Raja Kalayarasan

Venous Thromboembolism in Cancer Patients Undergoing Major Abdominal Surgery: Prevention and Management

Cancer is an important risk factor for venous thrombosis. Venous thromboembolism is one of the most common complications of cancer and the second leading cause of death in these patients. Recent research has given insight into mechanism and various risk factors in cancer patients which predispose to thromboembolism. The purpose of this review is to summarize the current knowledge on the prophylaxis, diagnosis, and management of venous thromboembolism in these patients.

Enhanced Recovery After Surgery: Applicability and Results for Abdominal Surgery and Impediments for Universal Usage

Surgery is a cause of stress, the intensity of which depends on the procedure. Despite a better understanding of the sequence of events leading to the physiological stress response, there has not been any major change in the perioperative care of patients. Perioperative care is often based on the age old so-called inviolable principles [1]. Elements of perioperative care such as prolonged use of drains, forced bed rest, graduated diets, etc. were deemed essential and were taught to successive generations of surgeons as the standard of care. However, in the light of evolving evidence, many of these traditional principles were not found to be evidence based, and some of them may have been detrimental to the patient’s recovery [2–5]. This has led to the need for a judicious evidence-based approach for accelerating the patients’ recovery. The field of perioperative care has witnessed a revolutionary change in the form of enhanced recovery after surgery (ERAS) pathways or ‘fast-track’ protocols, which primarily aim at sustainable improvements in patient care, both in terms of speed of recovery and more importantly quality.

Double Trouble: Synchronous Adenocarcinoma of Gallbladder and Pancreas

Multiple primary malignant neoplasms in a single patient have been documented in the literature. It can be either synchronous or metachronous. Metachronous primary malignancies are becoming increasingly frequent because of an increase in the number of elderly patients and improvements in diagnostic techniques. However, synchronous primary malignancies are still unusual. Synchronous or metachronous cancers in the biliary system are often attributed to abnormal pancreaticobiliary junction (APBJ). Synchronous gallbladder and bile duct cancer are the most common association reported in patients with APBJ. An extremely rare association of gallbladder and pancreatic cancer in a middle-aged female is described in this report.

Laparoscopic Removal of an Ingested Foreign Body with Transesophageal Migration into the Mediastinum

Removal of a transesophageal migrated foreign body is recommended to prevent injury to adjacent structures. As the endoscopic approach is not feasible for a transesophageal foreign body migrated into the mediastinum, the thoracoscopic approach is recommended. The thoracoscopic approach often requires single lung ventilation and is associated with more pulmonary complications. The use of a laparoscopic approach to remove a mediastinal foreign body has not been reported earlier. In this report, the authors describe a laparoscopic approach for the removal of a transesophageal migrated foreign body into the lower mediastinum.

Revision of an Article and How to Deal with the Rejected Manuscript

Not following the instructions to authors of a journal is a fundamental mistake and one of the common reasons for revision of the submitted manuscript. It is important not to disagree with the reviewer’s comments unless the change suggested by the reviewer can negatively influence the content of your manuscript. Never forget to incorporate relevant responses to reviewer’s comments in the revised manuscript. Resubmission of the rejected manuscript to the same journal is the least favored option and should be used only in exceptional circumstances. Choosing a correct journal and incorporating the changes suggested by the reviewers will improve the chance of acceptance of rejected manuscript in a different journal.

Thoracoscopic management of oesophageal mucocele: Old complication, new approach

Oesophageal mucocele is an uncommon complication of bipolar exclusion of oesophagus. Traditionally, this condition is managed through thoracotomy which is associated with significant morbidity. The present report outlines the thoracoscopic management of oesophageal mucocele following surgical exclusion for oesophageal perforation. Left thoracoscopic oesophagectomy for oesophageal mucocele described in this report has not been published earlier.

Role of preoperative endoscopy in bariatric surgery

To the Editor, The role of routine upper gastrointestinal (GI) endoscopy before surgery for obesity is controversial with opinion divided between various societies. While European Association for Endoscopic Surgery recommends it in all, Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) advocates endoscopy in patients when a gastric pathology is suspected. Such a variation in practice is also evident from National Health Service survey of bariatric units [1]. We retrospectively reviewed the prevalence and spectrum of findings on endoscopy in our patients before bariatric surgery between January 2015 and December 2016. A total of 33 patients (19 women) underwent bariatric surgery during the period. Their mean (SD) age was 40.7 (12.2) years and mean body mass index (BMI) was 44.5. Nearly half of them had diabetes mellitus or hypertension. BMI was more than 40 in 23, 35–40 in 9, and 30–35 in 1 patient. The type of bariatric surgery included laparoscopic sleeve gastrectomy (LSG) in 18 and laparoscopic Rouxen-Y gastric bypass (LRYGB) in 15 patients. Only five patients (15.2%) had upper GI symptoms. A majority of them had one or more findings on upper GI endoscopy. They are summarized in Table 1. Four patients (12.1%) had significant findings on gastroscopy that would alter the surgical management and all were symptomatic. Five patients with hiatal hernia had concomitant laxity of lower esophageal sphincter (LES). All of them except one underwent LRYGB instead of LSG as LSG induces or worsens gastroesophageal reflux by increasing the intragastric pressure. Three patients with grade A reflux esophagitis and laxity of LES were treated with proton pump inhibitors and then underwent LSG. The three common pathologies in endoscopy that were noted in studies to have an impact on surgical management were large hiatal hernia, severe gastritis, and peptic ulcer disease [1, 2]. LRYGB is preferred to LSG in symptomatic large hiatal hernia and patients with severe reflux esophagitis. A systematic review and meta-analysis on the role of routine preoperative upper endoscopy in bariatric surgery concluded that it should be optional in asymptomatic patients given its low probability to effect a change in surgical management [1]. However, there is no consensus on the definition of what constitutes a change in surgical management and no clear agreement amongst studies for treatment of hiatal hernia detected in preoperative endoscopy [1]. Another large systematic review and meta-analysis [2] observed an overall 7.6% influence of preoperative endoscopic findings in altering or delaying surgical treatment of obesity. However, they noted as limitations the significant heterogeneity in the studies, lack of randomization, and differing institutional protocols for preoperative endoscopy. American Society of Gastrointestinal Endoscopy (ASGE) along with SAGES has recently recommended preoperative endoscopy to be individualized in patients undergoing bariatric surgery [3]. We observed preoperative endoscopy to alter surgical management of obesity in 12%. It may be reasonable to consider preoperative endoscopy in select patients based on symptom profile and type of planned surgical procedure. * Pazhanivel Mohan dr.pazhani@gmail.com

Standard Radical Cholecystectomy for T1 and T2 Gallbladder Cancer

Gallbladder cancer (GBC) is the most common malignancy of the biliary tract. Though traditionally considered to be an aggressive disease with rapid progression and dismal outcome, several recent reports have suggested that aggressive surgical resection improves survival. Adenocarcinoma is the most common histological type; squamous cell carcinoma, adenosquamous carcinoma, neuroendocrine carcinoma, and carcinosarcoma are the rare histological variants. According to the recent AJCC/UICC TNM staging system, T1 and T2 GBC includes patients with carcinoma limited to the mucosa (T1a) or muscularis proper (T1b) or invading the perimuscular connective tissue (T2) without liver infiltration. T1a tumors are difficult to diagnose preoperatively and are usually diagnosed after histopathology of the cholecystectomy specimen. Simple cholecystectomy is sufficient for cure in these patients, provided that the cystic duct margin is free of tumor and there is no intraoperative bile spillage. According to the National Comprehensive Cancer Network (NCCN) guidelines, a radical cholecystectomy is recommended for patients with a lesion T1b and beyond.

Tuberculous bronchoesophageal fistula: A case report

Tracheoesophageal fistula and bronchoesophageal fistula (BEF) usually result from malignancy. BEF caused due to benign conditions is rare. Here, we report a case of BEF due to tuberculosis. A 65-year-old lady presented with 15 days history of dysphagia, cough, and fever. Esophagoscopy revealed an ulcerated lesion at 22 cm. Further evaluation with contrast-enhanced computed tomography revealed mid-esophageal wall thickening, mediastinal and supraclavicular lymphadenopathy, along with BEF. Endoscopic tissue biopsy from ulcer revealed tuberculosis. The patient was put on antituberculous drugs and showed good response to therapy.