Impact of Covid-19 pandemic on upper gastrointestinal cancer services: Experience from an oncosurgical unit.

Background The Covid-19 pandemic continues to affect the delivery of cancer care across the world. We evaluated the impact of the pandemic on the delivery of cancer care, to patients diagnosed with upper gastrointestinal (UGI) tract malignancies, during the first 4 months of the pandemic in India. Methods We retrospectively analysed a database of patients with UGI malignancies discussed in the Multidisciplinary Tumour Board (MDTB) between 24 March and 24 July 2020. The results in the study group were compared to that of a similar group of patients from the corresponding period in 2019. Results A total of 117 and 61 patients were discussed in the MDTB in 2019 and 2020, respectively, thereby showing a 48% reduction in the number of new cases seen in 2020. The reduction in the number of new cases was huge for oesophageal cancer (53-13; 75.5% reduction), compared to gastric cancer (53-43; 18.9%). The proportion of patients with metastatic disease at presentation was significantly higher in 2020, compared to 2019 (39.3% v. 23.1%; p=0.023). In 8 (13.1%) patients, the pre-existing treatment protocol had to be modified to suit the prevailing pandemic situation. Two patients with gastric cancer acquired asymptomatic Covid-19 infection during the treatment, which delayed the delivery of further therapy. Oncosurgeries were less in 2020 compared to 2019 (25 v. 63). The rate of 30-day major postoperative complications in 2020 was comparable with that in 2019 (12% v. 6.3%; p=0.4). Conclusions The number of new patients with UGI cancer, seeking elective cancer care and the number of oncosurgical procedures reduced during the Covid-19 pandemic. Continuous delivery of UGI cancer services was ensured during the pandemic through clinical prioritization, the adaptation of specific care pathways and selective modification of protocols, to suit the prevailing local conditions.

Feasibility, safety and oncological outcomes of minimally invasive oesophagectomy following neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma - Experience from a tertiary care centre.

Background: Neoadjuvant chemoradiotherapy (nCRT) has improved the resectability and survival of operable oesophageal squamous cell carcinoma (OSCC). We aimed to study if nCRT for OSCC makes minimally invasive oesophagectomy (MIO) technically more challenging and if the peri-operative and oncological outcomes are acceptable for MIO following nCRT. Materials and Methods: A retrospective review of patients with OSCC (cT1-2N1-2, cT3-4aN0-2) treated with nCRT and MIO between 2013 and 2019 was performed. The operative details including the technical difficulty in tumour dissection and lymphadenectomy, the post-operative complications and oncological outcomes were studied. Results: Seventy-five patients (male:female - 50:25; mean [range] age - 55.49 ± 8.43 [22-72] years; stage II - 34.7%; stage III - 37.3%; stage IVA - 28.0%) were enrolled. The concurrent chemotherapy course was completed by 25.3% of patients and the most common reason limiting the completion of chemotherapy was neutropaenia (66.0%). A thoraco-laparoscopic (n = 60) or hybrid (n = 15) McKeown's oesophagectomy with a two-field lymphadenectomy was performed. The increased surgical difficulty was reported in 41 (54.7%) patients, particularly for mid-thoracic tumours and tumours exhibiting incomplete response. The 30-day overall and major complication rate was 48.0% and 20.0%, respectively, and there was no mortality. The rate of R0 resection, pathological complete response and median lymph nodal yield were 93.3%, 48% and 8 (range: 1-25), respectively. The mean overall survival (OS) was 62.2 months (95% confidence interval [CI]: 52.6-71.8) and recurrence-free survival (RFS) was 53.5 months (95% CI: 43.5-63.5). The 1-, 2- and 3-year OS and RFS were 89.5%, 78.8% and 64.4% and 71.1%, 61.3% and 56.6%, respectively. Conclusion: Minimally invasive McKeown's oesophagectomy is feasible and safe in patients with OSCC receiving nCRT. The radiation component of nCRT increases the degree of operative difficulty, especially in relation to the supracarinal dissection and lymphadenectomy. However, this drawback did not adversely affect the short-term surgical or the long-term oncological outcomes.

Minimally invasive surgery for adult oesophageal duplication cysts: Clinical profile and outcomes of treatment from a tertiary care centre and a review of literature.

BACKGROUND: Oesophageal duplication cysts (ODC) are rare in adults. Complete surgical excision is the ideal treatment. Conventionally, it is performed through a thoracotomy. We aimed to study the feasibility and safety of minimally invasive surgery (MIS) in the management of ODC and briefly reviewed the available literature. MATERIALS AND METHODS: A retrospective study of all adult patients with ODC diagnosed and treated at our tertiary care centre, from 2015 to 2019, was done. All patients were operated on by MIS. Their demographic, clinicopathological, radiological and surgical details and outcomes were analysed. RESULTS: A total of six patients (four females and two males) were diagnosed to have ODC by contrast-enhanced computed tomography. The mean age was 38 ± 4.4 years. The most common presenting complaint was chest pain (50%). Upper gastrointestinal endoscopy was normal in four patients. Endoscopic ultrasound was performed in five patients. In four patients, the cyst was located in the distal third of the oesophagus. The mean size of the cysts was 5.7 ± 2.02 cm. All the patients were operated upon by video-assisted thoracoscopic surgery (VATS). There was no conversion to open surgery. The resection was complete in all but one patient. The mean duration of surgery was 143.3 ± 35 min, and the average blood loss was 58.33 ± 20.4 mL. One patient had an oesophageal staple line leak on the 9th post-operative day. There was no mortality. The median duration of hospital stay was 7.5 days (range: 3-25 days). CONCLUSION: MIS is feasible and safe in the management of adult ODC.

Gastroesophageal reflux following per-oral endoscopic myotomy: Can we improve outcomes?

This editorial is an analysis the review article by Nabi et al recently published in this journal. Achalasia Cardia is a disease whose pathophysiology is still unclear. It is known that there is inflammation of unknown aetiology leading to loss of ganglion cells in the muscularis propria. The end result is lower oesophageal sphincter spasm, loss of receptive relaxation, decreased oesophageal peristalsis, all leading on to varying degrees of dysphagia. The treatment of this condition is palliative in nature, performed by myotomy of the lower oesophagus either surgically or endoscopically. Gastroesophageal reflux disease (GERD) has been associated with the myotomy performed, particularly with the Peroral Endoscopic Myotomy (POEM) procedure. Nabi et al have provided an excellent overview of the latest developments in predicting, preventing, evaluating, and managing GERD subsequent to POEM. Based on this theme, this review article explores the concept of using histology of the oesophageal muscle layer, to grade the disease and thereby help tailoring the length/type of myotomy performed during the POEM procedure. In the future, will a histology based algorithm available preoperatively, help modify the POEM procedure, thereby decreasing the incidence of GERD associated with POEM?

Extended multiorgan resection in locally advanced gastric cancer: a single centre experience from south India.

BACKGROUND: The prognostic and survival benefit of extended multiorgan resection for locally advanced gastric adenocarcinoma remains controversial. The morbidity associated with additional organ resection has been found to be higher when compared to patients undergoing gastrectomy alone. The aim of our study was to evaluate the morbidity, mortality and survival benefit associated with extended multiorgan resection for locally advanced gastric adenocarcinoma. METHODS: From January 2004 to December 2011, 721 patients underwent resectional surgery for gastric adenocarcinoma at the Christian Medical College, Vellore, India. Out of this group, 36 patients underwent primary resection and had one or more organs resected in addition to the stomach. A retrospective analysis of the case records of all these patients was performed. The Kaplan-Meier survival probability was estimated. Cox regression analysis was used to evaluate the clinico-pathological variables affecting the survival of these patients. RESULTS: The perioperative morbidity and mortality rates were 25% and 5.5% respectively. The most common organs resected were colon and spleen. The incidence of pathologically confirmed T4b cancers was only 50%. The median survival of these patients was 28 months. The survival was influenced by a R0 or curative resection. However, it was not statistically significant. CONCLUSION: Extended multiorganresection in locally advanced gastric cancer can be performed with acceptable morbidity and mortality. In our study, overstaging was found in 50% of the patients and hence, when the real nature of invasion is unclear, the surgeon may proceed with en bloc resection of the stomach with the involved adjacent organs. As long as an R0 resection can be achieved, extended multiorgan resection can be performed for carcinoma stomach.

Clinical profile and treatment outcomes of Boerhaave's syndrome: A 13-year experience from an upper gastrointestinal surgical unit.

Objectives: IBoerhaave's syndrome (BS) is a rare, but potentially fatal condition, characterized by barogenic esophageal rupture and carries a high mortality. We aimed to study our institutional experience of managing patients with BS. Material and Methods: A retrospective review of patients with BS presenting to a tertiary care centre from 2005 to 2018 was carried out in this study. Clinical presentation, diagnostic evaluations, treatments received, and treatment outcomes were studied. Perforations were classified as early (<24 hours) and delayed (>24 hours), based on the time elapsed. Surgical complications were graded using Clavien-Dindo grade. The Pittsburgh perforation severity score was correlated with short-term treatment outcomes. Results: Of the 12 patients [male, 75%; mean (range) age, 53 (28-80) years] included, 10 patients had a delayed (>24 hours) presentation. Chest pain was the dominant symptom (58.3%); six patients presented either in shock (n= 1) or with organ failure (n= 3) or both (n= 2). All the perforations were sited in the lower thoracic esophagus, of which three were contained and nine were uncontained. The seal of the perforation was achieved by surgical repair in four patients (primary repair, 2; repair over a T-tube, 2) and endoscopic techniques in four patients (clipping, 1; stenting, 3). Sepsis drainage [surgical, 7 (open-5, minimally-invasive-2); non-surgical, 5] and feeding jejunostomy were performed in all patients. Five (41.7%) patients received a re-intervention. Median (range) hospital stay was 25.5 (12-101) days, 30-day operative morbidity was 50%, and there was one in-hospital death. The Pittsburgh perforation severity score was as follows: 2-5 in two patients and >5 in 10 patients; there were more delayed presentations, increased surgical interventions, post-procedure morbidity, and in-hospital mortality in the latter group, but the differences were statistically not significant. In 11 patients followed-up [median (range):1507 (17-5929) days], there was no disease recurrence, symptomatic reflux or dysphagia. Conclusion: Favourable treatment outcomes, including reduced mortality and organ preservation can be achieved for Boerhaave's perforations, through a multimodality approach. Minimally invasive, endoluminal or open surgical techniques may be safely utilized in its management. The Pittsburgh severity score can be a useful clinical tool that can be used to select the initial intervention and to predict treatment outcomes.

Occult Omental Metastasis in Gastric Adenocarcinoma: An Analysis of Incidence, Predictors, and Outcomes.

Negine PaulIntroduction Traditionally, the concept of complete omentectomy during gastric resection for cancer was based on lymphatic drainage and the occurrence of occult omental metastasis (OM). However, recent emerging evidence has challenged this concept of complete omentectomy. We, therefore, aim to find the incidence and risk factors of occult OM and also evaluate the outcome of patients with and without such metastasis. Methods This is a single institutional, retrospective study of patients with gastric cancer who underwent curative radical gastrectomy for a period of 3 years (April 1, 2016, to March 31, 2019). A complete omentectomy was performed in all patients and the omentum and nodal stations were dissected in the resected specimen and sent for pathological analysis. Clinical and epidemiological data were collected from the hospital patient database and analysis was done. Results A total of 185 patients have been included in the study, with a mean age of 53.84 years. Twenty of the 185 patients had OM (10.8%). Age, sex, location of the tumor, and neoadjuvant chemotherapy were not statistically significant in predicting OM. However, tumor size and tumor depth were found to have a significant association with OM. The occurrence of OM was more likely to be associated with disease recurrence, especially in the peritoneum. The mean overall survival was 38.15 months (±3.33 SD), whereas patients with OM had lower survival, 23.31 months (±7.79 SD), with a p -value of 0.012. Conclusion OM was not encountered in T1 and T2 gastric cancers and the incidence of OM in T3 and T4 tumors was approximately 12.7%. Therefore, complete omentectomy may be omitted in early T1/T2 tumors. OM was associated with poor prognosis, increased peritoneal recurrence, and decreased overall survival, in spite of a complete omentectomy, and may serve as a prognostic indicator for disease recurrence and overall survival.

Minimally invasive retroperitoneal pancreatic necrosectomy.

INTRODUCTION: This article describes a case series outlining the experience and results of the retroperitoneal minimally invasive pancreatic necrosectomy (MIPN) procedure performed by, or done under the supervision of, a single surgeon. METHODS: All data of the patients who underwent MIPN from 2006 to 2008 were entered into a prospectively maintained, computerized database. RESULTS: A total of 93 MIPN procedures were performed on 32 patients. All patients had severe acute pancreatitis. The median number of MIPN procedures per patient was 3. Only 6 patients needed intensive care unit (ICU) admission after MIPN. There were 15 complications, which included bleeding requiring transfusion (n = 3), bowel fistulae (n = 7), thromboembolic events (n = 2) and acute myocardial infarction (n = 3). Four patients died after the procedure (13%); 1 died of ongoing multiorgan failure in spite of the MIPN. Four patients developed pancreatic pseudocysts within the follow-up period of 2 years. Three of these patients required intervention. CONCLUSION: This case series demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The ICU dependency after the procedure is minimal. As seen in this series, multiple MIPNs may be needed to eradicate the necrosis satisfactorily. and IAP.

Tracheal injury during oesophagectomy--incidence, treatment and outcome.

BACKGROUND AND AIM: Iatrogenic tracheal injuries are uncommon, potentially lethal and associated with significant morbidity. In this report we analyze the incidence of iatrogenic tracheobronchial injuries sustained during oesophagectomies and the results and outcome of repair using a pedicled intercostal muscle flap. METHODS: A retrospective analysis was done on all patients who underwent an oesophagectomy between June 2000 and May 2011. Data was collected from an electronic database and the medical records of patients, maintained at our hospital. RESULTS: One hundred and fourteen patient records were analyzed. There were 85 male and 29 female patients. Their mean age was 47 years (range 16 to 86 years). Forty two (36%) underwent a transhiatal oesophagectomy, 34 (31%) Mckeown's oesophagectomy, 35 (31%) Ivor Lewis oesophagectomy and 3 (2%) thoracoscopy assisted oesophagectomy. Of the 114 oesophagectomies, 86 (75%) were performed for malignant and 28 (25%) for benign pathologies (benign tumors and corrosive strictures of the esophagus). In our study, four patients sustained injury to the tracheobronchial tree during oesophagectomy. In patients who sustained injury during a transhiatal dissection a right anterolateral thoracotomy was made. All injuries in the thoracic tracheobronchial tree were repaired primarily and reinforced with an intercostal muscle flap. In the patient with injury to the cervical part of the trachea, repair was done primarily and reinforced with cyanoacrylate glue. All patients who sustained injury had malignancy and three patients had received neoadjuvant chemoradiotherapy. Two patients sustained injury during transhiatal oesophagectomy and two during a Mckeown's oesophagectomy. There was one mortality which was due to ventilator associated pneumonia and related complications. The remaining three were alive with no evidence of repair breakdown. CONCLUSIONS: Iatrogenic tracheal injuries are uncommon complications but associated with significant morbidity. Preoperative chemoradiotherapy and malignancy are risk factors for iatrogenic tracheal injuries. Reinforcement of the suture line with a muscle flap is an effective technique of repair. Prompt ontable identification and adequate surgical treatment is necessary for a good outcome.

'Wandering spleen with acute torsion' : a rare indication for splenectomy in an adult, complicated by postoperative splanchnic venous thrombosis and intestinal gangrene.

Wandering spleen (WS) is a hypermobile spleen that, due to the laxity of its ligaments, is prone to torsion. We report a case of a 45-year-old multiparous woman who presented with acute abdominal pain and a tender palpable mass. A contrast-enhanced computed tomography scan of the abdomen showed a WS with torsion. She underwent an emergency splenectomy and was discharged after an uneventful recovery. She was readmitted with splanchnic venous thrombosis and was managed with therapeutic low-molecular-weight heparin (LMWH) and discharged. Twenty days later, she presented with new-onset abdominal pain. She had not complied with LMWH as advised. The thrombosis had progressed, leading to small bowel gangrene, requiring resection and a stoma. Due to frequent metabolic disturbances, an early reversal of stoma was performed. She was lost to follow-up thereafter. This case highlights a rare indication for emergency splenectomy and one of its major postoperative complications.

Exocrine Pancreatic Insufficiency Following Gastric Resectional Surgery-is Routine Pancreatic Enzyme Replacement Therapy Necessary?

The data on exocrine pancreatic insufficiency (EPI) following gastric resectional surgery is variable, ranging from 26% to as high as 100%. This study aimed to document symptomatic EPI following gastric resectional surgery and to objectively document EPI, by fecal elastase (FE) testing. This was a cross-sectional study among patients undergoing gastric resection for adenocarcinoma of the stomach, at the Upper Gastrointestinal Surgical Unit at the Christian Medical College Hospital, Vellore, India. A detailed questionnaire was administered to the patients in the postoperative period, to evaluate clinical symptoms of EPI. Further, study participants were tested for FE pre- and postoperatively. Of the 60 patients in this study, the postoperative questionnaire administered to all patients during follow up. None showed symptoms suggestive of EPI. Pre- and post-operative FE testing were feasible in 27 of the 60 patients, which showed a 33% incidence of EPI. None of the patients had clinical symptoms of EPI, following gastric resectional surgery, on short-term follow-up. However, more than a third of the patients tested developed asymptomatic EPI after gastric resectional surgery, based on FE testing. This may be explained by the fact that in the early postoperative period, EPI following gastric resectional surgery perhaps has a mild, subclinical presentation. Therefore routine pancreatic supplementation after gastric resectional surgery may not be necessary. However, one needs to carefully look for worsening of symptoms of EPI on long-term follow-up, which may necessitate appropriate investigations followed by pancreatic enzyme replacement therapy.

Patterns of Recurrence in Locally Advanced Resectable Oesophageal Carcinoma: Retrospective Review from a Tertiary Cancer Centre in South India.

PURPOSE: The study aims to analyse patterns of recurrence following neoadjuvant treatment and surgery in carcinoma oesophagus with an intent to postulate optimal nodal radiation. METHODOLOGY: A retrospective review of patients who presented to our centre within a 5-year period (2014-2018), with recurrence following sequential neoadjuvant treatment and radical surgery, was conducted in this single-institution study. The patterns of recurrence and duration of disease-free survival were analysed. RESULTS: Twenty-one patients (14 men, 7 women) presented with recurrence, of which 13, 7, and 1 patient(s) had received NACT, NACTRT, or both, respectively. Six patients who did not receive neoadjuvant radiotherapy received adjuvant RT. Among the 10 patients who had nodal recurrence after RT (either neoadjuvant or adjuvant), 6 and 4 patients had in-field and out-of-field nodal recurrences, respectively-the latter were equally distributed within 5 cm and outside 5 cm of the PTV margin. CONCLUSION: Among the patients who presented with recurrence, more than half had not received neoadjuvant RT (treated in the 'pre-CROSS era' or due to long-segment disease), reasserting the therapeutic superiority of NACTRT. Increased regularity of recurrences in the draining nodal region was not noted in this study, but large-scale, prospective, randomised head-to-head comparative trials to determine optimal nodal irradiation in carcinoma oesophagus are required.

Docetaxel, Oxaliplatin and Capecitabine (TEX) triplet regimen as adjuvant chemotherapy in resected gastric adenocarcinoma.

BACKGROUND: Adjuvant chemotherapy after surgery for gastric cancer improves survival but is difficult to administer due to poor tolerance. Combination chemotherapy with Docetaxel (Taxotere), Oxaliplatin (Eloxatin) and Capecitabine (Xeloda) (TEX) is used in the treatment of advanced gastric cancer. The efficacy and tolerability of this regimen (TEX) post resection of gastric cancer have not been studied. MATERIALS AND METHODS: Patients diagnosed with gastric adenocarcinoma, post resection without any prior chemotherapy between July 2007 and May 2011 and treated with TEX regimen administered as T 35 mg/m2 and E 50 mg/m2 on days (d) 1, 8 and X 625 mg/m2 bid (twice daily) on d 1-14 every 21 days were included in this retrospective analysis. Patient's electronic medical records were studied and data on tolerance, progression­free survival (PFS) and overall survival (OS) was collected. RESULTS: Fifty-eight patients were treated with adjuvant TEX chemotherapy, majority 40 (68%) had distal gastric cancer. All patients underwent a D1 gastrectomy, and resection was performed for 44 (75%). Only 14 (24%) patients had more than 15 nodes studied in the resected specimen. Distribution for stages I, II and III is 14 (24%), 30 (52%) and 14 (24%), respectively. After a median follow-up of 40 months, the 3-year relapse free survival was 58% (95% CI: 42-68), and estimated median OS was 71 months (95% CI: 19-123 months). Twenty-three (40%) required dose reduction due to toxicity. Grade 3 or 4 toxicity was recorded for 22 (37%). Half (52%) of patients completed all planned chemotherapy of six cycles. CONCLUSION: Post resection of gastric adenocarcinoma adjuvant triplet TEX chemotherapy is a feasible and effective outpatient regimen. Diarrhoea, neutropenia and neuropathy were the common dose limiting toxicity. Post-surgery only half the numbers of patients are able to complete all planned cycles.

Primary malignant melanoma of the stomach: a rare entity.

A 54-year-old man presented with easy fatiguability, dyspnoea on exertion and dyspeptic symptoms. On evaluation, he was found to have an ulcero-proliferative growth in the gastric fundus, the biopsy of which was malignant melanoma of the stomach. Further evaluation with 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) scan showed operable disease with no focus of disease elsewhere. He was diagnosed as primary gastric melanoma and underwent radical total gastrectomy with adequate margins. His postoperative period was uneventful. Further adjuvant therapy was refused by the patient. At 6-month follow-up, an 18F-FDG PET-CT scan was done, which showed no evidence of disease. On follow-up at 1-year, he was alive and asymptomatic.

Self-expanding metal stent in esophageal perforations and anastomotic leaks.

BACKGROUND AND AIMS: Placement of self-expanding metal stents (SEMS) has emerged as a minimally invasive treatment option for esophageal perforation and leaks. The aim of our study was to assess the role of SEMS for the management of benign esophageal diseases such as perforations and anastomotic leaks. METHODS: All patients (n = 26) who underwent SEMS placement for esophageal perforation and anastomotic leaks between May 2012 and February 2019 were included. Data were analyzed in relation to the indications, type of stent used, complications, and outcomes. RESULTS: Indications for stent placement included anastomotic leaks 65% (n = 17) and perforations 35% (n = 9). Fully covered SEMS (FCSEMS) was placed in 25 patients, and in 1, partially covered SEMS (PCSEMS) was placed. Stent placement was successful in all the patients (n = 26). Four patients did not report for follow-up after stenting. Among the patients on follow-up, 91% (20/22) had healing of the mucosal defect. Stent-related complications were seen in 5 (23%) patients and included stent migration [3], reactive hyperplasia [1] and stricture [1]. CONCLUSION: Covered stent placement for a duration of 8 weeks is technically safe and clinically effective as a first-line procedure for bridging and healing benign esophageal perforation and leaks.

Obesity Indicators and Health-related Quality of Life - Insights from a Cohort of Morbidly Obese, Middle-aged South Indian Women.

OBJECTIVE: The global prevalence of obesity is increasing and has nearly doubled in the last decade, disproportionately impacting less-developed countries. The aim of this cross-sectional study was to analyse health-related quality of life (HRQOL) in morbidly obese women attending a bariatric clinic in India, and assess potential obesity indicators that can be utilised in under-resourced settings, to better understand HRQOL of individual patients. METHODS: Anthropometric measurements were collected, including waist circumference, hip circumference, waist-hip ratio, waist-height ratio and body mass index (BMI). HRQOL was assessed using an obesity-related quality-of-life questionnaire focused on the impact of obesity on physical distress, self-esteem, sexual life and work life. RESULTS: The average BMI of study participants was 39.6 kg/m2, with an average HRQOL of 40.2%. The strongest correlation was noted between BMI and HRQOL (R2=0.16). Exploratory analyses demonstrated that patients with higher BMI quartiles had lower scores for physical impact and psychosocial impact, and higher scores for sexual health, comfort with food, and experience with dieting compared to patients in lower quartiles. CONCLUSION: In South Indian, middle-aged, morbidly obese women, HRQOL is lower than average and is highly correlated with BMI, with different BMI levels having higher impacts in different subcategories, supporting the need for an individualised therapeutic focus for each patient.

Psychiatric Burden in the Morbidly Obese in Multidisciplinary Bariatric Clinic in South India.

BACKGROUND: Obesity is a global epidemic. Bariatric surgery is being considered as the treatment of choice in morbid obesity. Psychiatric comorbidity affects outcomes in this population. There is a dearth of data on psychiatric profile of the morbidly obese from Indian subcontinent. We studied people with morbid obesity to estimate the psychiatric burden among them and to identify factors associated for developing psychiatric disorders. METHODOLOGY: This is a cross-sectional study done in a bariatric clinic of a tertiary care teaching hospital in South India. Sixty morbidly obese patients were evaluated by psychiatrists and data from medical records were collected and analyzed. Prevalence of psychiatric disorders was estimated. They were compared with patients without psychiatric disorders using appropriate statistical tests. RESULTS: Nearly 33.33% of the patients had a psychiatric disorder. Depression and dysthymia accounted for about half of those cases. The variables that were associated with psychiatric disorders were current suicidal ideation, past self-injurious behavior, perceived poor social support, and past psychiatric history. CONCLUSION: One-third of the morbidly obese patients having psychiatric disorder is suggestive of high comorbidity. Considering this active involvement of psychiatrists in bariatric clinic would be useful.

Surgical Outcomes Associated with Operable Gastric Cancer in a Tertiary Care Indian Hospital.

PURPOSE: Data on operable gastric cancer from India is sparse. The purpose of this study was to investigate the clinical details, histopathological demographics, and 5-year overall survival (OS) and disease free survival (DFS) associated with operable, non-metastatic gastric cancer in a dedicated upper gastrointestinal (GI) surgical unit in India. MATERIALS AND METHODS: Data for patients diagnosed with operable gastric cancer between January 2006 and December 2014 were retrospectively analyzed. Data were collected from electronic hospital records in addition to mail and telephonic interviews when possible. RESULTS: A total of 427 patients were included. The tumor was located in the pyloro-antral region in 263 patients (61.7%). Subtotal gastrectomy was performed in 291 patients and total gastrectomy in 136 patients. Tumor stage classification revealed 43 patients (10.0%) with stage I, 40 patients (9.4%) with stage IIA, 59 patients (13.9%) with stage IIB, 76 patients (17.8%) with stage IIIA, 96 patients (22.5%) with stage IIIB, and 113 patients (26.4%) with stage IIIC disease. Follow-up data were available for 71.6% of the patients with a mean duration of 32.4 months. Five-year DFS and OS were 39% and 59%, respectively. CONCLUSIONS: Despite presenting at an advanced stage, the 5-year DFS and OS of patients with operable gastric cancer treated at a dedicated upper GI unit of a tertiary care center in India was good.

Palliative gastrectomy in advanced gastric cancer: is it worthwhile?

BACKGROUND: Gastric cancer remains one of the leading causes of cancer-related deaths. Many patients present late, and therefore, resections are often palliative in nature. The aim of this study was to assess the feasibility of resectional operation and the survival advantage of surgical resection in advanced gastric cancer. The effectiveness of palliation and the quality of life following operation for gastric cancer were assessed. METHODS: One hundred and fifty-one patients who underwent operation for gastric cancer at a tertiary centre in South India during a 5-year period between 1999 and 2003, were included in this study. Four sites of tumour spread were used as indicators of incurability in these patients. These were unresectable primary tumour or macroscopic residual primary tumour (T+), unresectable lymph nodal metastasis (L+), unresectable liver metastasis (H+) and peritoneal metastasis (P+). The resectability rate and survival were assessed in relation to these four factors. RESULTS: The resectability rate decreased as the number of sites of tumour spread increased. The overall survival was significantly better in the subgroup of patients who had a resectional operation (total gastrectomy or subtotal gastrectomy), as opposed to the subgroup who had non-resectional operation (exploratory laparotomy or laparotomy with gastrojejunostomy) (P = 0.0003). This survival advantage of resectional operation disappeared when more than two sites of tumour spread were present. The quality of life was significantly better when a resection operation was carried out. CONCLUSION: In advanced gastric cancer, palliative resection has a survival advantage if the tumour spread is restricted to two or less sites. Patients who undergo resectional operation have better palliation of symptoms and their postoperative quality of life is significantly better.