Ghost Stoma Solving the Dilemma of Diversion After Anterior Resection: Surgical Technique Description and Experience from a Single Centre.

Anastomotic leak is the most dreaded complication after anterior resection (AR). To do prophylactic diversion stoma or not is a matter of constant dilemma that most surgeons face. In such a situation, ghost stoma (GS) technique offers a middle path, wherein unnecessary prophylactic stomas can be avoided and at the same time ensuring that a diversion stoma can be created if need arises without the need of any major surgery or anaesthesia. Retrospective data of patients who underwent anterior resection with ghost stoma at our institute from January 2015 to December 2019 was analysed for clinical characteristics, operative outcomes and postoperative complications. Ghost stoma is fashioned by pulling up a loop of intestine up to parietal peritoneum layer of anterior abdominal wall with the help of silicone or plastic tube after anterior resection. During the study period, this technique was used in 68 patients of which 7 patients required creation of stoma under local anaesthesia for suspected or confirmed post-operative leak. One of these patients developed congestion of stoma for which the stoma was refashioned under regional anaesthesia. There were no major complications like bowel obstruction, strangulation or tube migration. However, two patients had prolonged ileus and were managed conservatively. Thus, unnecessary stoma was avoided in 89% patients of anterior resection. This is a simple, easy to learn, less time-consuming and oncologically safe procedure which can prevent patients from morbidity as well as psychological and financial burden associated with unnecessary stoma.

Efficacy of Periareolar Versus Peritumoral Injection of TC99-Labelled Sulphur Colloid and Methylene Blue Dye for Detection of Sentinel Lymph Node in Patients with Early Breast Cancer: a Comparative Study.

Sentinel lymph node biopsy using dual methods of blue dye and radioactive isotope is what is practised as the standard of care at most of the centres. The combined use of radioactive colloid and blue dye injection is considered the gold standard for axillary sentinel lymph node biopsy in breast cancer with a 97% accuracy rate. The aim of this study is to determine the optimal injection site for methylene blue dye and Tc99-labelled sulphur colloid for sentinel lymph node biopsy in early breast cancer. In both periareolar and peritumoral groups of patients, overall rate of identifying sentinel lymph node (hot, blue and hot and blue nodes) with dual dye was comparable (100% and 96.36%) with p value = 0.475. Also in both groups of patients, overall rate of getting pathological positive sentinel lymph node on final histopathological report was comparable (52.73% and 45.28%) with p value = 0.561. Periareolar versus peritumoral injection of dual dye shows comparable success rates for axillary sentinel lymph node identification and can be considered rapid and reliable method. However, the periareolar route is technically simple and especially privileged in nonpalpable (T0) and upper outer quadrant lesions mainly for the prevention of the shine through phenomenon.

Practical approach to extensive cutaneous spread without any underlying malignancy: a rare presentation of Paget's disease of breast.

Paget's disease of the breast is a rare intraepithelial malignancy involving the nipple-areola complex, often associated with an underlying in-situ or invasive carcinoma in the breast parenchyma. Most of the cases disease is usually limited to nipple-areola or surrounding periareolar skin. We are reporting a case of extensive Paget's disease, involving entire breast skin and even part of abdominal wall skin without any underlining breast pathology, which is a rare presentation.

Use of Intraoperative Ultrasound During Breast Conservation Surgery (BCS) for Palpable Breast Cancer: an Extremely Effective Approach with Improved Oncological Outcome.

For clinically low-volume breast cancer patients subjected to BCS, there is a concern regarding achieving microscopically negative margins and avoiding inadvertent resection of excessive volume of breast tissue. In this study, we utilized intraoperative ultrasound to guide resection in patients subjected to BCS. This was compared with palpation-guided resection. A total of 80 patients of invasive breast carcinoma (T1-2, N0-1, M0) (39 patients in USG-guided BCS (group A) and 41 patients in palpation-guided BCS (group B)) were enrolled. In group A, intraoperative localization was performed using a multifrequency 10-MHz linear array ultrasound probe and tumors were excised under USG guidance. In group B, tumor excision was guided by the palpation skills of the surgeon with the aim of achieving grossly negative margin circumferentially. Specimen volume was measured using water displacement technique. One out of 39 patients (2.56%) in group A and 5 out of 41(12.19%) in group B had positive margin in histopathology report. Mean of specimen volume in groups A and B was 42.67 and 57.97 ml respectively (P = 0.011). Mean of excess volume removed in study group was 4.19 ml and in control group, it was 24.11 ml (P = < 0.01). Mean of calculated resection ratio in study group was 1.1 and in control group was 1.73 (P = 0.01). Use of intraoperative ultrasound during BCS may help in improving margin clearance, reducing additional procedures, and preserving the normal breast parenchyma. The safety, ease, and effectivity of this technique may result in its wider application in future.

Rare Case Report of Neuroendocrine Tumor in Axilla-Metastasis from Unknown Primary or De Novo?

Neuroendocrine tumors (NET) are the neoplasm arising from neuroendocrine cells which are present throughout the body. It can be benign, being more common or malignant. Gut is the most common site, but they can be seen in any part of the body. We had a case of grade III NET in axilla presented with a fungating lesion with unknown primary. Clinical behavior of such tumor is predicted by tumor grade or differentiation. We treated this patient by surgery and adjuvant chemotherapy.

An observational study on safety and efficacy of povidone-iodine for pleurodesis in cancer patients.

INTRODUCTION: Pleurodesis is a time-honored procedure for malignant effusion as one of the palliative procedures to treat recurrent effusions. Various agents have been used in the past such as tetracycline, talc, bleomycin, and povidone-iodine. This paper aims at evaluating safety and efficacy of povidone-iodine for the procedure. MATERIALS AND METHODS: One hundred and four patients underwent of pleurodesis with povidone-iodine done at our center for malignant effusion between June 2008 and August 2015. The safety and efficacy of the procedure was analyzed. RESULTS: One hundred and four patients of malignant effusion with mean age of 53 years and a mean follow-up of 7.8 months were evaluated. A total of 79% patients did not show any reaccumulation of fluid in their follow-up. There was no periprocedural mortality. Eight patients had severe pain; eleven patients had fever, while one patient had arrhythmia. CONCLUSION: Povidone-iodine is a simple, cheap, and effective method of pleurodesis with no major complication and a high success rate.

Intussusception: a Rare Complication After Feeding Jejunostomy; a Case Report.

Feeding jejunostomy (FJ) is a commonly done surgical procedure for enteral nutrition. Intussusception is one of the rare complications of FJ. Clinical presentation may be similar to other causes of small bowel obstruction. Intussusception should be suspected if a patient with jejunostomy tube develops upper gastrointestinal obstructive symptoms, which are relieved by nasogastric tube drainage. CT or ultrasonography (USG) can help to confirm the diagnosis. It can be relieved spontaneously or sometimes requires laparotomy. We have encountered such complication in one patient. The patient developed intestinal obstruction after removal of FJ tube and was diagnosed as having intussusception radiologically. On exploration, intussusception was identified at FJ site for which surgical reduction was done.

Cervical esophago-gastric anastomosis using linear cutter stapler in esophageal cancer.

BACKGROUND: Anastomosis in gastrointestinal (GI) surgery is a commonly performed procedure. Irrelevant various methods of intestinal anastomosis were followed - recent advance is the use of a stapler as a device for GI anastomosis. Due to the use of staplers, technical failures are a rarity, anastomosis is more consistent and can be used at difficult locations. MATERIALS AND METHODS: : Between 2008 and August 2016, 75 patients with esophagus or gastroesophageal junction carcinoma underwent curative intent resection either via a right posterolateral thoracotomy (TTE) or transhiatal esophagectomy or video-assisted thoracoscopic surgery with linear stapler anastomosis. RESULTS: The average follow-up was approximately 9 months. Anastomotic leakage was observed in three patients. On follow-up, two patients presented with difficulty in swallowing, and on upper GI endoscopy, they were found to have anastomotic site stricture. There was no perioperative mortality. CONCLUSION: The linear-stapled esophagogastric anastomosis is a safe and effective anastomotic technique, which can decrease the rate of leak, postoperative dysphagia, and anastomotic stricture. As in this technique only two linear staplers are used in comparison to other techniques where three or more staplers are used, it is also cost-effective. The procedure deserves more attention and further application.

Spontaneous chemoport fracture and cardiac migration.

Central venous access devices are routinely used in oncology for delivering chemotherapy of which implantable chemoports are the most common. Spontaneous breakage and migration of the catheters is a very rare but known complication of the procedure. Patients will usually present with cardiac manifestations in form of chest pain or arrythmias. Herein we report a case of spontaneous breakage and cardiac migration in which the patient was asymptomatic. Patient was successfully managed by an interventional cardiologist.

The optimal use of granulocyte macrophage colony stimulating factor in radiation induced mucositis in head and neck squamous cell carcinoma.

OBJECTIVE: Evaluation of response of granulocyte macrophage colony stimulating factor (GM-CSF) on acute radiation toxicity profile in head and neck squamous cell carcinoma. METHODS AND MATERIALS: Thirty three patients with proven stage I or II head &neck carcinoma received conventional external beam radiation therapy. Out of these, six patients received postoperative adjuvant therapy while remaining 27 received definitive RT. Patients were given 100 mcg GM-CSF subcutaneously per day along with radiation after they developed grade 2 mucositis and /or grade 2 dysphagia and / or complained of moderate pain. GM-CSF was administered till there was a subjective relief or objective response. Patients were evaluated for oral ulceration, swallowing status, pain and weight loss. Response to the treatment and patient outcome was assessed. RESULTS: There was a decreased severity of mucositis and dysphagia in the evaluated patients. None of the patients suffered severe pain or required opioids. The mean weight loss was only 1.94%. Minimal side effects were experienced with GM-CSF. CONCLUSIONS: GM-CSF reduces the severity of acute side effects of radiation therapy thereby allowing completion of the treatment without interruption. Its remarkable response needs to be evaluated further in large randomized trials. The time of initiation and cessation of GM-CSF during radiation therapy and the required dose needs to be established.