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BACKGROUND: Management of esophageal cancer has changed to a combined modality approach over the past two decades due to poor outcome. Recently, multimodal treatment has become the standard practice. The aim of this study was to evaluate the changing trends in management and outcomes of esophagectomy over 15 years from a single center in Nepal. METHODS: Patients with squamous cell carcinoma and adenocarcinoma of esophagus/ gastroesophageal junction who underwent surgery between 2001-2018 were analyzed. Patients were grouped into three successive 5-year periods. RESULTS: 547 patients underwent esophagectomy during 2001-2018. There was increased trend of neoadjuvant treatment from 9-13% to 52% (p<.001) and minimally invasive surgery (MIS) from 0% to 80% (p<.001). 30-day mortality decreased from 8% to 1% (p=.01). The 5-overall survival was 24% which increased from 17% to 27% (p=.003). CONCLUSIONS: Long term outcome has improved over last 15 years with decreasing mortality which appears to be due to incorporation of MIS and neoadjuvant treatment.

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Esophageal cancer is diagnosed usually at a locally advanced stage. Surgery alone has less optimal results and a multimodality approach has been established as the standard of care for cII-III stages of esophageal cancer. This review focuses on the recent evidences of management of esophageal cancer with various variations in approaches in Eastern and Western countries. The major difference is the selection of induction treatment. Till the results of some ongoing trials become available, most of the evidences support neoadjuvant chemoradiation followed by surgery for squamous cell carcinoma and perioperative chemotherapy and surgery for adenocarcinoma.

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INTRODUCTION: Medical thoracoscopy has recently gained renewed interest due to its minimal invasive nature and high yield diagnostic outcome. This study aims to observe diagnostic yield and safety of medical thoracoscopy in undiagnosed exudative pleural effusion. METHODS: This is a descriptive cross-sectional study conducted in two tertiary care hospitals in Chitwan from March 2018 to May 2018. Ethical approval from the Institutional Review Board was obtained. Convenient sampling was done that included all the patients who met criteria for undiagnosed exudative pleural effusion after diagnostic thoracocentesis. Patients having contraindication to procedure and who refused consent were excluded. Statistical analysis was performed using IBM SPSS Statistics 20 and data are presented as mean ±SD and frequency (percentage). RESULTS: A total of 14 patients underwent rigid medical thoracoscopy. All 14 patients had unilateral pleural effusion. The overall diagnostic yield was 100%. Malignancy was the most frequent histopathology diagnosis seen in 11 (78.57%) patients, the commonest being metastatic adenocarcinoma in 8 (57.1%). Pleural tuberculosis and acute-on-chronic pleuritis were seen in 2 (14.3%) and 1 (7.1%) patients, respectively. Pleural deposits and hemorrhagic pleural fluid were the two commonest findings, seen in 10 (70.1%) and 9 (64.3%) patients, respectively. Two (14.3%) patients clinically treated as tuberculous pleural effusion was re-diagnosed to have metastatic adenocarcinoma. Procedure related mortality and major complications were nil. Common procedure-related minor complications observed were mild to moderate pain and mild bleeding, observed in 3 (21.4%) and 2 (14.3%) patients, respectively. CONCLUSIONS: Medical thoracoscopy is a safe, well-tolerated and high yield procedure in undiagnosed exudative pleural effusion. This art of medicine should be promoted in daily medical practice.

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INTRODUCTION: Medical thoracoscopy has recently gained renewed interest due to its minimal invasive nature and high yield diagnostic outcome. This study aims to observe diagnostic yield and safety of medical thoracoscopy in undiagnosed exudative pleural effusion. METHODS: This is a descriptive cross-sectional study conducted in two tertiary care hospitals in Chitwan from March 2018 to May 2018. Ethical approval from the Institutional Review Board was obtained. Convenient sampling was done that included all the patients who met criteria for undiagnosed exudative pleural effusion after diagnostic thoracocentesis. Patients having contraindication to procedure and who refused consent were excluded. Statistical analysis was performed using IBM SPSS Statistics 20 and data are presented as mean±SD and frequency (percentage). RESULTS: A total of 14 patients underwent rigid medical thoracoscopy. All 14 patients had unilateral pleural effusion. The overall diagnostic yield was 100%. Malignancy was the most frequent histopathology diagnosis seen in 11 (78.57%) patients, the commonest being metastatic adenocarcinoma in 8 (57.1%). Pleural tuberculosis and acute-on-chronic pleuritis were seen in 2 (14.3%) and 1 (7.1%) patients, respectively. Pleural deposits and hemorrhagic pleural fluid were the two commonest findings, seen in 10 (70.1%) and 9 (64.3%) patients, respectively. Two (14.3%) patients clinically treated as tuberculous pleural effusion was re-diagnosed to have metastatic adenocarcinoma.  Common procedure-related minor complications observed were mild to moderate pain and mild bleeding, observed in 3 (21.4%) and 2 (14.3%) patients, respectively. CONCLUSIONS: Medical thoracoscopy is a safe, well-tolerated and high yield procedure in undiagnosed exudative pleural effusion. This art of medicine should be promoted in daily medical practice.

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Gastric cancer is endemic in China, Japan, Korea, Brazil and Former Soviet Union. Patients are diagnosed usually in locally advanced stage. Endoscopy, Positron Emission Therapy- Computed Tomography, Endoscopic ultrasound and staging laparoscopy are the tools for proper evaluation of such patients. Locally advanced gastric cancer (T2-4N0 or TanyN+) requires multimodality treatment including surgery. Resection is the cornerstone of cure for gastric adenocarcinoma; however, several aspects of surgical intervention remain controversial or are suboptimally applied at a population level. Current evidence shows a D2 gastrectomy has got the best survival results. At least 15 lymph nodes should be assessed for adequate staging. Laparoscopic resections should be performed to the same standards as those for for open resections, by surgeons who are experienced in both advanced laparoscopic surgery and gastric cancer management. Keywords: Curative surgery; gastrectomy; stomach neoplasms.

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BACKGROUND: Optimal management of esophageal and GE junction cancer in Nepal has not been studied properly. We reviewed our results to recommend some practical guidelines. METHODS: An institutional review of 327 patients was done. Locally advanced cases were subjected to neoadjuvant treatment prior to surgery, whereas resectable cases were directly subjected to surgery or surgery followed by adjuvant treatment. Open and minimally invasive approaches were used in 246 (75%) and 81 (25%) patients, respectively. RESULTS: Final stages showed Ia (0.3%), Ib (2%), IIa (13%), IIb (8%), IIIa (17%), IIIb (11%), IIIc (41.7%) and IV (7%). The post operative mortality was 5.8%. Pneumonia/ pneumonitis, anastomotic leak and hoarseness of voice were observed in 21%, 11.6% and 7.6%, respectively. Median survival (in months) was as follows: St Ia - 60, Ib - 15, IIa - 23, IIb - 18, IIIa - 15, IIIb - 15, IIIc - 11 and IV - 8.5 (P<0.001). R0 and R+ resection was achieved in 299 (91%) and 28 (9%) cases, respectively with median survival of 27 and 9 months in R0 and R+ resections, respectively (P<0.001). 5-year overall survival was 22% with median survival of 25 months. After neoadjuvant treatment, Complete responders had median survival of 25.1 vs. 12.6 months for non-responders (P=0.042). CONCLUSION: Though the postoperative complications remain in acceptable range, the overall survival remains poor mainly due to the advanced stage of the disease at the time of diagnosis. Therefore, an approach of neoadjuvant chemoradiation/ chemotherapy prior to the surgery should be encouraged whenever feasible in order to achieve the best results.