Laparoscopic extralevator abdominoperineal resection for low rectal cancer: The myth of reinventing the wheel.

Background & Objective: To review oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.In locally advanced low rectal cancer, ELAPE which is en-bloc resection of levator muscles along with the tumor in a prone position has significantly decreased the rate of having either positive circumferential resection margin (CRM) or tumor perforation. The aim of the study was to determine the oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer. Methods: This retrospective study was performed at Shaukat Khanum Cancer Hospital and Research Centre Lahore. Patients who underwent ELAPE for low rectal and anal cancer from January 2014 to December 2019 were selected. Data was collected using an electronic database through a hospital information system. Results: A total of 82 patients were included in the study having a median age of 39 years. Clinically preoperative tumor sizes were T2:2, T3:65, T4:15. Neo-adjuvant chemo radiotherapy was administered to 79 (96.3%) patients. Pathologically tumor sizes were T0:12, T2:15, T3:50, T4:5 with 79.2% (n=65) R0 resections. The mean operative time was 340.36±64.51 minutes and the mean blood loss was 99 milliliters. The mean postoperative hospital stay was 6.58±4.64 days. Seventeen (20.7%) cases had pathological circumferential resection margins positive (pCRM<1mm). However, tumor perforation was found in 8(9.8%) patients. Ninety days mortality was none while 36 patients experienced recurrence (local: 23, distant: 30, local + distant 17). The median survival time was 53.00±2.69 months. Conclusion: For locally advanced low rectal cancer, ELAPE has evolved as a safe oncological procedure with acceptable outcomes.

Emergency esophagectomy: Experience of a high volume esophageal cancer center.

Objective: The objective of the study was to review the experience of dealing oncological emergency esophagectomies at a dedicated Cancer hospital. Methods: We performed a retrospective review of data of eleven esophagectomies at the Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore (SKMCH&RC) Pakistan, from 1st January, 2009 to 30th June, 2019. Out of 590 oncological esophagectomies, eleven patients had emergency resection. We collected the data of demographics, primary disease, comorbidities, location of tumor and perforation, cause of perforations, radiological and endoscopic findings, clinical findings and follow-up visits after discharge. Data was analyzed by SPSS version 21 for windows. Result: All 11 patients out of five hunded ninety had esophageal cancer. At the time of initial staging, eight (72%) had locally advanced stage (stage III and IV). Open transhiatal approach was used in six (55%) patients, and the rest had three stage esophagectomies. Primary reconstructions with gastric conduit were performed in all, except in two (18%) patients, Respiratory complications were the most common of the encountered complications, seven (63%) of the patients had palliative resection. Ninety day mortality was observed in 3(27.3%) patients. On long term follow up, six patients had recurrence, with median Disease-Free Survival (DFS) 5.88 months and Median Overall Survival (OS) was 6.37 months. Out of 11, only three patients are alive without disease, while one patient is lost during follow-up. Conclusion: Emergency esophagectomy is a lifesaving procedure; there should be multidisciplinary team approach towards the management. Early diagnosis and management is of paramount importance.

Post-esophagectomy Anastomosis Leak: A 10-Year Experience at a Specialized Center for Cancer Surgeries in Pakistan.

Esophageal cancer has been reported to be the seventh most common cancer and the sixth most common cause of mortality. Use of advanced diagnostic techniques has increased the detection of preoperative metastases and resulted in better patient selection for further management by curative surgery. We carried out a study to evaluate the outcome of esophagectomy at our institute in terms of acute leak, mortality and hospital stay. We also looked at various preoperative, intraoperative and postoperative risk factors contributing to leak after esophagectomy. We evaluated 589 patients during the period from January 2009 to December 2019. All these patients underwent elective esophagectomy for esophageal cancer at our hospital. Out of these, leak was seen in 30 patients (5.1%). We found no statistically significant difference when evaluating patient and tumour characteristics of patients who developed leak against those who did not. We also didn't find any significant difference in intraoperative or postoperative factors between the two groups. Proper preoperative evaluation and optimization are necessary to overcome various patient co-morbidities. On the basis of our study we conclude that when performed in high-volume centers with an adequately trained multi-disciplinary team approach, esophagectomy for carcinoma has a good outcome.

Airway Management of a Patient With Tracheoesophageal Fistula and Tracheal Stent.

A 69-year-old male patient, a known case of squamous cell carcinoma of the esophagus on palliative care and Do Not Attempt Resuscitation (DNAR) status, presented for urgent laparoscopic gastrostomy tube insertion under general anesthesia. The patient had developed an iatrogenic tracheoesophageal fistula (TEF) because of the tracheal stent, which was placed for tracheal stenosis. A preoperative assessment was done, and a plan of airway management via one-lung ventilation (OLV) through an endobronchial tube was devised by the anesthesia team and discussed with the surgery team. The airway was secured via asleep fiberoptic right endobronchial intubation using a microlaryngeal tube (MLT) size 6 since there was uncertainty regarding adequate patency of the airway due to the invasion by the tumor and the presence of the stent. The patient remained hemodynamically stable. After surgical incision and insufflation of CO2 in the abdominal cavity, the patient's airway pressures were increased and we were unable to deliver adequate tidal volumes. Surgery was stopped; the presence of a kink in the circuit or endotracheal tube (ETT), the possibility of laryngospasm/bronchospasm, and pneumothorax were ruled out. Fiberoptic bronchoscopy (FOB) revealed that the endobronchial tube was abutting the secondary carina. We pulled the MLT by 2 cm. The rest of the procedure was uneventful and we extubated the patient at the end of the procedure under vision using a fiber optic bronchoscope. The patient was discharged after two days of stay in the hospital. Our patient with TEF and tracheal stent posed a significant challenge for airway management. A thorough plan was drawn up and a team briefing was done. Perioperatively, the difficulty in ventilation was identified, and various other etiologies were ruled out with the successful identification and management of the problem.

Laparoscopy offers better clinical outcomes and long-term survival in patients with right colon cancer: experience from national cancer center.

PURPOSE: Laparoscopic approach to colonic tumor requires skill set and resources to be established as routine standard of care in most centers around the world. It presents particular challenge in country like Pakistan due to economic constrain and lack of teaching and training opportunities available for surgeons to be trained to deliver such service. The aim of this study is to look into changing practice of our institution from conventional approach of open to laparoscopic surgery for right colon cancer. METHODS: Consecutive patients between January 2010 to December 2018 who presented to Shaukat Khanum Memorial Cancer Hospital and Research Centre with diagnosis of right colon (cecum, ascending and transverse colon) adenocarcinoma and underwent surgical resections were included in this study. RESULTS: A total of 230 patients with adenocarcinoma of the right colon underwent curative resections during the study period. Of these, 141 patients (61.3%) underwent laparoscopic surgery while open resection was performed in 89 patients (38.7%). Five-year disease-free survival (DFS) of patients with American Joint Committee on Cancer (AJCC) stage III (80.9% vs. 54.8%, P = 0.021) was significantly better if these patients underwent laparoscopic surgery while a trend toward better DFS (96.7% vs. 84.1%, P = 0.111) was also observed in AJCC stage II patients, although this difference was not significant. CONCLUSION: This study demonstrates the adoption of a laparoscopic approach for right colon cancer over 10 years. With a standardized approach and using the principle of oncological surgery, we incorporated this in our minimally invasive surgery practice at our institution.

Body Mass Index and Other Risk Factors Effects on Colon Cancer Prognosis in Pakistan.

Introduction: Asian developing countries share the burden of colorectal cancer (CRC) with rising mortality rates. This prospective study aims to apprehend the clinical relevance of age, gender, lifestyle choices (dietary habits and addiction) and body mass index (BMI) to the occurrence and progression of colon cancer (CC). Methods: A cohort of non-cancer (NC) and CC patients of South-Central Asian origin registered for screening colonoscopy or surgery at Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH and RC), Lahore, Pakistan, from 2015 to 2020 was identified. BMI (Kg/m2) was classified according to the World Health Organization criteria as underweight (<18.5 Kg/m2), normal weight (18.5-24.9 Kg/m2) and overweight (≥25 Kg/m2). Results: Among 236 participants, 99 (41.9%) belonged to the NC group, and 137 (58.1 %) participants had CC Overall, participants included 74 women and 162 men aged 20-85 years (mean ± SD; 49.9 ± 14.9). Notably, 46.0% of cancer patients had a family history of cancer. There was a direct relationship between CC with abnormal BMI (underweight and overweight), positive smoking history and positive family history of cancer. Conclusion: Being underweight or overweight is a potential risk factor for CC patients. The overall survival in patients with CC is clinically associated with lifestyle choices before CC diagnosis. A balanced diet, walking and other forms of exercise should be strongly recommended to the community and those undergoing screening colonoscopy.

Clinical Practice Guidelines For The Management Of Colorectal Cancer, A Consensus Statement By The Society Of Surgeons® And Surgical Oncology Society Of Pakistan®.

A joint effort by the Society of Surgeons Pakistan and Society of Surgical Oncology Pakistan, these guidelines provide a framework for the practicing surgeons involved in care and management of patients with colorectal cancer. The guidelines take into account the issues related to our local circumstances and provide a minimum standard of care that must be given to these patients. The Guideline Committee had members from all disciplines, including surgery, surgical oncology, medical oncology and radiation oncology. The guidelines have attempted to simplify things to understand and follow for the practicing surgeons. With these guidelines we wish to eliminate disparities in treatment among institutions and prevent any under treatment of patients.

Why myringoplasties fail? Impact of relevant clinical factors on the surgical outcome; a study from pakistan.

BACKGROUND: Myringoplasty is the reconstruction of the tympanic membrane by grafting. Success varies from 50-100%. A study was conducted to unveil the vital causes for failed myringoplasty with an aim to attenuate graft rejections and augment better outcomes. METHODS: It was descriptive case series in which data was retrospectively collected at a tertiary care hospital (Rawalpindi, Pakistan) from January 2009 to December 2018. First 600 consecutive patients who qualified for inclusion/ exclusion criteria, underwent myringoplasties were followed-up for 6 months. Graft Take/Failure, the main outcome variable, was correlated with relevant independent variables. Data was collected on a structured pro forma, approved by hospital ethical committee. Data was analysed using IBM-SPSS- 21.0. RESULTS: Out of 600, 164 (27.3%) had graft rejection; failure being significantly enhanced by increasing age (p<0.001), larger perforation (p-0.025), co-morbidities (p<0.001), especially diabetics (p=0.040) and Eustachian tube (p-0.016) dysfunction amongst among systemic and ENT diseases respectively, and discharge-free ear (Dry Ear) for <4 weeks (p<0.001); while best graft take was achieved with end-aural surgical technique (p=0.048). Gender (p-0.897) did not caste a significant impact on graft outcome. CONCLUSIONS: The results of various surgical approaches of myringoplasty are equitable. Proper socio-demographic and clinical evaluation can improve graft outcome, and this surgery shall be discouraged in patients with diabetes mellitus and defective Eustachian Tube functions.

Laparoscopic Curative Resection for Right-Sided Colonic Tumors: Initial Experience From a Specialized Cancer Hospital of a Developing Country.

Introduction Laparoscopic colonic resection is increasingly becoming popular worldwide and aims to provide curative resection in addition to the inherent benefits of laparoscopic surgery. The aim of this study was to evaluate the long-term outcomes of laparoscopic right hemicolectomy in a Pakistani cohort of patients. Methods and procedures We retrospectively analyzed the medical records of all patients who presented to our hospital with the diagnosis of right-sided colon carcinoma from January 2010 to December 2018 and underwent laparoscopic right or extended right hemicolectomy. Demographics, operative findings, histopathology report, and follow-up of patients were recorded and the analysis was performed on Statistical Packages for the Social Sciences (SPSS) Version 20 (IBM Corp, Armonk, NY). Results Seventy-five patients were included, 56 (74.7%) of whom were males and 19 (25.3%) were females. The median age was 52 years (range 25-82 years). The median hospital stay was five days (Range 3-13 days). The median blood loss was 70 milliliters and the mean operative time was 195.5±77.6 minutes. Laparoscopic extended right hemicolectomy was performed in 23 (16.67%) patients and standard right hemicolectomy in 52 (83.33%) patients. Most (72%) of the patients had a pathological T3 tumor, and the majority (61.3%) of the patients had no nodal involvement (pN0). The mean number of lymph nodes removed was 20+8. The median numbers of involved lymph nodes were 1.14+2.19. All the patients had R0 resection. Postoperatively, two patients had pelvic collection, and there was no 30-day mortality. Local recurrence occurred in four patients and distant metastases were observed in nine patients. The median follow-up in our study was 40.5±18.35 months. The median disease-free survival was 42±2.17 months and the median overall survival was 44±2.16 months. Conclusion Our experience with laparoscopic right colon resections has confirmed the safety and feasibility of the procedure.

Prognostic Factors for Recurrence in Esophageal Cancer Patients Treated With Neoadjuvant Therapy and Surgery: A Single-institution Analysis.

Background The purpose of this study is to analyze potential predisposing factors for a higher risk of recurrence in our esophageal cancer patients managed with neoadjuvant chemotherapy, radiation therapy, and surgery, and to determine their impact on disease-free survival (DFS) and time to recurrence. Methods A total of 154 of 232 patients staged T1b to T4a managed electively at our institute from July 2005 through July 2015 with a tri-modality approach were retrospectively evaluated. Basic demographic, clinical, radiological, operative, and pathological disease-related parameters, along with waiting time for surgery and type of neoadjuvant modality used, were assessed as potential risk factors. The primary endpoint was the impact of these on the risk of recurrence. The secondary endpoint was to study their relation on DFS and time to recurrence. Results The recurrence rate in this particular study was 33.1% over a median follow-up of 35 months (interquartile range = 19-50.3). The median time to recurrence was 12 months, and 94% of recurrences occurred within two years. The median DFS was 33 months, and the one- and three-year DFS was 90% and 72%, respectively. On univariate and multivariate analysis, a complete pathological response (hazard ratio [HR]: 3.8, 95% confidence interval [CI]: 1.41-10.11), negative resection margins (HR: 5.9, 95% CI: 1.69-20.45), and a low nodal index (HR: 6.3, 95% CI: 1.37-28.67 for an index of 0.1-0.2; and HR: 15.2, 95% CI: 0.96-241.73 for an index of >0.2) were found as statistically significant (P = < 0.05) for risk to recurrence. In addition to these three, a low comorbidity index (P = 0.03; HR: 3.5; 95% CI: 1.16-10.52) was an individual positive predictor of DFS. Conclusions A complete pathological response, low nodal index, and margin-negative resection were the identified predictors of freedom from recurrence, with a better DFS and a low comorbidity index as additional indicators of prolonged DFS.

Benefits of Outcomes of the Microscopic Examination of Anastomotic Donuts After Colorectal Resection for Oncological Purposes: A Medical Record-Based Study.

Objective  The objective of the study is to investigate the benefits of pathological assessment of donuts removed during coloanal anastomosis after anterior resection. Methodology During three years, 220 patients underwent circular stapled anastomosis. It is a retrospective study with convenient sampling. Involvement of donuts, the involvement of margins, length of donuts, and margins were primarily recorded. Ethical review approval was taken from the Institutional Review Board. Hospital electronic system was used to retrieve the data. Results Two hundred and twenty patients underwent circular end to end anastomosis (CEEA) stapled gun anastomosis. All had adenocarcinoma. Most of the patients had T3 disease (n=113). Low anterior resection was the most common procedure followed by anterior resection and sigmoid colectomy, respectively. We performed all rectal cancers anastomosis with a circular stapling gun. On histological analyses among 220 patients, only two patients were found to have a positive distal donut. No proximal donuts were positive. Both patients were also found to have positive distal margins. The mean length of the proximal donut was 1.79±0.45 cm. The mean length of the distal donut was 1.68±0.48 cm. Two distal margins and none of the proximal margins were positive for cancer. The mean length of the proximal margin was 8.69±4.48 cm. The mean length of the distal margin was 4.9±5.98 cm. Both patients had already received six months of pre-operative chemoradiotherapy and were not offered any additional treatment. Both patients were kept on close surveillance. Conclusion Routine analyses of the donuts after anterior resection has no impact on the management and outcome of the disease.

Perioperative Anaesthetic Management for Laparoscopic Gastrectomy in a Patient with Coarctation of Aorta.

Coarctation of the aorta (CoA) is a congenital condition, usually diagnosed and corrected early in life. Long-term survival with untreated coarctation is uncommon and is associated with high mortality rates in the fifth decade. A patient with CoA may present with problems while undergoing cardiac or non-cardiac surgical procedures which could pose considerable challenges in their anaesthetic management. Hence, the choice of anaesthetic technique plays an important role in determining the perioperative course and postoperative outcome in patients with CoA. This report discusses a case of middle-age man, recently diagnosed with CoA while undergoing a preanaesthetic assessment prior to the surgery for gastric adenocarcinoma involving proximal gastro-oesophageal junction. It highlights the successful anaesthetic management of CoA scheduled for laparoscopic-assisted gastrectomy for gastric adenocarcinoma. Perioperative management goals of the patient included general anaesthesia, epidural analgesia to avoid pain-associated adverse effects and efficient control of blood pressure distal to coarctation to limit the risk of intraoperative morbidity. It also demonstrates a major impact on anaesthesiologists who serve the most important role in managing such patients undergoing surgery with 'red flag' features.

Lack of awareness among surgeons regarding safe use of electrosurgery. A cross sectional survey of surgeons in Pakistan.

OBJECTIVE: To assess our surgeons perceptive regarding the safe usage of electrosurgical devices. METHOD: ology: This cross sectional survey was carried out at two hospitals, A cancer hospital and a public sector general hospital. Consultants, fellows and senior residents (Resident year 3rd and year 4th) on the surgical floor were requested to fill up the questionnaire. Calculations were performed with Statistical Package for the Social Sciences (SPSS 20) for Windows version 20 statistical software. Data was described using median with minimum and maximum value for quantitative variables. For categorical variables, number of observations and percentages were reported. The study is complied with hospital guidelines on research involving human subjects. RESULTS: Out of 80 questionnaires 52 were filled and returned. 12 consultants, 16 fellows/Senior registrars and 24 senior residents filled their questionnaires. For the sake of anonymity no information was obtained regarding the level of training and experience. Total 12 questions were asked. An expert level was set for a score above 10/12. A moderate level was set at 8/12. A score of less than 8 was considered unsafe for using electrosurgical devices. Only 6 (11.5%) participants had an expert level of understanding. 16 (30.7%) had moderate understanding. 30 (57.7%) were considered unsafe regarding use of electrosurgical devices. 85% participants were not aware of the correct mode of current to use for coagulating vessels. 69% of surgeons would use electrocautery to control staple line bleeds. 67% participants weren't aware of the correct placement of dispersive electrode. 60% couldn't identify a safe device for use in patients with a pacemaker. 46% of surgeons would cut a dispersive electrode to fit it on a child. 69% believed that harmonic scalpel was a bipolar cautery. 61% couldn't differentiate between RFA and Microwave Ablation. 63% didn't know how to handle an operating room fire. CONCLUSION: In these two hospitals, high level of ignorance noticed regarding the procedure and indications of basic electrosurgical equipment which needs raising awareness and further training.

Prognostic significance of pre- and post-operative serum carcinoembryonic antigen levels in patients presented with rectal carcinoma; an experience from Shaukat Khanum Memorial Cancer Hospital and Research Center Lahore.

OBJECTIVE: To explore the importance of serum carcinoembryonic antigen level as a tumour marker in rectal carcinoma. METHODS: The retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan, and comprised data of patients with rectal carcinoma from January 1996 to December 2015. Serum carcinoembryonic antigen levels were analysed using immulite@2000 system analyser. On the basis of serum carcinoembryonic antigen levels, data of patients was divided into four groups. Group A had normal serum levels both before and after surgical resection; Group B had normal levels pre-surgery but post-surgery levels were raised; Group C had raised levels pre-surgery that went down to normal post-surgery; and Group D had raised levels both before and after surgery. SPSS 23 was used for data analysis. RESULTS: Of the 401 patients, 267(66.6%) were males, and 204(50.9%) were aged <50 years. Group A had 267(66.6%) patients, Group B 26(6.5%), Group C 79(`9.7) and Group D had 29(7.2%) patients. Stage III disease was the most common 343(85.5%) and it was true across the groups. Overall recurrence was in 141(35.2%) patients. Group D had the highest recurrence rate 26(89.7%), while Group C had the lowest 18(22.8%). CONCLUSIONS: Fluctuating levels of carcinoembryonic antigen affected post-operative outcome.

Pre-operative percutaneous endoscopic gastrostomy tube placement does not increase post-operative complications or mortality in oesophageal cancer.

BACKGROUND: The percutaneous endoscopic gastrostomy (PEG) tube in patients with oesophageal cancer is controversial, owing to a perceived risk of tumour seeding at the PEG site, theoretical difficulty in formation of gastric conduit during oesophagectomy and a fear of increased post-operative complications, including anastomotic leak. We aimed to assess the impact of PEG tubes on nutritional status and post-operative complications in patients with oesophageal cancer who underwent PEG tube insertion prior to neo-adjuvant treatment. METHODS: We performed a retrospective review of 800 patients with oesophageal or gastro oesophageal junction (GOJ) cancer, who underwent PEG insertion from June, 2010 to May, 2015. Out of these, 168 patients who fulfilled the inclusion criteria were analysed further. All of them were followed up for 3 years after treatment to assess overall survival. Thus, the follow up of the last patient included in the study was completed on May, 31, 2018. RESULTS: The average body mass index (BMI) of patients was maintained following PEG tube, during neo-adjuvant treatment (22.34±4.84 before PEG vs. 21.85±3.90 after PEG, P value: 0.1). Out of 168 patients, 33 (19.7%) developed a complication following PEG tube, with PEG site infection as the most common in 24 (14.2%). PEG-related mortality at 1 month was 0%. Ninety out of 168 patients (59%) underwent surgery after neo-adjuvant treatment. Three patients had tumour seeding at the PEG site and thus surgery could not be performed. Gastric conduit formation was possible in all 99 patients. Postoperative complications were seen in 17/99 (17%) patients, including surgical site infections in 7 (7.07%), anastomotic leak in 6 (6.06%) and anastomotic stricture in 4 (4.04%). Overall survival at 3 years was 87%. CONCLUSIONS: Pre-operative PEG tube in oesophageal cancer is safe and does not compromise the future anastomosis. Also, it helps in maintaining the nutritional status during neo-adjuvant treatment.

Diverse Anatomical Configuration Of Recurrent Laryngeal Nerve In Relation To Inferior Thyroid Artery, An Experience With 51 Thyroidectomies.

BACKGROUND: Objective of the study is to elaborate the anatomical variants of recurrent laryngeal nerve in relation to inferior thyroid artery, encountered during thyroidectomy operation. It is descriptive, case series, conducted at the Department of Ear Nose & Throat, Combined Military Hospital, Abbottabad. The study was conducted from January 2016 to September 2017. METHODS: Fifty-one patients underwent extra-capsular thyroidectomy in general anaesthesia. The dissection was carried out in a standard way in all patients. Recurrent laryngeal nerves were identified and exposed in every patient, and their anatomical relations were recorded in database. RESULTS: Recurrent laryngeal nerve was seen over riding the ramification of inferior thyroid artery in majority of left sided dissected specimen, however on the right side the principal nerve was found to be ascending through the branches of inferior thyroid artery.. CONCLUSIONS: Iatrogenic vocal cord paralysis has sinister implication on quality of life of the patient undergoing thyroidectomy. Anatomic variants of recurrent laryngeal nerve are well known and frequent. The disastrous outcome of inadvertent recurrent laryngeal nerve trauma can be adequately prevented by thoroughly knowing its anatomical variants, and intra-operatively identifying and exposing the principal nerves.

Synergy Estimation for Myoelectric Control Using Regularized NMF.

This paper investigates the problem of achieving robust control for assistive devices using surface electromyogram. We propose the use of regularized non-negative factorization using alternating least square algorithm for the estimation of muscle synergies. The proposed algorithm is tested for 3 different degrees of freedom only one active at a time, providing 97.6 - 99.5% accuracy and when compared with previously proposed methodology it reduces the delay time by 45%.

Risk Factors For Chyle Leak After Esophagectomy.

BACKGROUND: Chylothorax is an uncommon (3-8% risk) but potentially fatal complication of esophagectomy with poorly understood risk factors. It has a high morbidity due to loss of fluids, electrolytes, and other nutrients, loss of lymphocytes and immune dysfunction. METHODS: Retrospective chart review of adult patients who underwent esophagectomy between 2009 and 2016 was performed. Cases with chyle leak were identified according to a set criteria. Clinical features, operative findings and postoperative variables were recorded and predictors of chyle leak were analyzed. RESULTS: During the study period, a total of 193 adult patients underwent esophagectomy of which 186 received neo adjuvant chemotherapy. The mean age was 53 years with 118 males and 74 females. Type of procedure performed was 3-stage esophagectomy in 98, Transhiatal esophagectomy in 79 and Ivor-Lewis esophagectomy in 15 patients. Chyle leak was identified in 9 (4.6%) patients. There was no significant association of chyle leak with age, gender, co-morbid, level of tumor, Neoadjuvant therapy and Type of esophagectomy. Chest drain output on postoperative day 5 was significantly predictive of chyle leak (p-value<0.05). Drain output more than 1000 on day 4 was highly suggestive of chyle leak (p-value<0.05). Day on which chest drain was removed was also found to be significantly related to chyle leak (p-value <0.05). CONCLUSIONS: No significant preoperative risk factors were identified for chyle leak. High chest drain output on postoperative day 5 and drain output more than 1000 on day 4 are significant predictors of chyle leak.

Proteomics analysis of colon cancer progression.

BACKGROUND: The aim of this pilot study was to identify proteins associated with advancement of colon cancer (CC). METHODS: A quantitative proteomics approach was used to determine the global changes in the proteome of primary colon cancer from patients with non-cancer normal colon (NC), non-adenomatous colon polyp (NAP), non-metastatic tumor (CC NM) and metastatic tumor (CC M) tissues, to identify up- and down-regulated proteins. Total protein was extracted from each biopsy, trypsin-digested, iTRAQ-labeled and the resulting peptides separated using strong cation exchange (SCX) and reverse-phase (RP) chromatography on-line to electrospray ionization mass spectrometry (ESI-MS). RESULTS: Database searching of the MS/MS data resulted in the identification of 2777 proteins which were clustered into groups associated with disease progression. Proteins which were changed in all disease stages including benign, and hence indicative of the earliest molecular perturbations, were strongly associated with spliceosomal activity, cell cycle division, and stromal and cytoskeleton disruption reflecting increased proliferation and expansion into the surrounding healthy tissue. Those proteins changed in cancer stages but not in benign, were linked to inflammation/immune response, loss of cell adhesion, mitochondrial function and autophagy, demonstrating early evidence of cells within the nutrient-poor solid mass either undergoing cell death or adjusting for survival. Caveolin-1, which decreased and Matrix metalloproteinase-9, which increased through the three disease stages compared to normal tissue, was selected to validate the proteomics results, but significant patient-to-patient variation obfuscated interpretation so corroborated the contradictory observations made by others. CONCLUSION: Nevertheless, the study has provided significant insights into CC stage progression for further investigation.