Redo surgical aortic valve replacement for prosthetic valve valve-in-valve dysfunction.

Transcatheter aortic valve replacement (TAVR) has become the preferred intervention for patients with severe aortic stenosis and significant comorbidities. This technique can also be used for failed bioprosthetic valves and is known as the valve-in-valve (ViV) procedure. Placing TAVR in a small bioprosthesis (<23 mm) can lead to delayed dysfunction of the prosthetic valve. We present a case of a late explanted ViV 8 years post-initial aortic valve replacement and coronary artery bypass grafting, and 3 years post-ViV procedure in a 76-year-old female. A video of the surgical procedure is provided.

Influence of processing conditions on quality of Indian small grey donkey milk powder by spray drying.

The study was carried out to know the quality of small grey donkey milk powder by spray dryer. Donkey milk powder moisture, fat, protein, carbohydrate and ash were 4.12 (d.b), 5.97, 22.84, 4.64 and 62.43 (%). Donkey milk powder was produced at milk total solids of 20, 25 and 30% concentration at 160, 170 and 180 °C inlet air temperature using two fluid flow nozzle type atomizer of 0.84 mm diameter, pressure of 1.75 kg.cm-2, flow rate of 0.5 L.h-1, blower speed of 2100 rpm. L * , a * , b * and aw values decreased with increasing concentrated milk feed as well as inlet air temperature. Density decreased as increase of inlet air temperature and increased as increase milk concentration. Flowability was fair according to Hausner ratio (1.25) and Carr's index (20%) values. The heat utilization efficiency increased as increase of concentration and decreased as increase of inlet air temperature. Solubility decreased as increase of concentration and inlet air temperature. Dispersibility decreased as increase of inlet air temperature and increased as increase of concentration. Wetting time increased as increase of concentration and inlet air temperature. Structure of the donkey milk powder was spherical and minerals were abundant.

Off-pump myocardial revascularization with Impella 5.5-assisted for cardiogenic shock.

We report a case of Impella 5.5-assisted off-pump coronary artery bypass grafting for acute myocardial infarction with cardiogenic shock. The Impella 5.5 was placed in the left ventricle during the emergent procedure, and an off-pump coronary artery bypass grafting was successfully performed with exposure of all three walls of the heart. Our findings demonstrated the feasibility of off-pump coronary revascularization in three-vessel disease in a patient assisted with an Impella 5.5 percutaneous left ventricular assist device without displacement of the device during the entire perioperative period.

Use of a novel bicarbonate-based Impella 5.5 purge solution in a coagulopathic patient.

The Impella 5.5 with Smart Assist (Abiomed) is a life-saving treatment option in acute heart failure which utilizes a continuous heparin purge solution to prevent thrombosis. In patients with contraindications to heparin, alternative anticoagulation strategies are required. We describe the stepwise management of anticoagulation in a coagulopathic patient with persistent cardiogenic shock following a coronary artery bypass procedure who underwent Impella 5.5 placement. A direct thrombin inhibitor-based purge solution was utilized while evaluating for heparin-induced thrombocytopenia. The use of a novel bicarbonate-based purge solution (BBPS) was successfully used due to severe coagulopathy. There were no episodes of pump thrombosis or episodes of severe bleeding on the BBPS and systemic effects of alkalosis and hypernatremia were minimal.

Physico-chemical composition, minerals, vitamins, amino acids, fatty acid profile and sensory evaluation of donkey milk from Indian small grey breed.

Composition, nutritional value and sensory characteristics of donkey milk of Indian small grey breed was analysed using AOAC and other standard methods. Fresh donkey milk had 90.63% (w.b.) moisture content, 0.76% fat, 1.96% protein, 6.30% lactose, 0.40% ash. Particle size of donkey milk was 355.00 d.nm. The UHPLC analysis ascertained that lysozyme content was more in donkey milk sample. The ICPMS confirmed that Ca, K, Mg, Na, vitamin C and E, glutamic acid, leucine, proline were the most abundant in donkey milk, but Fe, Zn, Vitamin A and B1, methionine shown lower amount. The GC analysis determined that butyric acid, lauric acid was more and lower amount of unsaturated fatty acids were observed in donkey milk sample. Finally, the TPC, yeast and mould count were acceptable and confirmed that donkey milk is microbiologically safe and sensory evaluation studies of donkey milk confirmed that the desired sensory attributes.

Minimally Invasive Direct Coronary Artery Bypass for the management of Anomalous Left Coronary Artery from the Right Coronary Sinus.

OBJECTIVE: Anomalous left coronary artery from the right coronary sinus (ALCA) is a known cause of sudden death. Surgical correction is recommended for all patients with interarterial course. We describe two patients who underwent surgical correction through an off pump- minimally invasive direct coronary artery bypass (MIDCAB) approach with good short- and mid-term results.

Constitutional mismatch repair deficiency syndrome: Do we know it?

Constitutional mismatch repair deficiency syndrome is a rare autosomal recessive syndrome caused by homozygous mutations in mismatch repair genes. This is characterized by the childhood onset of brain tumors, colorectal cancers, cutaneous manifestations of neurofibromatosis-1 like café au lait spots, hematological malignancies, and occasionally other rare malignancies. Here, we would like to present a family in which the sibling had glioblastoma, and the present case had acute lymphoblastic lymphoma and colorectal cancer. We would like to present this case because of its rarity and would add to literature.

Predominant Use of Bilateral Internal Mammary Arteries in Off-Pump Coronary Artery Bypass Surgery.

Bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG) has been shown to provide long-term clinical benefits over single internal mammary artery (SIMA) grafting. Nevertheless, the perceived technical complexity of the procedure and concerns about potential early postoperative complications, particularly, sternal wound infections, have led to a utilization rate of BIMA grafting of less than 5% in the United States. We systematically compared early (30-day) postoperative outcomes between the BIMA and SIMA cohorts in patients with similar baseline characteristics. A retrospective single-center study was conducted on matched patients, using stabilized inverse probability treatment weighting to mitigate bias between the 2 study cohorts. From 546 patients who underwent off-pump CABG initially identified, we examined 328 B.M. and 213 SIMA grafts from the matched samples. Despite using 60.4% BIMA grafts, we observed similar rates of 30-day overall and cardiac mortality between the BIMA and SIMA groups. The rates of 30-day postoperative complications, including superficial and deep sternal wound infections, stroke, sepsis, acute kidney injury, and cardiac arrest, were similar between the 2 groups. The rates of 30-day overall and cardiac readmission were also similar. In addition, the median length of hospital stays, intensive care unit stay, and ventilation times were similar between the 2 groups. In conclusion, our data suggest that a BIMA utilization rate of 60.4% in off-pump CABG procedures is achievable without causing any significant increment in early postoperative complications, including deep sternal wound infection.

Shelf-life and colour change kinetics of Aloe vera gel powder under accelerated storage in three different packaging materials.

Aloe vera gel powder was produced through dehumidified air drying of Aloe vere gel at optimized conditions of temperature, relative humidity and air velocity of 64 °C, 18% and 0.8 m.s(-1), respectively. The powder was packed in three different packaging materials viz., laminated aluminum foil (AF), biaxially oriented polypropylene (BOPP) and polypropylene (PP). The shelf-life of the powder was predicted on the basis of free flowness of product under accelerated storage condition (38 ± 1 °C, 90 ± 1% relative humidity) and was calculated to be 33.87, 42.58 and 51.05 days in BOPP, PP and AF, respectively. The storage stability of powder in terms of colour change was studied. The magnitude of colour change of Aloe vera gel powder during storage suggests that AF was better than BOPP and PP. The colour change of powder during storage followed first order reaction kinetics with a rate constant of 0.0444 per day for AF, 0.075 per day for BOPP and 0.0498 per day for PP.

Who Needs Level III Lymph Node Dissection in Carcinoma Breast-Study from a Tertiary Care Center.

In Indian females, breast cancer is the most common cancer with a late stage of presentation leading to one-third of patients undergoing modified radical mastectomy (MRM). Our study is undertaken to find out predictors of level III axillary lymph node metastasis in breast cancer and who needs complete axillary lymph node dissection (ALND). Retrospective study of 146 patients who undergone MRM or breast-conserving surgery (BCS) with complete ALND at Kidwai Memorial Institute of Oncology was done, and data was analyzed to find out the frequency of level III lymph nodes and the demographic relation and its relation to positive lymph nodes in level I + II. Positive metastatic level III lymph node was found in 6% of patients, with the median age of the patient in our study with level III positivity was 48.5 years with 63% pathological stage II with 88% perinodal spread (PNS)- and lymphovascular invasion (LVI)-positive. Involvement of level III lymph node was associated with gross disease in level I + II lymph node having more than four lymph node-positive and with pT3 stage or more which has higher chances of level III lymph node involvement. Level III lymph node involvement, though rare in early-stage breast cancer, is associated with larger clinical and pathological sizes (T3 or more), more than 4 lymph node-positive in level I + II and with PNS and LVI. Hence, based on these results, we recommend that for inpatient with more than 5-cm tumor size and those with the gross disease in axilla, complete ALND is recommended.

Barriers related to Oral Cancer Screening, Diagnosis and Treatment in Karnataka, India.

BACKGROUND: The most predominant cancer in India is Oral cancer. Annually 130,000 people yield to oral cancer in India, which translates into about 14 deaths per hour and 60-80% of patients present with advanced disease as compared to 40% in developed countries. AIM: To decide factors associated with primary, secondary and tertiary delays and identify reasons for a lack of follow-up. MATERIALS AND METHODS: This study was conducted at the Kidwai Memorial Institute of Oncology, Bengaluru. A hospitalbased cross-sectional study using the direct personal interview method was done. A total of 200 oral cancer patients were included in the study. RESULTS: 34.5% were men and 65.5% were women. About 97.5% of patients were engaged with either one of the habits like smoking, chewing or alcohol consumption. 84% of patients were not aware of the risk of getting oral cancer. 29% of people agreed that tobacco and alcohol are risk factors for oral cancer and they know about the signs of oral cancer. If detected early, cure rates were higher compared to illiterate people and this difference is statistically significant p< 0.05. 83.5% of patients did not know that oral cancer can be diagnosed early by regular screening of the oral cavity. The cost of staying near a Regional cancer centre, job security, and the social and economic burden on relatives were significant barriers to incomplete treatment and a decreased follow-up rate. CONCLUSION: Low awareness is the main barrier to oral cancer detection. Conducting cancer awareness and screening camps frequently will detect oral cancers at an early stage. KEY WORDS: Oral Cancer, Barriers, Cancer awareness, Oral Screening.

Outcomes of Cancer Surgery During the COVID-19 Pandemic: Preparedness to Practising Continuous Cancer Care.

The COVID-19 pandemic has placed unprecedented pressure on healthcare services. Deprioritisation of nonemergency clinical services and growing concerns of adverse outcomes of COVID-19 in cancer patients is having a deleterious impact across oncologic practice. We report cancer surgery outcomes taking into account the acuity of the COVID-19 situation. A prospectively maintained database of the Department of Surgical Oncology was analysed from 1st May to 30th June, 2020, to evaluate the perioperative outcomes, morbidity and mortality following major surgical procedures. A total of 359, preoperatively, tested negative for COVID-19 underwent surgery. Median age was 52 years with 26.7% (n = 96) above the age of 60 years. Sixty-one percent (n = 219) patients were American Society of Anaesthesiology grades II-III. As per surgical complexity grading, 36.8% (n = 132) cases were lower grades (I-III) and 63.2% (n = 227) were complex surgeries (IV-VI). 5.3% (n = 19) had ≥ grade III Clavien-Dindo complication, and the postoperative mortality rate was 0.27% (n = 1). Major complication rates in patients > 60 years were 9.3% in comparison to 4.1% in < 60 years (p = 0·63). The median hospital stay was 1-10 days across subspecialties. Postoperatively, repeat COVID 19 testing in 2 suspected patients were negative. Our study showed that after screening, triaging and prioritisation, asymptomatic cases may undergo cancer surgeries without increased morbidity during COVID-19 pandemic.

Acute Presentation of Critical Aortic Stenosis, Cardiogenic Shock, and the "Heart Team" Approach to Management.

A 65-year-old male was admitted for cardiogenic shock (ejection fraction: 15%) with severe aortic stenosis and regurgitation. He underwent emergency angiography and mechanical circulatory support. A multidisciplinary heart team discussed treatment options. Ultimately, he underwent successful emergency surgical aortic valve replacement with recovery on extracorporeal membrane oxygenation. (Level of Difficulty: Intermediate.).

Clinical profile and outcomes in cervical cancer: An audit from a tertiary cancer center.

Background: Carcinoma cervix contributes to a major proportion of cancer treatment in tertiary oncology centers. The outcomes are dependent on multiple factors. We conducted an audit to establish the pattern of treatment practiced for carcinoma cervix at the institute and suggest changes thereof to improve the quality of care. Methodology: A retrospective observational study of 306 diagnosed cases of carcinoma cervix was carried out for the year 2010. Data was collected with regards to diagnosis, treatment, and follow-up. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20. Results: Out of 306 cases, 102 (33.33%) patients received only radiation therapy and 204 (66.66%) patients received concurrent chemotherapy. The most common chemotherapy used was weekly cisplatin 99 (48.52%), followed by weekly carboplatin 60 (29.41%) and three weekly cisplatin 45 (22.05%). Disease-free survival (DFS) at 5 years was 36.6% with patients of overall treatment time (OTT) of <8 weeks and >8 weeks showing DFS of 41.8% and 34% (P = 0.149), respectively. Overall survival (OS) was 34%. Concurrent chemoradiation improved overall survival by a median of 8 months (P = 0.035). There was a trend towards improved survival with three weekly cisplatin regimen, however, insignificant. Stage correlated with improved overall survival significantly with stage I and II showing 40% and stage III and IV showing 32% (P < 0.05) OS. Acute toxicity (grade I-III) was higher in the concurrent chemoradiation group (P < 0.05). Conclusion: This audit was a first of its kind in the institute and threw light on the treatment and survival trends. It also revealed the number of patients lost to follow-up and prompted us to review the reasons for it. It has laid the foundation for future audits and recognized the importance of electronic medical records in the maintenance of data.

PD-1 and PD-L1 Expression in Indian Women with Breast Cancer.

OBJECTIVE: The interaction between programmed cell death protein 1 (PD-1) on activated T-lymphocytes and programmed death-ligand 1 (PD-L1) on tumor cells or antigen-presenting cells sends immunosuppressive signals leading to the escape of tumor cells from the host anti-tumor immune response. Inhibiting this interaction with antibodies against PD-1 or PD-L1 is emerging as a valuable therapeutic strategy. However, tissue distribution patterns for PD-L1 and PD-1 in breast cancer patients from India are not reported, yet many clinical trials are underway. In this study the expression of PD-1 and PD-L1 in breast cancer patient samples from India was characterized. MATERIALS AND METHODS: The study included 392 cases of operated breast cancer (2012-2017) from a tertiary cancer care center in Bangalore, Karnataka, India. Paraffin blocks were retrievable and receptor status was known. Immunohistochemistry (IHC) was performed using anti-PD-L1 and anti-PD-1 antibodies. RNA was isolated from 76 fresh tumors and nine adjacent normal tissues (2019). PD-L1 transcript levels were measured by RT-qPCR using Hypoxanthine-guanine phosphoribosyl transferase (HPRT) as a reference gene. RESULTS: Based on IHC, PD-1 expression within tumor-infiltrating immune cells (TIICs) was observed in 55/385 cases (14%) across all breast cancer types. In triple-negative breast cancer (TNBC), 21/132 cases (16%) showed PD-1 staining in TIICs. The overall expression of PD-L1 in breast tumor cells across all breast cancer subtypes and TIICs was 11% (41/378) and 39% (151/385), respectively. A relatively higher proportion of TNBC cases had PD-L1 expression in tumor cells (17/132 cases, 13%) and immune cells (68/132 cases, 52%). We also detected PD-L1 transcript expression by qRT-PCR in freshly isolated tumor samples. CONCLUSION: These findings show that around 52% (68/132) of the TNBC cases express PD-L1 in TIICs. Hence, anti-PD-1/PD-L1 therapy alone or combined with chemotherapy may be a promising treatment for TNBC in Indian patients.

Revisiting Metaplastic Carcinoma of Breast: An Emphasis on the Clinico-pathological and Immunohistochemical Variables Analyzed at a Tertiary Cancer Centre in South India.

Background & Objective: Metaplastic carcinoma is a diverse variant of invasive breast carcinomas (IBC) characterized by dedifferentiation of malignant cells towards squamous and/or mesenchymal elements. It accounts for 0.3-1.2% of all IBC. These tumors are typically triple-negative by hormonal profiling with a high proliferation index and a dismal prognosis. Lymph node metastasis is an unusual feature in metaplastic carcinoma. Methods: The present study analyses 30 cases (26 cases of modified radical mastectomy and 4 cases of lumpectomy) of metaplastic carcinoma over 2018-2020 (3 years). Four oncopathologists reviewed routine histopathologic and immunohistochemical-stained slides. The clinical details were collected from the Medical Records Department of the Cancer Institute. Results: A total of 20 (66.67%) cases were patients >50 years of age, 21(70%) out of which were diagnosed as invasive carcinoma, grade 3 according to the Nottingham histological score. Five (16.7%) cases presented with lymph node metastasis. While immunohistochemically 28 (93.3%) cases were triple-negativeCK5/6, P63, EGFR, and Ki-67 (more than 40%) positivity was noted in 25 (83.3%) , 26 (86,7%) , 20 (66.7%), and 25 (83.3%) cases, respectively. Conclusion: Metaplastic carcinoma is characteristically triple-negative breast malignancies (TNBC) exhibiting a high Ki-67 index and a lower rate of lymph node metastasis. CK5/6, p63, and EGFR are pertinent immunohistochemical markers that may aid in diagnosis. However, those markers are non-specific for the disease and morphologic features are always the key to diagnosis of the process.

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group's practical consensus statements for surgical management of localized and locally advanced rectal cancer.

Introduction: There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods: Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results: Using the results of the review of the literature and experts' opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as "strong or weak", based on the GRADE framework. Conclusion: The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons' community in India.

Robotic Total Mesorectal Excision for Rectal Cancer: Short-Term Oncological Outcomes of Initial 178 Cases.

Emerging techniques in minimally invasive rectal resection include robotic total mesorectal excision (R-TME). The Da Vinci Surgical System offers precise dissection in narrow and deep confined spaces and is gaining increasing acceptance during recent times. The aim of this study is to analyse our initial experience of R-TME with Da Vinci Xi platform in terms of perioperative and oncological outcomes in the context of data from recently published randomised ROLARR trial amongst minimally invasive novice surgeons. Patients who underwent R-TME or tumour specific mesorectal excision for rectal cancer between May 2016 and November 2019 were identified from a prospectively maintained single institution colorectal database. Demographic, clinical-pathological and short-term oncological outcomes were analysed. Of the 178 patients, 117 (65.7%) and 31 (17.4%) patients had lower and mid third rectal cancer. Most of the tumours were locally advanced, cT3-T4: 138 (77.5%). One hundred/178 (56.2%) underwent sphincter preserving TME. Eighty-seven (48.8%) were grade II adenocarcinoma. Nonmucinous adenocarcinoma was the predominant histology, 138 (78.4%). One hundred one cases (56.7%) were pT3. The mean number of lymph node yield was 13 ± 5. Distal resection margin and circumferential resection margin were positive in 2 (1.12%), 12 cases (6.74%) respectively. Eleven cases (6.7%) had to be converted to open TME. Mean blood loss and duration of surgery was 170 ± 60 ml and 286 ± 45 min respectively. Five percent cases had an anastomotic leak. Grade IIIa-IIIb Clavien Dindo (CD) morbidity score was reported to be in 12 (6.75%) and 10 (5.61%) cases. Median length of hospitalisation was 7 days (range 4-14 days). Perioperative and pathologic outcomes following robotic rectal resection is associated with good short-term oncological outcomes and is safe, effective, and reproducible by a minimally invasive novice surgeon.

Robotic Complete Mesocolic Excision with Central Vascular Ligation for Right Colon Cancer: Surgical Technique and Short-term Outcomes.

BACKGROUND: Minimally invasive colorectal surgery has demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic assistance is an evolution of minimally invasive technique. PURPOSE: The study aims to present technical details and short-term oncological outcomes of robotic-assisted complete mesocolic excision (CME) with central vascular ligation (CVL) for right colon cancer. METHODOLOGY: Fifty-two consecutive patients affected by right colon cancer were operated between May 2016 and February 2020 with da Vinci Xi platform. Data regarding surgical and short-term oncological outcomes were systematically collected in a colorectal specific database for statistical analysis. RESULTS: Thirty-seven (71.15%) and 15 (28.85%) patients underwent right and extended right hemicoletomy with an extracorporeal anastomosis. Median age was 55 years. Mean operative time was 182 ± 36 min. Mean blood loss was 110 ± 90 ml. Conversion rate was 3.84% (two cases). 78.84% (41 cases) were pT3 and mean number of harvested lymph nodes was 28 ± 4. 1/52 (1.92%) had a documented anastomotic leak requiring exploratory laparotomy and diversion proximal ileostomy. Surgery-related grade IIIa-IIIb Calvien Dindo morbidity were noted in 9.61% and 1.92%, respectively. CONCLUSION: Robotic assistance allows performance of oncological adequate dissection of the right colon with radical lymphadenectomy as in open surgery, confirming the safety and oncological adequacy of this technique, with acceptable results and short-term outcomes.