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Neoadjuvant chemoradiotherapy (nCRT) has improved the resectability and survival of operable oesophageal squamous cell carcinoma (OSCC). We aimed to study if nCRT for OSCC makes minimally invasive oesophagectomy (MIO) technically more challenging and if the peri-operative and oncological outcomes are acceptable for MIO following nCRT.A retrospective review of patients with OSCC (cT1-2N1-2, cT3-4aN0-2) treated with nCRT and MIO between 2013 and 2019 was performed. The operative details including the technical difficulty in tumour dissection and lymphadenectomy, the post-operative complications and oncological outcomes were studied.Seventy-five patients (male:female - 50:25; mean [range] age - 55.49 ± 8.43 [22-72] years; stage II - 34.7%; stage III - 37.3%; stage IVA - 28.0%) were enrolled. The concurrent chemotherapy course was completed by 25.3% of patients and the most common reason limiting the completion of chemotherapy was neutropaenia (66.0%). A thoraco-laparoscopic (n = 60) or hybrid (n = 15) McKeown's oesophagectomy with a two-field lymphadenectomy was performed. The increased surgical difficulty was reported in 41 (54.7%) patients, particularly for mid-thoracic tumours and tumours exhibiting incomplete response. The 30-day overall and major complication rate was 48.0% and 20.0%, respectively, and there was no mortality. The rate of R0 resection, pathological complete response and median lymph nodal yield were 93.3%, 48% and 8 (range: 1-25), respectively. The mean overall survival (OS) was 62.2 months (95% confidence interval [CI]: 52.6-71.8) and recurrence-free survival (RFS) was 53.5 months (95% CI: 43.5-63.5). The 1-, 2- and 3-year OS and RFS were 89.5%, 78.8% and 64.4% and 71.1%, 61.3% and 56.6%, respectively.Minimally invasive McKeown's oesophagectomy is feasible and safe in patients with OSCC receiving nCRT. The radiation component of nCRT increases the degree of operative difficulty, especially in relation to the supracarinal dissection and lymphadenectomy. However, this drawback did not adversely affect the short-term surgical or the long-term oncological outcomes.

Oesophageal duplication cyst (ODC) is a rare congenital anomaly of the foregut. The reports of ODCs presenting in adulthood is relatively rare. Surgical excision is the ideal treatment. Traditionally, the excision is performed via a thoracotomy with its resultant morbidity. Minimally invasive surgical (MIS) approaches are feasible and can potentially reduce the postoperative discomfort and reduce the hospital stay. We aimed to study the feasibility and safety of MIS for ODC in adults. A retrospective review of all adult patients with ODCs treated in an oesophago-gastric surgery unit, between January 2015 and March 2022, was performed. All patients received MIS. The demographic, clinico-radiological, and operative details and outcomes were analysed. Nine patients (Female 7; mean age, 36.2 ± 4.4 years) were included. Chest pain was the commonest symptom (44.0%). Oesophago-gastroscopy showed normal mucosa in all patients. Endoscopic-ultrasound was performed in all except one; no cysts had atypical features. The cysts were frequently located in the distal thoracic oesophagus (78%) and the median (range) cyst size was 6.3(3.9–13.5) cm. All patients received MIS (Thoracoscopy,8; Thoraco-laparoscopic, 1); no conversion to open surgery. The techniques resection techniques were enucleation (5), stapler-assisted resection (3) or partial excision (1). The 30-day morbidity was 22.2% (Staple line leakthoracoscopic repair, 1; pleural collectionimage-guided drainage, 1). The median (range) hospital stay was 7(3–25) days and there was no mortality. MIS is feasible and safe for the management of adult ODCs and should be offered to patients, irrespective of the timing of its presentation or the location and size of the cyst.

Placement of self-expanding metal stents (SEMS) has emerged as a minimally invasive treatment option for esophageal perforation and leaks. The aim of our study was to assess the role of SEMS for the management of benign esophageal diseases such as perforations and anastomotic leaks. All patients (n = 26) who underwent SEMS placement for esophageal perforation and anastomotic leaks between May 2012 and February 2019 were included. Data were analyzed in relation to the indications, type of stent used, complications, and outcomes. Indications for stent placement included anastomotic leaks 65% (n = 17) and perforations 35% (n = 9). Fully covered SEMS (FCSEMS) was placed in 25 patients, and in 1, partially covered SEMS (PCSEMS) was placed. Stent placement was successful in all the patients (n = 26). Four patients did not report for follow-up after stenting. Among the patients on follow-up, 91% (20/22) had healing of the mucosal defect. Stent-related complications were seen in 5 (23%) patients and included stent migration [3], reactive hyperplasia [1] and stricture [1]. Covered stent placement for a duration of 8 weeks is technically safe and clinically effective as a first-line procedure for bridging and healing benign esophageal perforation and leaks.

Gossypibomas are masses formed by accidentally retained cotton matrix anywhere in the body, following a surgical procedure. It has catastrophic effects not only on patients but also on the health professionals and health care providers. We have retrospectively reviewed 6 patients of intra-abdominal gossypibomas who had presented over a 10-year period, to our centre. The relevant preoperative and intraoperative details along with the clinical course of these patients have been described. Through the management of these patients, we have shared our experience in relation to the clinical presentations, probable risk factors, and radiological features for diagnosis and treatment, along with the ethical and medicolegal implications of the issue. The safety measures that exist are also reviewed. An intraoperative “correct count” during a surgical operation does not always exclude the possibility of a gossypiboma or a retained foreign body. Increased awareness, familiarity with the existing local protocols, and strict adherence of these protocols, along with open communication, are essential in minimizing the frequency of such events. A concerted effort by the entire surgical team is crucial. Newer technology such as barcoding of sponges and radiofrequency identification (RFID) tagging may help decrease the occurrence of this problem.

A 54-year-old man presented with easy fatiguability, dyspnoea on exertion and dyspeptic symptoms. On evaluation, he was found to have an ulcero-proliferative growth in the gastric fundus, the biopsy of which was malignant melanoma of the stomach. Further evaluation with 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) scan showed operable disease with no focus of disease elsewhere. He was diagnosed as primary gastric melanoma and underwent radical total gastrectomy with adequate margins. His postoperative period was uneventful. Further adjuvant therapy was refused by the patient. At 6-month follow-up, an 18F-FDG PET-CT scan was done, which showed no evidence of disease. On follow-up at 1-year, he was alive and asymptomatic.

Introduction: Peritonitis, defined as inflammation of the peritoneal cavity can be of various causes, and is one of the most common surgical emergencies. This continues to be a challenge to diagnose and treat. Early intervention is essential to select patients who will need intensive care which brings out better outcome for the patients. This also helps us use the resources optimally. Over years, many scoring systems have been developed and studied to predict outcomes in patients with peritonitis. Aim: To evaluate the ability of Mannheim Peritonitis Index (MPI) and APACHE II (Acute Physiology And Chronic Health Evaluation II) scores in predicting mortality and morbidity in patients with peritonitis. Materials and Methods: A prospective, observational study was conducted at Christian Medical College and Hospital, Vellore, Tamil Nadu, India, for a period of two years from September 2014 to August 2016. A total of 78 patients were recruited for this study. These patients were scored with MPI and APACHE II scores. The primary outcome studied was in hospital death or discharge. The secondary outcome studied was morbidity in terms of local and systemic complications. The risk factors associated with mortality in patients with peritonitis were also studied. The best cut-off value for MPI and APACHE II from the data was calculated using Yuden index. The sensitivity, specificity and likelihood ratios were calculated and presented with 95% Confidence Interval(CI). The sub-group analysis was done for risk factors and complications. Results: There were more males than females. Age ≥48 years (p=0.002) and serum creatinine ≥1.3 g/dL (p=0.012) were found to be significant risk factors for mortality. The sensitivity and specificity of MPI ≥27 in predicting mortality was found to be 90% and 57% respectively. The sensitivity and specificity of APACHE II score ≥10 in predicting mortality was found to be 40% and 78%, respectively. MPI scores ≥27 were strongly associated with morbidity like prolonged ICU stay (p=0.004), mechanical ventilation requirement (p=0.001) and need for dialysis (p=0.035). Conclusion: Present study showed MPI to be a better predictor of mortality than APACHE II, though APACHE II showed better specificity. MPI score also was helpful in predicting morbidity such as prolonged ICU stay, mechanical ventilation requirement postoperatively and need for dialysis postoperatively. MPI was easier to use as it contained lesser variables. MPI could be of use in rural areas with no facility for laboratory investigations and blood gas analysis.

Background: Obesity is sweeping across continents and is a major public health concern of the modern society. Aims: The main objective of this study was to study the demographic, anthropometric and dietary patterns of the morbidly obese and study region wise variation in their nutrient intake. Materials and Methods: The study was conducted on 101 morbidly obese individuals from different regions of India who attended the Bariatric clinic of a tertiary care hospital in India. Their socio-demographic details, anthropometric measurements were collected. The dietary assessment was done using a 24 hour dietary recall and a food frequency questionnaire. The study was approved by the Institutional review board and informed consent was obtained from them. Results: More than 3/4th of the patients were females and 61 per cent had Type 2 diabetes mellitus. The mean age of the male and female population was 41.3 + 15.5 years and 36.7 + 11.9 years respectively. Their mean BMI was 41kg/m2. The mean daily intake of calories was more than 2200kcal/day with a gross deficit in the intake of micronutrients. Bonferroni Test showed that there was region wise variation in dietary intake, South Indian female population had the lowest intake of the micronutrients and those from East India had the highest intake. In the male population, there was a significant regional difference in intake of Proteins (p=0.039) and Energy (p=0.024). Independent Sample T test showed that South Indian had the highest intake of Energy and proteins. Anthropometric measures showed positive relation with various macronutrient intakes. Conclusion: The obese patients require intense counselling by a dedicated team of an endocrinologist, psychiatrist, dietician, bariatric surgeon and a social worker to make achievable changes in the quality of life of the morbidly obese patients. Regional influences must be considered when counselling the patient.

Petersen's hernia refers to an internal herniation of small bowel through the potential space between the transverse mesocolon and the Roux limb of gastrojejunal anastomosis. The incidence of this is increasing with the widespread practice of bariatric surgery in the last decade. In this report, we present the case of a 44-year-old male who had undergone a laparoscopic Roux-en-Y gastric bypass for morbid obesity and presented after 14 months with a history of nonspecific abdominal pain. The examination of his abdomen was unremarkable. The computed tomography scan revealed the suspicious features of internal herniation of the small bowel and a twist in the mesentery. On diagnostic laparoscopy, he was found to have Petersen's space hernia. His clinical presentation, investigations, and treatment have been highlighted in this case report with a review of the literature. Although rare, Petersen's hernia could lead to a disastrous complication of small bowel strangulation if not intervened early. Hence, if suspected, the threshold to perform a diagnostic laparoscopy should be low.

Background: Obesity is a global epidemic. Bariatric surgery is being considered as the treatment of choice in morbid obesity. Psychiatric comorbidity affects outcomes in this population. There is a dearth of data on psychiatric profile of the morbidly obese from Indian subcontinent. We studied people with morbid obesity to estimate the psychiatric burden among them and to identify factors associated for developing psychiatric disorders. Methodology: This is a cross-sectional study done in a bariatric clinic of a tertiary care teaching hospital in South India. Sixty morbidly obese patients were evaluated by psychiatrists and data from medical records were collected and analyzed. Prevalence of psychiatric disorders was estimated. They were compared with patients without psychiatric disorders using appropriate statistical tests. Results: Nearly 33.33% of the patients had a psychiatric disorder. Depression and dysthymia accounted for about half of those cases. The variables that were associated with psychiatric disorders were current suicidal ideation, past self-injurious behavior, perceived poor social support, and past psychiatric history. Conclusion: One-third of the morbidly obese patients having psychiatric disorder is suggestive of high comorbidity. Considering this active involvement of psychiatrists in bariatric clinic would be useful.

Background Adult esophago-respiratory fistula is a rare condition, which is usually seen in malignancies or in benign conditions following trauma, infection or as a delayed presentation of congenitall tracheoesophageal fistula. They pose a technical challenge in stabilisation and management requiring multidisciplinary approach. Methods In this retrospective analysis of such cases over a period of ten years, who presented to our centre. The aetiology, presentation and treatment modalities were studied in detail. Of these,18 patients with benign esophago repiratory fistulae underwent surgical correction oft he same. This is discussed in detail. Results There were a total of 62 cases of adult esophago-respiratory fistula, over the 10 year period. Of the patients, 34 of the cases to be of malignant etiology and 28 of the cases to be of benign etiology such as prolonged tracheostomy, corrosive injury, infection, trauma or delayed presentation of congenital fistula. The mean age of presentation was 44 years. (range 18 to 81 years of age). There were 35 tracheoesophageal fistulae and 27 bronchoesophageal fistulae. Fourteen patients underwent esophageal stenting and 9 underwent tracheal stenting either as a temporary intervention to alleviate symptoms or as palliative intervention. Eighteen patients underwent definitive surgical intervention. Surgical repair involved approach through neck in 6 patients and thorax in 11 patients and a combination of both approaches in one patient. The esophageal end of the fistula was primarily closed or closed with the help of a pleural or pedicled muscle flap or a subtotal esophagectomy was performed. The respiratory end of the fistula was either primarily closed or with the help of a vascularized patch of the esophageal wall. The latter technique was used in four patients and is explained in detail. Conclusion Due to risk of fatal complications, early diagnosis, multidisciplinary approach and appropriate surgical intervention after nutritional build up is the key to successful management of adult esophago-respiratory fistula. Disclosure All authors have declared no conflicts of interest.

Corrosive injuries to the upper gastrointestinal tract can occur by either acid or alkali ingestion. They can lead to significant morbidity and mortality, thus necessitating a rapid assessment and appropriate management. This article aims to provide an overview of corrosive injuries and to provide a management plan for corrosive injuries.

Purpose Data on operable gastric cancer from India is sparse. The purpose of this study was to investigate the clinical details, histopathological demographics, and 5-year overall survival (OS) and disease free survival (DFS) associated with operable, non-metastatic gastric cancer in a dedicated upper gastrointestinal (GI) surgical unit in India. Materials and Methods Data for patients diagnosed with operable gastric cancer between January 2006 and December 2014 were retrospectively analyzed. Data were collected from electronic hospital records in addition to mail and telephonic interviews when possible. Results A total of 427 patients were included. The tumor was located in the pyloro-antral region in 263 patients (61.7%). Subtotal gastrectomy was performed in 291 patients and total gastrectomy in 136 patients. Tumor stage classification revealed 43 patients (10.0%) with stage I, 40 patients (9.4%) with stage IIA, 59 patients (13.9%) with stage IIB, 76 patients (17.8%) with stage IIIA, 96 patients (22.5%) with stage IIIB, and 113 patients (26.4%) with stage IIIC disease. Follow-up data were available for 71.6% of the patients with a mean duration of 32.4 months. Five-year DFS and OS were 39% and 59%, respectively. Conclusions Despite presenting at an advanced stage, the 5-year DFS and OS of patients with operable gastric cancer treated at a dedicated upper GI unit of a tertiary care center in India was good.

Morgagni-Larrey hernia is an uncommon entity. The majority of the literature describes hernia occurring mostly on the right side, a few on the left side and rarely bilateral. Retrospective chart review was done for the patients with the diagnosis of adult diaphragmatic hernia from January 1997 to December 2010. Post-operative course was evaluated for outcome, morbidity and mortality. Out of 20 patients, 13 (65 %) were males and 7 (35 %) were females. Their age ranged from 17 to 50 years (mean = 29.6). Abdominal discomfort was the most common presentation. Eight patients (40 %) were asymptomatic at presentation. Plain X-Ray chest was done for all. Ten patients (50 %) underwent suture repair, 6 (30 %) had mesh placement and the other 4 (25 %) underwent both: suture repair buttressed with mesh. Volvulus of stomach was noted in 5 (25 %) cases. All patients had left sided hernia. There was insignificant morbidity and no mortality. There was no recurrence in 16 patients followed up for a mean duration of 20 months (range = 8 to 32 months). In Morgagni-Larrey hernia, abdominal approach gives good accessibility to reduce the hernia and to undertake repair. When complicated with incarceration, perforation, gangrene or volvulus of the herniated bowel; this can be dealt with ease. Plain X Ray of the chest is fairly accurate in suggesting the diagnosis of Morgagni-Larrey hernia.

Dysphagia lusoria, caused by aberrant subclavian artery, is an uncommon cause of dysphagia. When present it is mostly asymptomatic. Barium esophagogram may indicate the presence of this anomaly. Diagnosis needs to be confirmed by CT/MRI prior to any intervention. No treatment is required for asymptomatic patients. If causing significant symptoms, operative management offers definitive treatment. The choice of treatment depends on local expertise, equipment and experience of the surgical team. However, for those who are unfit or refuse operative intervention, there is a role for symptomatic and supportive treatment. Our cases demonstrate three different manifestations of this single entity.