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Competing Interests: Conflict of InterestThe authors declare no competing interests.

To determine factors influencing failure-to-rescue in patients with complications following cytoreductive surgery and HIPEC. A retrospective analysis of patients enrolled in the Indian HIPEC registry was performed. Complications were graded according to the CTCAE classification version 4.3. The 30- and 90-day morbidity were both recorded. Three hundred seventy-eight patients undergoing CRS with/without HIPEC for peritoneal metastases from various primary sites, between January 2013 and December 2017 were included. The median PCI was 11 [range 0-39] and a CC-0/1 resection was achieved in 353 (93.5%). Grade 3-4 morbidity was seen 95 (25.1%) at 30 days and 122 (32.5%) at 90 days. The most common complications were pulmonary complications (6.8%), neutropenia (3.7%), systemic sepsis (3.4%), anastomotic leaks (1.5%), and spontaneous bowel perforations (1.3%). Twenty-five (6.6%) patients died within 90 days of surgery due to complications. The failure-to-rescue rate was 20.4%. Pulmonary complications ( p  = 0.03), systemic sepsis ( p  < 0.001), spontaneous bowel perforations ( p  < 0.001) and PCI > 20 ( p  = 0.002) increased the risk of failure-to-rescue. The independent predictors were spontaneous bowel perforation ( p  = 0.05) and systemic sepsis ( p  = 0.001) and PCI > 20 ( p  = 0.02). The primary tumor site did not have an impact on the FTR rate ( p  = 0.09) or on the grade 3-4 morbidity ( p  = 0.08). Nearly one-fifth of the patients who developed complications succumbed to them. Systemic sepsis, spontaneous bowel perforations, and pulmonary complications increased the risk of FTR and multidisciplinary teams should develop protocols to prevent, identify, and effectively treat such complications. All surgeons pursuing this specialty should perform a regular audit of their results, irrespective of their experience., Competing Interests: Compliance with Ethical StandardsThe authors declare that they have no conflicts of interest.

Background: The Indian HIPEC registry is a self-funded registry instituted by a group of Indian surgeons for patients with peritoneal metastases (PM) undergoing surgical treatment. This work was performed to  • Evaluate outcomes of cytoreductive surgery ± HIPEC in patients enrolled in the registry.  • Identify operational problems., Methods: A retrospective analysis of patients enrolled in the registry from March 2016 to September 2017 was performed. An online survey was performed to study the surgeons' attitudes and existing practices pertaining to the registry and identify operational problems., Results: During the study period, 332 patients were enrolled in 8 participating centres. The common indication was ovarian cancer for three centres and pseudomyxoma peritonei for three others. The median PCI ranged from 3 to 23. A CC-0/1 resection was obtained in 94.7%. There was no significant difference in the morbidity (p = .25) and mortality (p = .19) rates between different centres. There was a high rate of failure-to-rescue (19.3%) patients with complications and the survival in patients with colorectal PM was inferior. A lack of dedicated personnel for data collection and entry was the main reason for only 10/43 surgeons contributing data. The other problem was the lack of complete electronic medical record systems at all centres., Conclusions: These results validate existing practices and identify country-specific problems that need to be addressed. Despite operational problems, the registry is an invaluable tool for audit and research. It shows the feasibility of fruitful collaboration between surgeons in the absence of any regulatory body or funding for the project.

Background: HIPEC using custom-made machines (CMM) remains unaffordable for many patients in low-income countries. We describe the assembly and use homemade HIPEC machine (HMM) as a cost-effective alternative., Methods: We evaluated the cost of setting up the HMM, maintenance, expenses per procedure as well as technical aspects including target temperature and flow rate, safety aspects, technical failures and the technical support required. The comparison with CMM was based on the manufacturer information and published reports and not on personal experience., Results: Form 2011 to 2017, we performed HIPEC (Coliseum technique) in 81 patients using HMM. HMM was a cardiopulmonary bypass machine available in our institution, with an additional water bath. Flow rate was 2 L/min and target temperature between 41 and 43 °C could be achieved in all cases. There were no technical failures and there was no safety issue recorded. Routine maintenance was provided yearly by an in-house technician. Chemotherapy costs (between 20 and 500 USD) were independent from the devices used. Cost of consumables was 450 USD/procedure, as compared to 1800 to 3500 USD/procedure for commercially available products. Investment cost for CMM is between 70,000 and 1,35,000 USD., Conclusions: The HMM is a cost-effective option allowing access to HIPEC to patients in low-resource countries without loss of efficacy or additional safety concerns. The initial cost and cost per procedure were substantially less for HMM while the maintenance of both systems was similar in terms of complexity and cost. The CMM are more user-friendly and require less technical support., Competing Interests: Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

There are various registries for patients with peritoneal metastases (PM) that aid pooling of data and generate evidence that dictates current clinical practice. This manuscript describes the setting up of the Indian HIPEC registry that was set up with a similar goal by a group of Indian surgeons. This is a registry for patients with PM treated with CRS and HIPEC in India. It also acts as a database for storing treatment-related information. Patients with PM from colorectal ovarian, gastric, appendiceal tumors, and other rare peritoneal tumors/metastases from rare tumors are enrolled in the registry. A coordinator updates the disease status of patients on a yearly basis. A private organization maintains the database. A non-disclosure agreement is signed between the company and each surgeon contributing to the registry to maintain confidentiality. For enrolling patients, securing institutional permission depends on the requirement of each institute; patient consent is mandatory. Data entry can be prospective or retrospective. To propose and conduct a study, the approval of a scientific committee linked to the registry is required. The Indian HIPEC registry is a practical database for Indian surgeons. There is no regulatory body that mandates collection and publication of scientific data in India. The onus is on each surgeon to capture valuable information pertaining to these common and rare diseases that could contribute to the existing scientific knowledge and guide the treatment of these patients in the future. The next challenge will be to enter data into the registry.

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.

Peritoneal mesothelioma is a surface malignancy involving the serous surfaces of the abdominal cavity. In the case presented here, the disease presented itself in a manner that has not been previously described. The tumor involved the full thickness of the bowel besides the familiar surface spread which is characteristic of the disease. Intestinal obstruction is a rare or late presentation of mesothelioma. It was the presenting symptom in the present case due to the full thickness infiltration of the small bowel by the tumor. The offending segment was resected and the ascites was treated with intraperitoneal chemotherapy. Though the patient at present has progression of disease he enjoys a reasonable quality of life after palliation of the ascites and obstruction.

Background: Cystic peritoneal mesothelioma is a rare disease associated with a favorable short-term prognosis. Longer follow-up documenting a persistence of symptoms and a high rate of recurrence after debulking surgery along with an uncertain natural history prompt a re-evaluation of prior treatment recommendations. No prior long-term clinical study of these patients is available., Methods: The experience with five cases of cystic peritoneal mesothelioma, four females and one male, are reviewed. All of these patients were treated with cytoreductive surgery with peritonectomy procedures and heated intraoperative intraperitoneal chemotherapy. CT, pathology and current status were investigated in order to learn more about the natural history of this disease., Results: All patients were symptomatic from abdominal distention and three of the four complained of severe pain. Female patients complained of long periods of recurrent abdominal and pelvic pain poorly managed by oral analgesics. In one patient prolonged conservative management over ten years resulted in transition to an invasive process with extensive lymph nodal metastases. Her prognosis for long-term survival is guarded because of mesothelioma extension into the chest. Disease control of both ascites and pain in the abdomen and pelvis was achieved in all five patients treated with cytoreductive surgery plus intraperitoneal chemotherapy., Conclusions: Cystic peritoneal mesothelioma should no longer be referred to as "benign" cystic mesothelioma. An aggressive approach with complete disease eradication is the correct goal of treatment. From our experience, cytoreductive surgery to remove all visible tumor and intraperitoneal chemotherapy to control microscopic residual disease will help patients with peritoneal cystic mesothelioma to remain symptom- and disease-free over an extended time period with a single surgical intervention. Disease eradication may prevent the transition to an aggressive and fatal disease process.

Leiomyoma of the duodenum is a rare tumour. Small intestinal tumours contributing to upper gastrointestinal bleed is still rare. They usually present with malena and anaemia, rarely hematemesis. We report a case of leiomyoma of duodenum diagnosed on endoscopic ultrasound that presented with massive haematemesis.

Antigen 85 (mol. wt 30,000) (30 kD), secreted by actively growing mycobacteria under axenic conditions, and mol. wt 65,000 (65 kD), a cytoplasmic antigen released during mycobacterial lysis, were used to monitor the efficacy of chemotherapy in previously untreated pulmonary tuberculosis (UPTB) patients using enzyme-linked immunosorbent assay. Sera from 125 UPTB patients were examined for each of the 2 antigens individually and for the ratio of secretory (30 kD) to cytoplasmic (65 kD) antigen (SCR), before commencement of treatment, after intensive phase (IP), completion of optimum period of treatment (COPT) and 6 months post-COPT. 116 controls (normals and contacts) were also checked for these antigens. The detection of 30 kD and 65 kD antigens in UPTB patients had a sensitivity ranging from 50-57% (mean 30 kD value: 0.64 +/- 1.24 ngs/ml) to 20-22% (mean 65 kD value: 0.51 +/- 1.87 ngs/ml), respectively, whereas in controls it ranged from 2-8% (0.05 +/- 0.28 ngs/ml) to 14-47% (0.09 +/- 0.22 ngs/ml), respectively. Although the decline in 30 kD positivity was more evident at COPT, computation of the SCR denoted efficacy of chemotherapy more readily at IP. Similarly, SCR resolved the ambiguity between individual antigen levels and the clinical status of a patient. Since significant numbers of patients demonstrated 30 kD at IP it may be computed that the lifespan of circulating 30 kD in serum could be at least 2 months after the start of treatment, declining gradually thereafter. Although seromonitoring for secretory antigen generally reflects the efficacy of chemotherapy, the interpretation of findings clearly requires further elucidation.

Spontaneous rupture of the stomach is a rare but rapidly fatal accident. In the reported case, the galloping pace of deterioration claimed the life of the patient in spite of timely institution of resuscitative measures. However, in less catastrophic forms, provided the condition is recognised by its characteristic features, it is possible to improve the prognosis by expeditious surgical correction. It behoves us to briefly review the clinical features of this condition while presenting the case report.