Surgical Site Infection in Head and Neck Cancer Patients: Observations from A Tertiary Care Hospital.

Ramakrishna Pai JakribettuBackground Surgical site infections (SSIs) in head and neck cancer (HNC) patients can significantly affect the outcome of the surgery. Appropriate antimicrobial prophylaxis is needed for prevention of SSI. Aim To study the causative agents causing SSI among the HNC patients and their drug resistance pattern. Materials and Methods This was a retrospective study. The antibiotic suspectibility pattern of the aerobic bacteria isolated from the wound infection in the patients underwent surgery for head and neck cancer, admitted from January 2015 to December 2016 were added in the study. The demographic details of patients, pathogens isolated, and their antimicrobial susceptibility were collected, entered into Microsoft Excel, and statistical analysis was done as per percentage of isolates and drug resistance. Results A total of 130 culture-positive pus samples were included in the study. The majority of the samples were from males (71.5%), one-third of the patients belonged to the sixth decade of their life. Buccal mucosa and tongue were the common cancer in the head and neck region. The common gram-negative pathogens were Klebsiella sp. and Acinetobacter sp. and Staphylococcus aureus and Enterococcus sp. among the gram-positive bacteria. Methicillin-resistant S. aureus isolation rate was noted to be as high as 64.28%. High levels of resistance to aminopenicillins, third generation cephalosporins, co-trimoxazole and fluoroquinolones among the gram-negative pathogens. Anti-MRSA drugs such as vancomycin, linezolid, and teicoplanin resistance was not seen among S. aureus . Conclusion The resistance pattern among the pathogens isolated from SSI in HNC patients is alarming. So, implementation of strict infection control practices to prevent SSI rather than treating them with high end antimicrobials is the best option.

A comparative study of indocyanine green instillation in inguinal node versus foot web space using da Vinci indocyanine green FireFly™ technology in identifying thoracic duct during robotic-assisted transthoracic oesophagectomy.

INTRODUCTION: Chyle leak is a serious complication following oesophagectomy with incidence varies from 1% to 9%. Near infra-red fluorescence imaging of thoracic duct (TD) can provide real-time dynamic imaging during the surgery. In this study, we intend to compare indocyanine green (ICG) dye instillation through inguinal node with subcutaneous first web space instillation for visualisation of TD during robotic-assisted minimally invasive oesophagectomy (RAMIE) procedure. PATIENTS AND METHODS: A prospective study of 50 patients underwent RAMIE with da Vinci X System. After general anaesthesia, patients were divided into inguinal node and foot first web space ICG instillation group. The former group had 1 ml of ICG dye instilled on bilateral inguinal nodes under ultrasound guidance and while the other group received 1 mL of ICG dye injected at bilateral foot first web space and then underwent surgery. TD was visualised using ICG FireFly™ fluorescence technology, first at the time of docking and subsequently for every 5 min until 60 min of instillation time and analysed. RESULTS: Twenty-five patients were enrolled in each group. The mean docking time for thoracic phase was 13.76 ± 3.43 min. TD was visualised in 72% (18/25) of cases of first web space instillation group, whereas 100% in ultrasound guidance inguinal node instillation group. None of the patients had a chyle leak. CONCLUSION: ICG FireFly™ fluorescence technology for the identification of TD during oesophageal mobilisation is safe and effective and provides real-time dynamic visualisation with high accuracy in ultrasound-guided bilateral inguinal node instillation group. It is an effective method for the surgeons planning to negotiate their initial learning curve in RAMIE procedures.

Beyond Traditional Approaches: A Pilot Study Exploring the Role of Injection Mitomycin C on the Surgical Resection Bed in Oral Cancer Treatment.

Background Oral cavity cancer ranks sixth among all cancers worldwide. India has the most oral cancer cases and accounts for one-third of the global oral cancer burden. Oral cavity cancer is known to be associated with an elevated likelihood of locoregional recurrences, which account for the bulk of post-surgery and radiotherapy treatment failures. Mitomycin C (MMC) is an antineoplastic and antibiotic agent that is administered topically rather than intravenously to treat bladder and intraperitoneal tumors to avoid recurrences. This study aimed to investigate the use of injection MMC as a local application on surgical resection beds for patients undergoing surgery for oral cancer and to assess its efficacy in preventing regional recurrences. Methodology In this prospective, interventional, pilot study, patients were assigned randomly to two groups using simple randomization. Group A involved the application of two gauze pieces soaked with MMC injection. Group B involved the application of two gauze pieces soaked with a 10% betadine solution. During the pectoralis major myocutaneous flap harvest procedure for reconstruction, two gauze pieces soaked with either injection MMC solution (20 mg MMC in 20 mL of 0.9% normal saline) or 10% betadine solution were placed on the surgical resection bed for a 45-minute contact period. Patients were evaluated daily in the postoperative period for local complications. Regular follow-up visits were scheduled for 15 months of follow-up. Results After exclusions at various phases, the final analysis included 50 patients in Group A and 50 patients in Group B. Minor complications, specifically blackening of the skin flap in the neck resulting in surgical site infections, were observed in 16% (eight patients) of the MMC group and in 6% (three patients) of the betadine group (p = 0.1997) patients. In the MMC group, two (4%) patients experienced locoregional recurrences at three months, four (8%) patients at six months, six (12%) patients at nine months, eight (16%) patients at 12 months, and 10 (20%) patients at 15 months of follow-up. In contrast, locoregional recurrences occurred in two (4%) patients in the betadine group at three months, six (12%) patients at six months, nine (18%) patients at nine months, 12 (24%) patients at 12 months, and 15 (30%) patients at 15 months. Although the difference in locoregional recurrences between the two groups was not statistically significant, there was a trend of decreasing locoregional recurrences in the MMC group relative to the betadine group as the duration of follow-up increased. In the subgroup analysis of patients with pathological extranodal extension (ENE), only 10 of 18 patients with ENE in Group A (55.55%) experienced a recurrence, whereas all 12 patients with ENE in Group B (100%) experienced a recurrence within the same time frame. This difference in locoregional recurrence rates between the two groups was statistically significant, with a p-value of 0.0100. Conclusions Our study demonstrated that the local administration of MMC on surgical resection beds may lower the risk of locoregional recurrences in patients with oral cancer, especially those with ENE. These findings contribute to the ongoing efforts to enhance treatment strategies and patient outcomes for this challenging malignancy.

Prospective analysis of 164 fires of da Vinci SureForm SmartFire stapler in oncological cases: Indian cohort of 76 consecutive cases.

Background: The application of robotic staplers in surgeries has increased in recent years. Robotic platform enhances ability of the surgeon to directly control and manoeuvre staplers to achieve required angulation and sealing within the confines of the thorax and pelvis. Hence, in this study, we intended to learn the effectiveness of the SureForm™ SmartFire™ technology stapling system in various oncological procedures. Patients and Methods: Prospective study of 76 patients who underwent robotic-assisted total oesophagectomy, gastrectomies, hemicolectomies, low anterior resection/abdominoperineal resection and lobectomies/metastasectomy for respective malignancies for 16 months. Internal data log of the da Vinci surgical system for reload colour, reloads used, clamp attempts and staple fires used during each procedure along with patient's post-operative outcomes were recorded. Results: One hundred and sixty-four firings have been made in 76 cases, with the majority being green reloads (76.8%) and average reloads for radical cystectomy 3.5, lobectomies/metastasectomy 3.44 and oesophagectomy 2.55. None of the cases had incomplete firings and required force-fire activation. In forty per cent of cases, the robotic stapler had to pause for sequential compression and seal. Seventy per cent of anterior resection procedures had at least one firing >45° beyond the laparoscopy limit. Collectively 52% SureForm stapler fires in anterior resection with >45° angle of fire. None of the cases had bleed or leak. Conclusion: SureForm™ SmartFire™ robotic staplers can be used for various oncological surgeries with minimal peri-operative leak and bleeding and has better articulation in closed spaces. Further case-matched comparative studies with laparoscopic or handheld powered staplers would be required for useful operative decision-making and analyse the clinical outcomes.

Prospective analysis of impact of learning curve in robotic-assisted rectal surgery in the high-volume Indian tertiary care centre.

Background: Minimally invasive surgery in rectal cancer has gained prominence owing to its various advantages in surgical outcomes. Due to rapid adoption of robotics in rectal surgery, we intended to assess the pace in which surgeons gain proficiency using cumulative summation (CUSUM) technique in learning curve. Materials and Methods: This was a prospective study of 262 rectal cancer cases who underwent robotic-assisted low anterior resection and abdominoperineal resection (RA-LAR and RA-APR). Parameters considered for the study were console time, docking time, lymph nodal yield, total operative time and post-operative outcomes. We used Manipal technique of port placements and modified centroside docking for the procedure. Results: The mean age of our study was 46.62 ± 5.7 years, the mean body mass index (BMI) was 31.51 ± 3.2 kg/m2. 215 (82.06%) underwent RA-LAR and 47 (17.93%) underwent RA-APR. 2.67% of cases required to open during our initial period. We had three phases of learning curve, initial phase (11th case), plateau phase (29th case) and then phases of mastery (30th case onwards). Our mean total operative time reduced from 5.5 to 3.5 h (210 ± 8.2 min), console time from 4.5 to 2.9 h (174 ± 4.5 min) and docking time from 15 to 9 ± 1 min from 30th case onwards. Conclusion: RA surgeries for rectal cancer have got good oncological and functional outcomes in high BMI, male pelvis and low rectal cancers. Learning curve can be shortened with constant self-auditing of the surgeon and team with each surgeries performed, reviewing the steps and by improving techniques.

NIPEC with Single-Dose Intraperitoneal Cisplatin and Paclitaxel in Stage III Epithelial Ovarian Cancer.

Sanjay M. DesaiObjectives Epithelial ovarian cancer (EOC) is a heterogeneous, essentially peritoneal disease. Standard treatment consists of staging, cytoreductive surgery (CRS), and adjuvant chemotherapy. In this study, we intended to assess the effectiveness of single-dose intraperitoneal (IP) chemotherapy in optimally debulked advanced EOC patients. Materials and Methods A prospective randomized study of 87 patients with advanced EOC was done from January 2017 to May 2021 in a tertiary care center. Patients who underwent primary and interval cytoreduction received a single dose of IP chemotherapy for 24 hours after being divided into four groups: group A, IP cisplatin; group B, IP paclitaxel; group C, IP paclitaxel and cisplatin; and group D, saline. Pre- and postperitoneal IP cytology was assessed along with possible complications. Statistical Analysis Logistic regression analysis was used to assess for intergroup significance in cytology and complications. Kaplan-Meir analysis was done to assess disease-free survival (DFS). Results Of 87 patients, 17.2% of patients had FIGO stage IIIA, 47.2% had IIIB, and 35.6% had IIIC. Also, 22 (25.3%) patients were in group A (cisplatin), 22 (25.3%) patients in group B (paclitaxel), 23 (26.4%) in group C (cisplatin and paclitaxel), and 20 (23%) in group D (saline). Cytology samples taken during staging laparotomy were positive, and 48 hours post-IP chemotherapy, 2 (9%) of 22 samples in cisplatin group and 14 (70%) of 20 samples in saline group were positive; all of the post-IP samples in groups B and C were negative. No major morbidity was noted. In our study, DFS in saline group was 15 months, while in IP chemotherapy group it was 28 months and was statistically significant based log-rank test. However, there was no significant difference in DFS between different IP chemotherapy groups. Conclusion Complete or optimal CRS in advanced EOC does have a possibility of microscopic peritoneal residue. Adjuvant locoregional strategies should be considered to prolong DFS. Single-dose normothermic IP chemotherapy can be offered to the patients with minimal morbidity, and its prognostic benefits are comparable to hyperthermic IP chemotherapy. Future clinical trials are required to validate these protocols.

Comparison of Functional and Survival Outcomes in Pedicled and Microsurgical Flap Reconstruction for Near-Total and Total Glossectomies.

Introduction: Patients with advanced carcinoma tongue end up with near-total/total glossectomy (NTG/TG). We intended to compare functional, oncological, and survival outcomes of patients undergoing pedicled and microsurgical flap reconstruction in NTG/TG patients at our hospital. Methodology: A prospective study was conducted for 7 years on 91 patients with carcinoma tongue who underwent NTG/TG at our institute. Patients underwent anterolateral thigh (ALT), free radial artery forearm flap (FRAFF), and pectoralis major myocutaneous (PMMC) flap reconstruction and were followed up for immediate complications and functional outcomes for speech, swallowing, and decannulation after completion of adjuvant treatment and then for survival rates for a period of 60 months and statistically analysed with log rank test and Fisher's exact test for correlation. Results: Ninety-one (42.85%) patients underwent NTG, while 57.14% underwent TG. 85% of patients had >5 mm margin, 14% had ≤ of 5 mm, and none were positive. 57% of patients did not have postoperative complications and 10% underwent re-exploration. During follow-up, 85.7% of patients were able to take orally: 52% soft diet and 32% liquid diet. Multivariate analysis of individual flaps, swallowing, and speech intelligibility values were significant. After 5 years of postadjuvant therapy, there was 76% overall survival, 11% local recurrence and 12% had regional recurrence. Discussion: Morbidity and functional outcome depends on the extent of resection. PMMC flaps can be done on lack of expertise. FRAFF has better functional outcomes owing to pliability of flap. ALT and other bulky flaps require expertise and are prone to flap-related complications. Planning of reconstruction should be based on the defect size together with counseling of patients regarding the risk of complications and delay in adjuvant therapy.

Treatment and Outcomes of Early and Operable Recurrent Cervical Cancer: A Prospective Study.

OBJECTIVES: The aim of this study was to evaluate outcomes, survival, patterns of recurrence, and morbidity in both early and recurrent operable cervical cancer patients following radical hysterectomy, pelvic lymph node dissection, and adjuvant radiotherapy. MATERIALS AND METHODS: This was a prospective analysis of 55 patients of stage IA-IIA and recurrent operable cervical cancer treated with radical hysterectomy, pelvic lymphadenectomy, and adjuvant radiotherapy from 2014 to 2017. Overall survival (OS), disease-free survival (DFS), morbidity, and mortality rates were the end points of this study. Survival analysis was performed using the Kaplan-Meir method. RESULTS: The median age of the study group was 45 years (range 18-68 years). The most common presentation was stage IB2 disease in 34.5% of patients. Fifty (90%) patients had squamous histology, whereas 5 (9.1%) had adenocarcinoma. Upfront radical hysterectomy was performed in 90.9% of patients, whereas 9.1% underwent surgery for recurrent cervical cancer. The most common indication for adjuvant radiotherapy was lymph node involvement, followed by parametrium involvement in 20% and 13% patients, respectively. Median follow-up period was 48 months (range 6-60 months). The OS and DFS rates were 85.0% and 81.8%, respectively. The most frequent complication encountered was paralytic ileus in 4 (7.2%) patients. CONCLUSION: Radical hysterectomy with pelvic lymphadenectomy for early cervical cancer has a favorable survival outcome with acceptable long-term morbidity.

Outcome Evaluation of Mandibular Pull-Through Approach for Glossectomies.

Patients with advanced carcinoma tongue in the Indian subcontinent have an additional component of submucosal fibrosis (SMF) due to chewing of betel. We intend to evaluate  mandibular pull-through approach for total or near-total glossectomy and assessed its functional and survival outcome. Prospective study of 77 patients with carcinoma tongue, who underwent total or near-total glossectomy at our institute, were assessed retrospectively. All the patients who underwent glossecomy through mandibular pull through approach with pedicled or free flap reconstruction were assessed for functional and survival outcomes. Of the 77 patients, 45 (58.44%) patients underwent total glossectomy, while 32 (41.55%) patients near-total glossectomy, 61 (79.22%) cases had operative time ≤ 30 min, 69 (89.61%) patients had margins of > 5 mm, and none of the margins were involved. Flaps were reconstructed with 42 (54.54%) PMMC, 24 (31.16%) FRAFF, and 11 (14.28%) ALT. Five (6.49%) patients had surgical site infections, 6 patients each had to undergo re-explorations and partial flap loss, 7 patients had oro-cutaneous fistula, while 53 (68.83%) patients had no complications/osteoradionecrosis. A total of 94% of patients underwent decannulation, 92% of patients got discharged, and 89% got NG tube removed within 21 POD. Forty patients had reasonably good speech. On the long-term follow-up, 9% of the patients developed local recurrence and 11% of patients had regional/lymph node recurrence. Mandibular pull-through approach had the advantages of good accessibility to the tumour with the least mutilating techniques with shorter operation time, lower rates of postoperative complications, and better aesthetics and based on available data, it is superior to the mandibular lip-spilt surgery for advanced tongue involving BOT and floor of mouth cancers when coupled with SMF surgeries for the Indian scenario.

External Jugular Cutdown Technique for Totally Implantable Venous Access Devices: a Single-Centre Study.

Chemotherapy drugs are the integral part of cancer treatment. Their administration is optimized by central venous access devices. We present our prospective study of chemoport implantation by external jugular vein cutdown technique. We studied 100 patients who underwent chemoport insertion over a span of 3 years for various solid and haematological malignancies via external jugular vein cutdown method. Outcomes such as type of disease, anaesthesia, choice of venous access, catheter tip position, length of the procedure, time to start chemotherapy and morbidity data were analysed. The Hundred /100 intravenous devices were implanted in 66% females and 33% males. Most common indication was breast cancer (64% of patients). A total of 80% of patients underwent procedure under local anaesthesia. Chemoports were inserted on the right side in 84 and left side in the remaining 16. The average surgical time was 32 min. The overall success rate was 97% with no intraoperative complications. Three postoperative complications were encountered due to displacement of catheter or wound infection. External jugular vein cutdown approach is a safe, reliable method for venous access device implantation. This approach has a high success rate and has minimal complications and can be easily learnt.

Quiescent Volcano-Chest Wall Hemangioma.

Chest wall hemangiomas are rare tumors that may originate within the soft tissue or from the ribs. Intramuscular hemangioma is infrequent, representing less than 1 % of all hemangiomas, and the localization in the chest wall is even less frequent. They are typically cutaneous in location, large, and poorly circumscribed and can be locally destructive. We present a case of a 34-year-old lady presented with firm lump 3 × 3 cm in left upper and inner quadrant of left breast well defined borders, non-pulsatile and restricted mobility. Sono-mammogram was suggestive of ill-defined lesion at 10 o'clock position. CT chest was conclusive of chest wall hemangioma. The patient underwent excision of the lump. HPE was suggestive of cavernous hemangioma. Cavernous hemangioma typically manifest at birth or before the age of 30 years. CT is more sensitive than plain radiography in detecting phleboliths, which are present in approximately 30 % of cavernous hemangiomas. Surgical excision would be treatment of choice. In this case, the site of the lesion was in the breast clinically mimicking that of a fibroadenoma which warrants hemangioma as a differential diagnosis.

The medicinal use of venoms and toxins.

Venoms have long since been known to have therapeutic value. Venoms have been characterised into their individual components and each of their functions extensively studied. These components of venoms and toxins show potential as antihypertensive, anticoagulant, fibrinolytic, anticancerous, immunomodulators, muscle relaxant, etc. Only the most promising and FDA approved and therapeutic options have been discussed here eg, hannalgesin, epibatidine, ancrod, lepirudin, fibrolase, lebecetin, pseutarin, captopril, eristostatin, botox.

Ocimum sanctum L (Holy Basil or Tulsi) and its phytochemicals in the prevention and treatment of cancer.

Ocimum sanctum L. or Ocimum tenuiflorum L, commonly known as the Holy Basil in English or Tulsi in the various Indian languages, is a important medicinal plant in the various traditional and folk systems of medicine in Southeast Asia. Scientific studies have shown it to possess antiinflammatory, analgesic, antipyretic, antidiabetic, hepatoprotective, hypolipidemic, antistress, and immunomodulatory activities. Preclinical studies have also shown that Tulsi and some of its phytochemicals eugenol, rosmarinic acid, apigenin, myretenal, luteolin, ß-sitosterol, and carnosic acid prevented chemical-induced skin, liver, oral, and lung cancers and to mediate these effects by increasing the antioxidant activity, altering the gene expressions, inducing apoptosis, and inhibiting angiogenesis and metastasis. The aqueous extract of Tulsi and its flavanoids, orintin, and vicenin are shown to protect mice against γ-radiation-induced sickness and mortality and to selectively protect the normal tissues against the tumoricidal effects of radiation. The other important phytochemicals like eugenol, rosmarinic acid, apigenin, and carnosic acid are also shown to prevent radiation-induced DNA damage. This review summarizes the results related to the chemopreventive and radioprotective properties of Tulsi and also emphasizes aspects that warrant future research to establish its activity and utility in cancer prevention and treatment.

Unicentric Mesenteric Castleman's Disease- A Diagnostic Quandary-A Case Report.

Castleman`s Disease (CD) is a rare lymphoproliferative disorder and a mesenteric location is unusual. The unicentric variety is more difficult to diagnose clinically and it requires a histopathological confirmation. The excision biopsy itself will help both in the diagnosis and in planning the treatment. Here, we are presenting a case of unicentric mesenteric Castleman`s disease which we suspected to be lymphoma.

A review of the gastroprotective effects of ginger (Zingiber officinale Roscoe).

The rhizomes of Zingiber officinale Roscoe (Zingiberaceae), commonly known as ginger is an important kitchen spice and also possess a myriad health benefits. The rhizomes have been used since antiquity in the various traditional systems of medicine to treat arthritis, rheumatism, sprains, muscular aches, pains, sore throats, cramps, hypertension, dementia, fever, infectious diseases, catarrh, nervous diseases, gingivitis, toothache, asthma, stroke and diabetes. Ginger is also used as home remedy and is of immense value in treating various gastric ailments like constipation, dyspepsia, belching, bloating, gastritis, epigastric discomfort, gastric ulcerations, indigestion, nausea and vomiting and scientific studies have validated the ethnomedicinal uses. Ginger is also shown to be effective in preventing gastric ulcers induced by nonsteroidal anti-inflammatory drugs [NSAIDs like indomethacin, aspirin], reserpine, ethanol, stress (hypothermic and swimming), acetic acid and Helicobacter pylori-induced gastric ulcerations in laboratory animals. Various preclinical and clinical studies have also shown ginger to possess anti-emetic effects against different emetogenic stimuli. However, conflicting reports especially in the prevention of chemotherapy-induced nausea and vomiting and motion sickness prevent us from drawing any firm conclusion on its effectiveness as a broad spectrum anti-emetic. Ginger has been shown to possess free radical scavenging, antioxidant; inhibition of lipid peroxidation and that these properties might have contributed to the observed gastroprotective effects. This review summarizes the various gastroprotective effects of ginger and also emphasizes on aspects that warranty future research to establish its activity and utility as a gastroprotective agent in humans.

Pharmacotherapy for weight management.

Weight management means lifestyle modification, behavioral therapy, pharmacotherapy and surgery. Drugs have wide ranging side effects and contraindication for its widespread use. Orlistat and sibutramine are the most popular in the present day context. Anti depressants especially fluoxetine is a valuable adjunct for therapy of obesity. There are many newer concepts in weight management and these are mainly hormonal and receptor based, thereby reducing the uncalled adverse effects of drugs like orlistat and sibutramine. Anti-obesity vaccine, an immunotherapy to be looked out for.

Status of disulfiram in present day alcoholic deaddiction therapy.

AIM: Assessment of safety and efficacy profile of disulfiram (DSM) in the alcoholic de-addiction regimen. OBJECTIVES: a. Assessment of Adverse Drug Reaction (ADR) profile; b. Evaluation of effectiveness of various deaddiction regimen; c. Defaulters and dropouts PATIENTS AND METHODS: Fifty-one patients in a de-addiction center were investigated on 0(th) , 30(th) and 60(th) day along with psychiatric evaluation, ADR surveillance was made. Statistical analysis was done thereafter. RESULTS: 125 mg DSM given OD for 2 months. 76.5% patients had taken full course of treatment, 45% didn't complain of any ADR. Of ADR reported 27.4% had drowsiness, 21.4% tiredness, 7.8% skin manifestation. CONCLUSION: DSM is the main drug among naltrexone, acamprosate, nalmefene and other drugs used in alcoholic de-addiction. Relative and effectiveness is lost by the degree of dropouts and hence relapses. Low-dose DSM had decreased adverse effects with 76.5% patients taking the full course of treatment. DSM alters liver functions as there were significant changes in the lab parameters of SGPT(P=0.007), SGOT(P=0.001), GGT(P=<0.001) between first and third samples. Occurrence of ADR is not the cause of default; patients find it confusing to differentiate between the symptoms of alcohol withdrawal and those due to ADR of DSM.