among 362 patients who were analyzed, the median age was 54 years, 72.6% were female, and the most common histopathologies were ovarian cancer (37.8%) and colorectal (36.2%) cancer. The median Peritoneal Cancer Index was 11 and 80.1% of the patients underwent complete cytoreduction. A single anastomosis was performed in 293 (80.9%) patients, two anastomoses in 51 (14.1%) and three anastomoses in 18 (5%) patients. Diverting stoma was performed in 43 (11.8%) patients. GAL was seen in 38 (10.5%) patients. Smoking (p

BACKGROUND: Gastrointestinal anastomotic leak (GAL) is a major cause of morbidity and mortality after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to determine the risk factors associated with GAL in peritoneal metastases (PM) surgery. METHODS: Patients who underwent CRS and HIPEC with gastrointestinal anastomosis were included. Charlson Comorbidity Index (CCI) and Eastern Cooperative Oncology Group (ECOG) performance status were used to assess preoperative condition of the patients. GAL was recorded as gastrointestinal extralumination diagnosed clinically, radiologicaly, or during reoperation. RESULTS: Among 362 patients who were analyzed, the median age was 54 years, 72.6% were female, and the most common histopathologies were ovarian cancer (37.8%) and colorectal (36.2%) cancer. The median Peritoneal Cancer Index was 11 and 80.1% of the patients underwent complete cytoreduction. A single anastomosis was performed in 293 (80.9%) patients, two anastomoses in 51 (14.1%) and three anastomoses in 18 (5%) patients. Diverting stoma was performed in 43 (11.8%) patients. GAL was seen in 38 (10.5%) patients. Smoking (p

Background and Aims: Managing the treatment of pancreatic cystic lesions is often difficult for the clinician. Therefore, history, clinical, laboratory, radiological imaging, endoscopic ultrasound, cyst fluid analysis obtained by endoscopic ultrasound guided fine needle aspiration biopsy and cytopathology data are important for differential diagnosis. In our study, we examined the performance of imaging methods in the management of pancreatic pseudocysts detected by endoscopic ultrasound and the clinical characteristics of patients who underwent endoscopic drainage by endoscopic ultrasound. Materials and Method: In our study, patients over 18 years of age who underwent endoscopic ultrasound for pancreatic cysts in the Endoscopy Unit of Dokuz Eylül University Faculty of Medicine, Department of Internal Medicine/Gastroenterology Clinic between July 2009 and January 2018 were evaluated retrospectively. 102 patients with pre-diagnosis of pancreatic pseudocyst according to Atlanta Classification as a result of endoscopic ultrasound and/or endoscopic ultrasound guided fine needle aspiration biopsy evaluation, and 36 patients who underwent cystogastrostomy/cystoduodenostomy were included in the study. Demographic data, clinical characteristics, laboratory data, radiological/endoscopic ultrasound image reports and pathological examination results of the patients were evaluated retrospectively. Results: Radiologically, the percentage of separating pancreatic cysts as pseudocyst was 58.3% for computed tomography, 70.5% for magnetic resonance imaging, 84.3% for endoscopic ultrasound, and 100% for endoscopic ultrasound guided fine needle aspiration biopsy. Diagnostic performance was found to be 47.5% in computed tomography, 63.1% in magnetic resonance imaging, 78.4% in endoscopic ultrasound, and 95% in endoscopic ultrasound guided fine needle aspiration biopsy. Drainage procedure was applied to 36 of 102 patients with pancreatic pseudocyst. Complete resolution was achieved in 35 of 36 patients who underwent drainage procedure, and partial resolution was achieved in 1 patient. When the age, gender, localization of the cyst, serum C-reactive protein, serum amylase, cyst amylase, cyst carcinoembryonic antigen, cyst arbohydrate antigen 19-9 levels were compared, no significant difference was found between patients who underwent and did not undergo drainage. Conclusion: Compared to computed tomography and magnetic resonance imaging, endoscopic ultrasound and endoscopic ultrasound guided fine needle aspiration biopsy have higher diagnostic sensitivity in the diagnosis and follow-up of pancreatic pseudocysts. Despite this, up to 15% of endoscopic ultrasound and endoscopic ultrasound guided fine needle aspiration biopsy are not sufficient to differentiate between neoplastic/benign cysts. Today, there is no consensus on the timing of endoscopic drainage in pancreatic pseudocyst. The high success and low complication rates in our endoscopic ultrasound - guided drainage procedures show us that this method is suitable for most of the patients and carries an acceptable risk., Giriş ve Amaç: Pankreas kistik lezyonlarının tedavisini yönetmek çoğu zaman klinisyen için zordur. Bu nedenle ayırıcı tanı yapılması için öykü, klinik, laboratuvar, radyolojik görüntüleme, endoskopik ultrasonografi, endoskopik ultrasonografi - ince iğne aspirasyon biyopsisi ile alınan kist sıvı analizi ve sitopatoloji verilerinin değerlendirilmesi önemlidir. Endoskopik ultrasonografi ile saptanan pankreatik psödokistlerin yönetiminde görüntüleme yöntemlerinin performansını ve endoskopik ultrasonografi eşliğinde endoskopik drenaj işlemi yaptığımız hastaların klinik özelliklerini çalışmamızda inceledik. Gereç ve Yöntem: Çalışmamızda Temmuz 2009-Ocak 2018 tarihleri arasında Dokuz Eylül Üniversitesi Tıp Fakültesi Hastanesi İç Hastalıkları Anabilim Dalı Gastroenteroloji Kliniği Endoskopi Ünitesinde pankreas kisti nedeniyle endoskopik ultrasonografi yapılan 18 yaş üstü hastalar retrospektif olarak değerlendirilmiştir. Endoskopik ultrasonografi ve/veya endoskopik ultrasonografi - ince iğne aspirasyon biyopsisi değerlendirilmesi sonucu Atlanta klasifikasyonuna göre pankreatik psödokist tanısı alan 102 hasta çalışmaya dahil edilmiştir. Hastaların demografik verileri, klinik özellikleri, laboratuvar verileri, radyolojik/endoskopik ultrasonografi görüntü raporları ve patolojik inceleme sonuçları retrospektif olarak değerlendirilmiştir. Bulgular: Radyolojik açıdan pankreas kistlerini, psödokist olarak ayırma yüzdesi bilgisayarlı tomografi için %58.3, magnetik rezonans için %70.5, endoskopik ultrasonografi için %84.3, endoskopik ultrasonografi + ince iğne aspirasyon biyopsisi için ise %100 olarak saptanmıştır. Tanısal performans olarak bilgisayarlı tomografi %47.5, magnetik rezonans %63.1, endoskopik ultrasonografi %78.4, endoskopik ultrasonografi + ince iğne aspirasyon biyopsisi %95 olarak saptanmıştır. Pankreatik psödokist tanılı 102 hastadan, 36’sına drenaj işlemi uygulanmıştır. Drenaj işlemi uygulanan 36 hastanın, 35’inde tam rezolüsyon, 1 hastada kısmi rezolüsyon sağlanmıştır. Drenaj işlemi uygulanan ve uygulanmayan hastalar arasında yaş, cinsiyet, kistin lokalizasyonu, serum C reaktif protein, serum amilaz, kist amilaz, kist karsinoembriyonik antijeni, kist karbonhidrat antijen 19-9 düzeyleri kıyaslandığında anlamlı farklılık elde edilememiştir. Sonuç: Pankreatik psödokistlerin tanısında ve izleminde bilgisayarlı tomografi ve magnetik rezonansa kıyasla endoskopik ultrasonografi ve endoskopik ultrasonografi - ince iğne aspirasyon biyopsisi daha yüksek tanısal duyarlılığa sahiptir. Buna rağmen %15’e varan oranda endoskopik ultrasonografi ve endoskopik ultrasonografi - ince iğne aspirasyon biyopsisi neoplastik/benign kist ayrımını yapmada yeterli olamamaktadır. Günümüzde pankreatik psödokistlerde endoskopik drenaj zamanlaması ile ilgili bir fikir birliği bulunmamaktadır. Bizim uyguladığımız endoskopik ultrasonografi eşliğinde drenaj işlemlerindeki yüksek başarı ve düşük komplikasyon oranları bize hastaların büyük bir kısmı için bu yöntemin uygun olduğunu ve kabul edilebilir oranda risk taşıdığını göstermektedir

Background:Cytoreductivesurgery(CRS) with hyperthermic intraperitoneal chemotherapy(HIPEC) has becomethe treatment of choice for resectable peritoneal metastasis(PM) to improve theoverall survival of these patients. It’s so difficult to predict how the morbi-mortalityresults and oncologic outcomes will be in repeated CRS(re-CRS). Objectives:Toevaluate the surgical and oncologic outcomes of primary CRS&HIPEC and re-CRS&HIPEC.Methods: Prospectivelymaintained database of 661 PM patients treated with potentially curative intentCRS&HIPEC thorough the years of 2007 and 2020 was evaluated. Re-cytoreductive surgery was performed in51 of them. Seven of these patients underwent CRS for the third time. The median age was 54 (ranging, 16-76) yearsand 72.5 % of the patients was female. The most common primaries were ovarian(39.2%)and colorectal(37.2%) tumors. The median Peritoneal Cancer Index(PCI) was 7(ranging, 3-21) and 84.3% of the patients underwent CC-0. Allstandart clinico-pathological characteristics, re-operative findings, morbi-mortalityresults, and final oncologic outcomes were reviewed and were compared with thoseof patients who had primary CRS&HIPEC.Results: Themedian operating time was 300 minutes(range, 120–570) and 305 minutes(ranging,120–650) during the primary CRS and re-CRS. While less than five organs wereresected in 82.7%(n=42) of the patients who underwent primary CRS, it was84.3%(n=43) for the patients who underwent re-CRS. The median length of hospital stay(LoHS) after primaryCRS and re-CRS were 15 days(ranging, 4-48) and 12 days(ranging, 5-90), respectively.Themorbidity rates were 31.3%(n=16) and 7.8%(n=4), respectively. Thehigh grade morbidity rate was lower in re-CRS group(grade III-IV 21.5% vs 7.8%).The mortality rates were similar in between the patients who underwent primaryCRS(5.8%) and re-CRS(5.8%). When the patients who underwent CRS for the thirdtime were compared with patients who underwent re-CRS, no significantdifference was found in terms of surgical outcomes. Thepatients in the group who underwent re-CRS had significantly shorter meanhospital(LoHS)(p. The3- and 5-year survival rates were lower in re-CRS group(17% and 5% vs 22% and11%), respectively.Conclusions: Re-CRSand HIPEC can be safely and effectively performed with acceptablemorbi-mortality results and oncologic outcomes in carefully selected andintensely followed-up PM patients at experienced centers.Key words: Repeated cytoreductive surgery, hyperthermicintraperitoneal chemotherapy, peritoneal metastasis.

Background:Urgentre-laparotomy(URL) can be accepted as an important index of quality indicatorin cytoreductive surgery(CRS) and hyperthermic intraperitonealchemotherapy(HIPEC). Complications after CRS are usually associated withshortened survival, early recurrence of primary tumor, exhaustion of center’ssources, and high costs. However, reports of URL tend to be scarce, very limited,and fragmented.Objectives:Toevaluate/determine the morbi-mortality outcomes of the urgent re-laparotomizedpatients treated with CRS and HIPEC. Methods:Prospectivelymaintained database of 661 patients treated with potentially curative intent ofCRS&HIPEC in years of 2007 and 2020 were evaluated. URL was done for 28patients as planned re-exploration(4.2%): 22(78.6%) of them was female. Themedian age was 57 year (ranging, 24 to 76). There were 22(78.6%) patients over65 years old. Sixty-four(n=18) percent of the URL patients were receivedneoadjuvant chemotherapy. All standart clinico-pathological characteristics,re-operative findings, and final outcomes were analyzed. The well-knownimmunoscores such as neutrophile-lymphocyte(N/L), neutrophile-thrombocyte (N/T),and CRP-albumin ratios(CAR) were determined.Results: Themain indication for URL was small bowel anastomotic leak(n=13; 46.4%). Theabdominal wall disruption(n=5; 17.9%) was the second indication. The frequentlocalization of damaged organ was again small bowel. The 28.6% of patients(n=8)were re-operated in early postoperative period(in 7 days), whileas the rest ofthem [71.4%(n=20)] in 90 days. There was only one re-URL patient in thisseries. Many of them(n=16; 57.1%) had more than one co-morbidities. Delvinginto the overall group, there were Dindo-Clavien(D-C) grade I-II complicationsin 104(16.4%) patients and D-C grade III-IV in 88(13.9%) patients, whereas inURL patient group, D-C grade III-IV complications were seen in 22(78.6%). Inthis prospective cohort, the mortality rate was 3.2%(n=20) without anyre-exploration. However, six(21.4%) patients were also lost in URL patients.The main reason for failure-to-rescue was sepsis due to entero-enteralanastomotic leak. In four of them, multiple co-morbidities were affected thepost-URL care. Fifty percent of mortal patients had neoadjuvant chemotherapy.The cut-off PCI scores of URL, saved-URL, and lost-URL patients were 13, 14,and 12, respectively. CC-0 score was detected in 23 URL patients in whom fourof them were lost, whileas CC-1 in 5 in whom two of them were lost. ForURL-patients, pre-urgent re-laparotomy median N/L, N/T, and CAR values were9.12(ranging, 1.72 to 37.5), 0.03(ranging, 0.01 to 0.12), and 41.4(ranging, 4.2to 181.3), respectively. Interestingly, N/L and CAR values(4.71 and 28.8)estimated before pre-CRS were also significantly higher(p=.01 and pConclusions:Thejudgemental factors at work were complex in even planned URL. The overallsurvival depends almost entirely on the severity of disease. Patients with highrisk factors could be selected to an intense care postoperatively for closemonitoring. Timely intervention and proper management strategy are utmost importantissues to lower further morbi-mortality in patients treated with URL.&nbsp

Objectives: Primary sclerosing cholangitis is a chronic inflammatory disease of the intrahepatic and extrahepatic bile ducts. More than half of the patients will face end-stage liver disease and require liver transplant. Here, we describe the long-term outcomes of liver transplant in patients with primary sclerosing cholangitis at our center.