Emergency Radical Gastrectomy with Pancreatico-duodenectomy for a Recent Onset Perforation of Locally Advanced Gastric Cancer with Pancreatic Head Involvement-Exceptional but a Definite Option.

Gastric cancer perforations are rare events with management options ranging from lavage and perforation closure, to resection. Usual aim is to perform a damage control procedure, and very few patients are suitable for a curative resection. We report the first case of emergency gastrectomy with pancreatico-duodenectomy performed in emergency for a perforated stomach cancer with pancreatic head invasion. The patient was a 32-year-old gentleman who presented with a perforated antro-pyloric cancer with infiltration of pancreatic head. Emergency radical gastrectomy with en-bloc pancreatico-duodenectomy was performed with due considerations to the patient and disease factors. He had an uneventful postoperative recovery and remains disease free at 18 months of follow-up after having received adjuvant chemotherapy. Curative resections should be selectively offered in advanced (T4b) gastric cancers in patients without multiple adverse factors. In an emergency situation with perforation peritonitis, if the magnitude of resection is deemed unlikely to add to significant morbidity of the surgery, taking multiple factors into consideration, an R0 resection can offer a large survival benefit in such settings.

Correction to: Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India.

The authors' affiliations are updated as reflected here.

Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India.

BACKGROUND: Pancreato-duodenectomy (PD) is a technically challenging operation with significant morbidity and mortality. Over the period of time, Tata Memorial Centre has evolved into a high-volume centre for management of pancreatic cancer. Aim of this study is to report the short- and long-term outcomes of 1200 consecutive PDs performed at single tertiary cancer centre in India. METHODS: 1200 PDs were performed from 1992 to 2017. Prospectively maintained database was used to retrospectively assess the short- and long-term outcomes. RESULTS: Study cohort was divided into periods A and B (500 and 700 patients, respectively). Both groups were comparable for demographic variables. Overall morbidity and mortality in entire cohort were 31.2% and 3.9%, respectively. Period B documented significant reduction in post-operative mortality (5.4% vs 2.8%), post-pancreatectomy haemorrhage (5.8% vs 3%) and bile leaks (3.4% vs 1.3%). However, incidence of delayed gastric emptying and clinically relevant post-operative pancreatic fistula was higher in period B. With median follow-up of 25 months, 3-year overall survival and disease-free survival for patients with pancreatic cancer were 43.7% and 38.7%, respectively, and that for periampullary tumours were 65.9% and 59.4%, respectively. Period B also corresponded with dissemination of technical expertise across diverse regions of India with specialised training of 35 surgeons. CONCLUSION: Our study demonstrates the feasibility of delivering high-quality care in a dedicated high-volume centre even in a country with low incidence of pancreatic cancer with marked disparities in medical care and socio-economic conditions. Improved outcomes underscore the need to promote regionalisation via a dedicated training programme.

Performance of Hong Kong Liver Cancer staging system in patients of hepatocellular carcinoma treated with surgical resection: An Indian validation study.

BACKGROUND: Hong Kong Liver Cancer staging (HKLCS) system lacks external validation. AIMS AND METHODS: We conducted a study to validate the prognostic and clinical utility of HKLCS system in the patients with hepatocellular carcinoma (HCC) of heterogeneous etiologies treated with hepatic resection with curative intent at Tata Memorial Centre, Mumbai, India. RESULTS: A total of 144 patients underwent resection for HCC. Our patient cohort was comparable to the original developmental cohort in median age and gender distribution but differed in etiology, liver function status, and tumor venous invasion. On Kaplan-Meier survival curve analysis for overall and disease-free survival, we could achieve statistically significant separation of curves in both Barcelona Clinic Liver Cancer staging (BCLCS) and HKLCS staging systems (P < .000). Interstage discrimination between early and intermediate stages for survival was higher in HKLCS system (P value of .039 vs .091). The area under the receiver operating characteristic curve for the survival of BCLCS and HKLCS systems for the entire patient population was 0.66 and 0.60, respectively, which was not statistically significant (P = .31). CONCLUSION: The HKLCS system offered higher interstage discrimination power in the patients with HCC treated with resection and may be equally applicable to nonalcoholic steatosis-related chronic liver disease and noncirrhotic patient population.

Achieving margin negative resection-doing less is justified: oncological outcomes of wedge excision of liver in gallbladder cancer (GBC) surgery.

BACKGROUND: The extent of liver resection for gallbladder cancer (GBC) is still debated. We evaluated the post-operative and oncological outcomes of patients with GBC who underwent liver wedge excision. METHODS: Patients who underwent an upfront radical cholecystectomy (with a liver wedge excision of 2.5- 3 centimetres) from June 2010 to December 2015 were retrospectively analysed. RESULTS: In total, 558 patients underwent surgery for GBC of which 97 cases of primary GBC who underwent upfront radical cholecystectomy were selected. At a median follow up of 47 months, 57.7% of patients were disease free where as 16.5% were alive with disease. Two (2.1%) patients died in postoperative period, 17 (17.5%) patients died of disease, and 6 (6.2%) died of unrelated causes. Eleven patients had loco-regional recurrence and 22 failed at distant sites. Only one patient recurred in the gall bladder bed. Three-year overall survival (OS) of stage II was 86.1% and of stage III was 59.6%. CONCLUSIONS: In our series surgical outcomes of radical cholecystectomy with wedge resection of the liver emphasizes its oncological equivalence compared to formal segment IVb/V excision. Our experience with wedge resection gains significance in the absence of any level I evidence and can prompt a multicentre randomised controlled trial (RCT) in future which may help in standardizing surgery for GBC.

Robotic surgery for gallbladder cancer: Operative technique and early outcomes.

BACKGROUND: The objective was to elucidate the operative technique of robotic radical cholecystectomy (RRC) and to compare the early outcomes of RRC with open radical cholecystectomy (ORC) for gallbladder cancer (GBC). METHODS: Patients who underwent RRC for suspected or incidental GBC between July 2015 and August 2018 were analyzed. Patients who underwent ORC during the same period and fulfilled the study criteria formed the control group. RESULTS: During the study period, 27 patients who underwent RRC formed the study group (group A) and 70 matched patients who underwent ORC formed the control group (group B). Median surgical time was higher in group A (295 vs 200 minutes, P < 0.001). However, median blood loss (200 vs 600 mL, P < 0.001), postoperative hospital stay (4 vs 5 days, P = 0.046) and postoperative morbidity (1 vs 15 patients, P = 0.035) were lower in group A. Median lymph node yield was 10 (range = 2-21) for group A and 9 (range = 2-25) for group B, and was comparable (P = 0.408). During a median follow up of 9 (1-46) months, two patients in group A developed recurrence (no port site recurrence). CONCLUSION: RRC is safe and feasible and the short-term results are compared with ORC.

Outcome of Robot-Assisted Radical Cholecystectomy in a High-Volume Tertiary Cancer Center in India.

Introduction: Minimally invasive radical cholecystectomy is a complex laparoscopy. Robotic surgery is now an option to complete a radical cholecystectomy because of its high definition, magnified three-dimensional view of the operative field, and articulating instrumentation.1-3 Robotic surgery enables a safe dissection in otherwise difficult to access areas such as the porta hepatis. This video reviews the role of robotic surgery in the management of gall bladder (GB) malignancy. Methods: A 28-year-old lady, with no comorbidities, presented with abdominal pain and underwent an evaluation with a contrast-enhanced CT scan of chest and abdomen. The CT scan revealed a mass in the GB with no evidence of distant metastases. Liver function tests were normal and a CA19-9 was 898 U/mL. A robotic radical cholecystectomy using five ports (four robotic and one assistant port) was performed. The procedure started by clearing the hepatoduodenal ligament nodes (stations 8, 12, and 13 with interaortocaval node sampling). The triangle of Calot was then dissected and secured with clips. Next a wide excision of segments 4b and 5 was performed including the GB. The complete specimen was extracted in a bag from a small incision at the assistant port. Results: The procedure was performed in 330 minutes with a blood loss of 200 mL. There were no perioperative complications and the postoperative stay was 3 days. Final histopathology report revealed moderately differentiated adenocarcinoma of GB invading serosa (pT3) with negative margins and 4 out of 14 lymph nodes showed presence of metastases. The overall cohort shows 22 robotic radical cholecystectomies for GB malignancy. The median age was 53 years. The average duration of surgery was 270 minutes with a median blood loss of 120 mL. The median postoperative stay was 4 days and the median nodal yield for radical cholecystectomy was 8. The overall median survival at 18 months was 100% with one recurrent hepatic lesion. Discussion: Robotic radical cholecystectomy may offer technical superiority over laparoscopic surgery and is an oncologically acceptable approach with good short-term oncologic outcomes. This type of surgery may require a highly specialized center with adequate experience in hepatopancreatobiliary surgery. No competing financial interests exist. Runtime of video: 9 mins 5 secs.

Radiological diagnosis alone risks overtreatment of benign disease in suspected gallbladder cancer: A word of caution in an era of radical surgery.

BACKGROUND: Incidental gallbladder cancer (iGBC) is on the rise world over. This may be a good scenario as we get to treat GBC in early stages. However, there is a practice of diagnosing patients based on clinicoradiological findings alone and subjecting them to a radical surgical procedure. This approach over-treats patient and has important implications for resource utilization. METHODS: We performed a retrospective analysis of 284 consecutive patients undergoing upfront surgery for suspected GBC from January 2010 to December 2016. The study cohort was divided into two groups, group A - benign (n = 138, 48.6%) and group B - malignant (n = 146, 51.4%). Both groups were compared with respect to demographic characteristics, tumor marker levels, clinicoradiological features, and perioperative outcomes. RESULTS: Approximately 48.6% patients with clinicoradiological suspicion of GBC turned out to be benign on final histology as confirmed on frozen section evaluation (FS). Only 2 patients who were reported benign on FS required revision surgery for malignancy in the final histopathology report. Demographic and clinicoradiological characteristics in both groups were comparable. However, there was a significant difference in blood loss, postoperative hospital stay, and complications between the two groups (P < 0.005). CONCLUSION: Every other patient who presented to a tertiary cancer center with high index suspicion for malignancy, based on clinicoradiological findings, turned out to be benign on final histology. This emphasizes the fact that, as a norm, for radiologically suspected gallbladder malignancy, we need to have a confirmed histological diagnosis at least during surgery before proceeding to radical resection.