Outcomes from chemoradiotherapy for patients with esophageal cancer.

Chemoradiotherapy is a widely used alternative treatment to surgical resection in certain patient groups with early esophageal cancer. The aim of this study was to retrospectively assess toxicity and outcome of patients treated with definitive chemoradiotherapy for early esophageal cancer at one institution. A retrospective analysis of all patients treated with chemoradiotherapy between February 2000 and December 2008 at a single tertiary center was performed with documentation of treatment given, toxicities recorded, and follow-up and outcome data. Sixty-two patients received chemoradiotherapy for esophageal cancer. There were 20 males and 42 female patients with an average age of 68 years. Histology revealed adenocarcinoma in 28 patients and squamous cell carcinoma in 34 patients. All patients were staged with a computerized tomography scan, endoscopic ultrasound and positron emission tomography scan. Selection criteria for chemoradiotherapy were unfit for surgery, upper esophageal squamous carcinoma, unresectable primary tumor, or patient choice. The majority of the patients received a combination of cisplatin and 5-fluorouracil chemotherapy with 55 Gy in 25 fractions of radiotherapy. Grade 3 toxicities were recorded in 11% of the patients. Eleven patients suffered from local recurrence and a stent was required in nine patients. Radiation strictures occurred in 10 patients requiring dilation in four. Five patients required a radiologically inserted feeding gastrostomy. The median overall survival was 21 months. Patients with adenocarcinomas and those with squamous cell carcinoma had a similar median survival. Overall survival was 70% at 1 year, 48% at 2 years, and 26% at 3 years. This case series of patients treated with chemoradiation for localized esophageal cancer suggest a generally well-tolerated treatment with survival rates after chemoradiotherapy comparable with those seen with surgery.

Is herniography an effective and safe investigation?

AIM: To assess the safety and effectiveness of herniography in adult patients with suspected hernia. METHOD: The records of all patients undergoing herniography within one unit over a 1 year period were studied retrospectively. A follow-up postal questionnaire was sent out to all patients enquiring about outcome and any complications of herniography. RESULTS: From a total of 64 patients undergoing a herniogram, 36% were found to have a positive result and 64% a negative result. This study showed a sensitivity rate of 0.94 and a specificity rate of 0.95. There was a 5% major complication rate leading to hospital admission, and 42% of patients described minor complications occurring within 24 hours of herniography. CONCLUSION: Herniography is a useful diagnostic tool for identification of clinically occult hernias, with good rates of sensitivity and specificity. In most cases it is a safe investigation but it is not without a significant complication rate.

The use of neoadjuvant CMF to avoid mastectomy.

AIMS: Large operable cancers have traditionally been treated surgically by mastectomy. More recently centres have investigated the use of neoadjuvant chemotherapy to allow breast-conserving surgery. Between 1991 and 1995, a prospective study into the response of large operable breast cancers to CMF neoadjuvant chemotherapy was performed. METHODS: Patients with cancers requiring mastectomy, and with or without clinically involved non-fixed lymph nodes, were offered neoadjuvant CMF chemotherapy. Patients declining neoadjuvant treatment underwent mastectomy and appropriate axillary surgery. Clinical response was assessed after two cycles in the neoadjuvant group. Subsequent surgical or non-surgical management was planned after this. RESULTS: Thirty-eight patients were suitable for neoadjuvant treatment. Twenty-two underwent two cycles of CMF and were then reassessed. Seventy-three per cent achieved a response [three (14%) complete remission, 13 (60%) partial remission]. Fifteen (68%) patients avoided mastectomy, with six (27%) requiring no surgery at all with no clinically detectable residual disease. Sixteen (42%) declined neoadjuvant chemotherapy and opted for immediate mastectomy, seven of whom accepted chemotherapy post-operatively. After 3 years' follow-up there is no statistical difference in local recurrence, distant recurrence or overall survival. CONCLUSION: Approximately 40% of patients offered neoadjuvant chemotherapy will demand prompt surgical treatment but will consider the use of adjuvant chemotherapy post-operatively. Sixty-eight per cent of patients receiving neoadjuvant CMF will successfully avoid mastectomy.

Crossover trial of partial shift working and a one in six rota system for house surgeons in two teaching hospitals.

The objective of this study was to compare an on call rota and partial shift working pattern for house surgeons in two hospitals. The study was conducted using a crossover trial of working both systems for 6 weeks each in two groups of newly appointed house surgeons. Assessment was by questionnaire to house surgeons, consultants, registrars, nursing staff and patients. The study took place at the departments of general surgery at Guy's and Lewisham Hospitals, London. A total of 12 house surgeons attached to four surgical firms and their consultants and registrars were the subject of our study. In addition the permanent nursing staff on designated general surgical wards and those patients of greater than 48 h stay on those wards on the day of assessment took part. Expectations of reduced fatigue levels using the partial shift system were not fulfilled. In contrast, this working pattern led to perceived disruption of the running of the surgical firms and demoralization of the house surgeons. Standards of patient care were, however, equally high using a rota or partial shift system. This comparison of a partial shift working pattern to an on call rota of similar average weekly hours demonstrated a marked preference for an on call rota from both medical and nursing staff although patients found both systems acceptable.

Aortic aneurysm leak after streptokinase treatment for myocardial infarction.

A leak from an abdominal aortic aneurysm following the administration of streptokinase treatment for myocardial infarction is reported. It is important to assess candidates for cardiac thrombolytic therapy for aortic pathology and give such treatment with extreme caution in those patients with abdominal aortic aneurysms.

Congenital fistulation of a Meckel's diverticulum to the surface of an exomphalos sac.

Exomphalos and vitellointestinal duct remnants are well-known entities. This report details the presentation of congenital fistulation of a Meckel's diverticulum to the surface of an exomphalos minor.

Late presentation of a congenital gastric diverticulum causing pyloric obstruction.

We report a case of adult pyloric obstruction caused by the delayed presentation of a congenital gastric diverticulum. The derivation, classification and treatment of these abnormalities are discussed.