Correlation between the current TNM staging and long-term survival after curative D1 lymphadenectomy for stomach cancer.

BACKGROUND AND AIMS: This study aims to assess the tumour-related factors that influence long-term survival after curative gastrectomy with standard D1 lymphadenectomy for patients with stomach cancer. PATIENTS AND METHODS: Patients who had undergone curative gastrectomy for carcinoma of the stomach at North Shore Hospital between 1990 and 2000 were identified from theatre records and the hospital database. Medical records were reviewed and included tumour location, type of operation, in-hospital mortality, gross morphology of tumour, histological type, and Helicobacter status; pathology slides were reviewed, and tumours were staged according to the new TNM staging. Patients were followed-up for 2-11 years. Length of survival was obtained for each patient from medical records or from family doctors. RESULTS: R0 gastrectomy was performed on 70 patients; median survival was 23 months, and all patients with early gastric cancer are currently still alive. T stage, nodal stage and histological type correlated significantly with survival, but multivariate analysis showed that T stage is the most significant predictor. Five-year survival was 26%. Significant survival difference was seen between T2a and T2b. CONCLUSION: Histological subtype, lymph node metastases and depth of invasion are factors that affect survival of patients with gastric cancer; however, depth of invasion is more important than other variables. Tumour location and type of gastrectomy has no effect on survival. The latest TNM classification (sixth edition) gives a better prognostication than the previous classification.

Patient satisfaction and symptom relief after anal dilatation.

Anal dilatation is used as a simple method of treatment and has been used for both anal fissure and haemorrhoids. This study examined longer-term results among a cohort of 162 patients, 132 of whom responded to a detailed questionnaire, an 82% response (66 patients were male; age range 17-75 years, median 42 years). Follow-up ranged from 16 months to 36 months (median 27 months) after anal dilatation (68 patients for fissure, 32 for haemorrhoids, and 32 for both). In the early months after dilatation, 83% had symptomatic improvement and 76% remained improved. Five (7%) patients with fissure and 11 with haemorrhoids (17%) required further hospital treatment, while 10% and 17%, respectively, had received further treatment from their general practitioners (GPs). Seventy-one percent said they would have a further anal dilation if symptoms recurred. There was no difference in results obtained by surgeons of different seniority. Complications--bleeding (29%) and difficulty controlling flatus (15%) or faeces (8%)--resolved in all cases. The results of anal dilatation for fissure are generally satisfactory in the longer term, with a trend toward better symptom relief in patients with fissure compared with those with haemorrhoids. We do not recommend anal dilatation as the sole treatment of patients with haemorrhoids, but it may be a useful adjunct to other treatments such as banding or sclerotherapy. Morbidity was generally acceptable and the majority of our patients would be prepared to have this procedure again if their symptoms were to return.

Hepatic cryotherapy and subsequent hepatic arterial chemotherapy for colorectal metastases to the liver.

This paper presents an experience of thirty consecutive patients with hepatic colorectal metastases who were treated with hepatic cryotherapy and subsequent hepatic arterial infusion (HAI) chemotherapy using 5 FU. Patients with colorectal metastases confined to the liver but not suitable for resection, and with liver involvement of less than 50% were offered the treatment. Prospective documentation of all patients was undertaken with data being recorded on a computerised database. Patients had a median of 6 (2-15) lesions with sizes ranging from 1-12 cm. There was no 30 day mortality. Postoperative complications developed in 8 patients but were followed by full recovery in all instances. Side effects from chemotherapy occurred in 23% of cycles. Twenty seven patients have died. Median survival from the time of cryotherapy was 18.2 months (7-34), or 23 months (9-44) from diagnosis of liver lesions. Hepatic cryotherapy with subsequent arterial chemotherapy is safe and well tolerated. The results suggest survival of patients with colorectal hepatic metastases can be improved by the use of this modality of treatment.

Bile duct imaging and injury: a regional audit of laparoscopic cholecystectomy.

BACKGROUND: The aim of the present study was to report details of practice with respect to bile duct imaging and bile duct injury. METHODS: A prospective audit of laparoscopic cholecystectomy (LC) was undertaken in the Otago region from the introduction of LC in 1991 through to December 1995. The audit includes all procedures done by all surgeons in public and private hospitals over the period without exclusion. RESULTS: Laparoscopic cholecystectomy was attempted in 929 patients and completed laparoscopically in 832 (89.6%). Intraoperative cholangiography (IOC) was undertaken with increasing frequency over the study period, from 5.9% in 1991 to 32.2% in 1995. The overall IOC rate for individual surgeons varied from 4.5 to 47.6%. The use of peri-operative endoscopic retrograde cholangiopancreatography (ERCP) increased with the introduction of LC but has plateaued at approximately 6%. A total of 15.4% of patients with one or more clinical indicators of choledocholithiasis underwent LC without any form of bile duct imaging. Eight main bile duct injuries (0.86%) and a further 18 bile leaks occurred (total bile duct injury rate 2.8%). Intra-operative cholangiography was attempted (unsuccessfully) in only one patient with main duct injury, although five of the eight injuries were recognized intra-operatively. CONCLUSION: This prospective regional audit demonstrates a gradual return to the use of IOC, a modest but stable reliance on peri-operative ERCP, and a higher than expected rate of bile-duct injury.

Hepatic cryotherapy for metastatic liver tumours.

Liver resection is the treatment of choice for resectable hepatic metastases; however, most patients have unresectable disease when diagnosed. Hepatic cryotherapy has been advocated to treat unresectable tumours in the liver although its precise role is still being evaluated. This article discusses mechanisms of action, technical considerations, current indications and the early results of cryotherapy in treating metastatic liver disease.

Consequences and costs of shutting off methadone.

In the face of rising fiscal conservatism, many states and localities with sizable addict populations have reduced or eliminated public funding for methadone maintenance (MM) programs and permitted private-fee-for-service programs to replace them. The social and economic costs of these changed funding policies with reference to the California experience were analyzed. A two-and-a-half year follow-up of a sample of San Diego MM clients (195 men, 129 women) terminated from a public subsidized program compared outcome results to clients from publicly funded MM programs in Orange, Riverside and San Bernardino counties (129 men, 131 women). In a secondary analysis, San Diego clients who transferred into private (fee-for-service) treatment programs were compared with those who did not transfer. Major adverse consequences were found for clients unable or unwilling to transfer to private programs: higher crime and dealing rates, more contact with the criminal justice system, and higher rates of illicit drug use were demonstrated by nontransfer clients. Moreover, the savings resulting from a reduction of MM program costs were nearly offset by increased direct costs for incarceration, legal supervision, and other government-funded drug treatment. Indirect costs were not assessed.

Ethnic differences in narcotics addiction. II. Chicano and Anglo addiction career patterns.

Part I of this series compared characteristics of 546 Chicanos and Anglo men and women methadone maintenance (MM) clients. In Part II, specific differences between Chicanos and Anglos are analyzed, by sex, for each of five stages in the addiction career: preexperimentation, experimentation addiction, initial MM treatment, and posttreatment. The analysis examines narcotic and other drug use, arrest, incarceration and legal supervision histories, criminal involvement, employment, interpersonal relationships, and treatment history. Whereas preaddiction differences between addicts parallel ethnic differences found in the general population, after addiction occurs the similarities are greater than the dissimilarities between ethnic groups, except for Chicanas. Chicanos appear to continue to function as part of their community after addiction, but Chicanas appear to risk becoming marginal. Treatment outcomes for Chicanos were, in general, less successful than for Anglos.

Ethnic differences in narcotics addiction. I. Characteristics of Chicano and Anglo methadone maintenance clients.

This paper reviews the research literature comparing Chicano (Mexican American) to Anglo heroin addicts. In addition, characteristics of 546 Chicano and Anglo men and women who had been clients of southern California methadone maintenance programs in 1978 are compared. Background factors examined include nativity, family socioeconomic status (SES) and family interpersonal relationships, education, and gang membership. Lifetime characteristics and status at follow-up interview are reported with particular attention to legal status, criminality, employment, and interpersonal relationships. Drug experimentation history and circumstances surrounding narcotics initiation are also compared. Most observed differences prior to addiction are similar to ethnic differences found in the general population. Part II analyzes ethnic differences progressing through five stages of the addiction career.

Similarity of behavior within addict couples. Part II. Addiction-related variables.

The similarity of behavioral patterns within addict couples before, during, and after a relationship is the focus of this paper. The correlations between partners in real and artificially constructed (pseudo) couples for employment, criminal activities, and other behaviors are examined. The effect of a relationship on behavior is also assessed before, during, and after treatment. Significant correlations during real relationships were found for employment, welfare, and illegal income. Joint couple entry into treatment appears to be more effective for women than men. Similarity within couples disappears when the relationship ends.

Similarity of behavior within addict couples. Part I. Methodology and narcotics patterns.

The development and initial assessment of a methodology for measuring the similarity of behavioral patterns within addicted couples over the duration of a relationship is presented. Two subsamples of addicts from methadone maintenance programs in southern California were established: one of couples who had a real relationship during their addiction and treatment careers, and a group of pseudocouples (matched as closely as possible) created from unrelated clients in the same programs. Narcotics use, abstinence, and support patterns are analyzed for couples before, during, and after their relationship. When it occurs during the relationship, treatment effects are also analyzed.

Sex differences in addict careers. 3. Addiction.

The process and correlates of addiction prior to treatment are examined for a sample of 546 women and men methadone maintenance clients. Narcotic addiction careers for women (defined both as from first daily use to first treatment intervention, and from first daily use to last daily use of heroin) were shorter than those for men, and women entered treatment earlier. However, the narcotic drug use patterns for women were not substantially different from those for men (including mean percentage of time using, number of times abstinent, number of relapses, and so forth). Narcotics use for many women was influenced by a spouse or partner, but some also reported increased use for hedonistic reasons. Criminal behaviors increased for both women and men after addiction, and the major sex difference was the type of crime committed. Differences for women and men for employment, welfare, and interpersonal relationships reflected patterns found in the larger society.

Sex differences in addict careers. 4. Treatment.

Comparisons of behaviors during treatment were made between a sample of women and a sample of men methadone maintenance clients. Women in this study exhibited high motivation for treatment. Overall, however, small differences were found between the sexes with respect to treatment process and outcome measures. The observed differences that were significant included use of substances other than heroin, interpersonal relationships, drug dealing, employment, and criminal behaviors. The differences seemed to be in accordance with traditional sex role expectations. The distinctive behavior pattern of Chicanas demonstrated in this study demands special attention. It is suggested that treatment programs should incorporate more services to meet women-specific needs.