Quality of Life in patients with resected oesophageal cancer.

Quality of Life (QL) is hard to assess and seldom measured in patients having carcinomas with an unfavourable prognosis. Oesophageal cancer is one of the malignancies with a low 5-year survival rate. Dysphagia (problems in swallowing food) is considered to be the most important indicator of QL in patients with oesophageal carcinoma. Moreover, the psycho-social aspects and subjective QL in cancer have recently gained importance. The present study investigated QL in a 132 patients with oesophageal cancer. Eighty-three of them had a surgical operation (removal of part of the oesophagus and part of the stomach, followed by a reconstruction of the digestive tract). Sixty-seven patients filled in questionnaires before and after the operation. Complete sets of data were obtained from 62 patients. Time interval between operation and postoperative assessment varied from 3 to 7 months. Indicators of QL were: Psychological Distress, Physical Symptoms, Global Evaluations, Activity Level, Swallowing Problems and Food Intake. Swallowing Problems showed moderate correlations with the other QL indicators. Physical Symptoms increased, whereas the Activity Level, Psychological Distress, and Swallowing Problems decreased; Global Evaluations remained unaltered.

An unusual cause of acute appendicitis.

A case is presented of a patient with a metastasis of cardia carcinoma to the appendix, causing acute appendicitis. Survey of the literature shows that metastasis to the appendix is very rare. When present, it is likely to be the cause of appendicitis by obstruction of the lumen.

A modified pectoralis muscle flap for closure of postpneumonectomy esophagopleural fistula: technique and results.

In surgical treatment of late postpneumonectomy esophagopleural fistula, closure of the empyema space is of prime importance. A wide thoracoplasty and ample decapitation of the empyema cavity allow sufficient room for a modified pectoralis muscle flap, which provides sufficient mass to obliterate the entire empyema cavity. We present the cases of 2 patients in whom an esophagopleural fistula occurring 3 and 16 years after pneumonectomy was successfully closed by this method.

Survival after resection for carcinoma of the oesophagus.

During the period 1978-1984, 525 patients referred with cancer of the oesophagus or gastro-oesophageal junction were assessed for operation and cure. After investigation, 276 patients were selected and operated upon, as a rule, 4 weeks after radiotherapy (40 Gy/4 weeks). In 224 patients (81 per cent) the oesophagus and cardia were resected and reconstructed with stomach (69 per cent), colon (21 per cent), free ileal graft (7 per cent) or Roux-en-Y-oesophagojejunostomy (3 per cent). The postresectional hospital mortality was 14 per cent in all patients and decreased to 5 per cent in 1983. Mortality was higher when the colon was used for reconstruction than when the stomach was used. By postresection staging, 82 patients were found to have stages I and II tumours and 142 patients stage III tumours. Estimated 3-year survival after resection for all male patients was 28 per cent and for all female patients was 42 per cent. Estimated 3-year survival for all patients treated for adenocarcinoma was 31 per cent. Survival was better for stages I and II patients with adenocarcinoma (52 per cent) than for stage III patients (18 per cent) (P less than 0.01). Estimated 3-year survival for all patients treated for squamous cell carcinoma was 33 per cent. Estimated 3-year survival was better for stages I and II patients with squamous cell carcinoma (48 per cent) than for stage III patients (25 per cent) (P less than 0.001). It can be concluded from this study that resection of oesophagus and cardia after radiotherapy offers hope for cure in a subgroup of patients with non-advanced oesophageal cancer. The operation can be performed with acceptable mortality by experienced surgeons, especially when the stomach is used for reconstruction.

Therapy of esophageal carcinoma. Results from the Joint Group on Esophageal Carcinoma in Rotterdam.

During the period 1978-1981 172 patients were referred to the Rotterdam Joint Group on Esophageal Carcinoma. Ninety-one patients were considered for combined therapy, comprising radiation therapy and surgery, and 10 patients refused surgery. The figures given in this material are actuarial survival values corrected for intercurrent death (the actuarial overall survival in parentheses). The 4-year survival in 69 patients who completed this treatment was 39 per cent (26%) (significantly better for women compared with men; significantly better for tumors less than 2 vertebrae compared with tumors greater than or equal to 2 vertebrae). The resectability rate was 85 per cent and the operation mortality rate 20 per cent. Thirty-eight patients had curative radiation therapy with a 4-year corrected survival of 5 per cent (3%). For palliative treatment, radiation therapy and endoscopic introduction of a Celestin tube were mostly used. The results of curative as well as of palliative treatment of esophageal carcinoma have shown improvement during the past decade compared with an earlier period.

Carcinoma of the esophagus: treatment results.

Of the 172 patients with carcinoma of the esophagus or the gastro-esophageal junction seen between January 1978 and January 1981, 69 patients had combined treatment, radiotherapy and resection, and 38 had curative radiotherapy. The remaining 65 were treated palliatively. The 4-year actuarial survival of the first two treatment groups was respectively 40% and 4%. The resectability rate of the operated patients was 84% with a post-operative mortality of 20%. The tumor size and sex were two important prognostic factors. Patients with combined treatment and a tumor size of less than two corresponding underlying vertebrae, had a 4-year actuarial survival of 60%.

Mural collagen in experimental reflux esophagitis in rats.

Changes in the collagen content of the esophageal wall in reflux esophagitis were studied in rats subjected to surgically induced and biochemically monitored pancreaticobiliary reflux into the esophagus. Reflux periods of 7, 14, 28, and 42 days were followed by a reflux-abolishing operation, which resulted in healing of the esophagitis. The collagen content of the esophageal wall at the end of the reflux period was higher than control values obtained from normal nonoperated rats, with a significant difference after 42 days of reflux. Strictures were not observed. After abolition of the reflux the esophageal collagen content showed an initial drop, but then increased with the period of observation to give a significant rise (P less than 0.05) as compared with control rats which had been subjected to 7, 28, and 42 days of reflux. The meaning of the results for the understanding of the sequelae of reflux esophagitis is discussed.

A plea for conservative treatment of large, unruptured omphaloceles.

Forty-six babies with an unruptured omphalocele were admitted over a 10-year period. The conservative treatment consisted of the application of mercurochrome or an antibiotic powder, while the primary surgical treatment consisted of either full-layer closure or silastic sac insertion. Liver containing omphaloceles were considered large. Of the 25 babies without associated life-threatening congenital anomalies, all 9 with a small omphalocele survived, irrespective of the method of treatment. Sixteen babies had a large omphalocele of which all 8 conservatively treated babies survived against only 4 of the 7 who underwent surgery. The remaining baby, weighting 960 g, died prior to treatment, due to respiratory distress. Eighteen of the 21 babies with associated life-threatening congenital anomalies died, irrespective the extent of the defect. Although the conservative treatment of the large defects did not result in an improved survival rate, therapy-related complications did not occur. From this study it appears that large unruptured omphaloceles should be treated conservatively. Babies not doing well with a small omphalocele or a large one treated conservatively, will have one or more major associated anomalies, necessitating urgent diagnosis and treatment.

Active trypsin and reflux oesophagitis: an experimental study in rats.

In order to clarify the role of active trypsin, bile acids and pepsin in reflux oesophagitis, a comparable series of experiments was performed in rats before and after reflux-inducing operations. Three control procedures were used--laparotomy (n = 10), oesophageal transection and reanastamosis (n = 7) and a Roux-en-Y reconstruction (n = 9)--and seven experimental procedures in order to produce gastric, bile and pancreatic reflux (G + B + P) (n = 9), gastric and pancreatic reflux (B + B) (n = 8), bile and pancreatic reflux (B + P) (n = 10), pancreatic reflux alone (P) (n = 9), gastric reflux alone (G) (n = 8), bile reflux alone (B) (n = 9) and gastric with bile reflux (G + B) (n = 9). Macroscopic and histologically confirmed oesophagitis was produced in groups G + B + P, G + P, B + P and P. The trypsin levels were significantly elevated in these groups, compared to both the control and other experimental groups (P less than 0.01). Bile acid levels were insignificantly different between the groups. Because these experiments involved vagal transection, no oesophagitis was found in the gastric juice reflux group. This study has shown for the first time a correlation between the presence of active trypsin in the oesophagus and the occurrence of oesophagitis. It is possible that active components of duodenal juice may contribute to the development of reflux oesophagitis in man.

Gastroschisis: factors affecting prognosis.

Over a ten-year period 21 children with gastroschisis were treated either with a direct full-layer closure or with a silastic sac closure of the abdominal wall defect. No mortality or longterm morbidity resulted from either form of therapy in the group of patients that had no anatomical interruption of the gastro-intestinal tract. Silastic sac closure did, however, result in a higher incidence of septicemia. In the group of patients that presented with an anatomical interruption of the G.I. tract, considerable mortality and morbidity resulted. The outcome in these patients was determined by the associated bowel lesion rather than by the gastroschisis as such.