Clinical Outcomes and Their Determinants in Patients With Gastric Variceal Bleed Undergoing Endoscopic Cyanoacrylate Injection: An Observational Study.

Background and aims: Gastric variceal bleeding (GVB), compared to esophageal varices, is rare but often massive and associated with high mortality. Endoscopic cyanoacrylate glue injection (ECGI) is the first-line treatment for GVB. Hence, we conducted this study to assess the clinical outcomes and the determinants of ECGI for gastric variceal bleeding. Methods: This was a prospective observational study of patients with ECGI for GVB between June 2019 and February 2023. The demographic characteristics, etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate, and survival at three months were studied. Results: A total of 135 patients underwent ECGI for GVB. Their mean (SD) age was 44.9 (13.6) years, with a male preponderance (n = 23, 68.1 %). Eighty-two patients (60.7 %) had cirrhosis. Their mean model for end-stage liver disease (MELD) score was 14.3 (7.3). Gastric varices were gastroesophageal varices (GOV)1 in 42 (31.1 %), GOV2 in 73 (54.1 %), and isolated gastric varices (IGV)1 in 20 (14.8 %) patients. Varices were large in 35 (25.9 %) and had F1 morphology in 89 (65.9 %) patients. The success rate of initial hemostasis was 98.5 %. The median sessions required were 1 (1-2), and the median volume of cyanoacrylate per session was 2 (1-2) ml. The procedure was associated with minor complications like transient abdominal pain in 11 (8.1 %) and fever in 2 (2.7 %) patients. Rebleeding was observed in 23 (17 %) patients. GOV2, F1 morphology, and a high MELD score were significantly associated with rebleeding. Five (3.7 %) patients died during the study; 2 (1.5 %) were due to failure to control bleeding. Conclusion: In conclusion, our study demonstrated ECGI to be very safe and effective for GVB. The technical success was high and could be achieved in fewer sessions with a smaller volume of cyanoacrylate during each session.

Prophylactic Negative Pressure Wound Therapy in Reducing Surgical Site Infections in Closed Abdominal Incision: A Randomized Controlled Trial.

Objective: This study aimed to evaluate the efficacy of prophylactic negative pressure wound therapy (PNPWT) in reducing the incidence of surgical site infection (SSI) and other wound complications in closed abdominal incisions. Approach: This was a prospective, single-center, open-label parallel arm superiority randomized controlled trial conducted over 2 years. Participants were randomly assigned to PNPWT and standard surgical dressing (SSD) group. The occurrence of postoperative SSI within 30 days, other wound-related complications, length of hospital (LOH) stay, and readmission within 1 month among both the study group were studied. Results: A total of 140 participants were included, with 70 each randomized to the PNPWT and SSD groups. In this study, 28.5% and 5.8% developed SSI in the SSD and PNPWT groups, respectively (relative risk = 0.26; 95% confidence interval = 0.08-0.80; p = 0.001). Similarly, the incidence of seroma (7.2% vs. 18.5%, p = 0.016), wound dehiscence (0% vs. 4.2%, p = 0.244), superficial and deep SSI (5.7% vs. 24.3%, p = 0.001) and (0% vs. 4.2%, p = 0.244), and LOH stay (days) (9 vs. 10.5, p = 0.07) were less in PNPWT compared to SSD group. Innovation: Despite the advances in surgical care, SSI rates continue to be high. The present findings might facilitate the use of PNPWT as a novel preventive strategy to reduce SSI in closed abdominal incision. Conclusion: The PNPWT in closed incisions following elective laparotomy can reduce the incidence of SSI when compared to SSD. The use of PNPWT was associated with a lower incidence of superficial SSI and seroma but without significant reduction in hospital stay. Clinical Trial Registry India: CTRI/2020/11/028795.

Spectrum of perforated peptic ulcer disease in a tertiary care hospital in South India: predictors of morbidity and mortality.

BACKGROUND: Perforated peptic ulcer remains one of the most common surgical emergencies in India with significant morbidity and mortality. The aim of this study was to identify the perioperative risk factors influencing the post-operative morbidity and mortality in patients with perforated peptic ulcer disease. METHODS: Five-hundred patients who underwent surgery for perforated peptic ulcer in our institution in the preceding 8 years were included in this observational retrospective study. Their clinical presentations, peri-operative managements were studied and analysed. RESULTS: Five hundred cases were analysed of which 96% were males. Mean age was 46.5 years. A total of 160 patients had duodenal perforation and 328 had gastric perforation with a mean size of 8.6 mm. Most patients (96.2%) underwent omental patch closure of the perforation with mean length of hospitalization being 14 days. The most common major and minor postoperative complications were prolonged intubation and pulmonary complaints respectively. Re-exploration was needed in 6.2% of cases with a post-operative leak rate of 5.8%. Age >60 years, presence of comorbid illnesses, shock at presentation and perforation size >1 cm were identified as independent predictors of postoperative morbidity. Overall mortality was 11.6% while specific mortality among males and females were 11.8% and 5% respectively. Age >60 years, shock at presentation, presence of abdominal rigidity and size of perforation >1 cm were independent predictors of mortality. CONCLUSION: Old age, comorbidities, shock at presentation, perforation size >1 cm, higher ASA grade, prolonged surgery and biliopurulent contamination >500 mL were independent predictors of both increased post-operative morbidity and mortality.

Role of specific nutritional biomarkers in predicting post-operative complications among patients undergoing elective abdominal surgery.

PURPOSE: Nutritional biomarkers like serum prealbumin, transferrin, retinol-binding protein (RBP), C-reactive protein (CRP), leptin, and insulin-like growth factor 1 (IGF1) have the inherent ability to diagnose undernutrition objectively before it is clinically manifested. The primary objective of the study was to evaluate the diagnostic efficacy of the specific nutritional biomarkers in predicting post-operative complications. METHODS: A prospective cohort study was conducted in the department of surgery and included all patients aged 18 years and above who underwent elective abdominal surgery. Demographic details and clinical and surgical details were documented from the case records. Nutritional biomarker assay was done at admission. The post-operative complications occurring until discharge were graded using the Clavien-Dindo classification. The diagnostic accuracy of the specific nutritional biomarkers in predicting post-operative complications was assessed. RESULTS: A total of 320 patients were included in the study. Of these, 126 (39.38%) developed post-operative complications. Major complications accounted for 19.05% of the complications, while 80.95% were minor complications. Patients with blood prealbumin level less than 17.287 mg/dL had a higher incidence of complications (p < 0.001). Serum transferrin levels less than 168.04 mg/dL and IGF1 levels less than < 44.51 ng/ml showed increased incidence of complications (p < 0.001). The AUC was found to be the highest for serum IGF1 with 0.7782. Sensitivity was equally high for IGF1 and serum transferrin, with 76.98% for the former and 76.19% for the latter. CONCLUSION: Specific nutritional biomarkers, like serum prealbumin and transferrin, were efficient in predicting postoperative complications of patients before undergoing elective abdominal surgeries even after adjusting for confounders. This can facilitate preoperative corrective measures to lower the overall postoperative complications.

Clinicopathological features and survival outcomes for gastric adenocarcinoma: Real-world single-center data.

INTRODUCTION: Gastric cancer is the fifth most-common cancer and fourth common cause for cancer-related deaths globally. Surgery preceded or followed by chemotherapy or chemoradiotherapy is considered an optimal treatment for locally advanced gastric cancer. This study is a real-world data from a tertiary referral institute in southern India, in its experience with treating gastric adenocarcinoma over a period of four years with a minimum of two-year follow-up. METHODS: This was a retrospective analysis of data of patients with histologically proven gastric adenocarcinoma enrolled in the Department of Medical Oncology from 2015 to 2018. The demographic details, presentation, staging, treatment received and outcomes of patients with gastric adenocarcinoma were collected and analyzed in this study. RESULTS: Total 488 patients with gastric adenocarcinoma were included for the study. The stage-wise distribution of patients revealed early and locally advanced (45%) and metastatic (55%). The peritoneum and liver were the common sites of metastasis. The treatment distribution of these patients included perioperative chemotherapy followed by surgery (25 [5%]), surgery followed by adjuvant chemotherapy (65 [13%]), surgery alone (16 [3%]), perioperative chemotherapy alone (23 [4%]), palliative chemotherapy (274 [56%]) and supportive care (85 [17%]). The median overall survival for curative, palliative and supportive treatment was 23 (18-28), nine (7.6-10.4) and four (2.7-5.3) months, respectively. The two-year overall survival in the intention to treat population in the primary surgery (n = 81) and perioperative chemotherapy groups (n = 66) was 67.4% vs. 29.9% (p < 0.0001), respectively. CONCLUSION: This study highlights the advanced nature of the presentation of gastric cancer patients and the poor rate of treatment completion. The median survival rates in curative patients remain to be dismally poor. The treatment sequence in curable gastric cancer of surgery followed by adjuvant chemotherapy vs. perioperative chemotherapy followed by surgery needs to be explored in our country.

Comparison of Enhanced Recovery After Surgery (ERAS) Pathway Versus Standard Care in Patients Undergoing Elective Stoma Reversal Surgery- A Randomized Controlled Trial.

BACKGROUND: Practices such as prolonged preoperative fasting, bowel preparation, delayed ambulation and resumption of orals result in morbidity in 15-20% of stoma reversal cases which can be improved by Enhanced Recovery After Surgery (ERAS) pathways. AIM: To evaluate the safety, feasibility and efficacy of ERAS pathway in patients undergoing elective loop ileostomy or colostomy reversal surgery METHODS: This was an open-labeled, superiority randomized controlled trial in which patients undergoing loop ileostomy or colostomy reversal were randomized to standard or ERAS care. Patients with ASA class ≥3, needing laparotomy for stoma reversal, cardiac, renal and neurological illnesses were excluded. Components of ERAS protocol included pre-operative carbohydrate loading, avoidance of mechanical bowel preparation, goal directed fluid therapy, avoidance of long-acting opioid anesthetics or analgesics, avoidance of drains, urinary catheter or nasogastric tube, early mobilization and early enteral feeding. The primary outcome was length of stay (LOS) while the secondary outcomes were postoperative recovery and morbidity parameters. RESULTS: Forty patients each were randomized to standard care and ERAS. Demographic and laboratory parameters between the two groups were comparable. ERAS group patients had significantly reduced LOS (5.3 ± 0.3 vs 7 ± 2.6; mean difference: 1.73 ± 0.98; p=0.0008). Functional recovery was earlier in the ERAS group compared to the standard care group, such as early resolution of ileus (median-2 days; p<0.001), time to first stool (median-3 days; p=0.0002), time to the resumption of liquid diet (median-3 days; p<0.001) and solid diet (median-4 days; p<0.001). Surgical site infections (SSI) were significantly lesser in ERAS group (12.5% vs 32.5%; p=0.03) while postoperative nausea/vomiting (p=0.08), pulmonary complications (p=0.17) and urinary tract infections (p=0.56) were comparable in both groups. CONCLUSION: ERAS pathways are feasible, safe and significantly reduces LOS in patients undergoing elective loop ileostomy or colostomy reversal surgery.

Comparison of Short-Course and Conventional Antimicrobial Duration in Mild and Moderate Complicated Intra-Abdominal Infections: A randomised controlled trial.

Objectives: Studies have shown the feasibility of short-course antimicrobials in complicated intra-abdominal infection (CIAI) following source control procedure (SCP). This study aimed to compare postoperative complication rates in short-course (5 days) and conventional (7-10 days) duration groups after antimicrobial therapy. Methods: This was a single-centre, open-labelled, randomised controlled trial conducted in Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, from July 2017 to December 2019 on patients with CIAI. Patients who were haemodynamically unstable, pregnant and had non-perforated, non-gangrenous appendicitis or cholecystitis were excluded. Primary endpoints were surgical site infection (SSI), recurrent intra-abdominal infection (IAI) and mortality. Secondary endpoints included time till occurrence of composite primary outcomes, duration of antimicrobial therapy, the length of hospital stays, antimicrobial-free interval, hospital-free days at 30 day intervals and the presence of extra-abdominal infections. Results: Overall, 140 patients were included whose demographic and clinico-pathological details were comparable in both groups. There was no difference in SSI (37% versus 35.6%) and recurrent IAI (5.7% versus 2.8%; P = 0.76); no mortality was observed in either groups. The composite primary outcome (37% versus 35.7%) was also similar in both groups. Secondary outcomes included the duration of antimicrobial therapy (5 versus 8 days; P <0.001) and length of hospitalisation (5 versus 7 days; P = 0.014) were significant. Times till occurrence of SSI and recurrent IAI, incidence of extra-abdominal infection and resistant pathogens were comparable. Conclusion: Short-course antimicrobial therapy for 5 days following SCP for mild and moderate CIAI was comparable to conventional duration antimicrobial therapy, indicating similar efficacy.

Diagnostic Utility of NLR, PLR and MLR in Early Diagnosis of Gastric Cancer: an Analytical Cross-Sectional Study.

PURPOSE: Inflammatory markers such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and monocyte-to-lymphocyte ratio (MLR) are linked with the pathogenesis of gastric cancer (GC). However, the clinical significance of the combination of these markers is unclear. Hence, this study was carried out to determine the individual and combined diagnostic accuracy of NLR, PLR and MLR among patients with GC. METHODS: In this prospective, cross-sectional study, patients were recruited into three groups, GC, precancerous lesions and age and gender-matched controls. The primary outcome was to determine the diagnostic accuracy of inflammatory markers in the diagnosis of GC. The secondary outcome was to determine the correlation of inflammatory markers with the stage of gastric cancer, nodal involvement and metastasis. RESULTS: A total of 228 patients, 76 in each group, were enrolled. The cut-off value of NLR, PLR and MLR were 2.23, 146.8 and 0.26, respectively, for the diagnosis of GC. The diagnostic abilities of NLR, PLR and MLR were significantly high at 79, 75 and 68.4, respectively, to predict GC compared to precancerous and control groups. All the models of inflammatory markers showed excellent discrimination between GC and the controls with an AUC > 0.7. The models also showed acceptable discrimination between GC and the precancerous lesion group with AUC between 0.65 and 0.70. No significant difference was found in correlating inflammatory markers with clinicopathological features. CONCLUSION: The discrimination capacity of the inflammatory markers could be used as screening biomarkers in diagnosing GC, even in its early stages.

Comparison of Efficacy of Aspirin Plus EOX vs. EOX Alone in Patients with Locally Advanced and Metastatic Gastric Cancer: a Randomized Clinical Trial.

PURPOSE: The role of aspirin in cancer prevention has been well defined; the last decade revealed its therapeutic role with improved efficacy when aspirin was added to capecitabine in heavily pre-treated metastatic colorectal cancer. Aspirin affects tumour growth through the PI3K pathway, which regulates apoptosis and autophagy. The objective was to compare the efficacy of aspirin plus epirubicin, oxaliplatin, capecitabine (EOX) chemotherapy versus EOX alone in locally advanced and metastatic gastric cancer. METHODS: All patients with advanced gastric cancer reporting to the Department of Medical oncology between March 2017 and May 2019 were screened for study eligibility. They were randomly assigned to standard EOX with or without aspirin at a daily dose of 150 mg. Tumour measurements were assessed at baseline and after 3-4 cycles by an independent blinded radiologist according to RECIST criteria 1.1. Toxicity profiles were recorded as per CTCAE v 4.03. Per-protocol group was identified as 70 patients. The primary endpoint was overall response rates in the per-protocol group (defined as patients who received a minimum of 3 cycles and had an evaluable response after randomization). The secondary endpoints included toxicity analysis, progression-free survival, and overall survival. RESULTS: Ninety-five patients who fulfilled the study inclusion and exclusion criteria were randomized to group 1 EOX (50) or group 2 EOX plus aspirin (45). Seventy patients were included for the per-protocol analysis. The overall response rate in group 1 was 27% compared to group 2, which was 42%, P = 0.176. The median duration of follow was 29 (18.56-39.45) months. The median overall survival (n = 95) of group 1 versus group 2 was 11 (8.58-13.42) months and 10 (6.86-13.14) months, respectively, P = 0.90. There was no statistical significance in the overall survival per-protocol analysis (n = 70) between group one 12 (8.75-15.25) months versus group two 12 (6.21-17.79) months, P = 0.50. CONCLUSIONS: There was no improvement in the response rates, progression-free survival, and overall survival on adding aspirin to EOX chemotherapy in locally advanced and metastatic gastric cancer in an unselected population. A further role of PI3K mutation as a biomarker needs to be evaluated in this setting.

Effect of Synbiotics in Reducing the Systemic Inflammatory Response and Septic Complications in Moderately Severe and Severe Acute Pancreatitis: A Prospective Parallel-Arm Double-Blind Randomized Trial.

AIM: This study aimed at evaluating the efficacy of synbiotics in reducing septic complications in moderately severe and severe acute pancreatitis. METHODS: This was a prospective, parallel-arm, double-blinded superiority randomized control study. All patients with moderately severe and severe acute pancreatitis were included in the study. Acute on chronic pancreatitis, pancreatitis due to trauma, ERCP and malignancy were excluded. 1 g of synbiotic containing both pre- and probiotics was administered to the cases twice a day for 14 days and a similar-looking placebo to controls. Patients were followed for 90 days. Primary outcomes were reduction of septic complications and inflammatory marker levels. Secondary outcomes were mortality, non-septic morbidity, length of hospitalization (LOH) and need for intervention. RESULTS: A total of 86 patients were randomized to 43 in each arm. Demographic profile and severity of pancreatitis were comparable. There was no significant difference in septic complications between the groups (59% vs. 64%; p 0.59). Total leucocyte and neutrophil counts showed a significant reduction in the first 7 days (p = 0.01 and 0.05). No significant difference was seen in other inflammatory markers. There was a significant reduction in the LOH (10 vs. 7; p = 0.02). Non-septic morbidity (41% vs. 62.2%; p 0.06) and length of ICU stay (3 vs. 2; p 0.06) had a trend towards significance. The need for intervention and mortality was comparable. CONCLUSION: Synbiotics did not significantly reduce the septic complications in patients with moderately severe and severe acute pancreatitis; however, they significantly reduced the LOH. There was no reduction in mortality and need for intervention. Clinical Trials Registry of India Number: CTRI/2018/03/012597.

Is There an Association between Variceal Bleed and Helicobacter pylori Infection in Cirrhotic Patients with Portal Hypertension?: A prospective cohort study.

Objectives: This study aimed to determine the association between Helicobacter pylori infection and variceal bleeding as well as rebleeding in cases of cirrhosis with portal hypertension. Methods: This prospective cohort study included patients with bleeding oesophageal varices and was conducted at the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, from August 2016 to July 2018. Results: A total of 190 patients were assessed for eligibility, of which 159 patients were included in this study. Among the 159 patients, 124 (78.0%) had alcohol-related liver disease and eight had hepatitis B virus-related liver disease. Seven patients with varices had bled neither at presentation nor during the follow-up period. A total of 78 (49.1%) patients were H. pylori infected. The primary outcome, which was correlation between prevalence of H. pylori and the incidence of bleeding/rebleeding from varices as well as encephalopathy found that patients with oesophageal varices (adjusted risk [AR] = 0.714) and H. pylori infection (AR = 0.682) had a lower risk of variceal rebleeding. Among H. pylori-negative patients, pepsinogen I was higher in patients with rebleeding (30.7 versus 14.4 ng/mL; P <0.001). The secondary outcome, which was correlation of the site of bleeding with H. pylori infection and the association of the ratio of pepsinogen I/II with bleeding showed that among H. pylori-positive patients, the ratio of pepsinogen I/II was higher in patients with rebleeding (2.9 versus 1.3 ng/mL; P = 0.023). Conclusion: H. pylori infection was associated with a lower risk of rebleeding in cases of cirrhosis with portal hypertension. Irrespective of the status of the H. pylori infection, rebleeding was associated with increased levels of gastric acid output, as demonstrated by the level of pepsinogen.

The Diagnostic Dilemma of Ruptured Liver Metastasis in a Patient with Lung Cancer: A case report.

Spontaneous rupture of a metastatic liver tumour is rarely documented in the literature when compared to hepatocellular carcinoma and other liver lesions, especially from a lung primary. We report a case of ruptured liver metastasis from an adenocarcinoma of the lung mimicking ruptured liver abscess, challenging the clinical diagnosis. A 42-year-female patient presented to a tertiary care institute in 2020 with complaints of abdominal pain, breathlessness and fever. On examination, the patient was tachypnoeic with a right hypochondriac mass. A contrast-enhanced computed tomography of abdomen and thorax revealed an ill-defined heterogeneously enhancing lesion in the liver with a communicating subcapsular collection and hypo-enhancing lesions in the left lobe and heterogeneously enhancing lesion in the left lung. Adenocarcinoma of the lung with hepatic metastasis was confirmed with a core needle biopsy. The patient was managed conservatively with intravenous antibiotics, intercostal drainage tube and gefitinib. However, despite best efforts, the patient succumbed to the disease.

Association Between Helicobacter pylori and Periampullary and Pancreatic Cancer: a Case-Control Study.

INTRODUCTION: Helicobacter pylori has been implicated in the etiopathogenesis of various malignant conditions; however, there is a dearth of studies on the correlation between H. pylori infection and pancreatic cancers. Hence, this study was carried out to evaluate the association between H. pylori infection and periampullary and pancreatic cancer. METHODS: This was a single-centre, retrospective, case-control study in which all consecutive patients of periampullary or pancreatic cancer were included. The demographic details with tumour characteristics were recorded. Age and gender-matched controls were patients with other extra-abdominal benign conditions. H. pylori and the Cag A status were determined using IgG antibodies and Cag A antibodies respectively. The association between H. pylori infection and periampullary and pancreatic cancer was the primary outcome. RESULTS: A total of 155 patients, 61 in the study and 94 in the control group were included. The overall prevalence of H. pylori in the study group (78.6%) was similar to that of the control group (76.5%) (p = 0.76). Although a higher trend of IgG and Cag A seropositivity was seen in the study group, the difference was not significant. The correlation of H. pylori and Cag A seropositivity showed a higher trend with site-specificity, differentiation, and nodal status. However, the difference was not significant. CONCLUSION: There was no association between H. pylori infection and Cag A seropositivity with periampullary and pancreatic cancers. The various tumour characteristics were also not associated with H. pylori infection. Thus, routine eradication of H. pylori infection may not be recommended in periampullary and pancreatic cancers.

Acute Upper Non-variceal and Lower Gastrointestinal Bleeding.

Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.

Hunger-Based Versus Conventional Oral Feeding in Moderate and Severe Acute Pancreatitis: A Randomized Controlled Trial.

BACKGROUND: The length of hospitalization is prolonged in patients with acute pancreatitis due to delay in feeding. The present study aimed at evaluating hunger-based early feeding for its efficacy in reducing length of hospitalisation. AIMS AND METHODS: This was a parallel arm superiority randomized control trial. Patients with moderate and severe acute pancreatitis were randomised into hunger-based feeding and conventional feeding groups. Patients in hunger-based feeding group commenced feeding once they felt hungry and in conventional feeding group after normalization of biochemical parameters and resolution of symptoms. Patients were followed up till their discharge and were analyzed for length of hospitalisation, fasting duration, feed intolerance, incidence of infective morbidities and invasive procedures. RESULTS: Hunger-based feeding and conventional feeding group included 56 and 54 patients, respectively. Hunger-based feeding led to a decrease in length of hospitalization (6.3 days in hunger-based feeding vs 7.3 days in conventional feeding group, P = 0.041) and fasting duration (1.6 days in hunger-based feeding vs 2.7 days in conventional feeding group, P = 0.001).The incidence of feed intolerance (P = 0.098), infective morbidities and invasive non-surgical procedures were similar in both the groups. CONCLUSION: Hunger-based feeding significantly reduces length of hospitalization and fasting duration in cases of moderate and severe acute pancreatitis without any significant rise in the incidence of complications. Registration number of Clinical Trails Registry India CTRI/2019/01/017,144.

Role of Sarcopenia in Predicting the Postoperative Morbidity and Perioperative Mortality in Patients Undergoing Elective Surgery for Gastric Cancer.

PURPOSE OF STUDY: This study was done to assess the effect of sarcopenia and other risk factors on the postoperative morbidity and perioperative mortality of patients undergoing elective surgery for gastric cancer. METHODS: This was a prospective cohort study comprising a single group of patients undergoing elective surgery for gastric cancer carried out in a tertiary care center in India. Patients diagnosed with gastric cancer underwent contrast-enhanced computed tomography preoperatively. Patients were considered sarcopenic when their skeletal muscle index (SMI) was < 34.9 cm2/m2 for women and < 40.8 cm2/m2 for men. Patients were planned for surgery ranging from gastrectomy with curative intent to palliative gastrojejunostomy. Postoperative complications including mortality were noted for 30 days following surgery and graded according to the Clavien-Dindo classification. The role of sarcopenia and other risk factors on the postoperative outcome of patients was noted. RESULTS: A total of 100 patients were included in the study. There was a high prevalence of sarcopenia (62%) among patients with gastric cancer who underwent elective surgery. However, sarcopenia was not associated with any postoperative complication (p > 0.05) including 30-day mortality (p = 0.155), prolonged postoperative hospital stay (p = 0.876), or 30-day readmission rate (0.524). Among the variables considered, only esophagojejunostomy (p < 0.001) was associated with a poor postoperative outcome. CONCLUSION: The present study showed that there was a high prevalence of sarcopenia (62%) in patients undergoing elective surgery for gastric cancer. However, it did not adversely affect the postoperative outcome. Among the variables considered, esophagojejunostomy alone was associated with a poor postoperative outcome.

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Surgery for Perforation Peritonitis-a Randomized Controlled Trial.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways have an uncertain role in emergencies. To the best of our knowledge, there are no trials studying ERAS in perforation peritonitis across the GI tract, despite it being a common surgical emergency. AIMS: To evaluate the safety, feasibility and efficacy of adapted ERAS protocols in emergency laparotomy for perforation peritonitis. METHODS: This was an open-labeled, superiority randomized controlled trial conducted between October 2018 and June 2020 in patients with perforation peritonitis assigned to standard care or adapted ERAS groups using block randomization. Patients with refractory shock, ASA class 4E, localized peritonitis, etc. were excluded. Components of the adapted ERAS protocol included epidural analgesia, goal-directed fluid therapy, avoidance of opioids, early mobilization, early removal of tubes, drains and catheters, and early enteral feeding. The primary outcome, length of hospitalization (LOH), and the secondary outcomes, functional recovery parameters, were analyzed between both the groups. RESULTS: A total of 59 patients in standard care group and 61 patients in adapted ERAS group were included and randomized, and were comparable in terms of demographic and clinico-pathological characteristics. LOH in adapted ERAS group was shorter by 3 days (p < 0.001), and patients showed reduction in time (days) to first flatus (2.84 vs 4.22, p < 0.001), first stool (4.38 vs 6.08, p < 0.001) and solid diet (4.67 vs 8.37, p < 0.001). Post-operative nausea, vomiting (p = 0.05) and surgical site infections (p < 0.001) were reduced in adapted ERAS group. Pre-existing malignancy, respiratory complications and high output stoma were reasons for delayed discharge in adapted ERAS group. CONCLUSION: Adapted ERAS pathways considerably reduce LOH in patients undergoing emergency surgery for perforation peritonitis, with no adverse events in 30 days after discharge. TRIAL REGISTRATION: Registered at http://ctri.nic.in/Clinicaltrials/login.php (CTRI/2019/02/017537).

Serial estimation of serum C-reactive protein and procalcitonin for early detection of anastomotic leak after elective intestinal surgeries: a prospective cohort study.

OBJECTIVES: Anastomotic leak can adversely affect the outcome of surgery especially if detected late. The present study was carried out to detect the anastomotic leak early in the postoperative period using serial estimation of procalcitonin (PCT) and C-reactive protein (CRP). MATERIAL AND METHODS: A single centre prospective cohort study was done on patients undergoing elective gastrointestinal surgery with anastomosis. Serial estimation of serum procalcitonin and C reactive protein was done on the first five postoperative days. Other parameters such as hemoglobin, total protein, albumin and WBC counts were noted perioperatively. Patients were followed up to 60th postoperative day to assess for anastomotic leak, wound infection and other septic foci. RESULTS: Eighty-four patients were included in the study. Anastomotic leak rate was 26.19% (22/84) and 3/22 patients died in the anastomotic leak group. Wound infection rate was 23.81%. The cut off value of CRP on third postoperative day in detecting anastomotic leak was 44.322 mg/dl with sensitivity of 72.73%, specificity of 66.13% and accuracy of 59.52%. The cut off value for WBC count measured perioperatively in detecting anastomotic leak was 9470 cell/mm3 with sensitivity of 72.73%, specificity of 56.45% and accuracy of 59.74%. Serum procalcitonin, haemoglobin, total protein and albumin measured were not sensitive enough to detect the anastomotic leak early. CONCLUSION: Measuring CRP on the third postoperative day can predict anastomotic leak with a cut off value of 44.32 mg/dl. Patients with raised CRP need careful evaluation to rule out anastomotic leak before deciding on early discharge.

Management of Helicobacter pylori infection: The Bhubaneswar Consensus Report of the Indian Society of Gastroenterology.

The Indian Society of Gastroenterology (ISG) felt the need to organize a consensus on Helicobacter pylori (H. pylori) infection and to update the current management of H. pylori infection; hence, ISG constituted the ISG's Task Force on Helicobacter pylori. The Task Force on H. pylori undertook an exercise to produce consensus statements on H. pylori infection. Twenty-five experts from different parts of India, including gastroenterologists, pathologists, surgeons, epidemiologists, pediatricians, and microbiologists participated in the meeting. The participants were allocated to one of following sections for the meeting: Epidemiology of H. pylori infection in India and H. pylori associated conditions; diagnosis; treatment and retreatment; H. pylori and gastric cancer, and H. pylori prevention/public health. Each group reviewed all published literature on H. pylori infection with special reference to the Indian scenario and prepared appropriate statements on different aspects for voting and consensus development. This consensus, which was produced through a modified Delphi process including two rounds of face-to-face meetings, reflects our current understanding and recommendations for the diagnosis and management of H. pylori infection. These consensus should serve as a reference for not only guiding treatment of H. pylori infection but also to guide future research on the subject.