Short-term outcomes of enhanced recovery after surgery protocol in minimally invasive oesophagectomy: A prospective study.

BACKGROUND: Although fast-track treatment pathways are well established in colorectal surgeries, their role in oesophageal resections has not been well studied. This study aims to prospectively evaluate the short-term outcomes of enhanced recovery after surgery (ERAS) protocol in patients undergoing minimally invasive oesophagectomy (MIE) for oesophageal malignancy. PATIENTS AND METHODS: We studied a prospective cohort of 46 consecutive patients from January 2019 to June 2022 who underwent MIE for oesophageal malignancy. The ERAS protocol mainly consists of pre-operative counselling, pre-operative carbohydrate loading, multimodal analgesia, early mobilisation, enteral nutrition and initiation oral feed. Principal outcome measures were the length of post-operative hospital stay, complication rate, mortality rate and 30-day readmission rate. RESULTS: The median (interquartile range [IQR]) age of patients was 49.5 (42, 62) years, and 52.2% were female. The median (IQR) post-operative day of intercoastal drain removal and initiation of oral feed was 4 (3, 4) and 4 (4, 6) days, respectively. The median (IQR) length of hospital stay was 6 (6.0, 7.25) days, with a 30-day readmission rate of 6.5%. The overall complication rate was 45.6%, with a major complication (Clavien-Dindo ≥3) rate of 10.9%. Compliance with the ERAS protocol was 86.9%, and the incidence of major complications was associated with failure to follow the protocol ( P = 0.000). CONCLUSIONS: ERAS protocol in minimally invasive oesophagectomy is feasible and safe. This may result in early recovery with shortened length of hospital stay without an increase in complication and readmission rates.

Open injury, robotic repair-moving ahead! Total robotic Roux-en-Y hepaticojejunostomy for post-open cholecystectomy Bismuth type 2 biliary stricture using indocyanine green dye.

Hepaticojejunostomy is currently the best treatment for post-cholecystectomy biliary strictures. Laparoscopic repair has not gained popularity due to difficult reconstruction. We present case of 43-year-old-female with Bismuth type 2 stricture following laparoscopic converted open cholecystectomy with bile duct injury done elsewhere. Position was modified Llyod-Davis position and four 8-mm robotic ports (including camera) and 12-mm assistant port were placed. The procedure included noticeable steps such as adhesiolysis, identification of gallbladder fossa, identification of common hepatic duct, lowering of hilar plate etc. Operating and console time were 420 and 350 minutes and blood loss was 100 mL. Patient was discharged on postoperative day 4. Robotic repair (hepaticojejunostomy) of biliary tract stricture after cholecystectomy is safe and feasible with good outcomes.

Carcinosarcoma of the Esophagus-A Diagnostic Challenge.

Background: Esophageal carcinosarcoma is an uncommon histologic variant of esophageal malignancy, occurring in approximately 0.5% to 2.8% of patients. Esophageal carcinosarcoma usually involves the middle and lower esophagus and consists of both epithelial and mesenchymal components. Case Report: A 54-year-old male presented with painless progressive dysphagia associated with loss of weight for 2 months. Esophagogastroduodenoscopy suggested an ulceroproliferative polypoidal growth in the lower thoracic esophagus. Biopsies from the growth showed leiomyosarcoma with tumor cells immunopositive for vimentin, h-Caldesmon, and smooth muscle actin and negative for pan-cytokeratin. Imaging suggested a heterogeneously enhancing polypoidal growth arising in the lower third of the esophagus. Thoracoscopic-assisted McKeown esophagectomy with gastric pull-up and standard 2-field lymphadenectomy was performed. A minor epithelial component was identified on final pathologic examination in addition to the leiomyosarcoma found on the preoperative biopsy. This epithelial component was invasive squamous cell carcinoma and was positive for pan-cytokeratin and p40, both of which were negative in the sarcomatous component. The patient received 4 cycles of adjuvant chemotherapy (carboplatin and paclitaxel). However, he developed a recurrence in the left cervical lymph node 4 months after adjuvant treatment and died 2 months after the diagnosis of recurrence. Conclusion: Carcinosarcoma can be easily missed in the presence of predominantly sarcomatous components even on immunohistochemical analysis. These tumors may be associated with poor prognosis and may have early recurrence despite surgery and adjuvant treatment.

Synchronous Squamous Cell Carcinoma of Rectum and Anal Canal Detected by FDG PET/CT-A Rare Entity.

ABSTRACT: Squamous cell carcinoma is the most common malignancy of the anal canal, and FDG PET/CT is recommended in its nodal staging, radiotherapy planning, and response assessment. We share an interesting case of dual primary malignancy of the anal canal and rectum, which was detected by 18 F-FDG PET/CT and confirmed on histopathology as synchronous squamous cell carcinoma.

Intra-Nodal Indocyanine Green Injection to Delineate Thoracic Duct During Minimally Invasive Esophagectomy.

INTRODUCTION: Post-operative chylothorax is a dreaded complication after esophagectomy; hence real-time identification of the thoracic duct (TD) may aid in avoiding its injury or promptly tackling injury when it occurs. We utilized intra-nodal injection of Indocyanine green (ICG) dye to delineate TD anatomy while performing esophagectomy for esophageal carcinoma. METHOD: Two ml of 1 mg/ml solution of ICG was injected into the inguinal lymph nodes under ultrasound guidance. TD was checked with the laparoscopic Karl Storz IMAGE1 STM or Robotic da Vinci Xi system. The thoracic esophagus, periesophageal tissue, and lymph nodes were dissected. The TD was visualized throughout the dissection using OverlayTM technology & Firefly mode™ and checked at the end to rule out any dye leak. TD was clipped if any dye leakage or TD injury (TDI) was noted using Near Infra-Red Spectroscopy. RESULTS: Twenty one patients with M:F 13:8 underwent minimally invasive esophagectomy (MIE) [thoracoscopic assisted (n = 15) and robotic-assisted (n = 6)]. TD was visualized in all the cases after a median (IQR) time of 35 (30, 35) min. The median (IQR) duration of the thoracic phase was 150 (120,165) min. TDI occurred in 1 case, identified intra-operatively, and TD was successfully clipped. There were no post-operative chylothorax or adverse reactions from the ICG injection. CONCLUSION: Intra-nodal ICG injection before MIE helps to identify the TD in real-time and is a valuable intra-operative aid to prevent or successfully manage a TD injury. It may help to prevent the dreaded complication of post-operative chylothorax after esophagectomy.

Adenosquamous Carcinoma of the Extrahepatic Bile Duct.

Background: Most malignant tumors arising from the biliary tract are adenocarcinomas. Adenosquamous carcinoma is an uncommon variant of extrahepatic bile duct cancer that is associated with more aggressive behavior than adenocarcinoma. Case Report: A 58-year-old male presented with complaints of obstructive jaundice and dull aching pain in the abdomen. At his initial evaluation in another hospital, ultrasound of the abdomen and magnetic resonance cholangiopancreatography revealed common bile duct dilatation with an ill-defined lesion in the periampullary region. Endoscopic retrograde cholangiopancreatography showed infiltration of the ampulla. Biopsy specimen taken during stenting of the common bile duct suggested dysplasia. Because of recurrent jaundice, the patient was referred to our institution, and contrast-enhanced computed tomography (CT) of the abdomen showed a hypoenhancing lesion with ill-defined margins in the head of the pancreas. The patient underwent a Whipple procedure. Microscopic examination of the pancreaticoduodenectomy specimen showed an invasive adenosquamous tumor arising from the distal part of the common bile duct that infiltrated the body and head of the pancreas, involved the wall of the duodenum, and reached the duodenal mucosa. Morphologic diagnosis was supported by immunohistochemistry profile. Postoperative contrast-enhanced CT of the abdomen showed multiple enlarged mesenteric lymph nodes and multiple lesions in both lobes of the liver, suggestive of metastasis. The patient died 1 week after surgery. Conclusion: Because the clinical, pathologic, and prognostic characteristics of adenosquamous carcinoma are poorly known, early diagnosis of this rare entity is warranted for patient management.

Laparoscopic transhiatal oesophageal diverticulectomy: An experience of large epiphrenic oesophageal diverticulum and review literature.

Epiphrenic diverticulum is a rare abnormality of the distal oesophagus. Both thoracic and abdominal approaches are suitable for this diverticulum. A 46-year-old male presented with complaints of regurgitation and chest pain for 2 years. Contrast-enhanced computed tomography of the neck, thorax, abdomen and oesophageal endoscopy revealed 12 cm × 10 cm size large intrathoracic oesophageal diverticulum. He underwent an elective laparoscopic transabdominal oesophageal diverticulectomy. Gastrograffin study on the first post-operative day did not reveal any leak. In this case report, we are sharing our experience in the management of large epiphrenic oesophageal diverticulum through a laparoscopic approach. The benefits of the laparoscopic approach include decreased morbidity because we can avoid large thoracotomy or laparotomy incision.

Robotic-assisted resection of proximal jejunal ischemic stricture and intracorporeal robot-sewn anastomosis.

With the advent of robotic surgery as an effective means of minimally invasive surgery in the last decade, more and more surgeries are being performed robotically in today's world. Robotic surgery has several advantages over conventional laparoscopic surgery, such as three-dimensional vision with depth perception, magnified view, tremor filtration, and, more importantly, degrees of freedom of the articulating instruments. While the literature is abundant on robotic cholecystectomy and highly complex hepatobiliary surgeries, there is hardly any literature on robotic small bowel resection with intracorporeal anastomosis. We present a case of a 50-year-old male patient with a symptomatic proximal jejunal ischemic stricture who underwent robotic-assisted resection and robot-sewn intracorporeal anastomosis in two layers. He did well in the postoperative period and was discharged on postoperative day 4 with uneventful recovery. We hereby discuss the advantages and disadvantages of robotic surgery in such a scenario with a review of the literature.

Bacterial flora in the bile: Clinical implications and sensitivity pattern from a tertiary care centre.

BACKGROUND: Though preoperative biliary drainage (PBD) has been suggested to be linked with increased perioperative morbidity it is still practiced commonly. We studied the association of PBD and positive biliary culture with surgical site infection and also analysed the common pathogens and their antibiotic sensitivity spectrum. METHODS: Prospectively maintained data of patients who underwent various pancreatobiliary surgeries from 2017 to 2019 was analysed. Patients whose intraoperative bile culture reports were available were included in the study. Various factors associated with surgical site infection (SSI), microbial spectrum of bile culture and their sensitivity pattern were analysed. RESULTS: Out of 68 patients whose bile culture report were available, PBD was done in 65% (n = 44). Among patients with infected bile (n = 51), biliary stent was present in 78.4% (n = 40). On univariate analysis, the factors associated with SSI were low albumin level (<3.5 mg%), long operative time (>6 h), duration of abdominal drain (>4 days), length of hospital stay, intraoperative bile spillage and infected bile. However, on multivariate analysis, only presence of drain for >4 days (p = 0.04) and positive bile culture (p = 0.02) was linked with increased risk of SSI. Most common organism isolated was E coli (73.2%), with 100% sensitivity to Colistin and Tigecycline shown by gram negative isolates. CONCLUSION: Preoperative biliary stenting alone did not increase the risk of SSI, but the positive bile culture correlated with SSI irrespective of PBD. Most biliary pathogens were resistant to commonly used antibiotics and intraoperative bile culture will aid in providing appropriate antibiotic coverage.

Management options for post-esophagectomy chylothorax.

Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.

Thoracoscopic oesophagectomy for end-stage achalasia.

Achalasia cardia is an oesophageal motility disorder characterised by aperistalsis and failure of relaxation of the lower oesophageal sphincter. The management is predominantly palliative with focus on addressing the sphincter that involves either pneumatic dilatation or Heller myotomy which relieves dysphagia in the majority of the cases. End-stage achalasia (ESA) is characterised by failed myotomy, massively dilated and tortuous oesophagus with nutritional deterioration due to progressive dysphagia and vomiting. In these subgroups of patients, oesophagectomy may be the last resort. While oesophagectomy has been described for ESA before, thoracoscopic oesophagectomy has not been reported previously. Hereby, we report our experience of performing minimally invasive oesophagectomy (thoracoscopic) with the gastric pull-up.

Amebic colonic stricture: An unusual presentation.

Entamoeba histolytica infection can lead to colitis, peri-colic abscess, ameboma, perforation and rarely colonic stricture. Amebic colitis is usually managed with medical management and rarely needs surgical management. We hereby report a case of colonic amebiasis, presenting as a stricture in transverse colon, mimicking malignancy, and managed successfully.