Pathological determinants of survival in node-negative oesophageal cancer.

BACKGROUND: Many studies have analysed prognostic factors following oesophagectomy, but few have examined survival determinants in node-negative (N0) oesophageal cancer. The prognostic significance of a number of histological variables following surgical resection of N0 oesophageal cancer was studied. METHODS: The case notes of 219 patients undergoing potentially curative oesophagectomy for N0 squamous cell carcinoma or adenocarcinoma of the oesophagus were reviewed. Details of the patient's sex, age at operation, histological type, longitudinal tumour length, tumour (T) stage, circumferential resection margin involvement, tumour grade, presence of vascular invasion, perineural invasion, Barrett's metaplasia, and survival were noted. Univariate and multivariate analyses were performed to identify prognostic factors. RESULTS: Univariate analysis revealed three factors that correlated with poor prognosis: T stage (P = 0.024), adenocarcinoma (P = 0.033) and degree of differentiation (P = 0.001). Multivariate analysis revealed that all three were significant independent adverse prognostic indicators. CONCLUSION: Surgical resection of node-negative oesophageal cancer is associated with diverse long-term outcomes. This diversity of outcome is not reflected in the tumour node metastasis (TNM)-based staging system. The utility of the TNM system in predicting prognosis after surgical resection is open to question.

Prognostic significance of circumferential resection margin involvement following oesophagectomy for cancer.

The factors affecting long-term survival following oesophagectomy for oesophageal cancer are poorly understood. We examined the significance of microscopic tumour involvement at the circumferential resection margin (CRM) on postoperative survival following oesophagectomy. The case notes of 329 patients who underwent a potentially curative oesophagectomy for squamous or adenocarcinoma were reviewed retrospectively. As part of the procedure, all patients underwent an en-bloc resection of their periesophageal tissue. The presence of tumour either at, or within, 1 mm of the CRM was recorded and correlated with their TNM and survival data. A total of 67 patients (20%) were noted to have a positive CRM, of which 40 cases (12%) had tumour at the resection margin and the remainder had tumour within 1 mm of the margin. Univariate analysis showed no statistically significant association between survival and either category of CRM involvement. Multivariate analysis showed that only T-stage, nodal status and tumour grade were prognostic markers. In conclusion, the presence of microscopic tumour at the CRM following an en-bloc oesophagectomy is not a significant prognostic marker.

Coexisting achalasia and paraoesophageal hiatal hernia.

Disorders of the oesophagus present a diagnostic and therapeutic challenge. The presenting symptoms of dysphagia, reflux, pain and vomiting are almost universal, irrespective of the underlying pathology. A combination of endoscopy, barium studies, pH studies and manometry are often required to determine the exact diagnosis and to plan the most effective treatment. Paraoesophageal hiatal hernia is an uncommon condition, present in 14% of all hiatal hernias, which requires urgent correction to prevent life-threatening complications. It is unusual for other oesophageal disorders to coexist. We present a case where achalasia and a paraoesophageal hiatal hernia probably coexisted.

Vascular amyloidosis causing spontaneous mediastinal haemorrhage with haemothorax.

Bleeding diathesis is a recognised complication of amyloid disease. Localised and generalised bleeding manifestations are usually associated with intravascular coagulopathy related to isolated or multiple coagulation factor deficiencies. Recently, there have been reports of haemorrhage due to amyloid deposition in blood vessel walls and in the perivascular region leading to increased fragility and poor haemostasis. We report a case of spontaneous mediastinal haemorrhage due to amyloid involvement of vascular tissue in the absence of coagulopathy.

Surgical treatment of para-oesophageal hiatal hernia.

The development of laparoscopic antireflux surgery has stimulated interest in laparoscopic para-oesophageal hiatal hernia repair. This review of our practice over 10 years using a standard transthoracic technique was undertaken to establish the safety and effectiveness of the open technique to allow comparison. Sixty patients with para-oesophageal hiatal hernia were operated on between 1989 and 1999. There were 38 women and 22 men with a median age of 69.5 years. There were 47 elective and 13 emergency presentations. Operation consisted of a left thoracotomy, hernia reduction and crural repair. An antireflux procedure was added in selected patients. There were no deaths among the elective cases and one among the emergency cases. Median follow-up time was 19 months. There was one recurrence (1.5%). Seven patients (12%) required a single oesophagoscopy and dilatation up to 2 years postoperatively but have been asymptomatic since. Two patients (3%) developed symptomatic reflux which has been well controlled on proton-pump inhibitors. Transthoracic para-oesophageal hernia repair can be safely performed with minimal recurrence.

Management of benign oesophageal stricture by total fundoplication gastroplasty.

In the Department of Thoracic Surgery, City Hospital, Nottingham, we use total fundoplication gastroplasty routinely in the management of patients with benign peptic strictures who are unresponsive to medical treatment. This is an analysis of our results between 1983 and 1987. Fifty-six patients are included. There was no operative mortality. An overall good result was achieved in 83.9% of the patients. The results were better earlier in the disease (86.7% in grade II and 90.3% in grade I) than later (60% in grade III). We believe that conservative surgery should not be unduly delayed once medical management has failed. We now reserve resection for patients with fibrotic undilatable strictures and failures of conservative surgery.

Thoracic injuries sustained by the survivors of the M1 (Kegworth) aircraft accident. The Nottingham, Leicester, Derby, Belfast Study Group.

On 8 January 1989, a Boeing 737 carrying 126 passengers and crew crashed onto the M1 motorway killing 39 passengers. Of 87 initial survivors, 74 had major injuries making this an unusual accident as most aircraft crashes result in very few severely injured survivors. This prompted the setting up of a major study group, the Nottingham, Leicester, Derby, Belfast Study Group (NLDB) to examine in detail the accident and its aftermath. This paper is part of that work and is an initial survey of the thoracic injuries sustained by the 87 survivors. Twenty-three passengers sustained major chest trauma and all had major injury to other parts of the body. Five of these patients died within 12 h of admission. Various patterns of chest trauma emerged from this study, including an increasing incidence of rib fractures with age and a distinctive pattern of upper zone pulmonary contusion in younger patients.

Breakage of Redivac suction drains.

An investigation is described which defines points of weakness in the design of Redivac suction drains.

A comparison of intravenous and oral metronidazole as prophylactic in colorectal surgery.

In a prospective randomized double-blind trial we have compared oral (n = 46) and parenteral prophylaxis (n = 51) with metronidazole in elective colonic resection. All patients received oral or intravenous metronidazole, together with oral neomycin. The overall infection rate was 11.3 per cent. Six out of 46 patients in the oral group (13 per cent) had a wound infection postoperatively compared with 5 out of 51 patients who received intravenous metronidazole (9.8 per cent). These results suggest that there is no significant difference whether metronidazole is administered intravenously of orally as a prophylactic in elective colonic surgery.