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Objectives The Enhanced recovery after surgery (ERAS) program is designed to achieve faster recovery by maintaining pre-operative organ function and reducing stress response following surgery. A two part ERAS guidelines specific for Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was recently published with intent of extending the benefit to patients with peritoneal surface malignancies. This survey was performed to examine clinicians’ knowledge, practice and obstacles about ERAS implementation in patients undergoing CRS and HIPEC. Methods Requests to participate in survey of ERAS practices were sent to 238 members of Indian Society of Peritoneal Surface malignancies (ISPSM) via email. They were requested to answer a 37-item questionnaire on elements of preoperative (n=7), intraoperative (n=10) and postoperative (n=11) practices. It also queried demographic information and individual attitudes to ERAS. Results Data from 164 respondents were analysed. 27.4 % were aware of the formal ERAS protocol for CRS and HIPEC. 88.4 % of respondents reported implementing ERAS practices for CRS and HIPEC either, completely (20.7 %) or partially (67.7 %). The adherence to the protocol among the respondents were as follows: pre operative (55.5–97.6 %), intra operative (32.6–84.8 %) and post operative (25.6–89 %). While most respondents considered implementation of ERAS for CRS and HIPEC in the present format, 34.1 % felt certain aspects of perioperative practice have potential for improvement. The main barriers to implementation were difficulty in adhering to all elements (65.2 %), insufficient evidence to apply in clinical practice (32.4 %), safety concerns (50.6 %) and administrative issues (47.6 %). Conclusions Majority agreed the implementation of ERAS guidelines is beneficial but are followed by HIPEC centres partially. Efforts are required to overcome barriers like improving certain aspects of perioperative practice to increase the adherence, confirming the benefit and safety of protocol with level I evidence and solving administrative issues by setting up dedicated multi-disciplinary ERAS teams.

Introduction There has been an exponential rise in number of coronavirus disease 2019 (COVID-19)-positive infections since March 23, 2020. However, cancer management cannot take a backseat. Objective The aim of this study was to identify any difference in the complication and mortality rates for the cancer patients operated during the ongoing COVID-19 pandemic. Materials and Methods This was a retrospective study of a prospectively maintained database of five centers situated in different parts of India. Variables such as demographics, intraoperative, and postoperative complications were compared between COVID-19 (group A—March 23, 2020–May 22, 2020) and pre-COVID time period (group B—January 1 to January 31, 2020). Results One-hundred sixty-eight cancer surgeries were performed in group B as compared with 148 patients who underwent oncosurgeries in group A. Sixty-two percent lesser cancer surgeries were performed in the COVID-19 period as compared with the specific pre-COVID-19 period. There was no significant difference in age group, gender, comorbidities, and type of cancer surgeries. Except for the duration of surgery, all other intraoperative parameters like blood loss and intraoperative parameters were similar in both the groups. Minimally invasive procedures were significantly lesser in group A. Postoperative parameters including period of intensive care unit stay, rate of infection, need for the change of antibiotics, and culture growth were similar for both the groups. While minor complication like Clavien-Dindo classification type 2 was significantly higher for group A, all other complication rates were similar in the groups. Also, postoperatively no COVID-19-related symptoms were encountered in the study group. A subset analysis was done among the study groups between those tested preoperatively for COVID-19 versus those untested showed no difference in intraoperative and postoperative parameters. No health-care worker was infected from the patient during the time period of this study. Conclusion Our study shows that there is no significant difference in the incidence of postoperative morbidity and mortality rates in surgeries performed during COVID-19 pandemic as compared with non-COVID-19 time period.

Objectives The use of monitored anesthesia care (MAC) for transcatheter aortic valve replacement (TAVR) is gaining favor in the United States, although general anesthesia (GA) continues to be common for these procedures. Open surgical cutdown for transfemoral TAVR has been a relative contraindication for TAVR with MAC at most centers. The objective of this study was to review the authors’ results of transfemoral TAVR performed in patients with open surgical cutdown with the use of MAC. Design Retrospective study design from a prospectively recorded database. Setting Tertiary academic (teaching) hospital. Participants Two hundred eighty-two patients undergoing transfemoral TAVR with open surgical cutdown under MAC from 2015 to 2017. Interventions Transfemoral TAVR under MAC with surgical cutdown for femoral vascular access. Measurements and Main Results The study cohort consisted of 282 patients with severe aortic stenosis (mean area 0.65 [± 0.16] cm2, mean gradient of 48.9 [±13.3] mmHg, and mean age of 82.7 [± 7.31] years). Eleven (3.9%) patients required conversion to GA. First postoperative pain score (0-10) was 2.9 and highest postoperative pain score was 4.6. Major and minor vascular complications occurred in 2 (0.7%) and 6 (2.1%) patients, respectively. Twenty-nine (10.3%) patients were readmitted within 30 days, and 6 (2.1%) patients had in-hospital mortality. Conclusions Open surgical cutdown for transfemoral TAVR can be performed safely using MAC and ilioinguinal block with low rates of conversion to general anesthesia and acceptable postoperative outcomes and pain scores.

5525 Background: Improved long-term results can be achieved in advanced epithelial ovarian cancer (EOC) patients using optimal cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). Methods: Indian society of peritoneal surface malignancy (ISPSM) is a registered body which maintains prospective data of 26 centers across India who perform CRS –HIPEC. From February 2017 until January 2022, 1470 patients with advanced EOC were treated with CRS-HIPEC. He general practice patterns and the oncological outcomes in terms of progression free survival (PFS) and overall survival (OS) & post-operative morbidity and mortality is reported. Results: Upfront (n = 156), interval (n = 645) and recurrent (n = 669) cytoreductions were performed based on the timeline at presentation. Mean age 54.5±10.74, PCI 13. 6±5.2, duration of surgery 10.6±1.h hrs. 36.4% had total peritonectomy, 12.7% had multivisceral resection, 41.8%had bowel resections and stoma rate was 7.4%. 60.3% had semiopen HIPEC, 83.1% used cisplatin for HIPEC and 83.1 % had HIPEC for 90 minutes. Overall G3-G5 morbidity was 25.4% with major ones being post-operative intra-abdominal collection (21.8%), electrolyte imbalance (16.4%), pulmonary (16.4%) followed by hematological (12.7%). Surgical morbidity was more in upfront cytoreduction group compared to interval group (20% versus 13.5%) and recurrent group (20% versus 15%), respectively. The 30 day mortality was 3.8%. With a median follow-up of 46 months, median PFS was 33 months in primary (upfront plus interval) group and 16 months in recurrent cytoreduction group. Median OS was not achieved in both primary and recurrent groups (4 year OS rates: 60 and 55%, respectively). Conclusions: This prospective database provides a collation and audit of the management of advanced epithelial ovarian cancer with CRS HIPEC in multiple centers registered under ISPSM. In advanced EOC patients, CRS plus HIPEC offers potential benefits in PFS and OS rates, with acceptable rates of morbidity and mortality and can be practiced even in resource constrained setting.

Objectives To study the extent of surgery to achieve completeness of cytoreduction (CC) score 0 and perioperative morbidity in interval surgical cytoreduction in comparison to primary surgical cytoreduction of advanced epithelial ovarian cancer. Methods It is an interim analysis of ongoing prospective comparative study of patients with stage III/IV ovarian, tubal and peritoneal cancers undergoing interval or primary surgical cytoreduction during the period 2015 to 2018. The extent of surgery to achieve CC score-0 was the primary endpoint and perioperative morbidity was the secondary endpoint. Indication for NACT was bulky upper abdomen disease based on clinical evaluation and imaging or PS >2. Results Among 124 cases, 73 were in stage III/IV epithelial cancer; 46 of them had NACT and underwent interval surgical cytoreduction and 27 had primary surgical cytoreduction. The two groups did not differ significantly in median surgical peritoneal carcinomatosis index (PCI) (p 0.5755) or surgery duration (p 0.2301). In the interval group 78.3% and in the primary group, 81.5% were cytoreduced to CC score of 0. The types of procedures to achieve CC 0 were not statistically different between the two groups. A higher incidence of paraaortic lymph node dissection was observed in the primary group (p 0.0137). The perioperative morbidity in the interval group was not significantly different from the primary group. Conclusions In our experience, NACT could not significantly reduce the surgical extent to achieve CC 0 or the perioperative morbidity in comparison to patients undergoing primary surgical cytoreduction.

To evaluate the accuracy of 18F-FDG PET/CT in detecting regional lymph node metastasis in patients with endometrial cancer. A retrospective analysis was done for 50 patients having biopsy-proven endometrial cancer who underwent FDG PET/CT as a part of preoperative evaluation. All of these underwent Type I hysterectomy with lymphadenectomy either by open or robot-assisted surgery. PET/CT findings were then compared with the final histopathology. The criterion for malignancy on PET/CT images was increased FDG uptake by a lymph node independent of its size. Hyper-metabolic FDG-avid lymph nodes were present in 9 out of 50 patients. Twelve patients had metastasis to lymph nodes on histopathology, and 38 were negative for nodal metastasis. The overall sensitivity, specificity, positive and negative predictive value and accuracy of PET/CT for detecting nodal metastases were 66.67, 97.4, 88.9, 90.24 and 90%, respectively. Though FDG PET/CT has a high specificity and negative predictive value, its accuracy in diagnosing nodal metastasis in patients with endometrial cancer is limited because of its low sensitivity.

Cardiopulmonary bypass (CPB) has been one of the most important additions to the field of heart surgery in the past century. However, significant morbidity associated with CPB has led to the increasing implementation of off-pump coronary artery bypass (OPCAB). The use of OPCAB has broadened surgical revascularization for patient populations at high risk for undergoing CPB, including the very elderly and patients with impending end-organ failure. Intraoperative hemodynamic instability requires expeditious correction of hypotension with various medical and surgical techniques that require the close attention and skill of both the anesthesia and surgical teams. Technical skill at performing and interpreting transesophageal echocardiography is essential to help differentiate regional wall motion abnormalities from coronary ischemia and external compression from manipulation of the heart, which require different management strategies to resolve hemodynamic collapse. Flawless communication between the anesthesiologist and surgeons, with frequent intraoperative adjustments, is paramount for the completion of successful OPCAB.

Background International registries for acute type A aortic dissection (TAAD) demonstrate stagnant operative mortality rates in excess of 20% and stroke rates of 9% to 25%, with little global emphasis on stroke reduction or carotid involvement. Cerebral malperfusion with TAAD has been linked to poorer outcome. We hypothesize that concomitant carotid dissection or complex dissection flaps in the arch play a major role in stroke development and that aggressive reconstruction of the arch and carotid arteries can improve neurologic outcomes in TAAD. Methods A standardized protocol focused on expedient care, neurocerebral protection, and common carotid and total arch reconstruction was developed for 264 consecutive TAADs. Arch and complete carotid replacement was based on arch dissection anatomy, carotid involvement, or an intraarch tear. Neurocerebral monitoring with continuous electroencephalogram/somatosensory evoked potentials was used in all cases. Results The postoperative stroke and hospital mortality rates were 3.4% and 9.1%, and stroke rates by extent of arch replacement were 4%, 3%, and 0% for hemiarch, total arch, and total arch with complete carotid replacement, respectively. An intraoperative change in the electroencephalogram/somatosensory evoked potentials was strongly predictive of stroke and had a negative predictive value of 98.2%. Conclusions An algorithmic approach to TAAD including (1) rapid transport-to-incision-to-cardiopulmonary bypass established centrally, (2) neurocerebral monitoring, (3) liberal use of total arch replacement for clearly defined indications (and hemiarch for all others), and (4) common carotid arterial replacement for concomitant carotid dissections significantly improves outcomes.

For patients with stage III/IV endometrial carcinoma, prognosis remains poor and an optimum therapy is yet to be established. Treatment is individualized based on disease extent at presentation, patient’s performance status, and hormonal status of the tumor. Surgery is often the mainstay of treatment in stage III disease. The role of adjuvant radiotherapy in conferring survival is controversial. Chemotherapy is fast emerging as an effective adjuvant treatment for advanced endometrial cancer. Hormonal therapy with variable response rates has been used for metastatic and recurrent endometrial carcinoma. The GOG continues to investigate multimodality therapy.

In this report, we describe the feasibility of locating the sacral plexus nerve using a parasacral approach and an ultrasound-guided technique. The parasacral region using a curved probe (2-5 MHz) was scanned in 17 patients in search of the medial border of the ischial bone and the lateral border of the sacrum, which represent the limit of the greater sciatic foramen. In addition, attempts were made to identify the piriformis muscles and the gluteal arteries. The sacral plexus was identified at the level of the sciatic foramen as a round hyperechoic structure. The gluteal arteries were identified in 10 of 17 patients, but we failed to positively identify the piriformis muscle in any patient. To confirm localization of the sacral plexus, an insulated needle attached to a nerve stimulator was advanced and, in each case, a sacral plexus motor response was elicited (plantar flexion-12, dorsal flexion-1, hamstring muscle stimulation-3, gastrocnemius muscle stimulation-1-not recorded) at a current between 0.2 and 0.5 mA. No complications were observed. This report confirms the feasibility of using ultrasound to locate the sacral plexus using a parasacral approach.

We report a case of late-onset postoperative sciatic palsy after total hip arthroplasty in a 30-yr-old man with congenital hip dysplasia. The patient was receiving continuous lumbar plexus blockade and had received low-molecular-weight heparin 3 h before the onset of symptoms. Anatomic distinction between the nerve block and the sciatic palsy facilitated rapid diagnosis and treatment of a periarticular hematoma, with resulting neurologic recovery. This case illustrates that, with the expanded role of regional anesthetic techniques in acute pain management, the finding of a new postoperative deficit must be jointly investigated by both anesthesiologists and surgeons. Timely and open communication between services is critical because rapid intervention may be essential to achieving full recovery of an affected nerve.A case is presented of sciatic palsy developing after total hip arthroplasty in a patient receiving a continuous lumbar plexus block. The case highlights various issues in the use of continuous peripheral nerve blocks for postoperative analgesia.

The Opaque-2 (O2) gene from maize encodes a transcriptional activator of the b-ZIP class. We have isolated and characterized a gene from sorghum, related in sequence to the O2 gene from maize. A single copy of the gene is present in sorghum. Both genomic and cDNA sequences of the O2-related sorghum gene were determined. The sequence is highly homologous to maize O2 both in the promoter and in the coding region. The most closely related sequences contain the b-ZIP domain with only 11 amino acid substitutions in a total of 122 residues. In transient expression assays, the sorghum O2-related coding sequence, expressed from a CaMV 35S promoter, activates expression from the maize b-32 promoter as effectively as that obtained with the maize O2 sequence.

Rama Joshi The British used the particular form which gender divisions.took in India as a vehicleforproving.their liberality, as a demonstration of their superiority, and as a legitimation of their rule. They signally failed to understand the particular form of male supremacy in their own culture, or to analyse how they created and reirforced aspects of male oppression within Indian culture, seeing no parallels between the different culturalforms of male dominance in the two countries. The women's movement in India did not concentrate on male supremacy to the exclusion of foreign domination as the cause of their inequality, for in India male domination alone did not account for women's subordination. The colonists both improved women's position and worsened it in particular ways, but their actions were dictated, not out of concern for women, but out of the desire to maintain their financial inlterests and political power in the foreign country. Equally, it is clear that women's inequality was not identical with foreign rule, for the men in the nationalist movement opposed the women's demands when these threatened male privileges in the family; and despite the gains made at Independence, women's subordination did not disappear with the ending of political domination. The women's movement recognised this, constructing their demands around women's domestic, as well as political oppression, and organising autonomously for the emancipation of women rather than simply absorbing themselves into the freedom movement. So the Indian women's movement attacked both male supremacy and foreign domination. What inhibited them from emphasising male supremacy as one cause of their oppression was the use thait would be made of such a focus in Britain. This concern itself supports the movement's analysis that neither male domination nor imperialism alone accounts for women's subordination, but that both act upon the gender division, and are linked in perpetuating women's oppression.

The popular media have recently born witness to a renewed interest in India under British rule. This article examines the portrayal of Indian liberation struggles in two of the more serious expositions, The Jewel in the Crown and Gandhi , questioning the political implications of this portrayal. It shows that they both neglect the crucial role played by women in the maintenance and demise of the Raj. We argue that women's contribution was so significant that its omission constitutes a misrepresentation of history that can fairly be termed revisionist. We suggest that the reason for this process of mystification lies in the relevance of India's fight for national liberation and sexual equality in the early twentieth century, to present day struggles against imperialism and male domination, which are two of the most explosive issues affecting the modern Western world.