The "two-week wait" referral pathway allows prompt treatment but does not improve outcome for patients with oesophago-gastric cancer.

INTRODUCTION: The Two Week Wait Referral Service (2WW) has been implemented as a means of fast-tracking patients with suspected upper gastrointestinal cancers for endoscopy. Whether or not it impacts on the outcome of these patients is unclear. The aim of this study was to compare the outcome of patients referred through 2WW with that of patients with oesophago-gastric cancer identified through alternate referral pathways (routine, emergency). METHODS: The study population was 340 patients with oesophago-gastric carcinoma (gastric 154) diagnosed during the time period 01/2006-12/2007 at University Hospitals of Leicester NHS Trust. Data were collected prospectively by the MDT co-ordinator and analysed retrospectively. RESULTS: 135 of the 340 patients with oesophago-gastric cancer were diagnosed through the 2WW, 115 patients through routine referral pathways, and 90 patients were admitted on an emergency basis. Patients referred through 2WW had a median referral to 1st treatment time of 47 days (routine 79, emergency 28, p < 0.001 all group comparisons). The number of patients treated with potentially curative intent was 37 of 135 for the 2WW, 42 of 115 for the routine referrals and 10 of 90 for patients admitted as emergencies. The corresponding median survivals for the groups were 239 days (2WW), 405 days (routine) and 121 days (emergency), p < 0.001 (log rank). CONCLUSIONS: Referral by 2WW resulted in more rapid treatment than routine referral but this did not translate into an improvement in survival. This suggests that the targeting of endoscopy to patients with alarm symptoms is flawed and a less selective approach should be promoted if curable cancers are to be detected.

The early use of PET-CT alters the management of patients with esophageal cancer.

INTRODUCTION: The routine use of positron emission tomography-computed tomography (PET-CT) in the staging of patients with esophageal carcinoma remains contentious, with conflicting reports of its benefit. In our unit, PET-CT has been used routinely in the staging of all patients considered for radical therapy (surgery or chemoradiotherapy). Our aim was to determine the frequency with which PET-CT influenced decision making in the management of patients with carcinoma of the esophagus or gastroesophageal junction. METHODS: CT, PET-CT, and outcome information were collected on 38 patients considered for radical therapy. Patient proformas, with and without PET-CT findings, were constructed and each independently reviewed in a randomized and blinded fashion by five multidisciplinary team members (three surgeons, two oncologists) and a treatment strategy determined. RESULTS: PET-CT changed the staging for ten patients (26%). This translated into a change in management decision for seven patients (18%). The concordance between individual management plans and treatment intent was 79% for CT (150 of 190 decisions) and it was 92% for PET-CT (175 of 190 decisions). Full concordance between multidisciplinary team members was 66% with CT staging and 74% with the addition of PET-CT. CONCLUSION: The use of PET-CT early in the staging algorithm for esophageal carcinoma altered the staging for a quarter of patients and the management for a fifth of patients, supporting its inclusion early in the staging algorithm.

Laparoscopic repair of direct inguinal hernia: a new technique that reduces the development of postoperative seroma.

BACKGROUND: Seroma are common early postoperative complications encountered in laparoscopic inguinal hernia repair. Previous anecdotal evidence from our surgical practice suggested a lower incidence of postoperative seroma formation with direct hernia repairs when the lax transversalis fascia (TF) is inverted by tacking to the pubic ramus. We undertook a study to investigate whether TF inversion in this way reduces the incidence of postoperative seroma. METHOD: A total of 216 patients undergoing transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repairs from August 2003 to December 2005 were included in this prospective non-randomised controlled study. Surgeon 1 would routinely invert the TF whereas surgeon 2 would not. At follow-up the presence of postoperative seroma and pain was recorded. RESULTS: Mann-Whitney U test demonstrated no significant difference in terms of age, sex and time to follow-up between the surgeons' patient groups (P > 0.05), and Chi-square test demonstrated significantly that inversion of the TF is associated with a lower incidence of postoperative seroma (P < 0.05). There was no significant difference in terms of postoperative pain at follow-up. CONCLUSION: Inversion of the TF is associated with a statistically lower incidence of postoperative seroma, without increasing postoperative pain despite the use of one or two additional tacks.

Humidified gas prevents hypothermia induced by laparoscopic insufflation: a randomized controlled study in a pig model.

BACKGROUND: This experimental study evaluated whether humidification of warmed insufflated CO2 during laparoscopic procedures would resolve the problem of laparoscopy-induced hypothermia. METHODS: Changes in core temperature were quantified over a 3-h period of high-flow CO2 insufflation in a randomized, controlled trial of five pigs. Each animal was anesthetized and studied on three occasions under standardized conditions, acting as its own control by insufflation with no gas compared with insufflation by cool dry gas and heated humidified gas. RESULTS: Core temperatures after insufflation with heated humidified gas were no different from that of controls. After insufflation with cool dry gas, core temperature dropped by 1.8 degreesC, which was significantly more than the 0.6 degreesC drop experienced by control animals and those insufflated with heated humidified gas (p < 0.01). Calculations of the heat expended in evaporation of water were also performed. The temperature drop due to water evaporation alone in pigs insufflated with cool dry gas was calculated to be 1.5 degreesC. This compares favorably with the measured 1.2 degreesC temperature difference between these animals and the control group. CONCLUSIONS: The majority of heat lost during laparoscopic insufflation is due to water evaporation, and laparoscopic hypothermia may be prevented by using heated and humidified gas insufflation.

A negative herniogram does not exclude the presence of a hernia.

A retrospective review of 63 consecutive herniograms over a 3-year period was performed to assess the reliability in diagnosis of occult hernias. In all, 26 hernias were diagnosed in 23 patients, of which 13 were confirmed at operation. However, there were three false-positive results. Of the 38 negative herniograms, four proceeded to surgery with three positive hernia findings. We therefore found false-positive and false-negative rates of 18.7% and 7.9%, respectively. All of the false-positive results were in patients with a history of pain as the presenting complaint, while all of the patients with false-negative results had presented with a history of both pain and jump but no clinically detectable hernia. Our experience of this investigation is not as encouraging as others have reported.

Preliminary results of the use of intraperitoneal carbon-adsorbed mitomycin C in intra-abdominal malignancy.

Eleven patients suffering from intra-abdominal malignancy were treated with various doses of intraperitoneal mitomycin C adsorbed onto activated carbon particles. Seven of the patients underwent resection of their primary gastric tumour and all developed potentially life-threatening severe complications that proved to be fatal in four patients. The pattern of complications seen in these patients was unusual in patients undergoing gastrectomy and must be presumed to be secondary to the intraperitoneal mitomycin C. Intraperitoneal mitomycin C at a dose of 25 mg and 50 mg in the presence of an anastomosis or other suture line does not appear to be safe.

Anxiety in patients with symptomatic breast disease: effects of immediate versus delayed communication of results.

Immediate reporting of fine needle aspiration biopsy (FNAB) specimens has been introduced into many breast clinics; in others, women return to a later clinic to receive the result. This delay in communication of results may lead to elevated anxiety. This study compared anxiety levels in two groups having FNAB. One group received results at the initial clinic visit (n = 51), the other having delayed communication (n = 51). Anxiety was measured using the six-item short form of the Spielberger State-Trait Anxiety Inventory (STAI-SSF) and was administered before and after each consultation. Initial anxiety was high in both groups. Women with malignant results had higher post-communication anxiety compared with women with benign results. However, within the group with benign results (the vast majority), immediate communication was associated with a significantly greater fall in STAI-SSF scores from before to after the first consultation (U = 587.0; P < 0.02). There was no difference between the immediate and delayed communication among women with a malignant diagnosis (U = 26.0; P = 0.91). These results provide preliminary support for the more widespread introduction of a cytologist into breast clinics to allow immediate communication of results.

Which surgeons in a district general hospital should treat patients with carcinoma of the rectum?

There has recently been considerable media and medical interest in the apparent differences of the results of the surgical treatment of colorectal cancer by specialist and non-specialist colorectal surgeons. We have therefore audited and compared the results of the elective treatment of cancers of the rectum and distal sigmoid colon undertaken by two surgeons working in the same hospital, one a general surgeon with a vascular special interest and the other a colorectal specialist. Although our results demonstrate no difference in overall survival, the higher clinical leak rate and higher rate of palliative diversional surgery in the general surgeon's group lends some support to the argument that carcinoma of the rectum should be treated by surgeons with a special interest in colorectal surgery.

Evaluation of the safety of recombinant interleukin-2 (rIL-2) and rIL-2 plus 5-fluorouracil (5-FU) in the adjuvant treatment of gastric cancer patients.

Eight patients received either recombinant Interleukin-2 (rIL-2) alone or rIL-2 plus 5-Fluorouracil (5-FU) by constant infusion after undergoing potentially curative surgery for gastric cancer. rIL-2, given at a dose of 18 x 10(6) IU/m2/24 hours, was safely tolerated and only two episodes of WHO grade 3 toxicities occurred, both of which promptly responded to treatment and temporary interruptions of rIL-2 infusions. 5-FU infusions given at 12.5 mg/kg/24 hours did not alter the rebound lymphocytosis seen after completion of rIL-2 infusions. We conclude that the administration of rIL-2 and rIL-2 plus 5-FU to cancer patients recovering from major surgery is safe and well tolerated.

Changes in biochemical laboratory investigation in patients treated with constant infusion recombinant interleukin-2.

Eight patients with metastatic hypernephroma were treated with constant infusion recombinant Interleukin-2 (rIL-2), changes in renal and hepatic function and protein levels were monitored during 2 cycles of treatment. The rIL-2 infusion caused a reversible fall in ures and a non-reversible rise in creatinine. Liver function tests (bilirubin, ALT, ALP and GGT) rose during rIL-2 treatment and had returned to pretreatment levels 3 weeks after the last day of rIL-2. There was also a reversible fall in serum protein levels during rIL-2 infusion. Although constant infusion rIL-2 ameliorated much of the severe toxicities usually seen with high-dose bolus rIL-2, the non-reversible rise in serum creatinine levels is not a previously reported feature of rIL-2 therapy.

Anti-CD3 enhancement of cellular cytotoxicity in cancer patients treated with interleukin-2.

Anti-CD3 monoclonal antibody was found to enhance non-MHC restricted cellular cytotoxicity in vitro in the peripheral blood mononuclear cells from normal healthy individuals. This effect was dose dependent (maximal at 0.11 micrograms/ml) and was complete within 30 minutes. Peripheral blood mononuclear cells from 4 out of 8 cancer patients treated with Interleukin-2 were deficient in their ability to respond to anti-CD3 in vitro. In contrast, peripheral blood mononuclear cells from cancer patients who subsequently displayed a tumour response to Interleukin-2, were able to respond to anti-CD3 by enhanced non-MHC restricted cellular cytotoxicity. This study demonstrates the importance of CD3+ lymphocytes in the generation of antitumour activity following in vivo Interleukin-2 administration and the ability of CD3+ve lymphocytes to respond to anti-CD3 in vitro may indicate those patients who would benefit from Interleukin-2 therapy.

Infective arthritis secondary to bladder outflow obstruction.

We describe two cases of septic arthritis occurring in association with lower urinary tract infection in elderly men. In both cases the organism isolated from both the joint and the urine was Staphylococcus aureus. Further investigation of the urinary tract in both individuals identified bladder outflow obstruction secondary to benign prostatic hyperplasia predisposing them to infection. The urinary tract should be suspected as a focus of infection in septic arthritis in elderly men and further investigation of the urinary system may disclose a surgically correctable lesion.