Outcome in colorectal adenocarcinoma: two seven-year studies of a population.

OBJECTIVE--To record every patient with proved colorectal adenocarcinoma presenting from a defined population over two years in 1968-9 and during 1980-2, and to compare treatment and outcome over seven years. DESIGN--Retrospective in 1968-9 and prospective in 1980-2. SETTING--Aberdeen general hospitals. SUBJECTS--Every patient presenting to the four general surgical units with histological proof of colorectal adenocarcinoma. MAIN FINDINGS--On average, one new patient presented each week per 100,000 population. The proportion of patients aged 65 and over rose from 67% to 71%. An operation was performed on 385 patients in 1968-9 and on 399 during 1980-2. At laparotomy the proportion of patients who seemed to be curable and had a radical operation rose slightly, from 56% to 61%, and operative mortality fell from 9% to 5%. In all there were 421 survivors of curative surgery, and seven years later three quarters were either alive (51%) or had died without recurrence (25%). In both studies some 40% of patients were considered incurable when they presented, but the number who had a palliative resection rose from 59% to 85%. CONCLUSIONS--The contribution of radical surgery to the treatment of colorectal adenocarcinoma is substantial, with three quarters of patients so treated showing no evidence of recurrence after seven years. Operative mortality in an elderly population is now low, and improvement in late outcome is more likely to come from developments in adjuvant therapy than in operative technique. A continuing problem is that 40% of patients are not curable when they present, although palliative resection can now be offered to over 80%.     

Evolution précoce et tardive après pontage aortocoronarien: expérience de 500 cas.

Between 1971 and 1976, 500 patients underwent aortocoronary bypass surgery. There were 15 operative deaths (3%) and the total frequency of perioperative infarction was 7%. The operative mortality was 7.4% in unstable angina, as compared with 1.1% in stable angina (P less than 0.01). The proportion of grafts patent at 2 weeks was 92% and at 18 months 87.6%. Postoperative follow-up was complete for 99% of the patients. There were 15 late deaths (3%) and the rates of survival at 2 and 4 years were 94.4% and 92.1% respectively. The actuarial curve of survival after surgery was not significantly different from that of the general population. After a mean follow-up of 27 months 73% of the patients were completely free of angina and 19% were markedly improved. The rate of recurrence of angina averaged 10% per year and the annual infarction rate was 0.7%. Fourteen patients (3%) underwent reoperation during the follow-up period. Thus, coronary revascularization surgery offers effective and sustained relief of incapacitating angina and might also improve survival if the operative mortality is low.     

Socioeconomic status and its relation with breast cancer recurrence and survival in young women in the Netherlands

BackgroundAssociations between socioeconomic status (SES) and breast cancer survival are most pronounced in young patients. We further investigated the relation between SES, subsequent recurrent events and mortality in breast cancer patients < 40 years. Using detailed data on all recurrences that occur between date of diagnosis of the primary tumor and last observation, we provide a unique insight in the prognosis of young breast cancer patients according to SES.MethodsAll women < 40 years diagnosed with primary operated stage I-III breast cancer in 2005 were selected from the nationwide population-based Netherlands Cancer Registry. Data on all recurrences within 10 years from primary tumor diagnosis were collected directly from patient files. Recurrence patterns and absolute risks of recurrence, contralateral breast cancer (CBC) and mortality – accounting for competing risks – were analysed according to SES. Relationships between SES, recurrence patterns and excess mortality were estimated using a multivariable joint model, wherein the association between recurrent events and excess mortality (expected mortality derived from the general population) was included.ResultsWe included 525 patients. The 10-year recurrence risk was lowest in high SES (18.1%), highest in low SES (29.8%). Death and CBC as first events were rare. In high, medium and low SES 13.2%, 15.3% and 19.1% died following a recurrence. Low SES patients had shorter median time intervals between diagnosis, first recurrence and 10-year mortality (2.6 and 2.7 years, respectively) compared to high SES (3.5 and 3.3 years, respectively). In multivariable joint modeling, high SES was significantly related to lower recurrence rates over 10-year follow-up, compared to low SES. A strong association between the recurrent event process and excess mortality was found.ConclusionsHigh SES is associated with lower recurrence risks, less subsequent events and better prognosis after recurrence over 10 years than low SES. Breast cancer risk factors, adjuvant treatment adherence and treatment of recurrence may possibly play a role in this association.     

Simplified oesophageal transection for bleeding varices.

Thirty patients with bleeding oesophageal varices were treated by oesophageal transection using the SPTU gun. Any form of shunt was contraindicated in all the patients. Twelve operations were done as urgent procedures within 36 hours of haemorrhage. The overall operative mortality rate was 10%, and there were two late deaths during follow-up, which has so far extended from two months to two years. Three of the patients had recurrent bleeding, and residual varices were probably the source in two. There were no cases of portal systemic encephalopathy. Although the follow-up is too short to allow any definite conclusions, these early results suggest that oesophageal transection with the SPTU gun may be useful in the large proportion of patients in whom injection sclerotherapy, shunt surgery, or conservative treatment is inappropriate.     

Perforated Peptic Ulcer in the Vancouver Area: A Survey of 852 Cases

A total of 852 perforations of peptic ulcers occurring in the Greater Vancouver area during the decade 1959-1968 have been studied. The incidence of perforation has declined during this period owing to a decrease in the number of perforations occurring in males. The incidence of perforation was similar to that in the South of England and New Zealand (approximately 10 per 100,000 population) but less than half that reported from Scotland.The sex ratio of 3.6 males to 1 female was similar to that found in other countries. The mean age of the males was 53.9 years and of the females 56.5 years. The peak incidence occurred in the decade 40 to 49 years. Patients with gastric perforations were significantly older than patients with pyloroduodenal perforations.Perforation occurred most frequently in the late afternoon, on Wednesday and during December; least commonly during the night, at the beginning of the week and through September.The pyloroduodenal was the commonest site of perforation (88%) and the usual treatment was simple closure (81%). The overall mortality rate was 18.3% and one-third of all fatalities were due to misdiagnosis. The operative mortality rate was 9%.     

Vagotomy and Pyloroplasty for Gastric Ulcer

In a series of 68 patients with gastric ulcer who were treated by vagotomy and pyloroplasty there were no operative deaths, though one patient who received massive transfusions died 14 weeks later from hepatic necrosis probably associated with serum hepatitis. Four patients developed recurrent peptic ulceration requiring further surgical treatment. The clinical condition of all but three of the remainder was satisfactory after an average follow-up period of three years and two months. Of the 14 patients who presented with an acutely bleeding gastric ulcer, one subsequently required gastrectomy for continued bleeding; in all the others the immediate and long-term results were satisfactory. Of 21 patients with a “high” ulcer and 29 with combined gastric and duodenal ulceration one (4·8%) and three (10%) respectively suffered recurrences. We conclude that vagotomy and pyloroplasty is a satisfactory form of treatment for a high or bleeding gastric ulcer, but that for all other gastric ulcers some form of gastric resection is preferable.     

Surgical Treatment of Severe Attacks of Ulcerative Colitis,with Special Reference to the Advantages of Early Operation

The management and outcome of 258 severe attacks of ulcerative colitis from 1952 to 1969 has been reviewed. If remission did not occur during an initial course of intensive medical treatment, including administration of corticosteroids, operation (generally ileostomy with proctocolectomy or subtotal colectomy) was performed. This took place some 12 to 17 days after admission as a rule during the years 1952-63, but usually within five to seven days from 1964 to 1969.Roughly half the attacks underwent spontaneous remission during the two periods, but the medical mortality was 4·8% in the former and 0·7% in the latter, the operative mortality 20·0 and 7·0%, and the overall mortality 11·3 and 4.5% respectively. The lowering of the mortality was particularly striking in severe first attacks and in severe attacks in patients over 60 years of age.Perforation of the colon was found in 21 cases, or nearly 20% of 112 patients coming to operation during attacks, being commoner in the first period (32·5%) than in the second (11·1%). The immediate mortality of all such operations was 11·6%; in cases with perforation it was 28·6%.Acute colonic dilatation was observed in 28 cases. All but one were treated by emergency colectomy, at which the colon was noted to be perforated in 11. The mortality of these operations was 18·5%.Follow-up of the 140 patients who survived without coming to operation during their attacks shows that 52 (37·1%) subsequently underwent surgical treatment either during further attacks or electively.Though all 258 attacks were thought at the time to be due to ordinary ulcerative colitis, subsequent pathological examination of operative specimens derived from 98 patients who came to urgent or subsequent operation during the 1964-9 period revealed that the lesion in the large bowel was Crohn''s disease in 17 instances.     

The mortality risk of voluntary surgical contraception

The mortality risk of voluntary surgical contraception (VSC) is compared to the mortality risk of other methods of fertility control, pregnancy and delivery, and selected nonreproductive-related events. After 1 year the rates per 100,000 are .1 for vasectomies, .3 for IUD use, 2.2 for legal abortion, 4.0 for female VSC in developed countries, and 18.7 for pregnancy and delivery. Rates for female VSC, pregnancy and delivery, and legal induced abortion were expressed as deaths per 100,000 procedures or live births and mortality risks for IUD use were presented as deaths per 100,000 women per year, per 5 years, and 10 years. After 10 years the mortality risks remain constant for single-exposure events but increase to 3.0/100,000 for IUD use, to 12/100,000 for the lowest risk category of OC users, and to much higher cumulative totals for higher risk pill users. Risks at 5 and 10 years after abortion and other pregnancy outcomes depend on the reproductive alternatives chosen; risks of barrier methods appear related to unintended pregnancy during use. In developed countries the mortality risks of smoking, driving, power boating, and drinking are higher than those for female VSC and vasectomy at 1 year. Mortality rates for all reproductive strategies in developing countries are estimated to be higher: the rate for female VSC in Bangladesh was recently estimated at 16.2/100,000 and of vasectomy at 19.0/100,000, although vasectomy death rate estimates as low as .1/100,000 have also been made for some developing countries. The risks of VSC in developing countries are considerably lower than those of a single pregnancy or delivery. The risk of VSC is concentrated in the 1st 6 weeks after the procedure and thereafter is related to pregnancy resulting from method failure.     

Prospective trial of operative versus non-operative treatment of severe vesicoureteric reflux in children: five years' observation. Birmingham Reflux Study Group.

Children with severe vesicoureteric reflux were allocated randomly to either operative or non-operative treatment and followed up. Altogether 161 children were observed for two years, of whom 104 were followed up for five years. Reflux was abolished in 98% of ureters reimplanted, but more than half of the patients treated non-operatively continued to show severe reflux at five years. Two patients progressed to end stage renal failure, and a further four with extensive bilateral renal scarring became hypertensive. There were no significant differences between treatment groups in the incidence of breakthrough urinary infection, renal excretory function and concentrating ability, renal growth, progression of existing renal scars, or new scar formation. Progressive scarring occurred at all ages but was significantly more common during the first two years'' observation. Furthermore, new scars developed exclusively during the first two years'' observation, affecting 10 children aged 2-7 at allocation. Neither treatment can claim superiority or fully protect the kidneys from further damage, and efforts must continue to be directed towards identifying those at risk before scarring develops.     

IABP在危重症冠状动脉旁路移植术围手术期的应用

目的:探讨危重症冠状动脉旁路移植术(CABG)患者围手术期应用主动脉球囊反搏(IABP)疗效。方法:回顾性分析2008年1月至2010年9月40例应用IABP治疗的危重症CABG患者围手术期资料。结果:术前安置IABP 19例,术中安置IABP 10例,术后安置IABP11例。平均IABP辅助时间98.6±48.2小时。32例患者治愈出院,死亡8例,死亡率20.0%。术前安置者死亡率为21.1%,若除外机械并发症原因则死亡率为10.5%;术中安置者死亡率为20.0%;术后安置者死亡率为18.2%。5例出现血小板减少症;1例出现肠系膜动脉栓塞。结论:IABP是一种安全有效的循环辅助方法,积极应用可以明显提高危重症CABG的治疗效果。     

Vagotomy or Gastrectomy for Gastric Ulcer

Patients treated in a randomized controlled comparison of management of benign gastric ulcer of the body of the stomach, comprising 50 patients treated by Billroth I partial gastrectomy and 50 patients treated by vagotomy and pyloroplasty and biopsy of the ulcer, were followed up for about five years (range one and a half to eight and a half years). No statistically significant difference has been found between the functional results (Visick grading) of the two groups. There was no operative mortality. Postoperative morbidity (17 against 5) and length of stay in hospital (14 against 10 days) were significantly greater after gastrectomy. Seven patients after vagotomy have been submitted to gastrectomy (three for recurrent gastric ulceration, three for gastric cancer, and one for bleeding), which is a statistically significant excess compared with no reoperation after gastrectomy. While vagotomy and pyloroplasty can be useful to avoid a technically difficult gastrectomy, it cannot be said to replace partial gastrectomy in the treatment of gastric ulcer.     

Venous Graft Surgery in Treatment of Coronary Heart Disease

Sixty-seven patients have had aortocoronary venous graft bypass surgery by one surgeon for the relief of symptoms of severe coronary heart disease, including eight emergency operations. The overall operative, hospital, and late mortality was low in patients with favourable myocardial function and no previous myocardial infarction. There was a 7% mortality in patients with a normal preoperative chest radiogram, 8% mortality when the left ventricular end-diastolic pressure was normal preoperatively, and a 5% mortality in patients who had normal left ventricular angiograms. The overall mortality in all elective operations for cardiac pain resistant to medical treatment was 15·8%. 89% of survivors improved; 67% are pain-free. Exercise tolerance in survivors is increased by 135%, atrial pacing results are improved by 10%. Left ventricular end-diastolic pressure is unchanged. Left ventricular function on angiography is improved. The improvement in left ventricular function assessed objectively correlates positively with vein-graft patency, as does freedom from angina pectoris.     

Long-term survival from adenocarcinoma of the esophagus after transthoracic and transhiatal esophagectomy

ABSTRACT: BACKGROUND: The effects of transthoracic or transhiatal esophagectomy on the long-term survival of patients who had adenocarcinoma of the esophagus were compared, as were factors applicable in preoperative stratification of patient treatment. METHODS: A cohort of 147 consecutive patients with adenocarcinoma of the esophagus was evaluated for esophagectomy between 1984 and 2000. The patients were followed prospectively and observed survival rates of patients with a transthoracic or transhiatal approach to esophagectomy were compared by standardized mortality ratio (SMR) and relative mortality ratio (RMR) using the expected survival of a matched Norwegian population. RESULTS: A R0 resection was performed by transthoracic (n = 33) or a transhiatal (n = 55) esophagectomy in 88 (60%) patients with a median age of 61 (range: 35-77) and 70 (42-88) years, respectively (P <0.001). Tumor stages and other possible risk factors were similar in the two groups. Transthoracic or transhiatal esophagectomy resulted in a median survival time of 20.5 (95% confidence interval (CI): 10.4-57.6) and 16.4 (10.6-28.7) months, respectively. The respective survival rates were 31.2% and 27.8% by 5 years, and 21.3% and 16.6% by 10 years with an overall RMR of 1.14 (P = 0.63). Median survival time in the absence or presence of lymph node metastases was 74.0 (95% CI: 17.5-166.4) and 10.7 (7.9- 14.9) months. The corresponding survival rates by 10 years with non-involved or involved nodes were 48.9% and 3.8% respectively (RMR 2.22, P = 0.007). Patients with a pT1-tumor were few and the survival rate was not very different from that of the general population (SMR = 1.7, 95% CI: 0.7-4.1). The median survival time of patients with a pT2-tumor was 30.4 (95% CI: 9.0-142) months and with a pT3-tumor 14 (9.2-16.4) months. The survival rates by 10 years among patients with a pT1 tumor were 57.0% (95% CI: 14.9-78.9), pT2 33.3% (11.8-52.2), and pT3 7.1% (1.9-15.5). The relative mortality for T3 stages compared to T1 stages was statistically significant (RMR = 3.22, P = 0.024). CONCLUSION: Transthoracic and transhiatal esophagectomy are both effective approaches for treatment of adenocarcinoma of the esophagus and survival of more than 10 years can be expected without adjuvant chemotherapy. However, increasing depth of tumor invasion and lymph node metastases reduce life expectancy.     

Modified operative technique for involutional lower lid entropion

The paper presents a modified operative technique for involutional lower lid entropion. The prospective noncomparative study of 101 lower eyelids of 88 patients undergoing surgery for involutional lower lid entropion was conducted in period from September 2005 until March 2012. Indication for the surgery was entropion, previously untreated, with moderate to severe horizontal lid laxity and no clinically relevant medial and lateral canthal tendon laxity. The operative technique is our modification of Quickert and Jones procedures. Photo was taken preoperatively and one month after surgery. Clinical follow-up was at 7th postoperative day, one month and six months after surgery and in case of the recurrence. Long-term follow-up was obtained via telephone interviews. There were 44 male (50%) and 44 female (50%) patients included in the study. The age of patients was in average 73.27 +/- 8.1 years (range 53-90 years). Early postoperative complication was localized lid swelling found in two patients starting 4-6 weeks postoperatively at the area of absorbable suture. It resolved spontaneously in two and three weeks respectively. There was recurrence of entropion in 11 eyelids (10.89%) of 10 patients. The mean interval between primary surgery and the recurrence was 17.45 +/- 14.84 months (range 4-48 months). In these eyelids Jones procedure was performed. However in four eyelids of four patients from the recurrent group an additional surgery needed to be performed after 6, 12, 12 and 17 months respectively. Our modification of surgical treatment for involutional lower lid entropion was effective in 89.11% of eyelids. Complications of the procedure were scarce.     

Clinical Problems: Elective Splenorenal Anastomosis

Thirty-six patients underwent splenorenal anastomosis for haemorrhage from oesophageal varices. Twenty-nine patients were cirrhotics and seven had extrahepatic blocks or congenital hepatic fibrosis. The patients have been followed from 16 years to 6 months. The operative mortality was 11%. Recurrent haemorrhage occurred in two patients (6%) and neurological manifestations in 38% of the patients at risk. It is concluded that splenorenal anastomosis is associated with a high degree of shunt patency.     

A new method of auditing surgical mortality rates: application to a group of elderly general surgical patients.

In a prospective study of 505 patients aged 65 years or over admitted to a general surgical unit the overall hospital mortality rate was 14.5% and the postoperative mortality rate 12.0%. These rates fell to 3.6% and 5.8% respectively when deaths in non-viable patients were excluded from the analysis. An audit of surgical outcome that fails to identify non-viable patients is therefore potentially misleading. A standardised system of reporting surgical mortality is proposed to aid the comparison of results from different units. The key elements of this system are (a) the separation of the results from non-viable and potentially viable patients; (b) the consideration of both operative and non-operative mortality; (c) the differentiation between medical and surgical causes of postoperative mortality; and (d) the identification of patients who are discharged from the unit but who have residual malignancy. Data presented in such a way should be of direct relevance to surgeons and physicians who are seeking ways of improving the service provided for surgical patients of all ages.     

Population-Level Impact of Shorter-Course Regimens for Tuberculosis: A Model-Based Analysis

Despite current control efforts, global tuberculosis (TB) incidence is decreasing slowly. New regimens that can shorten treatment hold promise for improving treatment completion and success, but their impact on population-level transmission remains unclear. Earlier models projected that a four-month regimen could reduce TB incidence by 10% but assumed that an entire course of therapy must be completed to derive any benefit. We constructed a dynamic transmission model of TB disease calibrated to global estimates of incidence, prevalence, mortality, and treatment success. To account for the efficacy of partial treatment, we used data from clinical trials of early short-course regimens to estimate relapse rates among TB patients who completed one-third, one-half, two-thirds, and all of their first-line treatment regimens. We projected population-level incidence and mortality over 10 years, comparing standard six-month therapy to hypothetical shorter-course regimens with equivalent treatment success but fewer defaults. The impact of hypothetical four-month regimens on TB incidence after 10 years was smaller than estimated in previous modeling analyses (1.9% [95% uncertainty range 0.6–3.1%] vs. 10%). Impact on TB mortality was larger (3.5% at 10 years) but still modest. Transmission impact was most sensitive to the proportion of patients completing therapy: four-month therapy led to greater incidence reductions in settings where 25% of patients leave care (“default”) over six months. Our findings remained robust under one-way variation of model parameters. These findings suggest that novel regimens that shorten treatment duration may have only a modest effect on TB transmission except in settings of very low treatment completion.     

Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival.

OBJECTIVE--To assess the differences among surgeons in postoperative complications, postoperative mortality, and survival in patients undergoing surgery for colorectal cancer. DESIGN--Prospective study of patients with colorectal cancer managed by one of 13 consultant surgeons, none of whom had a special interest in colorectal surgery. SETTING--Royal Infirmary, Glasgow. PATIENTS--645 sequential patients with colorectal cancer presenting over the six years from 1974 to 1979. MAIN OUTCOME MEASURES--Postoperative complications, postoperative mortality (within 30 days), and survival (up to 10 years); predictive factors for postoperative mortality and survival; and relative hazard rate ratios for individual surgeons. RESULTS--The proportion of patients undergoing apparently curative resection varied among surgeons from 40% to 76%; overall postoperative mortality varied from 8% to 30%. After curative resection postoperative mortality varied from 0% to 20%, local recurrence from 0% to 21%, and the rate of anastomotic leak from 0% to 25%. Survival at 10 years in patients who underwent curative resection varied from 20% to 63%, two year survival in those who underwent palliative resection varied from 7% to 32%, and median survival in those who underwent palliative diversion varied from one to eight months. The hazard rate ratios among individual surgeons, taking into account the identified risk factors, varied from 0.56 to 2.03, from 0.17 to 1.92, and from 0.57 to 1.50 for curative resection, palliative resection, and palliative diversion, respectively. CONCLUSION--There were significant variations in patient outcome among surgeons after surgery for colorectal cancer; such differences compromise survival. A considerable improvement in overall survival might be achieved if such surgery were undertaken by surgeons with a special interest in colorectal surgery or surgical oncology.     

Vitamin A supplementation in infectious diseases: a meta-analysis.

OBJECTIVE--To study the effect of vitamin A supplementation on morbidity and mortality from infectious disease. DESIGN--A meta-analysis aimed at identifying and combining mortality and morbidity data from all randomised controlled trials of vitamin A. RESULTS--Of 20 controlled trials identified, 12 trials were randomised trials and provided "intention to treat" data: six community trials in developing countries, three in children admitted to hospital with measles, and three in very low birth weight infants. Combined results for community studies suggest a reduction of 30% (95% confidence interval 21% to 38%; two tailed p < 0.0000001) in all cause mortality. Analysis of cause specific mortality showed a reduction in deaths from diarrhoeal disease (in community studies) by 39% (24% to 50%; two tailed p < 0.00001); from respiratory disease (in measles studies) by 70% (15% to 90%; two tailed p = 0.02); and from other causes of death (in community studies) by 34% (15% to 48%; two tailed p = 0.001). Reductions in morbidity were consistent with the findings for mortality, but fewer data were available. CONCLUSIONS--Adequate supply of vitamin A, either through supplementation or adequate diet, has a major role in preventing morbidity and mortality in children in developing countries. In developed countries vitamin A may also have a role in those with life threatening infections such as measles and those who may have a relative deficiency, such as premature infants.     

Debate: at what level of coronary heart disease risk should a statin be prescribed?

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are effective treatments for the primary and secondary prevention of coronary heart disease, but an outstanding issue is determining who should have such treatment. The benefit from treatment with statins appears to be proportional to the underlying risk of coronary heart disease and independent of the factors increasing risk. Most benefit will therefore be achieved by treating people at increased risk of coronary heart disease. Statins reduce coronary morbidity even when the risk of coronary heart disease is relatively low (6% over 10 years), but reduction in all-cause mortality, the true measure of safety has been shown only when the risk of a major coronary heart disease event is 15% over 10 years or greater. At this level of risk patients appear willing to take treatment to gain the benefit expected from statin treatment, and the cost effectiveness of statin treatment is within the range accepted for other treatments. The major impediments to the systematic introduction of statin treatment at this level of risk are the very high overall cost and the large workload in countries like Britain, where the population risk of coronary heart disease is high. For this reason, recent British guidelines correctly advise statin treatment for secondary prevention and primary prevention when the 10 year coronary heart disease risk is 30% or greater as the first priority, moving to a lower coronary heart disease threshold for primary prevention only when resources permit.