Hospital Universitario de Fuenlabrada. Servicio de Cirugía General y del Aparato Digestivo. Cº del Molino, 2 280942 Fuenlabrada. Madrid. Spain.
gortega@salud.madrid.org
1986-1992 - Medical School - Universidad Autonoma de Madrid, Spain, MD degree 1993-1997 - Residency in General and Digestive Surgery - Hospital Universitario Doce de Octubre. Madrid. Spain. 1997-2000 - Postgraduate Diploma in Research Methods and Statistics in Health Sciences, Universidad Autonoma de Barcelona. Spain. 1998 - IRCAD-EUROPEAN INSTITUTE OF TELESURGERY. STRASBOURG, FRANCE. Laparoscopic Surgery University Diploma Louis Pasteur University of Strasbourg. Postgraduate Certification 1998-2002 - Staff Surgeon - Department of General and Digestive Surgery. Hospital Universitario de Ciudad Real. Spain. 2000-2001 - Gastrointestinal Surgical Oncology Fellowship. Washington Hospital Center-Washington Cancer Institute. Washington DC. USA. 2002-2004 - Senior Surgeon - Department of Surgical Oncology. MD Anderson Cancer Center Madrid. Spain. 2004 - UEMS-European Board Qualification in Surgical Oncology 2004 to date - Senior Surgeon - Department of General and Digestive Surgery. Peritoneal Surface Malignancy Program. Hospital Universitario de Fuenlabrada. Madrid. Spain. 2004 t o date - Senior Consultant Surgeon - Department of Surgical Oncology. Breast and Melanoma Unit. MD Anderson Cancer Center Madrid. Spain. 2005-2007 - Centro Nacional de Investigaciones Oncológicas (CNIO)-EUROPEAN SCHOOL OF ONCOLOGY (ESO). Master Molecular Oncology. Molecular Basis of Cancer. 2008 - The Netherlands Cancer Institute. Department of Surgery. EUSOMA-ESSO-ESO-EONS Training programme “The training of specialised health professionals dealing with breast cancer”. Amsterdam. Netherland.
Abstract: Several methods of delivering hyperthermic intraperitoneal chemotherapy (HIPEC) during the course of cytoreductive surgery have been described, but no significant differences in treatment results have been found among them. HIPEC is a safe treatment for the patient and for healthcare workers involved in the procedure provided standard protective and environmental measures are used. This article describes the different techniques in use and the technology available for the administration of HIPEC. Also reviewed are the safety features that must be taken into consideration when performing this procedure. Recommended guidelines to prevent associated occupational hazards are provided.
Abstract: Electrochemotherapy (ECT) is a therapeutical procedure based on the induction of cell membrane electroporation, by cell exposure to electric fields lasting a few microseconds, combined with the local or systemic administration of cytotoxic drugs, with an intracellular target and high intrinsic efficacy, but poor cell membrane permeability. ECT is an effective local therapy for any histological tumour that has been used clinically since 2005 and is currently in use in 83 centres all over Europe. In the literature, ECT as a local oncological treatment shows an objective response between 70 and 90% in mucocutaneous primary and metastatic lesions, is cost effective and has few local and systemic side effects. In this manuscript, we present an overview of the European experience in ECT, as well as our own experience in a specialised Spanish oncological centre and in a basic oncological unit in Nicaragua. The purpose is to reflect on the role that this procedure could have in the treatment of skin and mucosal cancer as part of a multidisciplinary approach.
Abstract: Sentinel node biopsy has become the standard practice in lymph node staging in breast cancer in early stages. However, uncertainty remains regarding the best method of radiotracer/dye injection. Currently, the subareolar injection is being widely used because of its technical simplicity and higher rates of SN location versus the so-called deep techniques (peritumoral, intratumoral) that require greater specialization and greater use of resources in the non-palpable lesions. We present a case of a discrepancy between the two techniques that could have caused a false negative.
Abstract: The combination of complete cytoreductive surgery and perioperative intraperitoneal chemotherapy provides the only chance for long-term survival for selected patients diagnosed with a variety of peritoneal neoplasms, either primary or secondary to digestive or gynecologic malignancy. Hyperthermic intraperitoneal chemotherapy (HIPEC) delivered in the operating room once the cytoreductive surgical procedure is finalized, constitutes the most common form of administration of perioperative intraperitoneal chemotherapy. This may be complemented in some instances with early postoperative intraperitoneal chemotherapy (EPIC). HIPEC combines the pharmacokinetic advantage inherent to the intracavitary delivery of certain cytotoxic drugs, which results in regional dose intensification, with the direct cytotoxic effect of hyperthermia. Hyperthermia exhibits a selective cell-killing effect in malignant cells by itself, potentiates the cytotoxic effect of certain chemotherapy agents and enhances the tissue penetration of the administered drug. The chemotherapeutic agents employed in HIPEC need to have a cell cycle nonspecific mechanism of action and should ideally show a heat-synergistic cytotoxic effect. Delivery of HIPEC requires an apparatus that heats and circulates the chemotherapeutic solution so that a stable temperature is maintained in the peritoneal cavity during the procedure. An open abdomen (Coliseum) or closed abdomen technique may be used, with no significant differences in efficacy proven to date. Specific technical training and a solid knowledge of regional chemotherapy management are required. Concerns about safety of the procedure for operating room personnel are expected but are manageable if universal precautions and standard chemotherapy handling procedures are used. Different HIPEC drug regimens and dosages are currently in use. A tendency for concurrent intravenous chemotherapy administration (bidirectional chemotherapy, so-called "HIPEC plus") has been observed in recent years, with the aim to further enhance the cytotoxic potential of HIPEC. Future trials to ascertain the ideal HIPEC regimen in different diseases and to evaluate the efficacy of new drugs or drug combinations in this context are warranted.
Abstract: Imaging studies are crucial in the evaluation of patients with suspected or known peritoneal cancerous dissemination. Despite the major progress that has occurred in radiological technology in the last few years, adequate and early detection of peritoneal surface disease remains a challenge. Improvements in spatial resolution are still insufficient to detect small volume peritoneal implants, often resulting in an underestimation of peritoneal disease burden, as assessed at subsequent surgical exploration. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has provided unprecedented results in the management of peritoneal-based neoplasms, provided that a complete (adequate) cytoreduction is achieved. Diagnostic imaging tests are used to select patients who may benefit from this combined treatment by ruling out extraperitoneal involvement and signs of unresectable peritoneal disease. Furthermore, a careful assessment of the disease distribution within the peritoneal cavity, guided by a deep knowledge of the disease's clinical and biological behavior helps in planning the surgical procedure. Close interaction and cooperation between surgeons and radiologists is of utmost importance in this regard, and dedicated, motivated radiologists are required. Contrast-enhanced, multidetector computed tomography scan remains the standard imaging modality in the assessment of peritoneal carcinomatosis. Magnetic resonance imaging may offer complementary valuable data. Positron emission tomography (PET) has a more limited role, its main indication being the detection of unsuspected extraperitoneal involvement in nonmucinous neoplasms.
Abstract: Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has provided unprecedented results in the management of peritoneal-based neoplasms. Prognostic factors leading to a survival advantage when this treatment modality is employed have been identified. A steep learning curve has been described as well. Therefore, knowledgeable indication setting and proper selection of patients to whom this combined treatment can be offered is warranted in order to obtain the best results at the lowest possible toxicity.
Abstract: Peritoneal carcinomatosis, considered years ago as a final stage of unresectable cancer, can now be managed with curative intention by means of a radical cytoreductive surgical procedure with associated peritonectomy and intraperitoneal chemotherapy, as described by Sugarbaker. Malignant neoplasms such as mesothelioma and pseudomyxoma peritonei, ovarian and colon cancer nowadays are experiencing some new therapeutical approaches. Higher survival rates can be reached in ovarian cancer, which is commonly diagnosed in the presence of peritoneal carcinomatosis, using an optimal cytoreductive radical surgery with intraperitoneal chemotherapy. An actualised review of the treatment of advanced ovarian cancer and a proposal of a national multicentre protocol for the treatment of peritoneal carcinomatosis from ovarian cancer has been performed by a group of Spanish surgeons and oncologists dedicated to a therapeutical approach to this pathology.
Abstract: The new treatment strategy for Peritoneal Surface Malignancy combines a cytoreductive surgery and perioperative intraperitoneal chemotherapy. Cytoreduction removes all macroscopic tumor. Intraperitoneal chemotherapy avoids implantation of microscopic residual tumor cells on intra-abdominal surfaces when it is administered intraoperatively and/or early in the postoperative period. Delivering cytotoxic drugs directly into the peritoneal cavity maximizes dose intensity and minimizes systemic toxicity. Hyperthermia is selectively cytotoxic for malignant cells and potentiates the effect of chemotherapy. Implementation of this procedure makes the perioperative personnel to face a risk of exposure to cytotoxic agents. Furthermore, peritonectomies and electro-evaporation of tumor nodules are performed with high voltage electrocautery, generating a large amount of surgical smoke during several hours. Inhalation of these fumes may be also a risk for healthcare workers. In this article, we analyse in depth these new risks of the operating room personnel, we review the literature, and we give guidelines for secure performance of cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy, as well as for early postoperative intraperitoneal chemotherapy administration. These new procedures are safe techniques for patients and healthcare workers provided adequate policies are adopted to avoid occupational exposure.
Abstract: Combined local and distant dissemination for colorectal cancer occurs especially in younger patients. New strategies combining maximal cytoreductive surgery with intraperitoneal and systemic chemotherapy have been used in an attempt to prolong survival with an acceptable morbidity and mortality.
Abstract: Peritoneal mesothelioma is a rare disease, but increasing in frequency. The incidence is approximately one per 1,000,000 and about one fifth to one third of all mesotheliomas are peritoneal. Because of its unusual nature, the disease has not been clearly defined either in terms of its natural history, diagnosis, or management. This article reviews a single institution's experience with 51 patients prospectively treated over the past decade with increasingly aggressive local/regional protocols. Peritoneal mesothelioma patients generally present with two types of symptoms and signs; those with abdominal pain, usually localized and related to a dominant tumor mass with little or no ascites and those without abdominal pain, but with ascites and abdominal distention. Pathologically, a positive immunostain for calretinin has markedly increased the accuracy of diagnosis. Prognosis as determined by clinical presentation, the completeness of cytoreduction, and gender (females survive longer than males) appears to be improved by the use of intraperitoneal chemotherapy. Over the past decade, the management of these patients has evolved similarly to ovarian cancer treatment and now involves cytoreductive surgery, heated intraoperative intraperitoneal chemotherapy (HIIC) with cisplatin and doxorubicin, and early postoperative intraperitoneal paclitaxel. These perioperative treatments are followed by adjuvant intraperitoneal paclitaxel and second-look cytoreduction. Prolonged disease-free survival and reduced adverse symptoms with the current management strategy are documented by a high complete response rate as assessed by a negative second-look. This multimodality treatment approach with cytoreductive surgery and intraperitoneal chemotherapy has resulted in a median survival of 50 to 60 months. Peritoneal mesothelioma is an orphan disease that is treatable with expectations for "potential" cure in a small number of patients if diagnosed and treated early with definitive local/regional treatments. A prolonged high quality of life is possible in the majority of patients.
Abstract: Appendiceal carcinoma is a rare disease with low malignant potential. The resection site and the peritoneal cavity are the most common sites of tumor relapse. Despite extensive peritoneal involvement, the presence of regional lymph nodes and hematogenous metastases is exceptional. We report four cases of appendiceal carcinoma metastatic to the right psoas muscle/aortoiliac region and hypothesize regarding the mechanisms of dissemination. We use our experience with this unusual condition to make recommendations regarding treatment.
Abstract: Despite new developments in multi-modality treatments, complete resection remains as an absolute requirement for cure of gastrointestinal cancer. We have reported benefits from combined treatment with complete cytoreduction and intraperitoneal chemotherapy. This has been achieved with low morbidity and mortality. Success in the surgical management of peritoneal surface malignancy depends on the surgeon's ability to complete complex cytoreductive procedures so that only microscopic residual disease remains. This paper describes the current strategy that the surgical oncologist should pursue in the treatment of patients with peritoneal carcinomatosis, sarcomatosis and mesothelioma. Technical details required for this surgery include patient position, incision and exposure, complete lysis of adhesion, electroevaporative dissection with irrigation and suction to preserve the translucent quality of tissues, peritonectomy procedures, proper positioning of tubes and drains for intraperitoneal chemotherapy, and reconstructive surgery. Understanding the treatment and mastery of surgical skills to manage the peritoneal surface spread of cancer has led to long-term survival of selected patients. Combination of this treatment strategy with proper patient selection has reduced the mortality and morbidity. The success of cytoreductive surgery and perioperative intraperitoneal chemotherapy depends on a long-term dedication to achieve the full potential of a curative outcome. Our unit has continued to achieve good results over two decades as improved results of treatment have evolved.
Abstract: The presentation of a hepatic subcapsular hematoma as a complication following the carrying out of an extracorporeal renal shock wave lithotripsy is fairly uncommon. We would like to describe the case of a patient who showed after extracorporeal renal post-lithotripsy intense abdominal symptoms and in which the presence of any prior hepatic pathology was ruled out, alterations in the blood coagulation system as well as anomalies in the execution of the extracorporeal lithotripsy as etiological mechanisms. We carried out a bibliographical review due to the rarity of the process described.
Abstract: Although most nipple discharge is due to a benign etiology, approximately 10-15% is due to breast carcinoma. The standard management of nipple discharge includes major duct excision, and although this procedure may eliminate future nipple discharge, a specific etiology is not always found. This study investigates the utility of preoperative galactography in targeting the causative lesion.
Abstract: Parathyroid glands originate from the third and fourth branchial pouches and migrate caudally to their final positions. Aberrations during migration result in anomalous locations. Intrathyroidal location is not common.
Abstract: PTH(1-84) short half life permits us to monitor parathyroidectomy efficacy, confirming complete resection after unilateral surgical approach in some cases of primary hyperparathyroidism. Nevertheless, this utility has been tested in controlled clinical trials and there is no agreement regarding the extraction of samples, their processing and interpretation of results.
