Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for patients with peritoneal carcinomatosis. Total pelvic exenteration (TPE) is an established treatment option for locally advanced pelvic malignancy. These two procedures have high mortality and morbidity, and therefore, their combination is not currently recommended. Herein, we reported our experience on TPE associated with CRS/HIPEC with a critical analysis for rectal cancer with associate peritoneal metastases. Methods: From March 2006 to August 2020, 319 patients underwent a CRS/HIPEC in our hospital. Among them, 16 (12 men and four women) underwent an associated TPE. The primary endpoints were perioperative morbidity and mortality. Results: There was locally recurrent rectal cancer in nine cases, six locally advanced primary rectal cancer, and a recurrent appendiceal adenocarcinoma. The median Peritoneal Cancer Index (PCI) was 8. (4–16). Mean duration of the surgical procedure was 596 min (420–840). Complete cytoreduction (CC0) was achieved in all patients, while clear resection (R0) margins on the resected pelvic organs were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications (grade III to V) that led to death in two cases (12.5%). The total reoperation rate for patients was 6/16 (37.5%) and 3/16 (18.75%) with percutaneous radiological-guided drainage. Conclusions: In summary, TPE/extended TPE (ETPE) associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface diseases if a R0 resection could be achieved on all sites. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended.

Background By inhibiting the growth of pathogenic bacteria and modulating the local intestinal immune system, probiotics may reduce bacterial translocation and systemic endotoxaemia, factors partially responsible for post‐operative complications following liver resection for hepatocellular carcinoma in patients with cirrhosis. Methods Patients with resectable hepatocellular carcinoma developed in the setting of chronic liver disease were prospectively divided into two equal‐sized groups: one receiving probiotic treatment 14 days prior to surgery and the other receiving placebo. The primary endpoint was the level of circulating endotoxins after hepatectomy. Secondary endpoints were systemic inflammation (inflammatory cytokine levels), post‐operative liver function and overall post‐operative complication rate. Results From May 2013 to December 2018, 64 patients were randomized, and 54 patients were included in the analysis, 27 in each arm. No significant change in endotoxin levels was observed over time in either group (P = 0.299). No difference between the groups in terms of post‐operative liver function and overall complication rates was observed. The only differences observed were significant increases in the levels of TNFalpha (P = 0.019) and interleukin 1‐b (P = 0.028) in the probiotic group in the post‐operative period. Conclusion Contrary to the modest data reported in the literature, the administration of probiotics before minor liver resection for hepatocellular carcinoma developed in the setting of compensated chronic liver disease does not seem to have an impact on circulating endotoxin levels or post‐operative complication rates. Trial registration Trial registration: NCT02021253.

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Thymectomy remains a therapeutic challenge in elderly patients with thymoma associated with myasthenia gravis (MG). Thymectomy, in the multimodality therapy of these patients should be discussed by multidisciplinary expert teams. Available data show that robotic thymectomy seems to be as safe and as effective as an open procedure with better short-term outcomes and with at least the same quality of oncologic resection. Nevertheless, data are limited on the safety and effectiveness of robotic thymectomy in elderly patients. We present here, our surgical technique of robotic radical en bloc thymothymectomy that we use in all our patients with thymoma associated with MG, with particularities related to elderly patients. We also review the medical and surgical literature on robotic thymectomy for thymoma and MG. The robotic platform allows us to "mimic an open procedure by a minimally invasive approach", and thus, we are able to perform a complete and radical thymothymectomy comparable to open procedure with the same quality of oncologic resection, but with the advantages of a minimally invasive approach regarding short-term outcomes.

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