Oesophagogastrectomy for carcinoma of the oesophagus and cardia.

A retrospective review was undertaken of all oesophagectomies performed within a single unit over a 12-year period. In all, 298 patients with primary oesophageal cancer underwent resection between March 1979 and December 1991. Four patients had a three-stage oesophagogastrectomy, 27 a thoracoabdominal oesophagogastrectomy and 267 a Lewis procedure. Dysphagia was the predominant presenting symptom. The duration of symptoms was not related to the stage of disease. Before diagnosis, 52 per cent of patients tolerated symptoms for 2-4 months. Adenocarcinoma was found in 180 tumours and squamous cell carcinoma in 103. Half of the patients had evidence of metastatic spread at the time of laparotomy or thoracotomy. The 30-day mortality rate was 10 per cent and the overall actuarial 5-year survival rate of all patients 23 per cent. The actuarial 5-year survival rate of patients without lymph node involvement was 39 per cent compared with 17 per cent for those with positive nodes (P < 0.05). Five of eight patients who had anastomotic leakage died. The almost unselected nature of this series, coupled with the favourable results of oesophagectomy, support the contention that resection remains the preferred mode of treatment for carcinoma of the oesophagus of all histological types.

Empyema thoracis: a problem with late referral?

BACKGROUND: Patients are often referred to thoracic units for management of empyema after the acute phase has been treated with antibiotics but without adequate drainage. This study evaluates the effects of delay in surgical treatment of empyema thoracis on morbidity and mortality. METHODS: Thirty nine consecutive patients were studied from January 1991 to June 1992. Two groups (group 1, 16 patients; group 2, 23 patients) were compared depending on the time spent under the care of other specialists before referral to the thoracic unit (group 1, seven days or less; group 2, eight days or more). The reasons for delay in referral were analysed. RESULTS: Four patients were treated conservatively with chest drainage alone (all in group 1). Thirty five patients required rib resection and drainage of their empyema (group 1, 12 patients; group 2, 23 patients). Nineteen (all in group 2) of the 35 patients who had rib resections went on to have decortication. The commonest cause of empyema was post-pneumonic (37 out of 39 patients). Staphylococcus aureus was the commonest organism isolated. Misdiagnosis (five patients), inappropriate antibiotics (six patients), and inappropriate placement of chest drainage tubes (three patients) all contributed to persistence and eventual progression of empyema. The overall mortality was 10% and mortality increased with age. The median stay in hospital was 9.5 days (range 7-12 days, n = 4) for patients treated with closed tube drainage only; 18 days (range 10-33 days, n = 16) for patients who had undergone rib resections and open drainage; and 28 days (range 22-49 days, n = 19) for patients who underwent decortication. The likelihood of having a staged procedure (antibiotics, closed tube drainage, open drainage with rib resection, and finally decortication) increased when closed tube drainage was persevered with for more than seven days. The total hospital stay was positively related with the time before referral for surgical treatment. Anaemia, low albumin concentrations, and worsening liver function were found in group 2 compared with group 1. CONCLUSIONS: Early adequate operative drainage in patients with empyema results in low morbidity, shorter stays in hospital, and good long term outcome. These patients should be treated aggressively and early referral for definitive surgical management is recommended.

A self-administered patient questionnaire in the assessment of symptoms before and after prostatectomy.

A self-administered patient questionnaire was developed to assess the severity of key symptoms before and after transurethral prostatectomy (TURP). This questionnaire was validated by comparison with a standard assessment performed by the doctor. Complete data were obtained on 39 men studied before and 3 months after prostatectomy. Close associations were found between the scores resulting from the assessments performed by the patient and those carried out by the doctor. These associations were found for individual scores and for aggregate scores for obstructive and irritative symptoms before and after operation. Symptom scores after operation were significantly related to the patients' overall assessment of whether the operation had been a success--a low score being associated with a satisfactory outcome. It is suggested that self-administered symptom questionnaires can give a reliable picture of the outcome of prostatectomy and might be useful in developing audit systems.