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Background and Objectives Coronavirus disease‐2019 (COVID‐19) pandemic has impacted cancer care across India. This study aimed to assess (a) organizational preparedness of hospitals (establishment of screening clinics, COVID‐19 wards/committees/intensive care units [ICUs]/operating rooms [ORs]), (b) type of major/minor surgeries performed, and (c) employee well‐being (determined by salary deductions, paid leave provisions, and work in‐rotation). Methods This online questionnaire‐based cross‐sectional study was distributed to 480 oncosurgeons across India. We used χ 2 statistics to compare responses across geographical areas (COVID‐19 lockdown zones and city tiers) and type of organization (government/private, academic/nonacademic, and dedicated/multispecialty hospitals). P

Pancreatic malignancy with mesenterico-portal venous involvement can be safely managed with en bloc vein resection with comparable survival outcomes. Non-constructible venous encasement is regarded as criteria of unresectability in pancreatic cancer. In long-standing extra-hepatic venous obstruction, hepatopetal blood flow is established by collateralization in the hepatoduodenal and mesenteric region. Their importance in pancreatic malignancies is being recently acknowledged. The records of patients undergoing pancreatoduodenectomies were retrospectively evaluated from 2012 to 2019. Pre and intraoperative records of patients undergoing concomitant vein resection were evaluated for the presence of venous collaterals, and its impact on oncological management was studied. Over a period of 7 years, 947 pancreatoduodenectomies were performed, of which 56 patients underwent concomitant vein resection. Among these, six patients had significant collaterals due to venous obstruction. They had pancreatic adenocarcinoma (2), neuroendocrine tumour (2) and solid pseudopapillary epithelial neoplasm (2) respectively. All these patients successfully underwent pancreatoduodenectomy with vein resection without vascular reconstruction. Superior mesenteric vein (SMV) was resected in four patients, whereas spleno-portal junction was resected in two patients. Dominant collaterals were preserved in all, without compromising oncological safety. Bowel congestion was checked by tolerability to 20-minute mesenteric venous clamping test. There was no major morbidity or hospital mortality following this surgical approach. We recommend vein resection without reconstruction (VROR) as a novel approach in locally advanced pancreatic tumours (due to non-constructible vein involvement) with significant venous collaterals and emphasize the need to assess venous collateralization pre and intraoperatively.

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.

Gall bladder carcinoma is the most common biliary tract cancer. Delayed presentation and early spread of tumor make it one of the lethal tumors with poor prognosis. Considering that simple cholecystectomy for T1 disease could offer a potential cure, it is increasingly needed to identify it at early stages. Identification of high-risk cases and offering prophylactic cholecystectomy can decrease the incidence of gallbladder carcinoma. With advances in diagnostic tools like contrast-enhanced endoscopic ultrasound, elastography, multidetctor CT, MRI, and PET scan, we can potentially diagnose gallbladder carcinoma at early stages. This paper reviews the various diagnostic modalities available and an algorithmic approach to early diagnosis of gallbladder carcinoma.

Fournier’s gangrene is an acute, rapidly progressive, and potentially fatal, infective necrotizing fasciitis affecting the external genitalia, perineal or perianal regions, which commonly affects men, but can also occur in women and children. There has been an increase in number of cases in recent times. Despite advanced management mortality is still high and averages 20–30%. Early diagnosis using Laboratory Risk Indicator for Necrotizing Fasciitis score and stratification of patients into high risk category using Fournier's Gangrene Severity Index score help in early initiation of treatment. Triple antibiotic combined with radical debridement is the mainstay of treatment. There have been many advances in management of Fournier gangrene including use of vaccum assisted closure and hyperbaric oxygen therapy. With introduction of newer devices like Flexi-Seal, fecal diversion can be done, avoiding colostomy. Reconstruction of perineal defects using skin grafts, flaps, and urethral reconstruction using gracilis flaps can reduce the morbidity associated with FG and provide acceptable functional and aesthetic outcomes.

Background Esophagectomy is a daunting procedure with a steep learning curve. Minimally invasive esophagectomy is associated with reduced perioperative complications. However, most studies so far have evaluated thoracoscopic or laparoscopic approaches. We describe our initial experience with robotic esophagectomy using the da Vinci Xi system. Methods We performed a retrospective analysis of a prospectively maintained database of patients operated with radical intent for esophageal cancer between November 2014 and November 2017. Results Thirty-four of the 483 curative esophagectomies were performed robotically. We performed the thoracic part in the semi-prone position and the abdominal part in a supine position. The thoracic component of the procedure was completed robotically in all 34 patients. For the abdominal approach, 19(55.9%) patients underwent gastric mobilization by the robotic approach, 9(26.5%) by the laparoscopic approach, and 6(17.6%) by laporotomy. The median age was 51 years and 76.5% of the patients were male. 73.5% of the patients had T3 tumours and 52.9% of the patients did not have significant nodes (N0) on preoperative imaging by PET-CT. 70.6% of the patients received neoadjuvant chemotherapy and 2.9% of the patients received neoadjuvant chemoradiotherapy. Standard two field (infracarinal and abdominal) lymphadenectomy was performed in 88.2% and three field lymphadenectomy in 11.8%. The median blood loss was 275 ml, with 85% of patients having blood loss below 400ml. The total surgical time (including docking and changing patient position) was 390 min. No patient needed intra or post-operative blood transfusion. Median ICU and hospital stay were 0.6 days and 10 days respectively. Major morbidity (Clavin-Dindo score > 3A) occurred in 17.6% with one post-operative mortality (2.9%). Pulmonary complications were seen in 8.8% and anastomotic leak in 11.8%. The median lymph nodes retrieved were 18. At a median of 24-months follow-up, the disease free survival was 58%, and the overall survival was 70%. Conclusion Transthoracic total esophagectomy is safe and feasible through the robotic approach. Larger studies with longer follow-up are needed to establish robotic esophagectomy as a standard surgical option for patients with esophageal cancer. Disclosure All authors have declared no conflicts of interest.

A 15-year-old boy presented to us with a 4-month history of fever with worsening dyspnea since 1 month. His contrast-enhanced computed tomography scan of the thorax showed bilateral endobronchial lesions with complete collapse-consolidation of the left lung and partial collapse of the right lower lobe. His fiberoptic bronchoscopy guided biopsy had been reported in outside hospital as a neuroendocrine tumor. Due to worsening breathlessness, he had to be intubated. We repeated the endobronchial biopsy and combined with outside slides and blocks, was diagnosed to have an anaplastic lymphoma kinase-1 positive anaplastic large cell lymphoma (ALCL). We started the patient on chemotherapy to which he had a dramatic response radiologically and clinically. ALCL presenting as endobronchial mass is an extremely rare occurrence and it presenting with bilateral endobronchial masses has not been reported yet in literature. Pathologists and clinicians should be aware of this presentation as prompt diagnosis and treatment give promising results.

Ulcer disease remains the most common cause of gastroduodenal perforation, with an incidence between 2% and 10% in patients with ulcers. With the advent of proton pump inhibitors(PPI) the surgery for perforated peptic ulcer has changed from perforation closure with definitive acid reduction surgeries to simple omental patch. The trend of minimal is better holds good. With advances in laparoscopic surgery and its application in emergency abdominal conditions it has been shown feasible for management of perforated peptic ulcer. Though there have been various studies showing successful nonoperative management of perforated peptic ulcer, Conservative treatment has not gained widespread acceptance as an alternative approach to surgery. The reason being lack of uniform selection criteria and management guidelines for conservative management. This review article aims at introducing an algorithm approach towards successful non operative management of perforated peptic ulcer.

Aim. Loop ileostomy has high complication rates and causes much patient inconvenience. This study was performed to compare the outcome of tube versus loop ileostomy in management of ileal perforations. Patients and Methods. From July 2008 to July 2011, all patients with ileal perforation on laparotomy where a defunctioning proximal protective loop ileostomy was considered advisable were chosen for study. Patients were randomly assigned to undergo either tube ileostomy or classical loop ileostomy as the diversion procedure. Tube ileostomy was constructed in the fashion of feeding jejunostomy, with postoperative saline irrigation. Results. A total of 60 diversion procedures were performed over the period with 30 for each of tube and loop ileostomy. Typhoid and tuberculosis formed the most common etiology for ileal perforation. The complication rate of tube ileostomy was 33%. Main complications related to tube ileostomy were peritubal leak, tube blockage. In patients with loop, overall complications in 53% majority were peristomal skin irritation and wound infection following ileostomy closure. Two patients developed obstruction following ileostomy closure which needed reoperation. Conclusions. Tube ileostomy is effective and feasible as a diversion procedure and has reduced morbidity. It can be used as an alternative to loop ileostomy.

Papillary thyroid carcinoma is the most common thyroid malignancy, accounting for 80% of all thyroid cancers. The most common presentation of thyroid cancer is an asymptomatic thyroid mass or a nodule. Usually as thyroid enlarges, it extends in to mediastinum. Papillary thyroid carcinoma presentation as multiple true cystic swelling extending from neck to anterior chest wall in subcutaneous plane is not present in the literature. We present a rare case of cystic papillary thyroid carcinoma which is presented as subcutaneous swelling with sinus formation.

A 70 year old female presented with dysphagia of 6 months duration. Upper GI endoscopy showed a proliferative growth in mid esophagus with occlusion of lumen. Biopsy showed adenocarcinoma of signet ring pattern. Contrast enhanced computer tomography of abdomen showed infiltrating tumor involving esophagus and entire stomach with calcification in lower esophagus and lesser curvature of stomach with ascites. Due to extensive nature of tumor and malignant ascites palliative chemotherapy with feeding jejunostomy was planned. Patient decline all treatment. This case report and review describes the rare phenomenon of calcification of stomach and esophagus.

Macrodystrophia lipomatosa (ML), a rare congenital disorder, is considered by some to be a localized form of Proteus syndrome. A 12year old girl presented with progressive enlargement of little finger of right hand since birth. Magnetic resonance imaging showed unencapsulated excessive fibroadipose tissue infiltrating interosseous muscles. Partial debulking of the lipomatous tissues was performed. Microscopic examination of the specimen revealed fat deposits, ligamentous, and neural tissue elements in normal structure. We report a case of atypical ML involving 5th digit with normal osseous elements.

To the Editor Lipomas are common benign soft tissue neoplasms of mature adipose tissue. The peak incidence is usually in the fifth or sixth decade of life, while occurrence in children is very uncommo. Multiple presentations may occur in about 5% patients [1]. The tumors may or encapsulated may not be. In a review of more than 1000 benign tumors of adipose tissue, over 80% were ordinary lipomas; nearly all the others were angiolipomas, intramuscular lipomas, or lipoblastomas. Other types accounted for less than 2% of all benign lipomatous neoplasms [2]. The occurrence in the head and neck is relatively rare [3]. Only 25% lipomas arise from the head and neck. Lipomas of the anterior neck are extremely rare. They may extend posteriomedially between the sternocleidomastoid and digastric muscles. Most commonly, they arise at the posterior subcutaneous neck [4]. The deep lipoma is usually larger and deforms the surrounding tissue as compared to superficial lipomas which are generally more circumscribed. The subfascial or deep lipomas can be classified as parosteal, interosseous or visceral; and as intermuscular or intramuscular. Deep lipomas that are either intermuscular or intramuscular have been described as infiltrating lipomas by Terziogluet et al. [5] Lipomas are typically asymptomatic unless they compress neurovascular structures. The deep lipoma often present without clinical symptoms and therefore grow to a large size before they are detected. Intermuscular lipomas are rare, with an incidence of 1.8%. After complete resection, there is a 19% recurrence rate of intramuscular lipomas. Surgical intervention is challenging because of the proximity of the blood vessels and the nerves and thus the knowledge of anatomy and meticulous surgical technique are essential. We report a rare case of infiltrating lipoma of the neck in a young male. A 20­year­old male presented with swelling in the neck since six months which was painless and gradually increasing in size. Clinical examination revealed a soft swellling in anterolateral aspect of the neck extending behind the clavicle. A probable diagnosis of cystic hygroma was made. A computer tomography (CT) scan of neck and thorax was performed before and after administration of intravenous contrast material. Sagittal and coronal images demostrated a homogenous lobulated lesion extending superiorly from the angle of mandible to sternal angle inferiorly (Figures 1–3). Medio­laterally it extended from just across the midline into the posterior neck and also extending anterior to subscapularis. It was extending inferiorly into the axilla and upper arm LETTER TO EDITORS OPEN ACCESS