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

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

Extracavitary primary effusion lymphoma: A case report from India.

We present a case of extracavitary primary effusion lymphoma presenting, as jejunal polyps in a 38-year-old man. This is the first report of this entity from India. Although rare in our country, the diagnosis should be suspected in cases of CD20 negative large cell lymphoma with plasmablastic or immunoblastic differentiation in seropositive patients. Immunostaining for latency-associated nuclear antigen-1 and in situ hybridization for Epstein-Barr virus-associated RNA will confirm the diagnosis.

Tracheal injury during oesophagectomy – incidence, treatment and outcome.

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

The abdominal cocoon and an effective technique of surgical management.

The Abdominal Cocoon is a very rare cause of small bowel obstruction. It is caused by encapsulation of the small bowel by a fibrous membrane. This tropical disease, seen in young females, has also been reported in males. This is one of the largest series of the Abdominal Cocoon, with five new patients (3 males and 2 females) being reported. The traditional surgical treatment of choice is by lysis of adhesions. All patients in this case series had small bowel intubation done in addition to adhesiolysis. Although small bowel intubation is an established procedure for various causes of recurrent small bowel obstruction, to our knowledge this is the first report of its use in the management of the Abdominal Cocoon. We report our surgical technique in the management of this rare disease.