Surgical resection of hepatic metastases from gastric cancer: outcomes from national series in England.

BACKGROUND: The objectives of this national study were to examine the short-term safety and long-term survival benefit associated with surgical resection of hepatic metastases from gastric cancer. METHODS: Patients from the Hospital Episode Statistics database were classified by disease and treatment approach. Gastric cancer: 1. Without liver metastases treated by gastrectomy (GG). 2. With liver metastases treated by gastrectomy and hepatectomy (GGH). 3. With liver metastases treated by gastrectomy without hepatectomy (GGNH). 4. With liver metastases treated with no surgery (GNS). Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics. RESULTS: During the study period, 87,482 were patients diagnosed with gastric cancer, of whom 13,841 underwent partial or total gastrectomy. Of those who underwent gastrectomy, 336 had a diagnosis of liver metastases and 78 of these had a hepatectomy. Propensity-matched analysis showed no significant differences in 30- or 90-day mortality between the GGH and GG groups. The GGH group had significantly improved 1-year mortality (35.9 % vs. 50.0 %, p = 0.049) and 5-year mortality (61.5 % vs. 75.7 %, p = 0.031) compared to the GGNH group, and compared to the GNS group, the GCH group had 1-year mortality (35.9 % vs. 84.6 %, p < 0.001) and 5-year mortality (61.5 % vs. 90.8 %, p < 0.001). CONCLUSIONS: This study showed that hepatectomy for synchronous gastric cancer hepatic metastases may carry survival benefits in selected patients. The data presented should not be a rationale to change current clinical practice but rather a stimulus to prospectively study the role of surgery in a selected group of patients who are currently treated with palliative chemotherapy.

Boerhaave syndrome: a diagnostic conundrum.

A 79-year-old man presented to the Emergency Department with abdominal pain 1 day after an elective total knee replacement. The patient was confused and drowsy, with a high fever, hypotension and uncontrolled atrial fibrillation. He subsequently developed respiratory failure, requiring admission to intensive care. It was then noted that a large pleural effusion had developed between two chest radiographs performed only 4 h apart. A pigtail catheter inserted into the pleural space revealed a transudate of pH 7.0 with an amylase of 17 220 U (serum amylase 54 U), and thus a diagnosis of spontaneous oesophageal rupture or Boerhaave syndrome was made. Despite drainage of the pleural space, the patient developed shock and multiorgan failure requiring mechanical ventilation, renal replacement therapy and cardiovascular support. The oesophageal leak was treated conservatively with intercostal tube drainage; the patient made a full recovery and was discharged from hospital 75 days later.