Surgery for oesophageal carcinoma in the elderly

OBJECTIVE

There has been a gradual increase in the number of elderly patients referred for oesophageal surgery. The aim of this study is to review our experience with oesophageal cancer surgery in the elderly.

METHODS

Between January 1974 and December 1996, 591 patients (408 males, 183 females; mean age 66 years) underwent an oesophageal resection for carcinoma. 221 were aged greater than 70 years of age (group A) and 370 less than 70 (group B).

RESULTS

Total in hospital mortality was 8.8% (52/591). This has decreased to less than 5% over the last decade. There was no significant difference in perioperative morbidity or mortality between the groups (P = 0.11). When deaths from unrelated medical conditions were excluded, there was no significant difference in survival between the different age groups (P = 0.96).

CONCLUSION

Oesophageal surgery can be performed in a selected elderly population with a low operative morbidity and mortality. The survival benefit of resection is the same in the elderly as for younger patients.

Lung resection for the treatment of severe localised bronchiectasis in cystic fibrosis patients

BACKGROUND

A small proportion of cystic fibrosis patients develop severe localised bronchiectasis. When this persists despite maximal medical therapy it presents a difficult management problem. Lung transplantation cannot be justified. We report encouraging results in six patients with severe localised bronchiectasis and cystic fibrosis who underwent pulmonary resection.

METHODS

Each child had severe localised bronchiectasis despite maximal medical therapy. Intensive preoperative toilet was instituted and pulmonary resection undertaken when lung function was optimal.

RESULTS

There was a marked improvement in symptoms in every case. No significant long-standing morbidity was associated with the resection. There was no significant decrease in pulmonary function following resection.

CONCLUSION

Pulmonary resection should be considered in the management of severe localised bronchiectasis unresponsive to maximal medical therapy in cystic fibrosis patients.

Oesophagectomy for carcinoma of the oesophagus and oesophagogastric junction

OBJECTIVE

Oesophageal carcinoma has a poor prognosis; surgical resection remains the only chance of cure but is still associated with a significant morbidity and mortality. The aim of this study was to review the results of one surgeon for oesophageal resection for carcinoma of the oesophagus and oesophagogastric junction over a 23 year period.

METHODS

Between January 1974 and December 1996, 591 patients (408 males; 183 females; mean age 66 years) underwent an oesophageal resection for carcinoma of the oesophagus or oesophagogastric junction.

RESULTS

In hospital mortality was 8.8% (52/591). This has decreased to less than 5% for resections between 1985 and 1996. Non-fatal complications occurred in 21% of patients (123/591). Survival, including in hospital mortality (+/-SEM), was 53.98% (+/-2), 31.77% (+/-2) and 15.3% (+/-2) at 1, 2 and 5 years respectively.

CONCLUSION

Early mortality following oesophageal resection has fallen in recent years. Despite considerable experience, long term survival remains disappointingly low.

A randomized controlled trial of continuous extra-pleural analgesia post-thoracotomy: efficacy and choice of local anaesthetic

Controversy persists over the efficacy of intercostal nerve block administered through a tunnelled extrapleural catheter. We have undertaken a randomized, prospective double-blind trial of two different local anaesthetic regimes to evaluate the effect of this technique on post-thoracotomy pain relief and pulmonary function. Sixty-eight patients were randomized to receive bupivacaine 0.25% (n = 22), lignocaine 1% (n = 21) or 0.9% NaCl (saline) (n = 20) via an extrapleural catheter, inserted peroperatively. All patients underwent a standard posterolateral thoracotomy. Pain was assessed using a visual analogue pain score and by the requirement for opiate analgesia. Pulmonary function was measured using bedside spirometry. Pain scores were lower in the local anaesthetic groups at 24, 32 and 72 h compared with placebo (P < 0.05) and the total amount of opiate required was less than placebo for both lignocaine and bupivicaine (P < 0.05). Pulmonary function was better in the local anaesthetic groups throughout the post-operative period and was most pronounced at 24 h with a mean improvement of 30% for forced expiratory volume (FEV1), 24% for forced vital capacity (FVC) and 19% for peak expiratory flow rate (PEFR) compared with placebo. There was no significant difference between pain scores, opiate requirement or pulmonary function between lignocaine and bupivicaine. CT scanning demonstrated containment of the local anaesthetic in an extra-pleural tunnel. Extra-pleural infusion of local anaesthetics is a simple technique, with low risk of complications and provides effective pain relief as well as an improvement in post-operative pulmonary function. Lignocaine is equally as effective as bupivacaine and its use would result in some cost-saving.

Migration of pectus excavatum correction bar into the left ventricle

We present the case of a 19-year-old student who underwent correction of a pectus excavatum deformity using a pectus bar. At least 6 months following surgery, one end of the bar had migrated into his right ventricle, across the interventricular septum, to lie with its free end in the left ventricular cavity. This acted as a source of thrombus formation and lead to several systemic embolic events. The patient made a full recovery after removal of the bar. A review of the literature demonstrates that this has not been reported before.

Spontaneous oesophageal haematoma: a review of the difficult diagnosis

Three cases of spontaneous oesophageal haematoma are described, with particular emphasis on their confusing clinical presentation. CT scanning was found to be helpful in making a correct diagnosis. This led to conservative treatment and ultimate full recovery.

Spontaneous hypoglycaemia and pleural fibroma: role of insulin like growth factors

Spontaneous hypoglycaemia was the presenting feature of a man with a large subpleural fibroma. Preoperative and postoperative studies support the view that the tumour induced hypoglycaemia was due to the secretion of peptide hormones by the tumour.

Late presentation of diaphragmatic hernia: a missed diagnosis

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Comparative trial of rectal indomethacin and cryoanalgesia for control of early postthoracotomy pain

A randomised double blind trial was carried out over the first two days after thoracotomy to compare the analgesic effects of rectal indomethacin 100 mg administered eight hourly, cryoanalgesia, and a combination of both of these with the effects of conventional intramuscular opiate analgesia. Pain scores were significantly reduced with both rectal indomethacin alone and cryoanalgesia alone; these treatments had an additive effect when used in combination. Pain on movement was significantly increased, and indomethacin was more effective in reducing this than cryoanalgesia. Groups receiving either indomethacin alone or the combination treatment required significantly less opiate on the first day and exhibited improved peak flow values over the first two days. It is concluded that rectal indomethacin, in this dosage, can provide good, safe analgesia after thoracotomy with minimum administrative difficulty. When used as an adjunct to cryoanalgesia it has an additive effect. There are many potential uses for this drug in other branches of surgery.