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Author(s): Shibani Padhy [1]; Indira Gurajala [2]; Padmaja Durga [1]; Akhya Kumar Kar (corresponding author) [1]; Manjeera Doppalapudi [1]; P Pranay [1] INTRODUCTION A disparity between oxygen consumption (VO[sub.2] ) [...], Background and Aims: Predicting complications after major oncosurgery is particularly daunting in the elderly subcategory of patients owing to factors like preexisting age-related immune cellular senescence and a significant imbalance of oxygen delivery (DO[sub.2]) and consumption (VO[sub.2]) characteristic of major oncological surgeries. The respiratory exchange ratio (RER) indicates DO[sub.2]-VO[sub.2] balance and onset of anaerobic metabolism. We evaluated the ability of RER in predicting the occurrence of postoperative complications following geriatric oncosurgery. Materials and Methods: In the study, we enrolled 96 patients aged 65 years and above undergoing definitive surgery for gastrointestinal malignancy. The RER was calculated at predefined time points by a non-volumetric method from the respiratory parameters as RER = (end-tidal fractional carbon dioxide [FetCO[sub.2]] - fraction of inspired carbon dioxide [FiCO[sub.2]]/fraction of inspired oxygen [FiO[sub.2]] - end-tidal fractional oxygen [FetO[sub.2]]). Other indices of tissue perfusion, like central venous oxygen saturation and lactate levels, were also recorded. The patients were followed up for postsurgical complications. The predictive value of RER and other perfusion parameters was assessed and compared by appropriate statistical methods. Results: The patients who sustained major complications had a higher RER than the patients who did not sustain complications (1.47 ± 0.99 vs. 0.90 ± 0.31, P = 0.001). An intraoperative cutoff value of RER ≥0.89 was found to best predict postoperative complications at a specificity and sensitivity rate of 81.2 and 76, respectively. End-operative partial pressure of carbon dioxide (pCO[sub.2]) gap of >5.2 mm and elevated arterial lactate could also predict postsurgical complications in this age group. Conclusion: The RER can serve as a noninvasive, real-time and sensitive indicator of tissue hypoperfusion and postoperative complications in geriatric gastrointestinal oncosurgery. Keywords: Gastrointestinal malignancy, geriatrics, perfusion, postoperative complications

Endoscopic mucosal resection (EMR) has made it possible for patients with Barrett esophagus and superficial adenocarcinomas to be treated nonsurgically. This option is attractive given the risks of mortality and [...], * Context.--Endoscopic mucosal resection (EMR) has made it possible for Barrett esophagus patients with superficial cancers to be treated without esophagectomy. Recent guidelines recommend measuring depth of invasion (DOI) in submucosal cancers based on reports that in low-risk cancers, submucosal invasion 500 [micro]m or less is associated with low nodal metastasis rates. However, pathologists face challenges in reproducibly measuring DOI. Objective.--To determine how often DOI measurements could impact treatment and to evaluate reproducibility in measuring submucosal DOI in EMR specimens. Design.--Consecutive adenocarcinoma EMR cases were identified, including cases of "low histologic risk" submucosal cancer, as follows: those with negative deep margins, no high-grade histology (G3), and no lymphovascular invasion. Submucosal dOi was measured by 7 pathologists according to guidelines. Results.--Of 213 cancer EMR cases, 46 were submucosa invasive and 6 cases were low histologic risk submucosal cancers for which measurement could impact decision-making. Of these low histologic risk cases, 3 were categorized as superficial, indicating that measurement would be a clinically actionable decision point in only 1.4% of adenocarcinoma EMRs. Interobserver agreement for in-depth categorization between 7 pathologists was moderate ([kappa] = 0.42), and the range of measurements spanned the 500-[micro]m relevant threshold in 40 of 55 measured samples (72.7%). Conclusions.--While therapeutic decisions would rarely have depended on DOI measurements alone in our cohort, interobserver variability raises concerns about their use as a sole factor on which to offer patients conservative therapy. Responsibly reporting and clinically using submucosal DOI measurements will require practical experience troubleshooting common histologic artifacts, as well as multidisciplinary awareness of the impact of variable specimen-handling practices. doi: 10.5858/arpa.2021-0072-OA

Author(s): Hua Xiao [sup.1] , Huijun Zhou [sup.2] , Peng Zhang [sup.3] , Haifan Xiao [sup.4] , Ke Liu [sup.5] , Xiaoyan Chen [sup.6] , Hu Quan [sup.1] , Bin [...], Background/objective To investigate the impact of preoperative immunological and nutritional status, using the prognostic nutritional index (PNI), on completion of planned adjuvant chemotherapy (AC), and the potential additive effects of low PNI and incomplete AC on gastric cancer-specific survival (CSS) after curative resection of stage II/III gastric cancer (GC). Methods Medical records of 1288 consecutive stage II/III GC patients who underwent curative resection and planned to receive AC between November 2010 and December 2017 were retrospectively reviewed. The optimal cut-off value of PNI for CSS was determined by X-tile. The independent predictive factors for incomplete AC were identified using univariate and multivariate analyses. Cox regression analyses assessed the association of low PNI, incomplete AC and CSS. Results Of the 1288 patients, 406 (31.5%) completed at least six cycles of AC within 6 months following initial of AC (complete AC). Low PNI ( Conclusions Low preoperative PNI significantly affects completion of AC. Low PNI and incomplete AC has an additive effect and is associated with even worse outcomes. Further prospective studies are needed to clarify whether perioperative nutrition intervention could improve completion of AC and improve prognosis of GC patients.

Author(s): Swapnil Y. Parab (corresponding author) [1]; Shubhangi Humane [1]; Prathmesh Pai [2]; George Karimundackal [2] Sir, Ventilation of the lungs when the airway is shared with the surgeons is [...]

More than 50 years ago, Turnbull and Cutait described colonic pull-through with delayed coloanal anastomosis (DCA) after rectal resection for the management of rectal cancer, chagasic megacolon and other colorectal [...], Background: Turnbull-Cutait abdominoperineal pull-through followed by delayed coloanal anastomosis (DCA) was first described in 1961. Studies have described its use for challenging colorectal conditions. We reviewed our experience with Turnbull-Cutait DCA as a salvage procedure for complex failure of colorectal anastomosis. Methods: We performed a retrospective cohort study from October 2010 to September 2011, with analysis of postoperative morbidity and mortality. Results: Seven DCAs were performed for anastomotic complications (3 chronic leaks, 2 rectovaginal fistulas, 1 colovesical fistula, 1 colonic ischemia) following surgery for rectal cancer. Six patients had a diverting ileostomy constructed as part of previous treatment for anastomotic complications before the salvage procedure. No anastomotic leaks were observed. All procedures but 1 were completed successfully. One patient who underwent DCA subsequently required an abdominoperineal resection and a permanent colostomy for postoperative extensive colonic ischemia. No 30-day mortality occurred. Conclusion: Salvage Turnbull-Cutait DCA appears to be a safe procedure and could be offered to patients with complex anastomotic complications. This procedure could be added to the surgeon's armamentarium as an alternative to the creation of a permanent stoma. Contexte : La resection colique abdominale avec extraction trans-anale et anastomose colo-anale differee (CAD) fut decrite initialement par Turnbull et Cutait en 1961. Cette intervention a recemment ete rapportee pour le traitement des conditions colorectales complexes. Nous avons revu notre experience avec la CAD comme chirurgie de sauvetage dans le traitement des complications complexes de l'anastomose colo-anale de premiere intention. Methodes : Nous avons effectue une etude de cohorte retrospective entre octobre 2010 et septembre 2011, en analysant la morbidite et la mortalite postoperatoires. Resultats : Sept CAD ont ete realisees en raison de complications anastomotiques (3 fuites anastomotiques chroniques, 2 fistules rectovaginales, 1 fistule colovesicale, 1 ischemie colique) resultant du traitement chirurgical d'un cancer rectal. Six patients avaient subi une ileostomie de derivation jour fuite anastomotique, dans la periode precedant la CAD de sauvetage. A l'exception d'un patient, toutes les procedures se sont soldees en succes. Aucune fuite anastomotique n'a ete observee apres CAD. Un patient a du subir une resection abdominoperineale avec colostomie terminale permanente en raison d'ischemie colique aigue du colon distal apres CAD. Aucun deces n'est survenu dans les 30 jours suivant la CAD. Conclusion : La CAD de sauvetage apparait comme une intervention securitaire qui represente une option therapeutique valable pour les patients souffrant de complications complexes de fuites anastomotiques colorectales. Cette intervention pourrait s'ajouter a l'arsenal du chirurgien comme alternative a la creation d'une stomie permanente.