Rare diaphragmatic complications following cytoreductive surgery and HIPEC: report of two cases

A rare case of pseudomyxoma peritonei with Morgagni hernia

Both pseudomyxoma peritonei and Morgagni hernias in adults are rare clinical conditions. A 70-year-old woman who was diagnosed with pseudomyxoma peritonei with Morgagni hernia underwent cytoreductive surgery and primary repair. Pseudomyxoma peritonei causes increased intra-abdominal pressure that may lead to acquired congenital diaphragmatic hernia when there is a local fragility in the diaphragmatic musculature. Parietal peritonectomy of the right diaphragmatic peritoneum can safely remove the hernia sac. The high rate of infections associated with cytoreductive surgery causes hesitation for concurrent mesh repair for Morgagni hernia. This is the first report of pseudomyxoma peritonei with Morgagni hernia. Cytoreductive surgery including parietal peritonectomy of the right diaphragmatic peritoneum plus primary repair of hernial defect was performed safely and successfully, which achieved positive short-term results for patients with pseudomyxoma peritonei-associated Morgagni hernia.

Gastric Volvulus: A Delayed Surgical Complication After Debulking and Hyperthermic Intraperitoneal Chemotherapy for Advanced Ovarian Cancer

Gastric volvulus in conjunction with diaphragmatic hernia is an uncommon but life-threatening presentation that is generally in association with hiatal hernia or diaphragmatic injuries. Diaphragmatic hernia with gastric volvulus can occur many years after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy despite initial diaphragm intactness, and should be suspected in this patient population when they present with upper gastrointestinal obstruction. An acute episode of gastric volvulus can have a mortality of 30% to 50%, hence the importance of early diagnosis and treatment. Surgical management remains the treatment of choice and can be an emergency in obstructive cases. We report the case of a 68-year-old woman presenting with signs and symptoms of acute upper gastrointestinal obstruction. Three years ago, the patient had undergone debulking surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis secondary to advanced ovarian cancer. A diagnosis of gastric volvulus was established. The pylorus was seen near the cardia on gastroscopy, and barium swallow showed stomach upside down and with a mirror image of normal anatomy suggestive of gastric volvulus. We opted for urgent laparotomy that revealed the presence of a rotated stomach adherent to the spleen and left diaphragm. After reduction, a diaphragmatic defect that was missed on the computed tomography scan was discovered and repaired, and the patient recovered uneventfully.

Passing Through a Hole: Delayed Diaphragmatic Hernia After Cytoreductive Surgery

A diaphragmatic hernia is a protrusion of abdominal contents into the thoracic cavity. Although it is commonly congenital, diaphragmatic hernias can also be acquired. Blunt or penetrating trauma are among the most frequent causes, although spontaneous or iatrogenic cases have been reported. Recently, some case reports related to diaphragmatic hernia after debulking surgery for advanced ovarian cancer have been described. This is an exceedingly rare but life-threatening complication, being prompt recognition and surgical correction critical.

We report a case of a delayed diaphragmatic hernia in a 19-year-old female resulting from cytoreductive surgery for advanced ovarian cancer. Rapid evolution from gastrointestinal symptoms to hypovolemic shock occurred, and intensive care admission was required. Immediate surgery was critical to improving the patient outcome.

This case highlights this uncommon but life-threatening complication, the challenges of diagnosing and managing those patients, and the need for early recognition, support, and surgical correction.

Diaphragm hernia after debulking surgery in patients with ovarian cancer

Over 80% of patients with epithelial ovarian cancer present with advanced disease, FIGO stage III or IV at the time of diagnosis. The majority require extensive upper abdominal surgery to obtain complete gross resection. This may include splenectomy, distal pancreatectomy, partial hepatectomy, cholecystectomy, and usually diaphragmatic peritonectomy or resection. Following surgery, diaphragmatic hernia-a very rare but serious complication-may occur. We describe four cases of left-sided diaphragmatic hernia resulting after debulking surgery, which included left diaphragm peritonectomy and splenectomy, in patients with advanced ovarian cancer. In association with the current shift towards more extensive debulking surgery for ovarian cancer, more patients may present with postoperative left-sided diaphragm hernia, making the prevention, diagnosis, and management of this complication important to practicing gynecologic oncologists. Intraoperatively the diaphragm should be checked thoroughly to rule out any defects, which should be closed. A diaphragmatic hernia may be easily misdiagnosed because the patient can present with various symptoms. While rare, these hernias require prompt identification, intervention and surgical correction to avoid serious complications.

Diaphragmatic Hernia with Gastric Volvulus and Complete Gastric Outlet Obstruction

A combination of Cytoreductive surgery (CRS) along with hyperthermic intraperitoneal chemotherapy (HIPEC) considers a crucial approach in treating designated patients with alimentary and gynecological malignancies with the involvement of the peritoneal cavity. The foremost frequent surgical complications are leakage, digestive perforations, fistulas, intestinal obstruction, abscess, and peripancreatitis. This report presents a case of a patient with a late acquired herniation of guts through the diaphragm after CRS and HIPEC that were already done 6 months back. A 26 -yearold male previously treated with CRS and HIPEC for testicular mesothelioma with peritoneal involvement, was admitted to our unit with the diagnosis of gastric outlet obstruction. His CT scan illustrated a left diaphragmatic hernia involving the stomach and splenocolic flexure. Each denudation of the diaphragmatic serosa throughout CRS which typically occurs during the surgical operation in a combination of the HIPEC heat can explain such complication. The herniation is extremely uncommonly diagnosed after CRS and HIPEC. Surgical techniques for hernia repair can be done by direct suturing of the defect or closure with artificial or biological tissue, each technique is a potential surgical technique for repair with reliable long-run results.

[Progressive paralysis of the diaphragm following intra-abdominal chemotherapy]

INTRODUCTION

In patients presenting with intra-abdominal tumor and peritoneal carcinomatosis, cytoreductive surgery associated with hyperthermic chemotherapy may offer improved survival. We describe a case of diaphragmatic paralysis following that kind of procedure.

CASE REPORT

A 60-year-old woman presented with respiratory insufficiency following cytoreductive surgery and intra-abdominal hyperthermic chemotherapy performed for pseudomyxoma intraperitonei. Pulmonary function assessment demonstrated a restrictive pattern. Three successive chest CT-scans demonstrated a thinning diaphragm muscle. Respiratory insufficiency eventually led to the death of our patient.

CONCLUSION

We conclude in favor of a muscular degeneration of the diaphragm consecutive to the combined effect of cytoreductive surgery and intraperitoneal chemotherapy. Owing to the unusual nature of this complication, we did not consider it as a hypothesis at an early point in this patient's management. We think physicians should be aware of such a complication in order to consider it in a timely way. We recommend performing a biopsy of the diaphragm for pathology examination to assess muscular degeneration.

Epididymitis following Cytoreductive Surgery with Intraperitoneal Oxaliplatin Chemotherapy: Two Case Reports

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy has emerged as an aggressive treatment option with intent to either cure or extend disease-free survival of selected patients with peritoneal carcinomatosis. However, postoperative complications are common. We describe the cases of 2 men who underwent CRS with hyperthermic intraperitoneal oxaliplatin and developed scrotal pain, which was consistent with noninfectious epididymitis.

Outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy on patients with diaphragmatic involvement

PURPOSE

The purpose of this study is to assess the short-term morbidity and mortality in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) with diaphragmatic involvement.

METHODS

All patients undergoing CRS/HIPEC at a tertiary care institution from April 2007 to October 2013 were retrospectively reviewed. Patients with diaphragmatic disease (Group 1) were compared to those who did not (Group 2). Univariate, propensity score analysis, and multivariate analysis were used to compare groups focusing on postoperative complications.

RESULTS

A total of 199 patients underwent CRS/HIPEC. Diagnoses included appendiceal/colorectal cancers (56 %), pseudomyxoma peritoneii (12 %), and gastric cancer (7 %). Group 1 was composed of 89 patients (44.7 %) with diaphragmatic involvement, of which 37.1 % underwent diaphragm stripping and 62.9 % required a full-thickness diaphragmatic resection. Group 1 had longer operative times (p = 0.009), increased transfusion requirements (p = 0.007), less optimal cytoreduction (p = 0.010), longer ICU stay (p = 0.003), and overall hospital stay (p = 0.039). Major complications were significantly higher in Group 1: 26 (29 %) versus 16 (15 %), p = 0.020. Rate of respiratory complications was not different between groups (G1: 14/26, 53.8 % and G2: 6/16, 37.5 %, p = NS). Ninety-day mortality was not significantly different. Diaphragmatic involvement (Estimate 1.235, SE 0.387, p = 0.017) was an independent predictor of 30-day morbidity in patients with <5 organs involved in cytoreduction.

CONCLUSIONS

Diaphragmatic involvement is associated with higher tumor burden and more complex operations. It is a strong independent predictor 30-day morbidity in patients with <5 organs involved in cytoreduction. However, perioperative mortality rates are not significantly different between the groups, suggesting that diaphragm stripping or resection is warranted in well-selected patients if it allows for complete cytoreduction.

Intrathoracic gastric volvulus as a severe, delayed surgical complication after left subphrenic peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced ovarian cancer

Patients with extensive peritoneal spread from advanced ovarian cancer often undergo several upper abdominal surgical procedures including subphrenic peritonectomy to obtain optimal cytoreduction. The most common complications are pleural effusions, pancreatic leakage and endoabdominal collections. This case report describes an unusual complication, a diaphragmatic hernia with an intrathoracic gastric volvulus developing four months after the patient underwent left subphrenic peritonectomy during interval debulking surgery and hyperthermic intraperitoneal chemotherapy for advanced ovarian cancer.