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There is ongoing controversy concerning the indications and benefits of early postoperative intraperitoneal chemotherapy (EPIC) following cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) in patients with pseudomyxoma peritonei. The main contra-indications preventing wide-spread use of EPIC are reports of an increased postoperative morbidity with no clear evidence of oncological benefit. This paper reports a single high volume institution experience with EPIC over a 25-year period.This is a retrospective analysis of a single institution prospective database of patients undergoing CRS and HIPEC for appendiceal neoplasms from March 1994 to December 2019. Sub group analysis of patients who received EPIC with 5FU 15mg/m2 is reported and compared with patients who did not receive EPIC.Overall, 632/1564 (40%) received EPIC. Patients who received EPIC were younger (median age 55 (IQR 45-63) vs 59 (IQR 50-68)) with similar extent of disease to those who did not have EPIC. EPIC was more likely to be given after complete cytoreduction. The use of EPIC has reduced over the last 25 years from 78% of patients initially to 16% most recently. Length of stay in critical care and total hospital stay were longer in patients who received EPIC but surprisingly major morbidity (Clavien Dindo Grade3) was lower (p = 0.001).EPIC can be administered safely following CRS and HIPEC for PMP of appendix origin when used in carefully selected patients in a high-volume centre. Randomised trials are needed to establish impact on disease free and overall survival to optimize selection criteria.

Hepatic cystogenesis in Polycystic Liver Disease (PLD) is associated with increased levels of cAMP in cholangiocytes lining liver cysts. TGR5, a G protein-coupled bile acid receptor, is linked to cAMP and expressed in cholangiocytes. Therefore, we hypothesized that TGR5 might contribute to disease progression. We examined expression of TGR5 and Gα proteins in cultured cholangiocytes and in livers of animal models and humans with PLD. In vitro, we assessed cholangiocyte proliferation, cAMP levels, and cyst growth in response to: (i) TGR5 agonists [taurolithocholic acid (TLCA), oleanolic acid (OA) and two synthetic compounds]; (ii) a novel TGR5 antagonist (SBI-115); and (iii) a combination of SBI-115 and pasireotide, a somatostatin receptor (SSTR) analog. In vivo, we examined hepatic cystogenesis in OA-treated PCK rats and after genetic elimination of TGR5 in double mutant TGR5-/-;Pkhd1del2/del2 mice. Compared to control, expression of TGR5 and Gαs (but not Gαi and Gαq) proteins was increased 2-3-fold in cystic cholangiocytes in vitro and in vivo. In vitro, TGR5 stimulation enhanced cAMP production, cell proliferation and cyst growth by ∼40%; these effects were abolished after TGR5 reduction by shRNA. OA increased cystogenesis in PCK rats by 35%; in contrast, hepatic cystic areas were decreased by 45% in TGR5-deficient TGR5-/-;Pkhd1del2/del2 mice. TGR5 expression and its co-localization with Gαs were increased ∼2-fold upon OA treatment. Levels of cAMP, cell proliferation and cyst growth in vitro were decreased by ∼30% in cystic cholangiocytes after treatment with SBI-115 alone and by ∼50% when SBI-115 was combined with pasireotide. Conclusion: TGR5 contributes to hepatic cystogenesis by increasing cAMP and enhancing cholangiocyte proliferation. Our data suggest that a TGR5 antagonist alone or concurrently with SSTR agonists represents novel therapeutic approaches in PLD. This article is protected by copyright. All rights reserved.

Context: Depression is a risk factor for vascular disease and vice versa. Identification of biological mechanisms common for depression and vascular pathology at microvascular level, and understanding their clinical significance may contribute to better treatment and prognosis of this combined physical/psychiatric disorder. Evidence Acquisition: We searched the PubMed computer database for the following key words “Microvascular AND Depression” on the 28th of October, 2015 to obtain relevant articles, which were consequently summarized to facilitate further research in the field of psychiatry. Results: The majority of studies support the suggestion that microvascular abnormality is associated with depression even if several documents do not necessarily support this idea. It seems probable that microvascular abnormality is only relevant in particular subtypes of depression, for example depression due to a general medical condition, late-life depression, or pharmacoresistant depression. The biological mechanisms by which microvascular abnormality is interconnected with depression may cover genetics, epigenetics, endothelial dysfunction, inflammation or hyperhomocysteinemia. Conclusions: Further research should be aimed at identifying biological mechanisms common in depression and microvascular pathology, including genetics and epigenetics, longitudinal studies of this subcategory of patients with depression, and possible pharmacotherapy overcoming the usual non-responsiveness. An active detection and aggressive treatment of physical diseases associated with microvascular pathology and depression, like hypertension, diabetes or inflammation, is warranted. This way, the patients experience less distress, their quality of life will increase, and societal cost of this vascular/psychiatric disorder will be reduced.