Enhanced recovery after surgery in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: national survey of peri-operative practice by Indian society of peritoneal surface malignancies.

Objectives: The Enhanced recovery after surgery (ERAS) program is designed to achieve faster recovery by maintaining pre-operative organ function and reducing stress response following surgery. A two part ERAS guidelines specific for Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was recently published with intent of extending the benefit to patients with peritoneal surface malignancies. This survey was performed to examine clinicians' knowledge, practice and obstacles about ERAS implementation in patients undergoing CRS and HIPEC. Methods: Requests to participate in survey of ERAS practices were sent to 238 members of Indian Society of Peritoneal Surface malignancies (ISPSM) via email. They were requested to answer a 37-item questionnaire on elements of preoperative (n=7), intraoperative (n=10) and postoperative (n=11) practices. It also queried demographic information and individual attitudes to ERAS. Results: Data from 164 respondents were analysed. 27.4 % were aware of the formal ERAS protocol for CRS and HIPEC. 88.4 % of respondents reported implementing ERAS practices for CRS and HIPEC either, completely (20.7 %) or partially (67.7 %). The adherence to the protocol among the respondents were as follows: pre operative (55.5-97.6 %), intra operative (32.6-84.8 %) and post operative (25.6-89 %). While most respondents considered implementation of ERAS for CRS and HIPEC in the present format, 34.1 % felt certain aspects of perioperative practice have potential for improvement. The main barriers to implementation were difficulty in adhering to all elements (65.2 %), insufficient evidence to apply in clinical practice (32.4 %), safety concerns (50.6 %) and administrative issues (47.6 %). Conclusions: Majority agreed the implementation of ERAS guidelines is beneficial but are followed by HIPEC centres partially. Efforts are required to overcome barriers like improving certain aspects of perioperative practice to increase the adherence, confirming the benefit and safety of protocol with level I evidence and solving administrative issues by setting up dedicated multi-disciplinary ERAS teams.

Long-Term Survival in Patients Treated by Cytoreductive Surgery with or Without HIPEC for Peritoneal Surface Malignancies-A report from the Indian HIPEC Registry.

A previous report from the Indian HIPEC registry showed acceptable early survival and morbidity in patients undergoing cytoreductive surgery (CRS) + / - hyperthermic intraperitoneal chemotherapy (HIPEC). The goal of this retrospective study was to evaluate the long-term outcomes in these patients. Three hundred seventy-four patients treated from December 2010 to December 2016 and enrolled in the Indian HIPEC registry were included. All patients had completed 5 years from the date of surgery. The 1-, 3-, 5- and 7-year progression-free (PFS) and overall survival (OS) and factors affecting these were evaluated. The histology was epithelial ovarian cancer in 209 (46.5%), pseudomyxoma peritonei (PMP) in 65 (17.3%) and colorectal cancer in 46 (12.9%) patients. The peritoneal cancer index (PCI) was ≥ 15 in 160 (42.8%). A completeness of cytoreduction (CC) score of 0/1 resection was obtained in 83% (CC-0-65%; CC-1-18%). HIPEC was performed in 59.2%. At a median, follow-up of 77 months (6-120 months), 243 (64.9%) patients developed recurrence, and 236 (63%) died of any cause; 138 (36.9%) were lost to follow-up. The median OS was 56 months (95% CI 53.42-61.07), and the median PFS was 28 months (95% CI 37.5-44.4). The 1-, 3-, 5- and 7-year OS was 97.6%, 63%, 37.7% and 24% respectively. The 1-, 3-, 5- and 7-year PFS was 84.8%, 36.5%, 27.3% and 22% respectively. The use of HIPEC (p = 0.03) and PMP of appendiceal origin (p = 0.01) was independent predictors of a longer OS. CRS + / - /HIPEC may achieve long-term survival in patients with PM from different primary sites in the Indian scenario. More prospective studies are needed to confirm these findings and identify factors influencing long-term survival. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-023-01727-7.

Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: Long-term outcomes of a propensity score matched study.

BACKGROUND AND OBJECTIVES: Laparoscopic resection for rectal cancer has short-term benefits when compared to open resection. The aim of this study was to compare the long-term oncological outcomes of laparoscopic and open resection for rectal cancer following neoadjuvant chemoradiation (NCRT). METHODS: In this propensity matched study, a series of 72 patients who underwent laparoscopic surgery for rectal cancer following NCRT between 2004 and 2010 (Lap group) were matched with 72 patients who underwent open surgery for rectal cancer in the same period (Open group). The survival and recurrence patterns were compared between the two groups. RESULTS: After a median follow-up of 69.5 months (range 1-138 months), local recurrence rate was observed in 4 patients (5.5%) and 7 patients (9.7%) in the Lap and Open groups, respectively (P = 0.35). The 5- and 10-year disease-free survival in the Lap and Open groups were 61.3% versus 47.9% and 48.8% versus 41%, respectively (P = 0.16). The 5- and 10-year overall survival was 66.9% versus 60.2% and 49% versus 46.2% in the Lap and Open groups, respectively (P = 0.38). CONCLUSION: Laparoscopic surgery following NCRT for low and mid third rectal cancers was associated with similar long-term oncological outcomes when compared to open surgery.

An Alpha Fetoprotein Producing Gastric Tumor with Yolk Sac, Hepatoid and Papillary Adenocarcinoma Components.

Alpha Fetoprotein (AFP) producing gastric carcinomas are very rare and have unique clinicopathological features and an extremely poor prognosis. Here, we report a case of AFP producing gastric carcinoma with three distinct histomorphologic patterns such as yolk sac like, hepatoid, tubular and papillary adenocarcinoma components. The uniqueness of this case is absence of metastases and associated findings such as fundic gland polyposis with varying degrees of dysplasia, gastric and duodenal well differentiated neuroendocrine tumour and rectal ganglioneuroma. The patient is symptom free as of two and half year's postoperative period. AFP producing gastric tumours although rare, need to be identified as it is known to carry poor prognosis.

Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: a matched case-control study of short-term outcomes.

BACKGROUND: Neoadjuvant chemoradiation (nCRT) currently is commonly incorporated into the multimodal treatment of locally advanced rectal cancers. This study aimed to compare the short-term outcomes and oncologic adequacy of laparoscopic and conventional open surgery for rectal cancer after nCRT. METHODS: A series of 72 patients who underwent laparoscopic surgery (Lap group) for rectal cancer after nCRT were matched for type of surgery, gender, and American Society of Anesthesiologists (ASA) class with 72 patients who underwent conventional surgery during the same time period (Open group). The short-term outcomes were compared between the two groups of patients. RESULTS: No significant difference was found between the two groups in terms of age, distance of tumor from the anal verge, body mass index, or posttreatment pathologic stage of the disease. There were significant differences between the Lap and Open groups in terms of blood loss (median: 200 vs 400 ml; P < 0.001), duration of surgery (median: 270 vs 240 min; P < 0.001), time to passing of first flatus (median: 2 vs 3 days; P < 0.001), time to start of normal diet (median: 5 vs 6 days; P < 0.001), and hospital stay (median: 12 vs 15 days; P < 0.001). A significant difference in the number of lymph nodes harvested was not identified between the two groups, although more patients in the Open group had a positive circumferential resection margin than in the Lap group (10 vs 1%; P = 0.03). The short-term benefits of laparoscopic surgery also were observed when the 64 patients who underwent abdominoperineal resection (APR) in each of the two groups were compared separately. CONCLUSION: Laparoscopic surgery for rectal cancer, especially laparoscopic APR, after nCRT is safe and associated with earlier recovery of bowel function, a shorter hospital stay, and an oncologically adequate specimen compared with conventional open surgery.