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Amonkar SJ, Irving M, Wayman J, Sriram T, Griffin SM, Nicoll JJ, Raimes SA. The changing use of palliative chemotherapy for recurrent esophagogastric cancer: a single center retrospective 15-year review. J Gastrointest Cancer 2009; 39:51-7. [PMID: 19238591 DOI: 10.1007/s12029-009-9051-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Accepted: 02/05/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Palliative chemotherapy is often recommended in the treatment of recurrent esophagogastric (EG) cancer with limited evidence of its benefit. This study aims to define the current practice and benefit of this treatment. METHODS Retrospective analysis of patients who developed EG cancer recurrence between 1991 and 2006 following surgery with curative intent. RESULTS There were 336 recurrences. Median time to disease recurrence was 13.4 months (range 1.3-118). Survival after recurrence ranged from 0-93.2 months (six patients are currently alive). A significant increase in the use of chemotherapy was observed rising from 10% prior to 1999 (n = 100) to 23% (n = 236) after 1999. The median survival for patients receiving chemotherapy (n = 64) was 10.6 months (range 1.5-75.7), patients undergoing nonchemotherapy palliative intervention (n = 142) median survival was 2.85 months (range 0-93.2), and for patients having no active intervention (n = 130), median survival was 1.3 months (range 0-16.2). Median duration of chemotherapy was 3.1 months (range 0.5-9.2). Median survival for these patients after chemotherapy treatment was 6.6 months (range 0.4-73.5). Twenty-eight patients (44%) experienced side effects of chemotherapy. Ten cases required treatment to be modified or stopped and two patients died during chemotherapy. CONCLUSION There has been a significant increase in the use of palliative chemotherapy for recurrent EG cancer. While survival appears improved, a substantial proportion of this time was spent receiving chemotherapy with many patients experiencing significant comorbidity. Further studies assessing both quality and quantity of life are required to fully evaluate the use of palliative chemotherapy and to identify patients most likely to benefit.
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Affiliation(s)
- S J Amonkar
- Northern Oesophago-Gastric Cancer Unit, Newcastle upon Tyne & Carlisle, UK
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2
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Bowrey DJ, Griffin SM, Wayman J, Karat D, Hayes N, Raimes SA. Use of alarm symptoms to select dyspeptics for endoscopy causes patients with curable esophagogastric cancer to be overlooked. Surg Endosc 2006; 20:1725-8. [PMID: 17024539 DOI: 10.1007/s00464-005-0679-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Accepted: 04/08/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND In August 2004, the United Kingdom Department of Health advisory body published dyspepsia referral guidelines for primary care practitioners. These guidelines advised empiric treatment with antisecretory medications and referral for endoscopy only in the presence of alarm symptoms. The current study aimed to evaluate the effect of these guidelines on the detection of esophagogastric cancer. METHODS The study reviewed a prospectively compiled database of 4,018 subjects who underwent open access gastroscopy during the years 1990 to 1998. The main outcome measures for the study were cancer detection rates, International Union Against Cancer (UICC) stage, and survival. RESULTS Gastroscopy identified esophagogastric carcinoma in 123 (3%) of the 4,018 subjects. Of these 123 patients, 104 (85%) with esophagogastric cancer had "alarm" symptoms (anemia, mass, dysphagia, weight loss, vomiting) and would have satisfied the referral criteria. The remaining 15% would not have been referred for initial endoscopic assessment because their symptoms were those of uncomplicated "benign" dyspepsia. The patients with "alarm" symptoms had a significantly more advanced tumor stage (metastatic disease in 47% vs 11%; p < 0.001), were less likely to undergo surgical resection (50% vs 95%; p < 0.001), and had a poorer survival (median, 11 vs 39 months; p = 0.01) than their counterparts without such symptoms. CONCLUSIONS The use of alarm symptoms to select dyspeptics for endoscopy identifies patients with advanced and usually incurable esophagogastric cancer. Patients with early curable cancers often have only dyspeptic symptoms, and their diagnosis will be delayed until the symptoms of advanced cancer develop.
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Affiliation(s)
- D J Bowrey
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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3
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Hayes N, Shaw IH, Raimes SA, Griffin SM. Erratum. Br J Surg 2005. [DOI: 10.1002/bjs.1800820360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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4
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Dresner SM, Griffin SM, Wayman J, Bennett MK, Hayes N, Raimes SA. Human model of duodenogastro-oesophageal reflux in the development of Barrett's metaplasia. Br J Surg 2003; 90:1120-8. [PMID: 12945080 DOI: 10.1002/bjs.4169] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with an intrathoracic oesophagogastrostomy after subtotal oesophagectomy experience profound duodenogastro-oesophageal reflux (DGOR). This study investigated the degree of mucosal injury and histopathological changes in oesophageal squamous epithelium after subtotal oesophagectomy with gastric interposition in relation to the extent of postoperative DGOR. METHODS Serial endoscopic assessment and systematic biopsy at the oesophagogastric anastomosis was undertaken in 40 patients following curative radical subtotal oesophagectomy and reconstruction with a gastric conduit subjected to a pyloroplasty. Thirty patients subsequently underwent combined 24-h ambulatory pH and bilirubin monitoring. RESULTS Grade I-III oesophagitis was identified in 14 patients and oesophageal columnar epithelium in 19 patients. Biopsies from columnar regeneration revealed cardiac-type epithelium in ten patients and intestinal metaplasia in nine. Seven patients followed serially showed progression from cardiac-type epithelium to intestinal metaplasia. The incidence of Barrett's metaplasia was similar irrespective of the histological subtype of the resected tumour. Patients with oesophageal columnar epithelium had significantly higher acid (P = 0.015) and bilirubin (P = 0.011) reflux. CONCLUSION Severe DGOR occurs following subtotal oesophagectomy and provides an environment for the acquisition of Barrett's metaplasia via a sequence of cardiac epithelium and eventual intestinal metaplasia.
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Affiliation(s)
- S M Dresner
- Northern Oesophago-Gastric Cancer Unit, Ward 36 Office, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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Chandrashekar MV, Irving M, Wayman J, Raimes SA, Linsley A. Immediate extubation and epidural analgesia allow safe management in a high-dependency unit after two-stage oesophagectomy. Results of eight years of experience in a specialized upper gastrointestinal unit in a district general hospital. Br J Anaesth 2003; 90:474-9. [PMID: 12644420 DOI: 10.1093/bja/aeg091] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The perioperative management of two-stage oesophagectomy has not been standardized and the prevailing practice regarding the timing of extubation after the procedure varies. This audit has evaluated the outcome, in particular the respiratory morbidity and mortality, after immediate extubation in patients who have had thoracic epidural analgesia. METHODS All the patients who underwent two-stage oesophagectomy by a single specialist upper gastrointestinal surgeon were recorded both retrospectively (1993-1999) and prospectively (1999-2001). Physical characteristics, comorbid factors, anaesthetic management and postoperative events were recorded on a computer database. Analysis was undertaken to evaluate the morbidity and mortality, in particular the need for reventilation and transfer to the ITU. RESULTS Seventy-six patients underwent two-stage oesophagectomy between 1993 and 2001. Seventy-three (96%) patients were extubated in theatre and transferred to a high-dependency bed. Three were ventilated electively and extubated within 36 h and made an uncomplicated recovery. Seven (10%) of the immediately extubated patients subsequently needed admission to the ICU and reventilation. Sixty-seven patients had effective epidural analgesia and nine needed i.v. morphine by patient-controlled analgesia. The 30-day or in-hospital mortality was 2.6% (2 of 76). A further two patients died within 90 days, but after discharge. Respiratory complications were responsible for half of the overall morbidity (44.7%). Respiratory failure occurred in 6.5% (5 of 76) and acute respiratory distress syndrome in 2.6% (2 of 76). Both the in-hospital deaths occurred in patients requiring reventilation and resulted from respiratory complications. The following factors were found to be significant in the reventilated patients: duration of one-lung ventilation; forced expiratory volume in the first second; and ratio of forced expiratory volume in the first second/forced vital capacity. CONCLUSIONS Immediate extubation after two-stage oesophagectomy in patients with thoracic epidural analgesia is safe and associated with low morbidity and mortality. Patients can be managed in a high-dependency unit, thus avoiding the need for intensive care. This has cost-saving and logistical implications.
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Affiliation(s)
- M V Chandrashekar
- Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, UK
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Wayman J, Linsley A, Raimes SA. Oesophagectomy and total gastrectomy in a specialized district general hospital unit. Br J Surg 2003. [DOI: 10.1046/j.1365-2168.1999.1062l.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
The aim was to demonstrate that a low operative mortality rate (less than 5 per cent) is achievable for both oesophagectomy and total gastrectomy (TG) in a medium-sized district general hospital (DGH).
Methods
This was a prospective audit of all oesophagectomies and TGs performed in the first 5 years after establishment of a specialized upper gastrointestinal surgical–anaesthetic team.
Results
Some 82 procedures were undertaken, all by the same surgical team. Forty patients (median age 66 (range 41–76) years) underwent subtotal oesophagectomy (STO) using the two-stage approach. Forty-two patients (median age 68 (range 35–80) years) underwent TG using a left thoracoabdominal approach in four and an abdominal approach in 38. There were no deaths in hospital or within 30 days for either procedure. Two patients in each group died within 90 days: one from myocardial infarction and one from paraneoplastic syndrome after STO; one from pulmonary embolism and one from malignant adhesive obstruction after TG. There was one anastomotic leak in each group. Four patients required a second procedure: for a postoperative bleed, a thoracic duct leak and a feeding jejunostomy (one patient each) after STO; and for drainage of a left subphrenic abscess after TG.
Conclusion
It is reasonable to aim for an operative mortality rate of under 5 per cent for both STO and TG even in a DGH treating relatively small numbers of patients. Preoperative assessment and peroperative management by a single surgical–anaesthetic team, use of epidural analgesia and treatment in dedicated ward areas are all contributory factors. Clinical, audit and research links to the Northern Oesophago-Gastric Cancer Unit in Newcastle have ensured a uniformity of care across the region.
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Affiliation(s)
- J Wayman
- Department of Surgery, Cumberland Infirmary, Carlisle, UK
| | - A Linsley
- Department of Anaesthesia, Cumberland Infirmary, Carlisle, UK
| | - S A Raimes
- Department of Surgery, Cumberland Infirmary, Carlisle, UK
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Wayman J, Bennett MK, Raimes SA, Griffin SM. The pattern of recurrence of adenocarcinoma of the oesophago-gastric junction. Br J Cancer 2002; 86:1223-9. [PMID: 11953876 PMCID: PMC2375328 DOI: 10.1038/sj.bjc.6600252] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2001] [Revised: 01/20/2002] [Accepted: 02/25/2002] [Indexed: 01/09/2023] Open
Abstract
Knowledge of the pattern of recurrence of surgically treated cases of adenocarcinoma of the oesophago-gastric junction is important both for better understanding of their biological nature and for future strategic planning of therapy. The aim of this study is to demonstrate and compare the pattern of dissemination and recurrence in patients with Type I and Type II adenocarcinoma of oesophago-gastric junction. A prospective audit of the clinico-pathological features of patients who had undergone surgery with curative intent for adenocarcinoma of oesophago-gastric junction between 1991 and 1996 was undertaken. Patients were followed up by regular clinical examination. Clinical evaluation was supported by ultrasound, computerised tomography, radio-isotope bone scan, endoscopy and laparotomy each with biopsy and histology where appropriate. One hundred and sixty-nine patients with oesophago-gastric junction tumours (94 Type I and 75 Type II) have been followed up for a median of 75.3 (57-133) months. One hundred and three patients developed proven recurrent disease. The median time to recurrence was 23.3 (14.2-32.4) months for Type I and 20.5 (11.6-29.4) for Type II cancers. The most frequent type of recurrence was haematogenous (56% of Type I recurrences and 54% of Type II) of which 56% were detected within 1 year of surgery. The most frequent sites were to liver (27%), bone (18%) brain (11%) and lung (11%). Local recurrence occurred in 33% of Type I cancer and 29% of Type II recurrences. Nodal recurrence occurred in 18 and 25% of Type I and Type II cancer recurrences, most frequently to coeliac or porta hepatis nodes (64%). Only 7% of Type I and 15% of Type II cancer recurrences were by peritoneal dissemination. Type I and Type II adenocarcinoma of the oesophago-gastric junction have a predominantly early, haematogenous pattern of recurrence. There is a need to better identify the group of patients with small metastases at the time of diagnosis who are destined to develop recurrent disease in order that they may be spared surgery and those with micro metastases in order that they can be offered multi-modality therapy including early post operative or neo-adjuvant chemotherapy.
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Affiliation(s)
- J Wayman
- The Northern Oesophago-Gastric Cancer Unit, University of Newcastle upon Tyne, The Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
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Wayman J, Hayes N, Raimes SA, Griffin SM. Prescription of proton pump inhibitors before endoscopy. A potential cause of missed diagnosis of early gastric cancers. Arch Fam Med 2000; 9:385-8. [PMID: 10776369 DOI: 10.1001/archfami.9.4.385] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Early gastric cancer is frequently seen with nonspecific dyspeptic symptoms and subtle endoscopic features. Treatment at this stage of the disease produces a high chance of cure. If the diagnosis is missed at this early stage, then the prognosis may be much poorer depending on the subsequent delay in reaching a diagnosis. OBJECTIVES To report the healing effect of proton pump inhibitors on early gastric cancer. METHODS This article reports a case series of 7 patients with ulcerated early gastric cancers indistinguishable as malignant gastric ulcers at endoscopy who were inadvertently prescribed a short course of a proton pump inhibitor prior to a second confirmatory endoscopy. The cases studied were patients with dyspeptic symptoms referred from primary care physicians for upper gastrointestinal endoscopy. RESULTS In each case the patient became asymptomatic, the endoscopic signs seen at the first endoscopy had resolved, and the lesions could not be recognized even by an experienced endoscopist. If the proton pump inhibitors had been prescribed by the referring physician before the first endoscopy, the diagnosis probably would have been missed. These cases demonstrate the potentially serious masking effect of prescribing a short course of these drugs before making an endoscopic diagnosis. Even though the patient has been referred for endoscopy, the endoscopist may fail to identify the lesion and thus miss the diagnosis. CONCLUSIONS Primary care physicians must resist the pressures to prescribe proton pump inhibitors before endoscopy, particularly in patients older than 45 years, if the diagnostic yield of gastric cancer in the early curable stages is to be maximized.
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Affiliation(s)
- J Wayman
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Queen Victoria Infirmary, Newcastle upon Tyne, England
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9
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Karat D, Brotherick I, Shenton BK, Scott D, Raimes SA, Griffin SM. Expression of oestrogen and progesterone receptors in gastric cancer: a flow cytometric study. Br J Cancer 1999; 80:1271-4. [PMID: 10376983 PMCID: PMC2362374 DOI: 10.1038/sj.bjc.6990497] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Increased expression of oestrogen (ER) and progesterone (PR) receptors have been reported in gastric adenocarcinoma, although results have been variable. Immunohistochemical staining methodologies, in particular in the detection of ER, have been inconsistent with many tumours being classified ER-negative. In this study we have used flow cytometry to quantify expression of ER and PR in gastric adenocarcinoma and examine their relationships with established prognostic indicators. Cytokeratin-positive cells obtained from tumour biopsies of 50 patients with gastric cancer and ten control patients were labelled with biotinylated ER or PR antibodies followed by streptavidin PE. Flow cytometry was seen to increase the detection of ER levels in gastric cancer with more receptor-positive patients in this study than in results published to date. We believe this is related to the sensitivity of the flow cytometric assay with the detection of small shifts in ER level detected using cytokeratin gating. On analysis, the data showed no significant correlations with tumour stage and grade, and no differences were seen between normal mucosa and gastric cancer samples.
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Affiliation(s)
- D Karat
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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10
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Abstract
BACKGROUND A thoracoabdominal approach has traditionally been described for the resection of tumours of the gastric cardia. The aim of this study was to evaluate a transhiatal approach for resection of cancers of the gastric cardia. METHODS Twenty consecutive patients undergoing transhiatal gastro-oesophagectomy for cancer of the gastric cardia were studied. Data were collected prospectively with regard to operating time, operative blood loss, intensive care unit (ICU) stay, analgesia use, duration of hospital stay, and pathological details of resection margin clearance and lymph node yield. Results were compared with those of the 20 preceding patients for whom the same prospective information had been recorded following resection via the standard thoracoabdominal approach. RESULTS The transhiatal approach required a shorter operating time (median 190 (range 105-255) versus 280 (225-330) min; P = 0.004). It resulted in less blood loss (median 405 (180-2000) versus 1000 (420-3200) ml; P = 0.03) and fewer days in the ICU (median 0 (0-31) versus 2 (1-8) days; P = 0.005) despite being performed in an older patient population (median 71 (43-78) versus 63 (59-70) years; P = 0.016). There was no difference in either the lymph node harvest or length or involvement of upper resection margins. CONCLUSION The transhiatal approach to the resection of tumours at the gastric cardia is a valid and safe alternative to the standard thoracoabdominal technique. This technique avoids thoracotomy and its associated morbidity and is accompanied by reduced blood loss, decreased operating time and a shorter ICU stay.
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Affiliation(s)
- J Wayman
- Northern Oesophago-Gastric Cancer Unit, Cumberland Infirmary, Carlisle and Royal Victoria Infirmary, Newcastle upon Tyne, UK
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11
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Abstract
Many patients undergoing surgery for gastric carcinoma will develop peritoneal metastases. A method to identify those patients at risk of peritoneal recurrence would help in the selection of patients for adjuvant therapy. Peritoneal cytology has received little attention in the West, but may prove a useful additional means of evaluating patients with gastric cancer. The aims of this study were to evaluate sampling techniques for peritoneal cytology in patients with gastric cancer, to assess the prognostic significance of free peritoneal malignant cells and to discover the effect of the operative procedure on dissemination of malignant cells. The study is based on 85 consecutive patients undergoing surgical treatment of gastric cancer and followed up for 2 years or until death. Peritoneal cytology samples were collected at laparoscopy, and at operation prior to resection by intraperitoneal lavage and serosal brushings. After resection, samples were taken by peritoneal lavage, imprint cytology of the resected specimen and post-operatively by peritoneal irrigation via a percutaneous catheter. Malignant cells were diagnosed by two independent microscopists. Preoperative peritoneal lavage yielded malignant cells in 16 out of 85 cases (19%). The yield of free malignant cells was increased by using serosal brushings (by four cases) and imprint cytology (by two cases); all of the cases had evidence of serosal penetration. One serosa-negative case exhibited positive cytology in the post-resection peritoneal specimen in which the preresection cytology specimen was negative. Survival was worse in the cytology-positive group (chi2 = 25.1; P< 0.0001). Among serosa-positive patients, survival was significantly reduced if cytology was positive, if cases yielded by brushings and imprint cytology were included (log-rank test = 8.44; 1 df, P = 0.004). In conclusion, free peritoneal malignant cells can be identified in patients with gastric cancer who have a poor prognosis; the yield can be increased with brushings and imprint cytology in addition to conventional peritoneal lavage. Evaluation of peritoneal cytology by these methods may have a role in the selection of patients with the poorest prognosis who may benefit most from adjuvant therapy.
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Affiliation(s)
- N Hayes
- The Northern Oesophago-Gastric Cancer Unit, The Royal Victoria Infirmary, Newcastle upon Tyne, UK
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12
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Hayes N, Ng EK, Raimes SA, Crofts TJ, Woods SD, Griffin SM, Chung SC. Total gastrectomy with extended lymphadenectomy for "curable" stomach cancer: experience in a non-Japanese Asian center. J Am Coll Surg 1999; 188:27-32. [PMID: 9915239 DOI: 10.1016/s1072-7515(98)00274-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- N Hayes
- Department of Surgery, Prince of Wales Hospital, Hong Kong, China
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13
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Griffin SM, Raimes SA. Proton pump inhibitors may mask early gastric cancer. Dyspeptic patients over 45 should undergo endoscopy before these drugs are started. BMJ 1998; 317:1606-7. [PMID: 9848895 PMCID: PMC1114430 DOI: 10.1136/bmj.317.7173.1606] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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14
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Karat D, Wayman J, Hayes N, Raimes SA, Griffin SM. Screening young people for gastric cancer. Gut 1998; 43:586-7. [PMID: 9882194 PMCID: PMC1727288 DOI: 10.1136/gut.43.4.586b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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15
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Abstract
Lymph node metastasis in patients with early gastric cancer was evaluated prospectively to determine whether radical (D2) lymphadenectomy is appropriate in such cases. Twenty-eight (18 per cent) of 156 patients having surgery for gastric cancer had early disease. Lymph node metastasis was found in 12 of the 28 patients. Metastasis was more likely in submucosal than mucosal early gastric cancer (nine of 14 versus three of 14; P = 0.024, Fisher's exact test). In two of three patients with metastasis at the N2 level, the N1 nodes were entirely clear. This study shows a higher incidence of lymph node metastasis than has been reported previously in both the UK and Japan. The high incidence of lymph node metastasis in early gastric cancer supports the continuing use of radical lymphadenectomy in patients who are fit for such major surgery.
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Affiliation(s)
- N Hayes
- Oesophago-Gastric Cancer Unit, Newcastle General Hospital, Newcastle upon Tyne, UK
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16
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Ng EK, Chung SC, Lau JT, Sung JJ, Leung JW, Raimes SA, Chan AC, Li AK. Risk of further ulcer complications after an episode of peptic ulcer bleeding. Br J Surg 1996; 83:840-4. [PMID: 8696756 DOI: 10.1002/bjs.1800830635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
To identify the risk factors for developing recurrent ulcer complications after recovery from an episode of peptic ulcer bleeding 611 patients admitted with peptic ulcer bleeding were studied. Some 557 (91 per cent) were discharged without operation. A total of 22 patients were lost to follow-up and five were excluded as maintenance H2 blockers were required. Of the remaining 530 patients at risk, 169 (32 per cent) developed another complication (166 bleeding, three perforations) over a median follow-up period of 36 months. Patients with duodenal ulcers at the time of bleeding, previous history of peptic ulcer, previous bleeding, history of dyspepsia longer than 3 months, and a short interval between previous ulcer complications and the index bleed were more likely to develop further complications. Sex, age, smoking, coexisting illness, non-steroidal anti-inflammatory drugs intake and time taken to achieve ulcer healing had no predictive value.
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Affiliation(s)
- E K Ng
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong
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Karat D, O'Hanlon DM, Hayes N, Scott D, Raimes SA, Griffin SM. Prospective study of Helicobacter pylori infection in primary gastric lymphoma. Br J Surg 1995; 82:1369-70. [PMID: 7489168 DOI: 10.1002/bjs.1800821025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- D Karat
- Department of Surgical Gastroenterology, Newcastle General Hospital, Newcastle upon Tyne, UK
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Hayes N, Shaw IH, Raimes SA, Griffin SM. Comparison of conventional Lewis-Tanner two-stage oesophagectomy with the synchronous two-team approach. Br J Surg 1995; 82:following 426. [PMID: 7795987 DOI: 10.1002/bjs.1800820361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Twenty-seven patients with oesophageal carcinoma had subtotal oesophagectomy by the Lewis-Tanner operation (group 1, n = 14) or a synchronous modification (group 2, n = 13). Synchronous operations were completed more quickly (230 versus 305 min, P < 0.01), but with more time spent under single-lung anaesthesia (160 versus 120 min, P < 0.01) and a greater fall in systolic blood pressure during hiatal manipulation (60 versus 30 mmHg, P < 0.01). Operative blood loss was not significantly greater in group 2, but the total volume of blood transfused in the peri-operative period was greater in this group (5 versus 3 units, P < 0.01). Four patients in group 1 suffered significant postoperative complications, compared with seven in group 2; three postoperative deaths occurred in group 2. This study suggests that the synchronous two-team oesophagectomy produces a higher incidence of complications than the conventional operation. Continued use of the Lewis-Tanner two-stage oesophagectomy is recommended for patients with carcinoma of the oesophagus.
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Affiliation(s)
- N Hayes
- Department of Surgical Gastroenterology, Newcastle General Hospital, Newcastle upon Tyne, UK
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Abstract
Twenty-seven patients with oesophageal carcinoma had subtotal oesophagectomy by the Lewis-Tanner operation (group 1, n = 14) or a synchronous modification (group 2, n = 13). Synchronous operations were completed more quickly (230 versus 305 min, P < 0.01), but with more time spent under single-lung anaesthesia (160 versus 120 min, P < 0.01) and a greater fall in systolic blood pressure during hiatal manipulation (60 versus 30 mmHg, P < 0.01). Operative blood loss was not significantly greater in group 2, but the total volume of blood transfused in the perioperative period was greater in this group (5 versus 3 units, P < 0.01). Four patients in group 1 suffered significant postoperative complications, compared with seven in group 2; three postoperative deaths occurred in group 2. This study suggests that the synchronous two-team oesophagectomy produces a higher incidence of complications than the conventional operation. Continued use of the Lewis-Tanner two-stage oesophagectomy is recommended for patients with carcinoma of the oesophagus.
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Affiliation(s)
- N Hayes
- Department of Surgical Gastroenterology, Newcastle General Hospital, Newcastle upon Tyne, UK
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Robertson CS, Chung SC, Woods SD, Griffin SM, Raimes SA, Lau JT, Li AK. A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy for antral cancer. Ann Surg 1994; 220:176-82. [PMID: 8053740 PMCID: PMC1234357 DOI: 10.1097/00000658-199408000-00009] [Citation(s) in RCA: 247] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The authors determined if more radical surgery with extended lymphadenectomy improves the results of gastrectomy in patients with adenocarcinoma of the gastric antrum. SUMMARY BACKGROUND DATA The overall survival in patients with gastric cancer is disappointing. Improved survival has been reported by Japanese authors. Whether this is because of a higher number of early gastric cancers in the Japanese series, different biologic behavior in Asians, or the adoption of radical surgery with lymphadenectomy remains unclear. METHODS R1 subtotal gastrectomy with omentectomy and R3 total gastrectomy (omentectomy, splenectomy, distal pancreatectomy, lymphatic clearance of the celiac axis, and skeletonization of vessels in the porta hepatis) were evaluated in a prospective, randomized comparison. RESULTS Fifty-five patients were randomized--25 to the R1 group and 30 to the R3 group. The two groups were comparable for age, sex, tumor size, TNM stage, and length of follow-up. The R3 group had a longer operating time (140 vs. 260 min; p < 0.05), a greater transfusion requirement (0 vs. 2 units, p < 0.05) and a longer hospital stay (8 vs. 16 days; p < 0.05) (medians; Mann-Whitney U test). The only postoperative death was in the R3 group and was caused by intra-abdominal sepsis. Fourteen patients in the R3 group developed left subphrenic abscesses. There were no major complications in the R1 group. Overall survival was significantly better in the R1 group (median survival estimated by Kaplan-Meier method, 1511 vs. 922 days, p < 0.05, log-rank test). CONCLUSIONS R3 total gastrectomy can be performed with a low mortality, but it has a high morbidity because of intra-abdominal sepsis. The data do not support the routine use of R3 total gastrectomy for treatment of patients with antral cancer.
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Affiliation(s)
- C S Robertson
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin
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Hayes N, Raimes SA, Griffin SM. Laparoscopic vagotomy: an operation for the 1990s? Ann R Coll Surg Engl 1994; 76:211. [PMID: 8017819 PMCID: PMC2502284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Hayes N, Griffin SM, Raimes SA. Surgical treatment for adenocarcinoma of the stomach. Lancet 1993; 342:1299-300. [PMID: 7901601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Stock SE, Raimes SA, Griffin SM. Laparoscopic truncal vagotomy without drainage. Br J Surg 1993; 80:1080; author reply 1081. [PMID: 8402079 DOI: 10.1002/bjs.1800800861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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25
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Chisholm EM, Raimes SA, Leong HT, Chung SC, Li AK. Proximal gastric vagotomy and anterior seromyotomy with posterior truncal vagotomy assessed by the endoscopic congo red test. Br J Surg 1993; 80:737-9. [PMID: 8330161 DOI: 10.1002/bjs.1800800625] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The completeness of vagotomy following proximal gastric vagotomy or anterior seromyotomy with posterior truncal vagotomy was assessed prospectively in 48 patients using the intraoperative congo red test. Pentagastrin (6 micrograms/kg) was given subcutaneously before the assessment. An endoscope was passed into the stomach and 180 ml congo red solution washed over the gastric mucosa. Continuing acid production was indicated by the appearance of a black colour (pH < 3) 2 min after introduction of the dye. A grading system was adopted where grades I and II showed little black discoloration and grades III and IV showed increasing areas of discoloration indicating that further denervation was required. All 20 patients undergoing anterior seromyotomy with posterior vagotomy were classified as grade I. Fifteen of an initial 23 patients receiving proximal gastric vagotomy were grade III or IV. Following division of either the right gastroepiploic nerve or the posterior vagal trunk, 22 patients improved to grade I (16) or II (six). In the subsequent five proximal vagotomies, modification of the dissection produced grade I results. Anterior seromyotomy with posterior truncal vagotomy gave consistently complete vagotomy. The congo red test highlighted major differences in the adequacy of vagotomy achieved using various dissection techniques during proximal gastric vagotomy. The test is a useful, reproducible and simple intraoperative method for assessing the completeness of denervation.
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Affiliation(s)
- E M Chisholm
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories
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Abstract
Truncal vagotomy and drainage is still the commonest operation for duodenal ulcer in the United Kingdom, despite its known association with diarrhoea. The frequency and severity of diarrhoea were compared in 102 randomly selected men 10 or more years after truncal vagotomy and pyloroplasty (TVP) and a control group of 62 men taking long-term maintenance cimetidine treatment 2 or more years after healing of duodenal ulcer. 53% of the TVP group still had diarrhoea attacks compared with only 7% of the cimetidine group (p less than 0.001). Of the TVP patients, 11% had continuous diarrhoea and a further 22% at least one attack a week. 24% were displeased with the change in bowel function, and 8% complained that diarrhoea still seriously affected their lives. This side-effect is unacceptable and truncal vagotomy should now be avoided whenever possible.
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Abstract
A refinement of the technique for constructing the temporary loop ileostomy using a subcutaneous absorbable bridge is described. This leaves the skin surface uncluttered and allows immediate fitting of a watertight appliance. Clinical experience in 22 patients confirms that this is a safe, simple defunctioning stoma with few complications and in our practice has also replaced the loop colostomy as the covering stoma for difficult colorectal anastomoses.
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