• encapsulating peritoneal sclerosis
• gastroenterology
• general surgery
• infectious disease
• tuberculosis

• Colorectal cancer
• Gastric cancer
• Gastrointestinal cancers
• Hyperthermic intraperitoneal chemotherapy
• Side effects

• Appendiceal neoplasm
• Bowel obstruction
• Colorectal neoplasm
• Peritoneal carcinomatosis
• Readmission

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction that is characterized by a thick greyish-white fibrotic membrane encasing the small bowel. The clinical features are typically nonspecific, and they occasionally present with recurrent episodes of incomplete or complete intestinal obstruction. The etiology of SEP remains unclear, and the diagnosis is often delayed mainly due to the lack of specific symptoms. Here, we first report a patient who suffered from SEP after treatment for malignant mesothelioma (MM) with tumor resection supplemented with hyperthermic intraperitoneal chemotherapy (HIPEC) once and intraperitoneal chemotherapy (IPC) eight times. The patient was discharged ten days after surgery and was free of complications at the 4-month follow-up. In addition, we reviewed the published literature from PubMed, only 7 articles of 16 cases finally met the defined requirements. Nine cases of SEP after IPC and 7 cases of SEP after HIPEC were previously reported. We synthetically review the pathogenesis, treatments, and outcomes. In conclusion, SEP is a rare abdominal disease, which is difficult to diagnose preoperatively. CT scanning is the most helpful imaging method for the diagnosis of SEP. Surgery is the most effective method for diagnosis and treatment, if conservative treatment has no effect or abdominal symptoms are aggravated.

• Sclerosing encapsulating peritonitis (SEP)
• case report
• intraperitoneal chemotherapy (IPC)
• malignant mesothelioma (MM)

The aim of the current study was to investigate the imaging features of abdominal cocoon (AC), the methods of diagnosis and treatment of AC and improve understanding of AC. To do this, the current study retrospectively analyzed the clinical data and imaging findings of nine patients with AC. The clinical manifestations included intestinal obstruction in six out of the nine cases of AC, which included two cases of bowel strangulation and five cases of soft masses in the abdomen. Imaging features of AC included the following: i) Bowel loops were usually present in a fixed cluster; ii) bowel loops were encapsulated partially or totally by a thickening fibrous membrane-like ‘cocoon’; iii) bowel wall thickened in the ‘cocoon’, and the bowel loops and sac adhered; iv) loculated ascites in the ‘cocoon’; v) abnormal clustering of the mesenteric vasculature, hypoplasia of the omentum majus was present or absent; and vi) Ileus occurred in some cases. The features of a plain abdominal X-ray, a gastrointestinal barium meal series and ultrasonography lacked specificity. The results of CT in eight out of nine cases of AC were consistent with the surgical findings. Surgery was the first choice of therapy. All cases were treated surgically, showing that the bowel loops were encapsulated partially or totally by a thickened fibrous membrane. All cases received operations including partial or total excision of the membrane and enterolysis. In conclusion, CT may be highly valuable in the preoperative diagnosis of AC.

• abdominal cocoon
• diagnosis
• imaging
• intestinal obstruction
• treatment

Congenital peritoneal encapsulation (CPE) is a very rare, congenital condition characterised by the presence of an accessory peritoneal membrane which encases a variable extent of the small bowel. It is unclear how CPE develops, however it is currently understood to be a result of an aberrant adhesion in the peritoneal lining of the physiological hernia in foetal mid-gut development. The condition was first described in 1868, and subsequently there have been only 45 case reports of the phenomenon. No formal, systematised review of CPE has yet been performed, meaning the condition remains poorly understood, underdiagnosed and mismanaged. Diagnosis of CPE remains clinical with important adjuncts provided by imaging and diagnostic laparoscopy. Two thirds of patients present with abdominal pain, likely secondary to sub-acute bowel obstruction. A fixed, asymmetrical distension of the abdomen and differential consistency on abdominal palpation are more specific clinical features present in approximately 10% of cases. CPE is virtually undetectable on plain imaging, and is only detected on 40% of patients with computed tomography scan. Most patients will undergo diagnostic laparotomy to confirm the diagnosis. Management of CPE includes both medical management of the critically-unstable patient and surgical laparotomy, partial peritonectomy and adhesiolysis. Prognosis following prompt surgical treatment is excellent, with a majority of patients being symptom free at follow up. This review summarises the current literature on the aetiology, diagnosis and treatment of this rare disease. We also introduce a novel classification system for encapsulating bowel diseases, which may distinguish CPE from the commoner, more morbid conditions of abdominal cocoon and encapsulating peritoneal sclerosis.

• Congenital
• Encapsulation
• Peritoneum
• Cocoon
• Sclerosis

• Humans
• Intestinal Obstruction/classification
• Intestinal Obstruction/congenital
• Intestinal Obstruction/surgery
• Intestine, Small/pathology
• Intestine, Small/surgery
• Peritoneal Fibrosis/classification
• Peritoneal Fibrosis/congenital
• Peritoneal Fibrosis/surgery
• Peritoneum/abnormalities
• Peritoneum/pathology
• Prognosis
• Treatment Outcome

Encapsulating peritoneal sclerosis (EPS) is a debilitating condition characterized by a fibrocollagenous membrane encasing the small intestine, resulting in recurrent small bowel obstructions. EPS is most commonly associated with long-term peritoneal dialysis, though medications, peritoneal infection, and systemic inflammatory disorders have been implicated. Many cases remain idiopathic. Diagnosis is often delayed given the rarity of the disorder combined with non-specific symptoms and laboratory findings. Although cross-sectional imaging with computed tomography of the abdomen can be suggestive of the disorder, many patients undergo exploratory laparotomy for diagnosis. Mortality approaches 50% one year after diagnosis. Treatment for EPS involves treating the underlying condition or eliminating possible inciting agents (i.e. peritoneal dialysis, medications, infections) and nutritional support, frequently with total parenteral nutrition. EPS-specific treatment depends on the disease stage. In the inflammatory stage, corticosteroids are the treatment of choice, while in the fibrotic stage, tamoxifen may be beneficial. In practice, distinguishing between stages may be difficult and both may be used. Surgical intervention, consisting of peritonectomy and enterolysis, is time-consuming and high-risk and is reserved for situations in which conservative medical therapy fails in institutions with surgical expertise in this area. Herein we review the available literature of the etiology, pathogenesis, diagnosis, and treatment of this rare, but potentially devastating disease.

• Abdominal cocoon
• Sclerosing encapsulating peritonitis
• Peritoneal sclerosis
• Peritonectomy
• Enterolysis
• Peritoneal dialysis
• Tamoxifen
• Corticosteroids

• Glucocorticoids/therapeutic use
• Humans
• Intestinal Obstruction/diagnosis
• Intestinal Obstruction/etiology
• Intestinal Obstruction/mortality
• Intestinal Obstruction/therapy
• Intestine, Small/diagnostic imaging
• Intestine, Small/pathology
• Intestine, Small/surgery
• Parenteral Nutrition, Total
• Peritoneal Dialysis/adverse effects
• Peritoneal Fibrosis/diagnosis
• Peritoneal Fibrosis/etiology
• Peritoneal Fibrosis/mortality
• Peritoneal Fibrosis/therapy
• Peritoneum/diagnostic imaging
• Peritoneum/pathology
• Peritoneum/surgery
• Peritonitis/complications
• Peritonitis/therapy
• Recurrence
• Sclerosis
• Tamoxifen/therapeutic use
• Tomography, X-Ray Computed
• Treatment Outcome

• Complications
• Encapsulated peritoneal sclerosis
• Intraperitoneal chemotherapy
• PIPAC
• Peritoneal metastasis
• Peritoneal sclerosis

Intraperitoneal chemotherapy is limited by tissue penetration. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has been shown to improve drug uptake by utilizing the physical properties of gas and pressure. This study investigated the effect of adding electrostatic precipitation to further enhance the pharmacologic properties of this technique.

A comparative study was performed using an in vivo porcine model. There were 3 cases in each group, PIPAC and electrostatic precipitation pressurized intraperitoneal aerosol chemotherapy (ePIPAC), plus 1 negative control comparing intraperitoneal distribution and tissue uptake of 2 tracer substances (toluidine blue and DT01). Tracer uptake was determined by measuring DT01 in tissue and peritoneal fluid at the end of each procedure.

Electrostatic precipitation of the aerosol was technically feasible in all ePIPAC animals. The aerosol was cleared completely from the visual field within 15 s in the ePIPAC group versus 30 min in the PIPAC group. The peritoneal surface was homogeneously stained in both groups. After 30 min, 1.5 % remaining DT01 was measured in samples of ePIPAC-treated peritoneal fluid versus 15 % in PIPAC animals (p = 0.01). Tissue concentration was increased after ePIPAC versus PIPAC (p = 0.06).

ePIPAC is technically feasible and improves tissue uptake of 2 tracer substances compared to PIPAC by up to tenfold. Intraperitoneal distribution was homogeneous in both groups. ePIPAC has the potential to allow more efficient drug uptake, further dose reduction, a significant shortening of the time required for PIPAC application, and improved health and safety measures.

The online version of this article (doi:10.1245/s10434-016-5108-4) contains supplementary material, which is available to authorized users.