Validation of a modified GTNM classification in peri-junctional oesophago-gastric carcinoma and its use as a prognostic indicator.

AIM: A modified GTNM classification (with additional T and N subdivisions) has been used for many years. The aim of this paper was to validate this classification in a group of patients with oesophago-gastric carcinoma and to see if the more detailed information may be useful. METHOD: The 3-year survival of 139 consecutive patients who survived resection has been related to the individual values of the modified and international classifications. RESULTS: A step-wise reduction in the survival was found with increasing values of G, T, N and M. The international T3 value yielded a 17.7% survival rate, when subdivided, rates of 37.5%, 17.3% and 3.2% were found. The international N1 value yielded a rate of 12.9% which subdivided into rates of 25.0%, 18.7% and 7.5%. CONCLUSION: If these results are repeated in a larger and more detailed study, this modified classification may provide added information when discussing prognosis and management.

Should we continue oesophageal surgery in a district general hospital? A review of 200 consecutive cases.

A series of 200 oesophageal resections is presented. The results show that acceptable standards are obtainable in a district general hospital (DGH) thus favouring the suggestion that such services could be organised by 'networking' rather than centralisation. This avoids the disadvantages to many DGH patients which follow centralisation.

Anatomical variations of the extrahepatic biliary tree: review of the world literature.

The anatomy facing a surgeon during cholecystectomy involves complex relationships between the hepatic artery, extrahepatic biliary tree, and gallbladder. A sound knowledge of the normal anatomy of the extrahepatic biliary tract is thus essential in the prevention of operative injury to it. Equally important, however, is an understanding of congenital variation of biliary and vascular anatomy, as the literature abounds with reports of specific anatomical variations, and their operative implications. This article reviews the world literature on congenital variation of extrahepatic biliary anatomy.

Quality-of-life study on four patients who underwent esophageal resection and delayed reconstruction for Boerhaave's syndrome.

Boerhaave's syndrome is the condition of spontaneous rupture of the esophagus as a consequence of the strain of emesis with or without predisposing esophageal disease. It is a condition with high mortality. We describe four patients who underwent a transthoracic esophagectomy to remove the rupture of the intrathoracic esophagus, closure of the esophageal gastric junction, fashioning of a feeding gastrostomy, and formation of a left cervical esophagostomy. Three patients underwent reconstruction with subcutaneous colon. We suggest that this method of management may be considered where primary repair is impossible in those patients too ill for prolonged reconstruction or as a salvage procedure where other methods have failed. The poor quality of life after esophagectomy is improved by reconstruction. Other surgical options include covering the repaired opening with a circumferential wrap of pleura, chest wall muscle, or omentum or closing the repair around a T-tube of large caliber. Esophageal exclusion using absorbable staples is another approach.

Congenital anatomical abnormalities of the extrahepatic biliary duct: a personal audit.

Awareness of variations in the anatomy of extrahepatic bile ducts may be important in preventing iatrogenic injury to the duct system during cholecystectomy. Their delineation, before or during surgery is therefore considered mandatory in this surgical unit, and a policy of always performing a per-operative cholangiogram has allowed us to evaluate the duct system in a retrospective review of 2080 cases. Twelve surgically significant anatomical variations were found, consisting of absent cystic duct (three cases), abnormal termination of cystic duct (two into the right hepatic duct, and one into the left hepatic duct), one case of double cystic duct, and five cases of significant accessory bile ducts.

Solitary benign papilloma (papillary adenoma) of the cystic duct: a rare cause of biliary colic.

Benign tumours of the extrahepatic bile ducts are rare, mostly occurring in the common bile duct and hepatic ducts. Solitary papillomas occur mainly in the gallbladder or at the ampulla of Vater. Tumours of the cystic duct are extremely rare, and we are unaware of any reports of solitary papilloma of the cystic duct. Such a case in a 72-year-old woman is presented.

Accuracy of intraoperative staging in colorectal cancer.

In 216 patients with colorectal adenocarcinoma 'operative' and 'final' staging using Duke's classification were compared. The overall 'accuracy' of operative staging was 66% with 17% of tumours understaged and 17% overstaged. The major error was found in nodal staging. If selective peroperative adjuvant therapy is to be considered, efforts should be directed to improve operative nodal staging. Any recommendation for adjuvant perioperative chemotherapy based on operative staging alone will result in a significant number of patients having unnecessary treatment.

Some clinical and technical aspects of circular stapled anastomoses of rectum and oesophagus.

A complete 8-year experience using the circular stapling instrument is described; 109 rectal and 59 oesophageal anastomoses were performed. Intra-operative problems included two suspected rectal leaks, damage to the tissues in two patients when using too large an instrument, cardiac arrythmias in one patient, precipitated by contact between the heart and the instrument, one instrument/operator failure, and inversion of the muscle layer was incomplete in three oesophageal anastomoses. Postoperative complications included two leaks, seven strictures, seven abscesses and one patient required reoperation. There were no deaths attributable to the use of the instrument or the method of anastomosis. The instrument has allowed satisfactory anastomoses to be performed in relatively inaccessible sites.