Tarek Amin

Background and Objectives: The aim of this study was to look at the overall survival (OS), progression‐free survival (PFS), and prognostic factors associated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) combined with intraoperative radiation therapy (IORT).Methods: This study is a single center retrospective study performed on 159 patients who underwent treatment with CRS and HIPEC combined with IORT for abdominopelvic malignancies. OS and PFS were used to evaluate the efficacy of this treatment strategy amongst patients with abdominopelvic malignancies.Results: The cohort's median age was 53 years, with a male predominance (58.5%). The median OS was not reached, but the mean OS was 76.87 months. In univariate analysis, several factors, including synchronous organ metastasis, Pathologic Peritoneal Carcinomatosis Index (pPCI) ≥10, increased estimated blood loss, and severe postoperative complications, were associated with worse OS. However, multivariate analysis identified pPCI ≥ 10 as the sole independent predictor of worse OS. The 1‐ and 3‐year survival rates were 83% and 70.4%, respectively. pPCI ≥ 10 and severe postoperative complications were significant predictors of worse survival outcomes.Conclusions: Radical surgery alone is not enough, and CRS combined with HIPEC and IORT, when indicated, was proven to be safe and effective with no added morbidity or mortality.

Peritoneal surface malignancies (PSM) are aggressive and associated with poor prognosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) have been used to treat PSM since 1990. In Saudi Arabia, the first HIPEC and pressurized intraperitoneal aerosol chemotherapy (PIPAC) were performed in 2008 and 2019, respectively. With increasing incidences of PSM in Saudi Arabia, the demand for such procedures has grown. This article outlines the status of PSM management in Saudi Arabia and its prospects.

Peritoneal sarcomatosis (PS) is a rare tumor with limited therapeutic options. Bidirectional intraoperative chemotherapy (BDIC) using intravenous ifosfamid

Lemmel syndrome is a rare cholestatic disease caused by a periampullary duodenal diverticulum (PAD) compressing the common bile duct (CBD) or pancreatic duct, which results in acute abdominal pain and/or obstructive jaundice in the absence of other pathology explaining the symptoms. It can be easily misdiagnosed unless carefully detected by abdominal ultrasound (US), barium studies, computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiography (ERCP), which is also the treatment modality of choice. We herein report a case of a 62-year-old male presenting with prolonged hypochondrial pain. He was diagnosed with Lemmel syndrome after performing US, barium meal, CT scan, EGD, and MRCP that was managed successfully by ERCP with sphincterotomy and stent placement.

Appendiceal mucinous adenocarcinoma is a term that was given for invasive appendiceal tumors. It is always present with pseudomyxoma peritonei which is a complex disease. These tumors have the tendency to surround the primary tumor then extend primarily and extensively all over the peritoneal cavity as the primary site of metastases. The invasion through the abdominal wall muscles is rare but the penetration and passing through these muscles to the subcutaneous tissue are extremely rare. A 62-year-old male patient known to have pseudomyxoma peritonei presented with gluteal abscess. After 2 weeks from the abscess drainage, the patient underwent cytoreductive surgery (CRS) combined with intraoperative radiotherapy (IORT) and hyperthermic intraperitoneal chemotherapy (HIPEC). He tolerated the operation well and discharged home in a good condition. Even with extensive appendiceal mucinous neoplasms presented with the penetration of the abdominal wall muscles, still aggressive management should be considered.

In spite of the advances in modern surgery, the outcome for patients suffering from pancreatic adenocarcinoma or periampullary adenocarcinoma is still bad. Recently, introperative radiotherapy (IORT) was introduced into the multimodality management approach to improve both tumor control and patient' survival. To evaluate our initial experience in combined surgical resection and IORT, and to evaluate the feasibility of the application of IORT and its effect on morbidity, mortality and local recurrence. This study was conducted at King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia. Data were collected retrospectively. A total of six patients were included in the study, during the period from November 2013 to April 2017. All surgeries were done by the same surgeon. The average age was 60 years (50-71). The patients were four males and two females. Five patients underwent complete surgical resection (pancreaticoduodenectomy) combined with IORT. One patient had locally advanced pancreatic tumor which was beyond surgical resection, for whom surgical bypass was done to overcome the biliary obstruction combined with IORT. Two patients died from disease progression and liver metastases. The remaining four patients survived without any evidence of local recurrence or metastases on follow-up. Application of IORT is safe and feasible. It can be applied without additional morbidities or mortalities. Although our results are satisfactory, yet they need to be applied on a larger number of patients with longer periods of follow-up to reach sound conclusions.

Cytopenia after hyperthermic intraperitoneal chemotherapy (HIPEC) with cytoreductive surgery (CRS) has been reported in non-comparative studies with various chemotherapeutic regimens. This study compared the incidence of leukopenia and thrombocytopenia in patients who underwent CRS/HIPEC and received melphalan or cisplatin plus mitomycin-c (CIS + MMC).

Introduction: Persistent Müllerian Duct Syndrome (PMDS) is a rare sexual disease. It is characterized by the presence of female reproductive structures such as uterus, cervix, fallopian tubes and upper part of vagina in a normal genotypically and phenotypically male. The diagnosis is usually incidental since the patients will present with normal external genitalia and secondary sexual characteristics. Imaging techniques such as magnetic resonance imaging (MRI), computed tomography (CT) scan, or ultrasound (US) could help in the diagnosis. Case presentation: A 45-year-old male presented with bilateral undescended testes since birth and 2 months history abdominal mass. CT scan showed a 13 × 17 × 20 cm solid pelvi-abdominal mass. The diagnosis of mixed germ cell tumor of the undescended testes was made based on the CT scan. During resection of the tumor, patient was found to have a uterus, fallopian tubes and ovaries. Discussion: Pathological investigation showed endometrial tissues with portion of lower uterine segment and cervix with remnant of testes with marked atrophy. No Ovarian tissues were found nor fallopian tube as well. The diagnosis of PMDS was made based on the pathological report. Conclusion: PMDS is a challenging condition to diagnose. Radiological investigation can miss the presence of the Müllerian duct structures as in our case because of the unusual presentation of this condition. Early diagnosis and management is important as the malignant transformation is high due to the undescended testes. Highlights:

Background Iatrogenic ureteric injury is a rare, yet serious operative complication in gynecologic procedures and associated with substantial morbidities such as prolonged hospitalization, additional financial-based ureter-related repairing procedures, impaired renal function, and compromised quality of life. Direct visual identification of ureters can be very challenging in managing patients with primary advanced or recurrent disseminated intraperitoneal gynecologic malignancies, who are referred to complex procedures such as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Aims To report our single-center experience (feasibility and morbidity) with prophylactic ureteric stents as a routine practice before CRS+HIPEC procedure in managing peritoneal carcinomatosis (PC) from gynecologic malignancies. Methods From June-2010 to March-2014, all patients with gynecologic-related PC, managed with CRS+HIPEC, and underwent prophylactic ureteric stents. The data were retrospectively abstracted and analyzed. Results Fifty-three patients were identified. Almost all PC cases were secondary/recurrence presentations (90.6 %) and originated from ovarian cancer (84.9 %). Optimal cytoreduction microscopic residual disease) was achieved in 35 patients (60 %). Average insertion time of ureteric stents was 8.9 ± 3.3 min. Fifty-two patients (98.1 %) received bilateral ureteric stents. Forty-nine patients (92.5 %) had their ureteric stents removed by the end of procedure. No patient experienced major peri-operative urinary tract-related complications. Conclusions Prophylactic ureteric stents appeared to be feasible, potentially safe, and could reduce the risk of iatrogenic ureteric injuries without incurring an increase in urinary tract-related complications. Prophylactic ureteric stenting does not eliminate the necessity for competent anatomical knowledge, meticulous retroperitoneal dissection and direct intra-operative visualization of ureters.

The metastatic breast cancer to the duodenum is rare in spite of common breast cancer. In this paper, we are reporting a rare case of 50-year-old lady who presented with intestinal obstruction as result of metastatic breast cancer which completely responds to chemotherapy. The tumor presents again as brain metastasis after stop of Herceptin due to cardiac toxicity.