Lockdown Britain: Evidence for reduced incidence and severity of some non-COVID acute medical illnesses.

Large reductions in emergency department attendances and hospitalisations with non-COVID acute medical illness early during the pandemic were attributed to reluctance to seek medical help and higher referral thresholds. Here, we compare acute medical admissions with a comparison cohort from 2017. Deaths in the same geographic area were examined, and Wales-wide deaths during these 4 weeks in 2020 were compared with a seasonally matched period in 2019. There were 528 patients admitted with non-COVID illness in 2020, versus 924 in 2017 (a reduction of 43%). Deaths from non-COVID causes increased by 10.9% compared with 2017, over half this rise being from neurological causes including stroke and dementia. While far fewer patients required hospitalisation as medical emergencies, rises in local non-COVID deaths proved small. Wales-wide non-COVID deaths rose by just 1% compared with 2019. The findings suggest that changes in population behaviour and lifestyle during lockdown brought about unforeseen health benefits.

Double duodenal perforation following foreign body ingestion.

Intentional ingestion of a foreign body in adults is a rare clinical presentation. This case is one of a 27-year-old Sudanese man who presented having swallowed a ballpoint pen intentionally. Clinical examination and plain chest radiograph exhibited no signs indicative of perforation with only a raised C reactive protein identified on blood tests. Subsequent gastroscopy revealed that the pen had simultaneously perforated the duodenum at both D1 and D3 requiring removal via a laparotomy. The patient fully recovered and was discharged 2 weeks postoperatively following psychiatric input.

Open-access gastroscopy is associated with improved outcomes in gastric cancer.

OBJECTIVE: To examine whether patients with gastric cancer diagnosed via open-access gastroscopy (OAG) differ in their outcomes compared with patients referred conventionally to outpatient clinics or as acute emergencies. DESIGN AND SETTING: Prospective observational study in the gastroenterology and surgical units of a large district general hospital. PARTICIPANTS: One hundred consecutive patients with gastric adenocarcinoma. MAIN OUTCOME MEASURES: Data were collected prospectively and subdivided into two groups according to whether the patients were referred via the open-access route or the conventional route. RESULTS: Diagnostic delay from onset of symptoms was shorter for patients referred via OAG compared with those referred conventionally. Stages of disease were significantly earlier in patients referred via OAG compared with patients referred conventionally. Potentially curative resection was significantly more likely following OAG than after conventional referral. Cumulative five-year survival for patients referred via OAG was 30% compared with 12% after conventional outpatient referral and 13% after acute referral. Multivariate analysis revealed three factors to be associated with survival: stage of disease, distant metastases and referral via the open-access route. CONCLUSIONS: Gastric cancers presenting at OAG were diagnosed at an earlier stage than cancers diagnosed after conventional referral. This led to a higher proportion of potentially curative resections and better five-year survival.

Relative value of repeat gastric ulcer surveillance gastroscopy in diagnosing gastric cancer.

BACKGROUND: Gastric cancer can present with the endoscopic appearances of a benign gastric ulcer (GU). Opinion remains divided on the need for follow-up of patients diagnosed with GU, and the aim of this study was to examine the long-term outcomes of patients whose GU proved malignant on follow-up gastroscopy. METHODS: Between October 1, 1995, and September 30, 2003, 25,579 gastroscopies were performed in one unit. These identified 544 patients with apparently benign GU, of whom 277 (51%) underwent 334 elective follow-up endoscopies. Twelve of these patients (4.3%) were shown to have a malignant ulcer; their outcomes were compared to those of the 296 other patients diagnosed with gastric cancers in this time frame. RESULTS: The patients in the GU cancer group had earlier stage disease (stage I, 33% vs 6.4%; chi2 = 11.2; DF1; P = 0.001), and were more likely to undergo R0 gastrectomy (50% vs 30%; chi2 = 2.064; DF1; P = 0.151) and to survive long term (46% vs 16%; log-rank chi2, 5.79; DF1; P = 0.0162) than patients in the comparison cohort. CONCLUSION: Gastroscopic follow-up of 50 patients with an apparently benign GU will identify 1 patient with a malignancy destined to survive for 5 years following R0 gastrectomy. This justifies the diagnostic effort of repeat gastroscopy to ensure complete healing of GU.

Progressive CT system technology and experience improve the perceived preoperative stage of gastric cancer.

BACKGROUND: Our goals were to measure the accuracy of specialist helical computed tomography (CT) in the preoperative staging of gastric cancer, to determine the relative benefit of progressive CT system technology, and to determine the magnitude of any learning curve in radiological interpretation. METHODS: One hundred patients (median age, 70 years; range 27-86 years; 68 male) underwent a preoperative CT (73 helical [hCT], 27 multislice [mCT]), performed by a single specialist radiologist, followed by surgery within 3 weeks. The strength of the agreement between the perceived CT stage and the histopathological stage was determined for each CT system and also for four serial cohorts of 25 patients, by the weighted Kappa statistic (Kw). RESULTS: The Kw values for T, N, M1 liver, and M1 peritoneal stage were 0.40, 0.18, 0.36, and 0.09 for hCT, compared with 0.57, 0.67, 0.66 (all P < 0.001), and 0.24 (P = 0.06) for mCT. Serial Kw for T and N stages improved from 0.26 and -0.14 in the first quartile of patients to 0.61 and 0.73 (P < 0.001) in the last quartile of patients. CONCLUSION: The role of CT in the preoperative staging of gastric cancer is becoming stronger as CT technology improves.

Influence of socio-economic deprivation on outcomes for patients diagnosed with gastric cancer.

OBJECTIVE: Socio-economic deprivation has an influence on the outcome for patients diagnosed with breast, colorectal and bronchial cancer, but there are few data on its association with gastric cancer. The aim of this study was to determine the influence of socio-economic deprivation on outcomes for patients with gastric cancer. MATERIAL AND METHODS: Three hundred and thirty consecutive patients with gastric adenocarcinoma presenting to a single hospital between 1 October 1995 and 30 June 2004 were studied prospectively and deprivation scores calculated using the National Assembly for Wales Indices of Multiple Deprivation. The patients were subdivided into quintiles for analysis. RESULTS: Inhabitants of the most deprived areas (quintile 5) were younger at presentation (median 70 years versus 74 years, p=0.007), and experienced longer delays in diagnosis (18 weeks versus 9 weeks, p=0.02) when compared with patients from the least deprived areas (quintile 1). Operative mortality was 3-fold higher for patients from the most deprived areas when compared with patients from less deprived areas (15% versus 5%, p=0.03). There was no correlation between stage of disease and socio-economic deprivation. For patients undergoing potentially curative surgery, the 5-year survival for patients from the most deprived areas was 32%, compared with 66% for patients from the least deprived areas (p=0.03). CONCLUSIONS: Socio-economic deprivation was associated with younger age at diagnosis, longer diagnostic delay, greater operative mortality and a shorter duration of survival following R0 gastrectomy. These poorer outcomes were not explained by the stage of disease at diagnosis.

D2 or not D2? The gastrectomy question.

BACKGROUND: The best reported long-term survival following surgery for gastric cancer is from centers performing radical D2 gastrectomy. Yet comparative studies from European centers report higher rates of postoperative complications following D2 gastrectomy than after the less radical D1 gastrectomy, without any benefit in survival. We aimed to compare the outcome after modified D2 gastrectomy (preserving spleen and pancreas where possible), performed by specialist surgeons, with that after conventional D1 gastrectomy performed by general surgeons for gastric cancer in a large United Kingdom cancer unit. METHODS: Two groups of patients were studied: a historical control group of 245 consecutive patients with gastric cancer, of whom 50 underwent a potentially curative D1 resection (median age, 69 years; 35 males) was compared with 200 consecutive patients, 72 of whom underwent a potentially curative D2 resection (median age, 71 years; 47 males). RESULTS: Among the 122 patients judged to have curable cancers, patients who underwent a D2 gastrectomy had lower operative mortality (8.3% vs 12%; chi(2) = 0.48; P = 0.50) and experienced fewer complications (28% vs 36%; chi(2) = 0.93; P = 0.35) than patients who underwent a D1 gastrectomy. Cumulative survival at 5 years was 56% after D2 resections, compared with 11% after D1 resections ( P < 0.00001). In a multivariate analysis, only the stage of disease (stage I, hazard ratio [HR], 0.068; P = 0.0001; stage II, HR, 0.165; P = 0.001; stage III, HR, 0.428; P = 0.053) and the level of lymphadenectomy (HR, 0.383; P = 0.00001) were independently associated with the duration of survival. CONCLUSION: Modified D2 gastrectomy without pancreatico-splenectomy, performed by specialist surgeons, can improve survival after R0 resections without increasing operative morbidity and mortality, when compared with D1 gastrectomy performed by general surgeons.

Prognostic significance of acute presentation with emergency complications of gastric cancer.

BACKGROUND: Although acute complications necessitating emergency hospital admission are well documented in patients with carcinoma of the colon, comparable data for patients with gastric carcinoma is thin. The aim of this study, therefore, was to examine the outcomes of patients presenting to hospital as acute admissions with emergency complications of previously undiagnosed gastric cancer. METHODS: Three hundred consecutive patients with gastric adenocarcinoma were studied prospectively, and subdivided into two groups according to whether the patients were referred as acute emergencies ( n = 116) or as outpatients ( n = 184). RESULTS: The commonest emergency complications were: abdominal pain (57%), vomiting (41%), gastrointestinal bleeding (37%), dysphagia (26%), and a palpable mass (18%). Stages of disease were significantly more advanced in patients presenting acutely (I : II : III : IV = 7 : 11 : 27 : 71) compared with patients referred via outpatients (20 : 23 : 50 : 91, Chi(2) = 3.955; DF, 1; P = 0.047). R0 gastrectomy was significantly less likely after acute presentation (23 patients; 20%) compared with patients referred via outpatients (70 patients; 38%; Chi(2) = 11.037; DF, 1; P = 0.001). Cumulative 5-year survival for patients referred acutely was 9%, compared with 22% after outpatient referral (Chi(2) = 9.11; DF, 1; P = 0.0025). Multivariate analysis revealed two factors to be significantly and independently associated with durations of survival: stage of disease (hazard ratio [HR], 1.742; 95% confidence interval [CI], 1.493-2.034; P = 0.0001) and presentation with acute complications (HR, 1.561; 95% CI, 1.151-2.117; P = 0.004). CONCLUSION: Emergency complications of gastric cancer are a significant and independent prognostic marker of poor outcome.

Laparoscopy significantly improves the perceived preoperative stage of gastric cancer.

BACKGROUND: The aim of this study was to examine the accuracy of laparoscopy is staging patients with gastric cancer in comparison with preoperative computed tomography (CT) examination. METHODS: One hundred patients out of a consecutive series of 258 patients with gastric adenocarcinoma underwent a preoperative staging CT followed by a staging laparoscopy. The strengths of the agreement between the CT stage, the laparoscopic stage, and the final histopathological stage were determined by the weighted Kappa statistic (Kw). RESULTS: The strengths of agreement between the CT stage and the final histopathological stage were Kw = 0.336 (95% confidence interval [CI]; 0.172-0.5; P = 0.0001) for T stage and 0.378 (95% CI; 0.226-0.53; P = 0.0001) for M stage, compared with 0.455 (95% CI; 0.301-0.609; P = 0.0001) and 0.73 (95% CI; 0.596-0.864; P = 0.0001) for the laparoscopic T and M stages, respectively. Unsuspected metastases that were not detected by CT, were found in 21 patients at laparoscopy, all of whom had T3 or T4 locally advanced tumors evident on CT. CONCLUSIONS: Preoperative laparoscopic staging of gastric cancer is indicated for potential surgical candidates with locally advanced disease in the absence of metastases on CT. The aim of this study was to examine the accuracy of laparoscopy in staging patients with gastric cancer in comparison with preoperative computed tomography (CT) examination.

Western body mass indices need not compromise outcomes after modified D2 gastrectomy for carcinoma.

BACKGROUND: To determine the role of body mass index (BMI) in a Western population on outcomes after modified D2 gastrectomy (preserving pancreas and spleen where possible) for gastric cancer. METHODS: Eighty-four consecutive patients undergoing an R0 modified D2 gastrectomy for gastric cancer were studied prospectively. Male patients with a BMI of greater than 24.7 kgm(-2) and female patients with a BMI of greater than 22.6 kgm(-2) were classified as overweight and compared with control patients with BMIs below these reference values. RESULTS: Thirty-eight of the patients (45%) were classified as overweight. The median BMI of the overweight patients was 27.0 kgm(-2) (range, 22.7-34.7 kgm(-2); 27 males) compared with 21.2 kgm(-2) (range, 15.2-24.7 kgm(-2), 31 males) for control patients. Operative morbidity and mortality were 26% and 7.9% in overweight patients compared with 22% and 6.5% in control patients (morbidity, chi(2) = 0.240; df = 1; P = 0.624; mortality, chi(2) = 0.059; df = 1; P = 0.808). Cumulative survival at 5 years was 52% for overweight patients compared with 55% for control patients (chi(2) = 0.15; df = 1; P = 0.7002). In a multivariate analysis, the number of lymph node metastases (hazard ratio, 1.441; 95% confidence interval [CI], 1.159-1.723; P = 0.009) and splenectomy (hazard ratio, 12.111; 95% CI, 9.645-14.577; P = 0.043) were independently associated with the duration of survival. CONCLUSION: High BMIs were not associated with increased operative risk, and longterm outcomes were similar in the two groups after modified D2 gastrectomy.