Total gastrectomy with extended lymphadenectomy for "curable" stomach cancer: experience in a non-Japanese Asian center.

BACKGROUND: Gastrectomy with extended lymphadenectomy is the advocated treatment in Japan for patients with "curable" stomach cancer. Attempts in units elsewhere adopting this approach failed to show any survival advantage, and the high operative mortality has prevented global acceptance of the operation. This study examines the safety and efficacy of radical gastrectomy in a Far East center outside Japan. STUDY DESIGN: A consecutive series of 121 patients with gastric cancer who fulfilled criteria for radical surgery had total gastrectomy with extended lymphadenectomy equivalent to D3 dissection over a 6-year period in a single unit. RESULTS: The operation carried a morbidity of 50%, with a perioperative mortality of 5%. Survival was best predicted by tumor stage: 5-year survival for patients with intact gastric serosa was 64%, versus 10% for those with serosal penetration (p < 0.001). The majority of documented metastases occurred by transperitoneal route in serosa-positive patients, but via the hematogenous mechanisms in those who were serosa-negative. CONCLUSIONS: Radical gastrectomy with extended lymphadenectomy carries high operative morbidity. Increased mortality occurred because of loco-regional recurrence in patients with T3/T4 diseases. Novel approaches including neoadjuvant treatment or regional therapy should be explored.

Biological characteristics of a newly established human oesophageal carcinoma cell line.

An epithelial cell line, EC/CUHKI was established from a human squamous cell carcinoma of the oesophagus. The cells were polygonal in shape with numerous microvilli. Transmission electron microscopy (TEM) revealed the presence of desmosomes and tonofilaments. Karyotypic analysis of cells from the cell line demonstrated an aneuploid human type with a modal chromosome number of 85. Epstein-Barr viral nuclear antigen (EBNA) has not been demonstrated in the cells from the primary culture or subcultures. The tumour cells form colonies in agar and have a plating efficiency of 20%. The cells are highly invasive in vitro and are tumorigenic in nude mouse.

Training in surgical outpatients.

The consultants in this department, where the trainees are predominantly SHOs, organise their outpatient clinics such that one consultant sees mainly new patients (A), another mainly follow-up patients (C) and the third a mixture (B). A prospective audit was conducted to assess the impact of these different arrangements on training. Details of the training received were recorded at 32 consecutive clinics. A training episode (TE) occurred if the trainee and consultant jointly reviewed, or directly discussed, the patient in the clinic. A total of 550 patients attended and trainees were involved with 254 (46 per cent). A TE occurred in only 88 (16 per cent). The 235 (43 per cent) new patients produced 66 (28 per cent) TE and the 315 follow-up patients 22 (7 per cent) TE. Seventeen of 46 (37 per cent) procedures were a TE. The TE for the individual consultants were (new and follow-up): A 0, 8 (7 per cent); B 19 (22 per cent), 7 (8 per cent); C 47 (57 per cent), 7 (6 per cent). Outpatient training was greatly influenced by clinic organisation. Follow-up patients, who often have complex problems, rarely generate a TE. Training in surgical outpatients has not received the same attention as operative training and this deficiency needs to be addressed.

Comparative assessment of surgical training using objective criteria.

The aims of the study were to develop and validate an objective method of assessing the operative experience of surgical trainees. Data were retrieved from a prospectively recorded computer database of operating activity in a single surgical unit over a three-year period. Operations were weighted using intermediate equivalent (IE) values. The number of operations performed (caseload), IE workload, consultant involvement and a subjective assessment of operative ability by consultant was obtained for each of 3 SHO IIIs and 7 SHO Is. The total caseload correlated poorly with subjective grading. The total workload correlated well with the subjective assessment of the SHO IIIs and, excluding minor operations, with the SHO Is. SHO IIIs' workload consisted of a higher number of more complex procedures than SHO Is' and for both types of trainee the degree of complexity increased during the tenure of each one year post. A consultant was the assistant in 50 per cent of the intermediate and major operations performed by the SHO Is in the first quarter of each one year post dropping to 30 per cent in the remaining three-quarters. In conclusion an objective assessment was easily obtained and interpreted. Similar data from other surgical units are required to place this work in perspective and to allow formulation of guidelines.

Intraoperative assessment of lymph node involvement in gastric carcinoma.

This study compares the assessment of lymph nodes by the surgeon, at the time of operation, with the pathologist's assessment on the resected specimen in 85 cases of total gastrectomy with extended lymphadenectomy for gastric carcinoma. There was correlation in 67% of cases, in 28% the disease was overstaged, and in only 5% was it understaged by intraoperative assessment. This has important implications for the comparison of trials and management decisions based on surgical assessment.

Surgical management of the septic complications of diverticular disease.

This retrospective study has reviewed the surgical management of the septic complications of diverticular disease involving the left colon in 77 patients who presented between 1980 and 1992. Over this period, Hartmann's resection continued to be the predominant surgical procedure. The overall mortality and morbidity rates in the study period were 10% and 31%, respectively. However, a marked improvement in survival was recorded in the latter half of the study (17% vs 6%). The mortality from Hartmann's resection was also reduced substantially in the second half of the study (24% vs 7.5%). These improvements occurred despite having a higher number of poor-risk patients (APACHE II score) with more severe pathology (generalised peritonitis, 35% vs 50%; faecal peritonitis, 9% vs 25%) in the latter half. There was a significantly worse survival in patients who were over 70 years of age (P < 0.03), those who had a severe concomitant medical illness (P < 0.02), those who had a generalised peritonitis (P < 0.02), and in those patients who had an APACHE II score of over 11 (P < 0.05) (Fisher's exact test). There was no difference in outcome (morbidity, mortality) between the various grades of surgeon involved in performing the emergency surgical procedures.

An objective assessment of surgical training.

The aim of this study was to determine the feasibility of assessing surgical training from routine, prospectively collected data and to establish whether weighted workload assessed surgical training more objectively than caseload (case counting). The surgeons in this surgical unit prospectively documented details of all operations and endoscopic procedures (caseload) on a database. Over a six-month period the workload was calculated by weighting the caseload using Intermediate Equivalent (IE) values. Some 1827 procedures were documented. The three consultants performed 796 (44 per cent) procedures, the senior registrar (SR) 137 (7.5 per cent), the registrar 241 (13 per cent) and the three senior house officers (SHO) 644 (35 per cent). The consultant was first assistant in 185 (66 per cent) procedures performed by the SHOs, in 52 (61 per cent) by the registrar in 9 (13 per cent) by the SR. When assessed by caseload one SHO (as a representative example) performed 224 procedures compared to 137 by the SR. The IE workloads were 156 and 166 respectively. This better reflected the greater complexity of the operations performed by the SR. This study has shown that details of surgical training can be easily retrieved from existing administrative databases. This can be used to document the number and type of operations performed by a trainee and the degree of consultant supervision. The degree of surgical training is better assessed by weighted workload rather than caseload.

Written discharge advice sheets reduce visits to the general practitioner.

A prospective audit of early post-operative morbidity in patients who would not normally receive routine outpatient review was undertaken. One-hundred-and forty-seven (92 per cent) of 162 patients invited returned for assessment. Thirty-five patients (24 per cent) had complications. These were of a minor nature with infected wounds being most numerous. Much of this morbidity appeared avoidable if the patients had received appropriate advice whilst in hospital. Also noted was the surprising frequency with which patients required to consult their general practitioner (GP) for guidance regarding an otherwise uncomplicated convalescence. Written advice sheets for the patients were drawn up and the study repeated. One-hundred-and-fifty (93 per cent) of 162 patients attended including 11 (7.3 per cent) who did not receive an advice sheet. Twenty-five (16.7 per cent) had complications. Although the overall complication rate was not significantly different there were significantly fewer wound infections in the second group (6 (4 per cent) versus 15 (10 per cent); p < 0.05). The number of GP visits was also reduced (24 (16.3 per cent) versus 13 (8.7 per cent); p < 0.05). Written post-operative advice sheets should be given to all patients following minor surgery.

Hepatic metastases in Hong Kong Chinese: evidence for an East-West difference in gastric cancer.

The incidence of hepatic metastases found at laparotomy for colorectal and gastric cancer amongst Hong Kong Chinese was found to be 16% and 5% respectively. These figures were compared to similar Western series, and the incidence of metastases from gastric cancer was significantly lower in the Chinese population. This geographical variation may have important implications for the interpretation of treatment results for gastric cancer in different parts of the world.

Consultant supervision of surgical trainees: an objective assessment of how much actually occurs.

Consultant-supervised operative experience must be at the core of any training programme. The level of consultant supervision of United Kingdom trainees is largely unknown. In this study, the unique Lothian Surgical Audit database was used to assess consultant supervised training.

Surgical training: an objective assessment of recent changes for a single health board.

The reduction in doctors' hours and the introduction of specialist training have reduced general surgical training by 60%. This study assessed the implications for a single health board. A questionnaire listing 13 representative operations was sent to 44 trainees and 52 trainers to determine the number of operations a trainee should perform. The total number of operations required for training was compared against the total actually performed across the health board. Operating times for five representative operations were audited prospectively. Trainers and trainees recommended a similar and conservative number of operations. The total number of operations available for training (4913) was 38% less than the number recommended (7946). Trainees required 50-75% more operating time than consultants. To increase the proportion of operations undertaken by trainees from the current 30% to 70% would require an extra 270 theatre days (of pounds 1.3m) yearly. The minimum number of operations required for training must be defined and the proportion of supervised operations undertaken by trainees substantially increased. Service and financial implications will have to be addressed. Action is needed urgently, as the first trainees will become consultants in less than five years.

Teaching corner--"lumps and bumps": a practical guide to minor surgery for the Core Surgical Trainee.

The first local anaesthetic operating list faced by a Core Surgical Trainee (CT) can appear a daunting task. Fresh from Foundation Year (FY) posts, (s)he will lack experience in basic surgical techniques. At present, there is no formal training in minor surgical skills for FY doctors, and exposure to operative surgery can be variable. This review provides an introduction and practical guide to the operative management of minor surgical pathologies.

Comparison of the Bonfils and Levitan optical stylets for tracheal intubation: a clinical study.

The Bonfils and Levitan FPS scopes are rigid fibreoptic stylets that may assist routine or difficult intubation. This study compared the effectiveness of each in patients with predicted normal airways when used by specialist anaesthetists with no prior experience using optical stylets. Twelve anaesthetists and 324 elective surgical patients participated. Six anaesthetists were randomised to first intubate 20 patients with the Levitan scope (Phase 1) followed by a further seven patients with the Bonfils scope (Phase 2). The other six participating anaesthetists undertook their first 20 intubations with the Bonfils (Phase 1), followed by seven intubations with the Levitan (Phase 2). Outcomes recorded were success rate, total time to intubation, number of attempts, ease of intubation score and incidence of complications. Overall failure rates were similar for the two scopes with 5.6% of patients not intubated after three attempts. Median total times to intubation were similar for the Levitan (44 seconds) and Bonfils (36 seconds) (P = 0.11). Participants using the Bonfils in Phase 1 had significantly higher chance of success on first attempt (73%) compared to Levitan users during Phase 1 (57%) (P = 0.008). These differences were not significant in the second phase and ease of intubation scores were similar for both scopes (P = 0.9). This study showed the two scopes were comparable but the high failure rate amongst novice users demonstrated the importance of familiarity and skill development prior to their introduction to a difficult airway cart.