Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer.

We aim to compare the outcomes of patients undergoing R0 esophagectomy by a multidisciplinary team (MDT) with outcomes after surgery alone performed by surgeons working independently in a UK cancer unit. An historical control group of 77 consecutive patients diagnosed with esophageal cancer and undergoing surgery with curative intent by six general surgeons between 1991 and 1997 (54 R0 esophagectomies) were compared with a group of 67 consecutive patients managed by the MDT between 1998 and 2003 (53 R0 esophagectomies, 26 patients received multimodal therapy). The proportion of patients undergoing open and closed laparotomy and thoracotomy decreased from 21% and 5%, respectively, in control patients, to 13% and 0% in MDT patients (chi2 = 11.90, DF = 1, P = 0.001; chi2 = 5.45, DF = 1, P = 0.02 respectively). MDT patients had lower operative mortality (5.7%vs. 26%; chi2 = 8.22, DF = 1, P = 0.004) than control patients, and were more likely to survive 5 years (52%vs. 10%, chi2 = 15.05, P = 0.0001). In a multivariate analysis, MDT management (HR = 0.337, 95% CI = 0.201-0.564, P < 0.001), lymph node metastases (HR = 1.728, 95% CI = 1.070-2.792, P = 0.025), and American Society of Anesthesiologists grade (HR = 2.207, 95% CI = 1.412-3.450, P = 0.001) were independently associated with duration of survival. Multidisciplinary team management and surgical subspecialization improved outcomes after surgery significantly for patients diagnosed with esophageal cancer.

Surgical time and motion: the intermediate equivalent revisited.

The relationship between operative time, the intermediate equivalent value (IEV) and the complexity of common general surgical operations was examined. Correlation was found between the BUPA schedule values for procedures categorized as intermediate and major, but complex major vascular reconstruction and oesophagogastric resection for cancer occupied significantly more theatre time than the four intermediate equivalents allocated by the Collins or BUPA schedule. Moreover, anaesthetic preparation time for complex major surgery in the latter surgical subspecialities contributed at least one further intermediate value. Re-evaluation of the ideal IEV weighting of all surgical operations including anaesthetic input from larger similar audits would allow more accurate audits of surgeons' work-load, and also facilitate transparent intensive management of operating theatre resource.

Haemophilus influenzae intra-amniotic infection with intact membranes.

BACKGROUND: Amnionitis rarely occurs with intact membranes. Haemophilus influenzae is a rare pathogen in intra-amniotic infection, but its importance and prevalence could be increasing, as reflected by the growing number of reported cases in the last 20 years. METHODS: Using the key words "amnionitis," "intra-amniotic infection," "chorioamnionitis," and "Haemophilus influenzae," we searched MEDLINE files from 1980 to the present. Articles dating before 1980 were accessed from cross-reference of the more recent studies. RESULTS AND CONCLUSIONS: H. influenzae, a nonmotile, aerobic, gram-negative rod-shaped bacteria, is primarily responsible for respiratory tract infections in children and neonatal meningitis; it has a low prevalence rate in genital tract cultures but a high attack rate of infection in mothers and neonates. With intact membranes, intra-amniotic infection occurs rarely and is thought to be caused by hematogenous transplacental seeding, direct invasion of the fetal membranes, or inoculation of the amniotic fluid during an invasive procedure. It can also be idiopathic. It occurs most often in the second and early third trimesters and can be definitively diagnosed by a positive amniotic fluid culture or positive maternal or neonatal blood cultures and clinical evidence of intra-amniotic infection. We present a case of intra-amniotic infection with intact membranes at 15 to 16 weeks in a patient with clinical evidence of intra-amniotic infection and positive blood cultures whose infection was treated successfully with antibiotics, prolonging her pregnancy by 16 weeks. Physicians caring for obstetric patients must be vigilant in diagnosing intra-amniotic infection, even with intact membranes, and this infection should be considered in the differential diagnoses for acute abdomen in pregnancy.

Acute, disruptive cough. Symptomatic therapy for a nagging problem.

Acute, disruptive cough should be viewed as a physiologic response to an intruder or irritant to the respiratory system and not as an isolated pathologic problem. Evaluation should include thorough history taking and physical examination supplemented by limited diagnostic tests. Once the cause is established, specific therapy can be implemented. If cough persists for days to weeks and is disruptive, symptomatic cough therapy should be instituted on the basis of the mechanisms of action of the available agents. Further controlled studies in the primary care setting are needed.

Acute intestinal ischaemia: options in surgical management.

Seven patients (mean age 67 years, range 52-82 years) presented with acute intestinal ischaemia over a 4-year period. Massive bowel resection was performed in all patients. Exteriorisation and secondary restoration of intestinal continuity was employed in four patients. In two patients a primary anastomosis was performed at the time of resection and one patient underwent a 'second-look' procedure. Massive bowel resection and exteriorisation allows direct observation of stoma viability, avoids the risk of anastomotic breakdown and should be considered in all but moribund patients with acute intestinal ischaemia. In elderly patients resection and primary anastomosis may be an alternative option.

'Diabetic tibial disease': the case for revascularisation.

Diabetic patients with critical ischaemia of the lower limb are frequently considered to have unreconstructable vascular disease. In the presence of a palpable popliteal pulse they are often labelled as having 'small vessel disease'. In nine patients (mean age 69 years) with 'diabetic tibial disease' and critical ischaemia we have avoided major amputation using short vein bypasses. All revascularisations remained patent at a mean follow-up of 32 months (range 12-60 months). Diabetic patients with critical ischaemia should at the very least undergo arteriography to ensure that the possibility of successful distal revascularisation is not feasible before amputation is performed. However, if arteriography fails to demonstrate patent distal vessels and limb salvage is considered practical, Doppler insonation of the tibial and pedal vessels should be performed.

Aortic aneurysms--who should do them?

All patients undergoing abdominal aortic aneurysm repairs in a district general hospital between 1 January 1983 and 31 December 1987 were reviewed. Of the 76 cases, 53 were planned and 23 were ruptured aneurysms. The male:female ratio was 4.4:1, and the age range was 47-84 years (mean 67.6 +/- 6.97 years). Half underwent an ultrasound scan, showing a maximum diameter range of 3-12 cm. Fifty-seven (75%) had tube grafts, and 19 (25%) bifurcation grafts. The 30-day mortality was 3.7% for planned cases, and 26% for ruptured cases. The principal operator in 55 (72.5%) cases was a consultant; consultant anaesthetists were involved in 61.3% cases. We conclude that aneurysm surgery can safely be performed in a district general hospital by a general surgeon with an interest in vascular surgery.

Restoration of the absent femoral pulse.

One hundred and eighty-three consecutive operations for ischemia of the lower limb were performed to restore an absent femoral pulse. Ninety-seven patients considered to be fit had an aortofemoral or iliofemoral bypass graft and 86 high risk patients had a femorofemoral or axillofemoral graft. The best results were obtained in those with the aortofemoral or iliofemoral grafts, but superficial grafts were a satisfactory alternative even in the unfit patients with critical ischemia.

Effect of intraluminal oxygen on endotoxin absorption in experimental occlusion of the superior mesenteric artery.

Absorption of bacterial endotoxin has been shown to occur after release of the occluded superior mesenteric artery in the rat. A significant reduction in endotoxin absorption was observed as a result of the infusion of gaseous oxygen into the bowel lumen during the period of ischaemia (P less than 0-001). The methods of endotoxin identification and assay are described, and the possible reasons for this effect of intraluminal oxygen are discussed.

Effect of intraluminal oxygen on experimental ischaemia of the intestine.

The small bowel of 44 rats has been made ischaemic for 120 minutes by occluding the superior mesenteric artery. Gaseous oxygen was introduced into the small bowel lumen of 18 of the rats, and gaseous nitrogen into the bowel lumen of a further eight, 30 minutes after the start of the ischaemia. The mortality rate of the control group of 18 rats was 89%, significantly higher than the 39% mortality of the oxygen-treated rats (p less than 0-005). None of the eight rats treated with intraluminal nitrogen survived. Histological changes caused by ischaemia were much reduced in the intestine of the oxygen treated rats. It is suggested that intraluminal oxygen might be useful additional form of therapy for the treatment of the partially ischaemic bowel that may be retained after the resection of definitely non-viable ischaemic bowel at initial laparotomy.