Publications by authors named "Ramakrishnan Ayloor Seshadri"

30 Publications

  • Page 1 of 1

Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey.

Pleura Peritoneum 2021 Sep 21;6(3):99-111. Epub 2021 Jun 21.

Department of Surgical Oncology, Zydus Hospital, Ahmedabad, India.

Objectives: Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians' practice about ERAS in patients undergoing CRS-HIPEC.

Methods: An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists.

Results: The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76-95%), preoperative (50-94%), and intraoperative (55-90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated.

Conclusions: Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices.
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http://dx.doi.org/10.1515/pp-2021-0117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8482448PMC
September 2021

The colorectal cancer-associated faecal microbiome of developing countries resembles that of developed countries.

Genome Med 2021 02 16;13(1):27. Epub 2021 Feb 16.

Pathology & Data Analytics, Leeds Institute of Medical Research at St James's University Hospital, University of Leeds, Level 4 Wellcome Trust Brenner Building, Leeds, LS9 7TF, UK.

Background: The incidence of colorectal cancer (CRC) is increasing in developing countries, yet limited research on the CRC- associated microbiota has been conducted in these areas, in part due to scarce resources, facilities, and the difficulty of fresh or frozen stool storage/transport. Here, we aimed (1) to establish a broad representation of diverse developing countries (Argentina, Chile, India, and Vietnam); (2) to validate a 'resource-light' sample-collection protocol translatable in these settings using guaiac faecal occult blood test (gFOBT) cards stored and, importantly, shipped internationally at room temperature; (3) to perform initial profiling of the collective CRC-associated microbiome of these developing countries; and (4) to compare this quantitatively with established CRC biomarkers from developed countries.

Methods: We assessed the effect of international storage and transport at room temperature by replicating gFOBT from five UK volunteers, storing two in the UK, and sending replicates to institutes in the four countries. Next, to determine the effect of prolonged UK storage, DNA extraction replicates for a subset of samples were performed up to 252 days apart. To profile the CRC-associated microbiome of developing countries, gFOBT were collected from 41 treatment-naïve CRC patients and 40 non-CRC controls from across the four institutes, and V4 16S rRNA gene sequencing was performed. Finally, we constructed a random forest (RF) model that was trained and tested against existing datasets from developed countries.

Results: The microbiome was stably assayed when samples were stored/transported at room temperature and after prolonged UK storage. Large-scale microbiome structure was separated by country and continent, with a smaller effect from CRC. Importantly, the RF model performed similarly to models trained using external datasets and identified similar taxa of importance (Parvimonas, Peptostreptococcus, Fusobacterium, Alistipes, and Escherichia).

Conclusions: This study demonstrates that gFOBT, stored and transported at room temperature, represents a suitable method of faecal sample collection for amplicon-based microbiome biomarkers in developing countries and suggests a CRC-faecal microbiome association that is consistent between developed and developing countries.
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http://dx.doi.org/10.1186/s13073-021-00844-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887780PMC
February 2021

Lymph Node Harvest After Neoadjuvant Treatment for Rectal Cancer and Its Impact on Oncological Outcomes.

Indian J Surg Oncol 2020 Dec 24;11(4):692-698. Epub 2020 Jul 24.

Department of Onco-Pathology, Cancer Institute (WIA), Chennai, 600036 India.

The aim of this study was to analyze the influence of neoadjuvant treatment on nodal harvest after rectal cancer surgery and its impact on long-term oncological outcomes. A retrospective analysis of patients with rectal cancer who received curative intent treatment from 2002 to 2012 in our institution was performed. Data on various clinic-pathological and treatment details were recovered from the records. The number of nodes harvested after surgery was analyzed. The influence of number of nodes harvested on overall survival and disease free survival was analyzed. Among the 459 patients included in this study, 326 underwent surgery after neoadjuvant treatment (NAT). The mean number of nodes harvested was significantly lower in patients who received NAT compared with those who did not (8.9 ± 5.77 vs 14 ± 9.84,  < 0.001). However, the mean number of pathologically positive nodes was not significantly different. A minimum of 12 nodes were harvested in only 27.9% of patients who received NAT. No lymph nodes were identified in the specimen in 15 patients (4.6%) who underwent surgery after NAT. The only independent factors influencing harvest of a minimum of 12 nodes were patient age and NAT. The 5-year overall survival was not significantly different in patients in whom < 12 or ≥ 12 nodes were harvested (64% vs 69% respectively,  = 0.5). Neoadjuvant chemoradiation significantly reduces nodal harvest in patients undergoing treatment for rectal cancer. However, this reduced nodal harvest did not adversely impact survival in patients. However, every effort must be made by the surgeon and the pathologist to maximize the nodal harvest.
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http://dx.doi.org/10.1007/s13193-020-01162-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714796PMC
December 2020

Perioperative versus postoperative chemotherapy for gastric cancer: A propensity score matched analysis.

Asia Pac J Clin Oncol 2020 Oct 28;16(5):e252-e256. Epub 2020 Jul 28.

Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India.

Aim: In advanced gastric cancer, chemotherapy, given either perioperatively or as an adjuvant treatment, has been shown to improve survival when compared to surgery alone. However, no trial has compared these two approaches head-to-head. Hence, we aimed to compare the short- and long-term outcomes of patients with gastric cancer who received either perioperative chemotherapy or adjuvant chemotherapy.

Methods: Retrospective analysis of patients with gastric cancers treated from 2010 to 2016. Using propensity score matching, resected patients who received perioperative chemotherapy were matched for histology, nodal dissection, and extent of surgery with another cohort of patients who received only adjuvant chemotherapy to create two matched groups of 101 patients each-group A (perioperative) and group B (adjuvant)-and the outcomes were compared between them.

Results: The patient demographics were evenly distributed in the two groups. There was no difference in the median number of chemotherapy cycles delivered (6 vs 6, P = .8) or the grade 3-4 toxicity (17.2% vs 12.1%, P = .26) in group A and group B, respectively. We could not demonstrate a significant difference in the postoperative mortality (2.6% vs 0%) or overall postoperative complications (23% vs 19%) between groups A and B. The overall recurrence rate (37% vs 42%), 3-year disease-free survival rate (51% vs 48%), and 3-year overall survival rate (53% vs 55%) were not significantly different in group A and group B, respectively.

Conclusions: We were unable to detect a significant difference in the short-term or long-term outcomes of patients with gastric cancer undergoing either perioperative or adjuvant chemotherapy.
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http://dx.doi.org/10.1111/ajco.13401DOI Listing
October 2020

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

Indian J Anaesth 2019 Dec 11;63(12):972-987. Epub 2019 Dec 11.

Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.
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http://dx.doi.org/10.4103/ija.IJA_765_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6921319PMC
December 2019

Prognostic Factors and Survival Outcomes of Surgical Resection of Huge Hepatocellular Carcinomas.

J Gastrointest Cancer 2020 Mar;51(1):250-253

Madras Cancer Care Foundation, Chennai, India.

Introduction: The aim of the study was to analyze the various prognostic factors that influence survival and clinical outcomes in patients undergoing liver resection for huge hepatocellular carcinomas.

Materials And Methods: The records of patients who underwent curative surgery between 1991 and 2011 for huge hepatocellular carcinoma were analyzed. Various prognostic factors that influenced the survival were studied. The patients were followed up till November 2016.

Results: The number of patients who underwent liver resection with huge hepatocellular carcinoma during the study period was 17; this included 14 males and 3 females. The median age of the study population was 52 years. The median serum AFP in the study population was 132.3 ng/ml (range 2 to 187,000 ng/ml). 41.2% of the patients were hepatitis B positive. The overall morbidity was 6%. The mortality rate was nil. The mean size of the resected specimen was 13.9 cm ± 3.6 cm. The overall recurrence rate was 76.5%. The local recurrence rate was 29.4%. The median time to recurrence was 8 months. The 5-year disease-free survival and overall survival of the study group were 26% and 32%, respectively. The factors that predicted an adverse survival outcome after the log-rank test for univariate analysis using life-table method were presence of lymphovascular invasion (p = 0.047), age ≤ 55 years (p = 0.021), and raised serum AFP (p = 0.041).

Conclusion: The factors that predict an adverse outcome after surgery in patients with huge hepatocellular carcinomas were the presence of lymphovascular invasion, raised serum AFP, and age ≤ 55 years.
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http://dx.doi.org/10.1007/s12029-019-00240-xDOI Listing
March 2020

Gastrointestinal mucormycosis in a child with acute lymphoblastic leukemia: An uncommon but ominous complication.

Indian J Cancer 2018 Jul-Sep;55(3):304-305

Department of Medical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India.

Invasive fungal infections constitute a major cause of morbidity and mortality in children undergoing therapy for hematological malignancies. We report a 1-year-old boy who was receiving chemotherapy for acute lymphoblastic leukemia. His clinical course was complicated by a clinical syndrome consistent with neutropenic enterocolitis to which he succumbed. Histopathology of the surgically resected bowel revealed evidence of mucormycosis. Gastrointestinal mucormycosis is an unusual presentation which requires high degree of clinical suspicion and aggressive management.
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http://dx.doi.org/10.4103/ijc.IJC_260_18DOI Listing
June 2019

Perineal Wound Complications Following Extralevator Abdominoperineal Excision: Experience of a Regional Cancer Center.

Indian J Surg Oncol 2018 Jun 14;9(2):211-214. Epub 2018 Apr 14.

1Department of Surgical Oncology, Cancer Institute (WIA), Chennai, 600036 India.

Extralevator abdominoperineal excision (ELAPE) results in a large perineal defect which needs reconstruction by a flap or biological mesh. The incidence of perineal wound complications is thought to be higher following an ELAPE compared to conventional abdominoperineal excision (APE). WE aimed to analyze the perineal wound complications following ELAPE in our institution. This was a retrospective analysis of all consecutive patients who underwent an APE (conventional and ELAPE) procedure in our institution between 2012 and 2015. We retrieved the demographic data, treatment data, and pathological data from the case records. Reconstruction of the perineal defect after a prone perineal dissection was performed using a local muscle flap. The incidence of perinealwound complications, hospital stay, and time to initiate adjuvant chemotherapy was compared between the two groups. A total of 71 patients underwent APE over a period of 41 months of which 21 patients underwent ELAPE. The perineal dissection during ELAPE was done in the prone position in 18 patients and in the supine position in 3 patients. Perineal wound complications were seen in 9 patients (42%) who underwent ELAPE compared to 17 patients (34%) who underwent conventional APE (p = 0.52). The mean duration of hospital stay was significantly longer in patients who underwent ELAPE when compared to those who underwent conventional APE (22.9 ± 3.6 days vs 14.6 ± 1.0 days, p = 0.03). The median interval between ELAPE and initiation of adjuvant chemo was 54 days (range 32-120 days) compared to 50 days (range 30-100 days) in patients undergoing conventional APE. A delay in initiating adjuvant chemotherapy of more than 12 weeks was seen in 4 patients (19%) following ELAPE. The incidence of perineal wound complications following ELAPE in this study was comparable to that reported in literature. Although the hospital stay following ELAPE was significantly longer than that following conventional APE in our institution, it did not unduly prolong initiation of adjuvant chemotherapy. Improving the perineal reconstruction techniques and selecting patients who will benefit from ELAPE may help to reduce the wound complications.
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http://dx.doi.org/10.1007/s13193-018-0741-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984859PMC
June 2018

Long-Term Functional and Oncological Outcomes Following Intersphincteric Resection for Low Rectal Cancers.

Indian J Surg Oncol 2017 Dec 28;8(4):457-461. Epub 2016 Oct 28.

Department of Psycho-Oncology, Cancer Institute (WIA), Chennai, India.

Surgery for low rectal cancer often involves a permanent stoma. Intersphincteric resection (ISR) with colo-anal anastomosis is a valuable sphincter sparing surgical procedure that avoids the need for permanent stoma in patients with low rectal cancer. The aim of this study was to analyze the long-term functional and oncological outcomes following ISR. This was a retrospective analysis of patients with low rectal cancer who underwent ISR with colo-anal anastomosis in our institution between 2007 and 2015. All patients had a diversion stoma. Bowel function outcomes were assessed prospectively using Wexner incontinence score, low anterior resection syndrome score (LARS), and the Cancer Institute Quality of Life (QoL) questionnaire. The histological reports were reviewed to assess the oncological adequacy of the surgery. Patterns of recurrence and survival were analyzed in this group of patients. Thirty-three patients who underwent an ISR were eligible for this study. Laparoscopic resection was performed in five patients. All the patients received neoadjuvant chemoradiation except the two who received short course radiation and one who did not receive any neoadjuvant treatment. The median distance from the anal verge to the distal edge of the tumor was 3 cm (range 1.5-5 cm). Distal resection margins and circumferential resection margins were negative in all the patients. The 30-day post-operative mortality rate was 3.03%. In 20 patients with a median follow-up of 48 months, the 3-year overall survival was 95%. One patient had recurrence in the para-aortic nodes. No patient had a local recurrence. Bowel function was assessed in 18 patients who had a minimum stoma free period of 1 year. After a median of 43 months following stoma closure, the median Wexner score was 3.56 (range 0-19), median LARS score was 4.78 (range 0-33), and the mean Cancer Institute QoL score was 151.56 ± 15.741. The QoL was average to very high with an overall acceptable quality of life. In this study, ISR was associated with acceptable long-term functional and oncological outcomes. It can be considered as a safe alternative to a permanent stoma in selected patients with low rectal cancer.
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http://dx.doi.org/10.1007/s13193-016-0571-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5705496PMC
December 2017

Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: Long-term outcomes of a propensity score matched study.

J Surg Oncol 2018 Mar 16;117(3):506-513. Epub 2017 Oct 16.

Department of Surgical Oncology, Madras Cancer Care Foundation, Chennai, India.

Background And Objectives: Laparoscopic resection for rectal cancer has short-term benefits when compared to open resection. The aim of this study was to compare the long-term oncological outcomes of laparoscopic and open resection for rectal cancer following neoadjuvant chemoradiation (NCRT).

Methods: In this propensity matched study, a series of 72 patients who underwent laparoscopic surgery for rectal cancer following NCRT between 2004 and 2010 (Lap group) were matched with 72 patients who underwent open surgery for rectal cancer in the same period (Open group). The survival and recurrence patterns were compared between the two groups.

Results: After a median follow-up of 69.5 months (range 1-138 months), local recurrence rate was observed in 4 patients (5.5%) and 7 patients (9.7%) in the Lap and Open groups, respectively (P = 0.35). The 5- and 10-year disease-free survival in the Lap and Open groups were 61.3% versus 47.9% and 48.8% versus 41%, respectively (P = 0.16). The 5- and 10-year overall survival was 66.9% versus 60.2% and 49% versus 46.2% in the Lap and Open groups, respectively (P = 0.38).

Conclusion: Laparoscopic surgery following NCRT for low and mid third rectal cancers was associated with similar long-term oncological outcomes when compared to open surgery.
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http://dx.doi.org/10.1002/jso.24868DOI Listing
March 2018

Acinar Cell Carcinoma of Pancreas: a Case Report and Review of Literature.

J Gastrointest Cancer 2019 Mar;50(1):134-136

Department of Oncopathology, Cancer Institute (WIA), Chennai, India.

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http://dx.doi.org/10.1007/s12029-017-9987-9DOI Listing
March 2019

Immunohistochemical expression and localization of cytokines/chemokines/growth factors in gastric cancer.

Cytokine 2017 01 25;89:82-90. Epub 2016 Oct 25.

Department of Molecular Oncology, Cancer Institute (WIA), 38, Sardar Patel Road, Guindy, Chennai 600020, Tamil Nadu, India. Electronic address:

Our previous studies on gastric cancer tissue and patient plasma samples identified several cytokines/chemokines/growth factors to be differentially expressed, compared to normal samples. In this study our aim was to understand the localization patterns of the markers in gastric tissues. We investigated the expression of PDGFRB, CCL3, MMP3, CXCL8, CXCL10, CCL20, IGFBP3, CXCL9, SPP1, CCL18, TIMP1, CCL15, CXCL5 and CCL4 in gastric tissues using Immunohistochemistry (IHC) on Tissue Microarrays (TMA). The TMA comprised of 25 apparently normal (AN), 87 paired normal (PN) and 134 gastric cancer (T) tissues. The epithelial and stromal expression of markers and their correlation with patient characteristics and outcome were analyzed. Several of the markers [PDGFRB (p<0.001), CCL3 (p<0.001), MMP3 (p<0.001), CXCL8 (p<0.001), CXCL10 (p<0.001), CCL20 (p<0.001), CXCL9 (p<0.001), CCL18 (p<0.001), TIMP1 (p=0.025), CCL15 (p<0.001)] were elevated in the stromal compartment of gastric cancers compared to AN tissues, with some having intermediate levels of expression in PN tissues. Epithelial and stromal PDGFRB (p=0.030, p=0.018) expression was associated with diffuse type gastric cancer. Stromal IGFBP3 (p=0.039), CXCL8 (p=0.008), TIMP1 (p<0.001), CCL4 (p=0.003) and SPP1 (p=0.048) expression was associated with intestinal type gastric cancer. Kaplan-Meier analysis showed higher epithelial PDGFRB (p=0.005 and p=0.004), CXCL8 (p=0.009 and p=0.007) were associated with poor disease free and overall survival. In multivariate analysis, high epithelial PDGFRB (p=0.036 and p=0.02) and SPP1 (p=0.003 and p<0.001) were independent prognostic factors for DFS and OS in patients with gastric cancer. The expression of cytokine/chemokine/growth factor markers is higher in the gastric tumor stroma compared to the normal gastric stroma and PDGFRB and SPP1 may serve as potential prognostic factors in gastric cancer.
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http://dx.doi.org/10.1016/j.cyto.2016.08.032DOI Listing
January 2017

Survival outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from gastric cancer: a systematic review.

Pleura Peritoneum 2016 Jun 9;1(2):67-77. Epub 2016 Jun 9.

Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India.

: The current treatment of choice for peritoneal carcinomatosis from gastric cancer is systemic chemotherapy. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a new aggressive form of loco-regional treatment that is currently being used in pseudomyxoma peritoneii, peritoneal mesothelioma and peritoneal carcinomatosis from colorectal cancer. It is still under investigation for its use in gastric cancer. : The literature between 1970 and 2016 was surveyed systematically through a review of published studies on the treatment outcomes of CRS and HIPEC for peritoneal carcinomatosis from gastric cancer. : Seventeen studies were included in this review. The median survival for all patients ranged from 6.6 to 15.8 months. The 5-years overall survival ranged from 6 to 31%. For patients with complete cytoreduction, the median survival was 11.2 to 43.4 months and the 5-years overall survival was 13 % to 23%. Important prognostic factors were found to be a low peritoneal carcarcinomatosis index (PCI) score and the completeness of cytoreduction. : The current evidence suggests that CRS and HIPEC has a role to play in the treatment of peritoneal carcinomatosis from gastric cancer. Long term survival has been shown for a select group of patients. However, further studies are needed to validate these results.
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http://dx.doi.org/10.1515/pp-2016-0010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386497PMC
June 2016

Diagnostic Laparoscopy in the Pre-operative Assessment of Patients Undergoing Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancies.

Indian J Surg Oncol 2016 Jun 11;7(2):230-5. Epub 2016 Jan 11.

Department of Surgical Oncology, Cancer Institute (WIA), Dr. S Krishnamurthy campus, No.18, Sardar Patel road, Guindy, Chennai 600036 India.

The introduction of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has led to an improvement in the survival of select patients with peritoneal surface malignancies (PSM). However, it is important to carefully identify patients who will benefit from this procedure and to avoid an unnecessary laparotomy in those who will not. The currently available imaging modalities are unable to accurately predict the peritoneal cancer index (PCI) score or the completeness of cytoreduction. In this article, we review the current status of staging laparoscopy in the assessment of patients with PSM who are planned for CRS & HIPEC. We discuss the patient selection, techniques, complications and efficacy of staging laparoscopy. To summarise, staging laparoscopy is a safe and feasible method of pre-operative assessment of patients with PSM. It has a high sensitivity and positive predictive value in identifying patients who can undergo a complete cytoreduction, thereby preventing many patients from undergoing an unnecessary laparotomy. With the exception of pseudomyxoma peritonei, it should be considered as a part of the routine assessment of patients with PSM who are being considered for CRS & HIPEC.
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http://dx.doi.org/10.1007/s13193-015-0486-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818625PMC
June 2016

The Role of Hyperthermic Intraperitoneal Chemotherapy in Gastric Cancer.

Indian J Surg Oncol 2016 Jun 2;7(2):198-207. Epub 2016 Feb 2.

Department of Surgical oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, 69495 Pierre-Bénite Cedex, France ; Université Lyon 1, EMR 3738, 69600 Oullins, France.

Peritoneal metastasis, either synchronous or metachronous, is commonly seen in gastric cancer. It is associated with a poor prognosis, with a median survival of less than one year. The outcomes are not significantly improved by the use of systemic chemotherapy. We review the relevant literature on the role of HIPEC in gastric cancer. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been used in three situations in gastric cancer. Besides its role as a definitive treatment in patients with established peritoneal metastasis (PM), it has been used as a prophylaxis against peritoneal recurrence after curative surgery and also as a palliative treatment in advanced peritoneal metastasis with intractable ascites. While prophylactic HIPEC has been shown to reduce peritoneal recurrence and improve survival in many randomised trials, palliative HIPEC can reduce the need for frequent paracentesis. Although CRS with HIPEC has shown promise in increasing the survival of selected patients with established PM from gastric cancer, larger studies are needed before this can be accepted as a standard of care.
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http://dx.doi.org/10.1007/s13193-016-0502-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818616PMC
June 2016

The Initial Indian Experience with Cytoreductive Surgery and HIPEC in the Treatment of Peritoneal Metastases.

Indian J Surg Oncol 2016 Jun 2;7(2):160-5. Epub 2016 Feb 2.

Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA.

Worldwide, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been used for nearly 3 decades to treat peritoneal metastases (PM), improve quality of life, and prolong survival substantially in selected patients. In India, the use of the combined modality of treatment dates back a decade with majority of the efforts taking place within the last 5 years. The first PSOGI workshop (India) held in April 2015, at Bangalore, India offered an opportunity for Indian surgeons performing CRS and HIPEC to share their experience. To study the methodologies of CRS and HIPEC (hospital set up, equipment, training and surgical background) as well as the outcomes in terms of perioperative morbidity and mortality and short and long term survival of patients treated in India, Indian surgeons who had treated at least 10 patients with this combined modality were invited to present their experience. Data collection was retrospective. Analysis of the pooled data was carried out. Eight surgeons treated 384 patients with CRS and HIPEC over a period of 10 years. The commonest primary sites were ovary (as first line therapy n = 124), followed by appendix, including pseudomyxoma peritonei (n = 99), colorectum (n = 77), recurrent ovary (as second line therapy, n = 33), stomach (n = 15), primary peritoneal cancer (n = 10), peritoneal mesothelioma (n = 9) and rare tumors in 17 patients. The weighted mean PCI for all 384 patients was 18.25. 349/384 patients (90.88 %) had a complete cytoreduction (completeness of cytoreduction score of CC-0/1). Grade 3-5 complications developed in 108 patients (27.34 %) and 30 day mortality occurred in 28 (7.29 %) patients. This study showed that CRS and HIPEC can be performed with an acceptable morbidity and mortality in Indian patients. Most of the surgeons are on the learning curve and further improvement in these outcomes is expected over a period of time. Pooling of data related to both common and rare peritoneal cancers would be useful in knowing the disease behavior, response to treatment and outcomes in Indian patients. The 2015 PSOGI meeting provided a unique platform for data presentation with feedback from international experts in the field of peritoneal surface oncology. Future meetings are planned to expand the evaluation of Indian data and progress.
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http://dx.doi.org/10.1007/s13193-016-0500-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818611PMC
June 2016

Postoperative Morbidity and Mortality Following D2 Gastrectomy-an Audit of 456 Cases.

Indian J Surg Oncol 2016 Mar 10;7(1):4-10. Epub 2015 Jul 10.

Department of Surgical Oncology, Cancer Institute (WIA), Dr.S.Krishnamurthy Campus, No. 18, Sardar Patel road, Guindy, Chennai, 600036 India.

Background: D2 gastrectomy is routinely performed in Japanese centres for carcinoma stomach with low morbidity and mortality. There were concerns in Western centres with regard to D2 gastrectomy in view of high morbidity and mortality rates. This study was aimed to study the postoperative morbidity and mortality following D2 gastrectomy for carcinoma stomach in a high volume centre in India.

Methods: It was a retrospective analysis of all the patients who underwent D2 gastrectomy from 1991 to 2010.

Results: D2 gastrectomy was performed in 456 patients during this period. Respiratory events were the most common cause of morbidity in the study group (2.4 %). Male gender (p = 0.007), presence of gastric outlet obstruction (p = 0.01) and pathological T4 (p = 0.05) independently predicted increased post operative morbidity in multivariate analysis. The morbidity and mortality rates declined with increase in hospital volume and experience of the surgeon.

Conclusion: D2 gastrectomy for carcinoma stomach can be performed safely in specialized centres with low morbidity and mortality rates.
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http://dx.doi.org/10.1007/s13193-015-0440-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4811820PMC
March 2016

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer.

World J Gastroenterol 2016 Jan;22(3):1114-30

Ramakrishnan Ayloor Seshadri, Department of Surgical Oncology, Cancer Institute (WIA), Chennai 600036, India.

Gastric cancer associated peritoneal carcinomatosis (GCPC) has a poor prognosis with a median survival of less than one year. Systemic chemotherapy including targeted agents has not been found to significantly increase the survival in GCPC. Since recurrent gastric cancer remains confined to the abdominal cavity in many patients, regional therapies like aggressive cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been investigated for GCPC. HIPEC has been used for three indications in GC- as an adjuvant therapy after a curative surgery, HIPEC has been shown to improve survival and reduce peritoneal recurrences in many randomised trials in Asian countries; as a definitive treatment in established PC, HIPEC along with CRS is the only therapeutic modality that has resulted in long-term survival in select groups of patients; as a palliative treatment in advanced PC with intractable ascites, HIPEC has been shown to control ascites and reduce the need for frequent paracentesis. While the results of randomised trials of adjuvant HIPEC from western centres are awaited, the role of HIPEC in the treatment of GCPC is still evolving and needs larger studies before it is accepted as a standard of care.
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http://dx.doi.org/10.3748/wjg.v22.i3.1114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716024PMC
January 2016

Squamous cell carcinoma of the rectum: Is chemoradiation sufficient?

J Cancer Res Ther 2015 Jul-Sep;11(3):664

Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India.

Primary squamous cell carcinoma of the rectum is uncommon. We report our experience of a case of squamous cell carcinoma of the rectum treated in our institution. Although primary chemoradiation produces a complete response in many patients, there is no consensus on a non-surgical management in these patients. Such an approach requires a strict surveillance schedule since recurrence is not uncommon. The prognosis of this tumour remains less favorable than its adenocarcinoma counterpart.
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http://dx.doi.org/10.4103/0973-1482.143350DOI Listing
August 2016

Clinicopathological attributes and outcomes of treatment in young-onset rectal cancer.

Int J Colorectal Dis 2016 Mar 24;31(3):757-9. Epub 2015 May 24.

Department of Surgical Oncology, Cancer Institute (WIA), Chennai, 600036, India.

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http://dx.doi.org/10.1007/s00384-015-2266-yDOI Listing
March 2016

Jejunojejunal intussusception: an unusual complication after feeding jejunostomy.

Indian J Surg Oncol 2013 Dec 16;4(4):383-4. Epub 2013 Sep 16.

Department of Surgical Oncology, Cancer Institute (WIA), Dr.S.Krishnamurthy Campus, No.18, Sardar Patel road, Guindy, Chennai, 600036 India.

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http://dx.doi.org/10.1007/s13193-013-0271-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3890015PMC
December 2013

Complete clinical response to neoadjuvant chemoradiation in rectal cancers: can surgery be avoided?

Hepatogastroenterology 2013 May;60(123):410-4

Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India.

Background/aims: Neoadjuvant chemoradiation for rectal cancers may result in complete clinical response (cCR) in some patients. The aim of this study was to analyze the long-term outcomes of such patients in a tertiary cancer center.

Methodology: Patients with rectal cancer who had a cCR to neoadjuvant chemoradiation were divided into two groups: Group A (n=23) did not undergo surgery, and Group B (n=10) underwent elective surgery. The recurrence patterns and survival outcomes were compared between the two groups.

Results: After a median follow-up of 72 months (range 12-180), seven patients (30%) in Group A developed an isolated local recurrence. In Group B, after a median follow-up of 37 months (range 12-180) there were no local recurrences. The median disease-free and overall survival was 36 months (range 6-168) and 66 months (range 12-180) in Group A and 36 months (range 12-180) and 37 months (range 18-180) in Group B respectively.

Conclusions: Our results suggest that surgery could be avoided in selected patients with rectal cancer who have a cCR to neoadjuvant chemoradiation. However, until the safety of a non-surgical approach is proven in a prospective randomized trial, it cannot be recommended outside a clinical protocol study.
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http://dx.doi.org/10.5754/hge12354DOI Listing
May 2013

Synchronous jejunal gastrointestinal stromal tumor and primary adenocarcinoma of the colon.

Indian J Surg 2012 Apr 1;74(2):196-8. Epub 2011 Apr 1.

Cancer Institute (WIA), Adyar, Chennai, 600020 India.

Synchronous gastrointestinal stromal tumors (GIST) and primary epithelial cancers of the gastrointestinal tract is an uncommon occurrence. We report a case of jejunal GIST which was detected incidentally in a patient during surgery for carcinoma of the sigmoid colon. The uncommon association of such synchronous tumors prompts a search for a common molecular pathway for carcinogenesis in gastrointestinal epithelial and stromal tumors.
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http://dx.doi.org/10.1007/s12262-011-0236-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309087PMC
April 2012

Modified technique of stapled esophagojejunostomy without a purse-string suture.

Indian J Surg Oncol 2011 Sep 17;2(3):189-92. Epub 2011 Aug 17.

Department of Surgical Oncology, Cancer Institute (WIA), No.18, Sardar Patel road, Chennai, 600036 India.

Placement of a purse-string suture during a stapled esophagojejunostomy following total gastrectomy is a technically demanding and time consuming procedure. Improper placement of the purse-string suture can lead to anastamotic breakdown with its associated complications. We describe a technique of stapled esophagojejunostomy without using a purse-string suture. We used this technique in 35 patients including 4 patients who underwent an extended total gastrectomy. We encountered a difficulty only in one patient due to malfunction of the stapler. None of the patients had an anastamotic leak. The modified technique of stapled esophagojejunostomy without a purse-string suture makes the procedure more easy, safe and simple.
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http://dx.doi.org/10.1007/s13193-011-0084-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3272169PMC
September 2011

Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: a matched case-control study of short-term outcomes.

Surg Endosc 2012 Jan 27;26(1):154-61. Epub 2011 Jul 27.

Department of Surgical Oncology, Cancer Institute (WIA), Annexe Campus, No.18, Sardar Patel Road, Guindy, Chennai, 600036, India.

Background: Neoadjuvant chemoradiation (nCRT) currently is commonly incorporated into the multimodal treatment of locally advanced rectal cancers. This study aimed to compare the short-term outcomes and oncologic adequacy of laparoscopic and conventional open surgery for rectal cancer after nCRT.

Methods: A series of 72 patients who underwent laparoscopic surgery (Lap group) for rectal cancer after nCRT were matched for type of surgery, gender, and American Society of Anesthesiologists (ASA) class with 72 patients who underwent conventional surgery during the same time period (Open group). The short-term outcomes were compared between the two groups of patients.

Results: No significant difference was found between the two groups in terms of age, distance of tumor from the anal verge, body mass index, or posttreatment pathologic stage of the disease. There were significant differences between the Lap and Open groups in terms of blood loss (median: 200 vs 400 ml; P < 0.001), duration of surgery (median: 270 vs 240 min; P < 0.001), time to passing of first flatus (median: 2 vs 3 days; P < 0.001), time to start of normal diet (median: 5 vs 6 days; P < 0.001), and hospital stay (median: 12 vs 15 days; P < 0.001). A significant difference in the number of lymph nodes harvested was not identified between the two groups, although more patients in the Open group had a positive circumferential resection margin than in the Lap group (10 vs 1%; P = 0.03). The short-term benefits of laparoscopic surgery also were observed when the 64 patients who underwent abdominoperineal resection (APR) in each of the two groups were compared separately.

Conclusion: Laparoscopic surgery for rectal cancer, especially laparoscopic APR, after nCRT is safe and associated with earlier recovery of bowel function, a shorter hospital stay, and an oncologically adequate specimen compared with conventional open surgery.
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http://dx.doi.org/10.1007/s00464-011-1844-5DOI Listing
January 2012

Hepatoblastoma: Analysis of treatment outcome from a tertiary care center.

J Indian Assoc Pediatr Surg 2011 Jan;16(1):11-4

Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai 36, Tamil Nadu, India.

Aim: This study was designed to retrospectively review our experience with the multimodality management of hepatoblastomas (HB).

Materials And Methods: Thirteen patients were treated for HB between 2000 and 2007. The clinical presentations, chemotherapy tolerance and response, surgical procedure undertaken, and complications were analysed.

Results: Median age of the population was 12 months (3-60 months), with a male-to-female ratio of 3.3:1. Nine patients were treated with neoadjuvant chemotherapy incorporating cisplatin and adriamycin. Primary surgery was done in four patients. Extent of hepatic resection in the operated patients varied. Mixed type was the predominant histopathological diagnosis. Adjuvant chemotherapy was well tolerated with no morbidity or mortality. Five-year event-free survival (EFS) and overall survival (OS) of all the 13 patients is 76.9%. All the nine patients who could complete multimodality treatment are alive with no evidence of disease or complications with median follow-up of 63 months (46-122 months).

Conclusions: Treatment of HB with multidisciplinary approach was well tolerated. OS and EFS of patients were comparable with published studies.
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http://dx.doi.org/10.4103/0971-9261.74514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047766PMC
January 2011

Signet ring cell histology and non-circumferential tumors predict pathological complete response following neoadjuvant chemoradiation in rectal cancers.

Int J Colorectal Dis 2011 Jan 3;26(1):23-7. Epub 2010 Nov 3.

Department of Surgical Oncology, Cancer Institute (WIA), Annexe Campus, No. 18, Sardar Patel road, Guindy, Chennai 600036, India.

Purpose: Neoadjuvant chemoradiation followed by surgery is now the standard of care for patients with locally advanced rectal cancers. The aim of this study was to determine the rate of pathological complete response (pCR) following neoadjuvant treatment in patients with rectal cancers and identify the factors predicting the same.

Methods: We conducted a retrospective analysis of patients with rectal cancers treated with neoadjuvant therapy followed by surgery at our institution from 1993 to 2008. Patients who achieved pCR were identified. Various patient, tumor, and treatment-related factors were studied for their influence on pCR by univariate and multivariate analyses. The influence of pCR on survival was also studied but was restricted to patients with a minimum follow-up of 5 years.

Results: Between 1993 and 2008, 248 patients with rectal cancers received neoadjuvant therapy followed by surgery. Two hundred and twenty-seven patients received chemoradiation and 21 patients received only radiation. Pathological complete response was seen in 32 patients (12.9%). On multivariate analysis, the factors found to be independently predictive of pathological response were circumferential extent of the primary tumor (p = 0.016) and signet ring cell histology (p = 0.001). Among 116 patients with a minimum follow-up of 5 years, there was a trend towards increased overall survival (75% versus 54%) and reduced local recurrence (6.2% versus 12.3%) in the 16 patients who achieved a pCR compared to those who did not, even though the difference was not statistically significant.

Conclusions: The factors that predict a pCR after neoadjuvant treatment for rectal cancers are absence of circumferential involvement and signet ring cell histology. Pathological complete response may confer an insignificant survival advantage.
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http://dx.doi.org/10.1007/s00384-010-1082-7DOI Listing
January 2011

Endobiliary metastasis from rectal cancer mimicking intrahepatic cholangiocarcinoma: a case report and review of literature.

J Gastrointest Cancer 2009 ;40(3-4):123-7

Department of Surgical Oncology, Cancer Institute (WIA), Annexe Campus, No.18, Sardar Patel Road, Guindy, Chennai 600036, India.

Purpose: The purpose of this study is to report an unusual case of liver metastasis from carcinoma rectum, which mimicked an intrahepatic cholangiocarcinoma (ICC) radiologically and pathologically, and to review the relevant literature.

Patient: A 64-year-old gentleman was treated for carcinoma rectum in our institution with neoadjuvant chemoradiation followed by low anterior resection and adjuvant chemotherapy. Two years later, he was found to have a nodule in the left hepatic duct on imaging. He underwent left hepatectomy.

Findings: The specimen revealed a tumor in the left hepatic duct, microscopically resembling an ICC. However, immunohistochemistry (IHC) showed the tumor cells to stain positively for cytokeratin 20, but not for cytokeratin 7, thus confirming the metastatic nature of the lesion.

Conclusion: Endobiliary metastasis from colorectal cancer can mimic ICC, and IHC studies may be needed to differentiate the two. Identifying endobiliary metastasis can have therapeutic and prognostic implications.
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http://dx.doi.org/10.1007/s12029-009-9115-6DOI Listing
March 2010

Risk factors for lymph node metastasis in clinically node-negative penile cancer patients.

Int J Urol 2009 Apr 17;16(4):383-6; discussion 386-7. Epub 2008 Feb 17.

Department of Surgical Oncology, Cancer Institute (WIA), Annexe Campus, Chennai, India.

Objectives: To analyze the effects of pathological T stage, grade, extent of surgery for primary tumor, and age group on the risk of developing lymph node metastasis in clinically node-negative penile cancer patients.

Methods: We performed a retrospective analysis of 200 clinically node-negative penile cancer patients who were kept under surveillance, after treatment of the primary tumor in our institution. The primary outcome parameter was cytologically or histologically proven lymph node metastasis. Logistic regression analysis was used to compute odds ratios in univariate and multivariate settings.

Results: Lymph node metastasis occurred in 31 patients at a median time of three months. Histological grade 3 and grade 2 tumors had a statistically significant increased odds ratio for lymph node metastasis, (7.1[P < 0.001] and 2.7 [P = 0.04], respectively), compared with grade 1 tumors. Although increasing pT stage was associated with increasing odds ratios, the differences were not statistically significant. Nor did the extent of surgery of the primary tumor or the age group significantly influence the risk of developing lymph node metastasis.

Conclusions: Histological grade is the most significant parameter influencing the risk of lymph node metastasis in clinically node-negative penile cancer patients on surveillance. Patients with grade 3 and grade 2 tumors may benefit from elective inguinal lymphadenectomy.
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http://dx.doi.org/10.1111/j.1442-2042.2009.02256.xDOI Listing
April 2009
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