CARCINOMA OF THE GALL-BLADDER: AN EXPERIENCE AND REVIEW OF THE LITERATURE

This paper summarizes the treatment results of 28 cases of gall-bladder carcinoma at Toowoomba Base Hospital, Toowoomba, Queensland. Australia. The literature is reviewed in order to determine whether more extensive resection is improving the outcome of a disease generally understood to have a deplorable prognosis. The complete records of 28 patients with this malignancy were obtained from the period 1978 to 1994 and analysed retrospectively. Twenty-three patients had cholecystec-tomy, but only one underwent formal lymph node dissection. Overall, the 5 year survival rate was 13%. and long-term survivors all had stage I or II disease. Those with stage III or IV disease had a median survival of 46 days. Recent literature confirms that simple cholecystectomy is not always curative for early lesions discovered incidentally and also that some patients with advanced disease can achieve long-term survival if treated with radical resection. Wedge resection of the liver and nodal clearance of the hepatoduodenal ligament at least has been recommended in patients with T₂ lesions (subserosal/perimuscular), and in selected patients with stage III disease.     

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY: THE HEIDELBERG REPATRIATION HOSPITAL EXPERIENCE

Percutaneous endoscopic gastrostomy (PEG) was performed on 32 patients (mean age 75 years) who were dysphagic but enteral alimentation was possible. Seventeen patients were recovering from a stroke; the interval between the onset of stroke and PEG averaged 44 days. The procedure was successful and well tolerated by 16 of these 17 patients. Ten patients (31%) still had a functioning PEG, a median of 30 weeks after placement. Seven patients whose swallowing recovered had their tubes removed an average of 3 months after their insertion. Fifteen patients (47%) subsequently died from their underlying disease, a mean of 126 days following PEG. There were no deaths directly related to catheter placement. Percutaneous endoscopic gastrostomy is a useful alternative to surgical gastrostomy in elderly patients with long-term oral feeding problems.     

TECHNIQUE AND COMPLICATIONS OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN CHILDREN

Percutaneous endoscopic gastrostomy (PEG) is now a well-established technique in children. In this study of 63 children (mean age 7.8 years, youngest 2.4 months), technical problems associated with insertion of the gastrostomy tube, and complications related to the procedure, were analysed. Complications included wound infection, oesophageal injury (probably sustained during extraction of the guide wire) and symptomatic gastro-oesophageal reflux (GOR) occurring after PEG insertion. Many of these complications can be avoided or reduced in likelihood by refinements to the technique of insertion.     

STAGING OF PROSTATE CANCER USING 3-DIMENSIONAL TRANSRECTAL ULTRASOUND IMAGES: A PILOT STUDY

PURPOSE: We used conventional transrectal ultrasound images for 3-dimensional (D) reconstruction of the prostate, and determined its value in staging clinically localized prostate cancer. MATERIALS AND METHODS: A total of 36 patients with newly diagnosed clinically localized prostate cancer were studied. All patients underwent conventional transrectal ultrasonography with 3-D reconstruction. Images were examined and analyzed blindly, and findings were compared to histopathological staging following radical prostatectomy. RESULTS: Pathological staging of specimens revealed 15 sites of extracapsular extension in 10 patients, of whom 8 had positive margins and 2 had seminal vesicle invasion. The 3-D imaging identified 12 sites of extracapsular extension in 9 patients with 80% sensitivity, 96% specificity and 90% positive predictive value. Of the 2 patients with seminal vesicle invasion 1 was identified correctly on 3-D images. Overall staging accuracy of 3-D imaging was 94%. CONCLUSIONS: The 3-D reconstruction of conventional transrectal ultrasonography imaging is superior to 2-D imaging for staging localized prostate cancer. However, this advantage relies entirely on the visibility of prostate cancer lesions on conventional ultrasonography. Further studies are warranted to evaluate this technology for the management of prostate cancer.     

OESOPHAGEAL PERFORATION—A REVIEW OF 37 CASES

We have reviewed 37 cases of ruptured oesophagus treated at st vincent's hospital from 1976 to 1986. Their age ranged from 20 to 89 years (mean 64 years) and 59% were female. The cause of rupture were spontaneous (9), foreign body (5), diagnostic oesophagoscopy (8), oesophagoscopy and dilatation (5), balloon dilatation (3), palliative intubation (6) and patient self dilatation (1). Eighty-six per cent of perforations occurred in the lower third of the oesophagus. The most common means of diagnosis was a positive contrast swallow (90%) and/or the presence of cervical or mediastinal air (4970). Eighteen patients underwent surgical treatment which consisted of a combination of thoracotomy, drainage and repair, or laparotomy and celestin tube insertion, with or without chest drainage. Two patients underwent oesophageal diversion. The overall mortality in all patients was 30% (37% non-operative and 22% operative group). We conclude that the management of ruptured oesophagus demands an individual approach depending upon the site and aetiology of perforation and the underlying disease. The condition is a disease of the elderly and continues to have a high morbidity and mortality.     

OESOPHAGEAL CANCER: OUTCOME OF MODERN SURGICAL MANAGEMENT

Many clinicians still associate oesophagectomy for oesophageal carcinoma with low cure rates, poor palliation and prohibitive peri-operative mortality. Surgical advances have rendered such perceptions inaccurate. A prospective study of all patients undergoing surgery for oesophageal cancer in an Australian teaching hospital between 1979 and 1993 has been undertaken. Selection. staging, pre-operative preparation, surgical technique and postoperative care were all carefully controlled. One hundred and thirty-seven patients were explored. Twenty-one were inoperable. One hundred and sixteen underwent resection with intent to cure. Hospital mortality for oesophagectomy was 1.7%. There were no cases of clinical anastomotic leakage. Eighty-nine per cent achieved excellent to good swallowing. The median survival for all cases was 14 months and the 5 year survival was 18%. Median survival for resected cases was 18 months and the 5 year survival was 26%. The long-term survival was related to postoperative stage of the disease but not to tumour type. Oesophagectomy for oesophageal cancer will restore good swallowing in 90% of cases. Operative mortality should be less than 5% and the overall 5 year survival 20–3096. Early tumours can often be cured (ca in situ 100%. stages I and II 50–60%), indicating the benefits of early detection. Poor survival in advanced disease (stage III 15%. stage IV 0%) on a background of low surgical mortality indicate the need for better staging and more effective adjuvant therapies.     

A SIMPLE TECHNIQUE OF PALLIATIVE OESOPHAGEAL BYPASS OPERATION*

Twelve consecutive oesophageal bypass operations using stomach, in which both the upper and the lower ends of the oesophagus proximal and distal to the growth were suture-closed are reported. There were no complications directly attributable to the closure of the oesophagus. The longest surviving patient with a benign stricture is well and eating a normal diet 40 months after operation. Suture closure of the oesophageal ends is a safe procedure. It avoids a difficult subdiaphragmatic anastomosis, saves on the number of anastomoses required and therefore improves the chances of survival.     

Role of endoscopic ultrasound in staging upper gastrointestinal cancers

The key clinical management points in this article are that (i) endoscopic ultrasound is the most accurate imaging method for local staging of oesophageal, gastric and pancreatic neoplasms; (ii) addition of fine-needle aspiration biopsy to the technique is safe and well tolerated and increases diagnostic accuracy for nodal staging purposes; and (iii) endoscopic ultrasound +/- fine-needle aspiration has the capacity to influence significantly, the management of patients with malignancies of the upper gastrointestinal tract, particularly with respect to selection for surgery. The learning objectives were that at the end of this paper the reader should be able to (i) understand the usefulness and limitations of various imaging methods in the staging of upper gastrointestinal cancers; and (ii) incorporate the various imaging methods, particularly endoscopic ultrasound, into management algorithms for oesophageal cancer, gastric cancer, mucosa-associated lymphoid tissue lymphomas, gastrointestinal stromal tumours, pancreatic cystic lesions and pancreatic cancer.     

SURGICAL BYPASS FOR PALLIATION OF MALIGNANT OESOPHAGEAL OBSTRUCTION

It is possible to achieve satisfactory palliation for most patients with malignant oesophageal obstruction by endoscopic means, surgical resection or radiotherapy. Despite these options, a small group of patients remains for whom another alternative should be considered. Fifteen patients presenting with extensive tumour, a non-dilatable stricture, or a tracheo-oesophageal fistula, not suitable for any of the standard methods of palliation, underwent palliative surgical bypass using stomach or colon. The hospital mortality was 33% and the median survival 6 months. Anastomotic leakage occurred in six patients and the median postoperative stay was 28 days (range 20–42 days). All patients who survived surgery, except one, achieved satisfactory palliation. The nature of these patients is such that whatever is done, mortality will almost inevitably be high. The authors believe that all patients in this series were better off than they would have been if left untreated, and oesophageal bypass should be considered for patients with distressing dysphagia due to disease not amenable to standard palliative methods.     

PROLONGED SURVIVAL FOLLOWS RESECTION OF OESOPHAGEAL SCC DOWNSTAGED BY PRIOR CHEMORADIOTHERAPY

Background: The poor survival rate of surgically treated patients with oesophageal cancer has not improved substantially over the last 25 years, but combined modality therapy has shown early promising results. Methods: A prospective study was undertaken to determine the effect of pre-operati ve synchronous chemoradiotherapy followed by oesophagectomy in 53 patients with squamous cell carcinoma (SCC) of the oesophagus. The patient group was unselected, other than by fitness for surgery. Results: In 25% of patients, complete pathological regression of the tumour was achieved. All but one of the patients in this subgroup had T2 tumours on pre-operative clinical staging and two had evidence of lymph node involvement, but postoperative pathological examination revealed that pre-operative chemoradiotherapy had downstaged their disease to TONO. There was no hospital mortality in this subgroup and the actuarial 7 year survival was 69%. Conclusions: For squarnous oesophageal tumours deep to the submucosa this is an extremely good survival. For the present, this form of therapy for SCC of the oesophagus appears capable of achieving results comparable to, or better than, those reported for 3-field lymphadenectomy.     

OESOPHAGEAL ATRESIA: THE FIRST SURVIVAL IN THE SOUTHERN HEMISPHERE

The first known survival in the Southern hemisphere following a corrective operation for oesophageal atresia, is reported. Contrary to previous reports, this survival was in 1948 not in 1949 and the survival occurred in New Zealand not in Australia.     

HEAD AND NECK CANCER STAGING SYSTEMS: A COMPARISON BETWEEN UICC AND AJC*

Two major TNM classification systems are currently in use for staging cancer of the head and neck region, i.e. UICC and AJC. This causes confusion when attempting to exchange information and evaluate treatment results between Australia and certain overseas centres. The two systems are described and the effect of any differences on altering survival data is assessed by reviewing 234 cases of squamous carcinoma of the larynx, hypopharynx, oropharynx and oral cavity. The direct correlation between the two systems is established. Shortcomings of the systems are demonstrated and important variables not included in either TNM system are discussed.     

INTRA-OPERATIVE ULTRASOUND FOR THE DETECTION OF HEPATIC METASTASES FROM COLORECTAL CANCER

The aim of this study was to compare the accuracy of intra-operative ultrasound (IOUS) with other imaging modalities and with surgical palpation in detecting liver metastases from colorectal cancer (CRC). Intra-operative ultrasound was performed in 100 patients undergoing surgery for CRC. All patients had pre-operative liver function tests, transcutaneous ultrasound and computerized tomography (CT) scan of the liver. The liver was palpated intra-operatively by a surgeon who was unaware of the pre-operative findings. The liver was then assessed by IOUS. Intra-operative ultrasound detected more patients with metastases than either CT scan, transcutaneous ultrasound or surgical palpation. It also detected a greater number of smaller metastases in these patients and allowed better anatomical definition compared with pre-operative investigations.     

THE TECHNIQUE OF ENDOSCOPIC EXPLORATION FOR PARATHYROID ADENOMA OF THE NECK

Background : The technical details of endoscopic exploration of parathyroid adenoma are described here, thereby drawing attention to the enormous potential of this new modality of minimal-access surgery. Methods : Four patients with a parathyroid adenoma that was clearly demonstrated by pre-operative localization imaging techniques were subject to endoscopic exploration using one 11 mm and two 5 mm ports: a technique heretofore undescribed. Results : An adenoma was successfully localized endoscopically in each case and was removed. The postoperative outcome proved most encouraging: no analgesics were required, the hypercalcaemia rapidly corrected and the patients were pleased with the smallness of scars. Conclusions : The described endoscopic approach is a viable and promising alternative to open surgery for parathyroid adenoma; further study would be fruitful.     

ENDOSCOPIC STAPLING TREATMENT OF PHARYNGEAL POUCH

Background: We describe our experience of a recently reported endoscopic stapling technique for the treatment of pharyngeal pouch. Methods: In contrast to other endoscopic procedures, which only divide the common wall between oesophagus and diverticulum, the linear cutting stapler also tightly seals the divided edges of mucosa and muscle. Results: The procedure was performed without complications in three patients with complete resolution of pre-treatment symptoms. Conclusions: To our knowledge this is the first report of the use of this procedure in Australia. This endoscopic stapling operation appears to be safe, simple and cost-effective and offers advantages over previously used techniques.     

RADIATION THERAPY OF GLOTTIC CARCINOMA: PETER MacCALLUM CANCER INSTITUTE EXPERIENCE

The medical records of patients with T1NO, T2NO and T3NO squamous cell carcinomas of the glottis treated at the Peter MacCallum Cancer Institute between January 1983 and October 1988 were retrospectively reviewed. One hundred and twenty-seven patients were identified. There were 93 T1, 26 T2 and eight T3 tumours. These patients were treated with curative radiotherapy (60–70 Gy). The survival from glottic cancer of patients with T1, T2 and T3 turnours at 5 years was estimated to be 97, 62 and 100% respectively. The local disease free survival for T1 and T2 disease at 5 years was estimated to be 82 and 65% respectively. The local disease free survival for T3 tumours at 2 years was estimated to be 63% with 5 year survival not yet reached. The surgical salvage rates for 24 radiotherapy failures were 77, 25 and 66% for T1, T2 and T3 turnours respectively. Radiotherapy remains the treatment of choice for T1 tumours and a viable alternative to primary laryngectomy in more advanced glottic tumours, with salvage surgery in reserve.     

超声在假体隆乳术后并发症诊断中的应用

目的：寻找一种快捷、无创、准确的检查手段，为临床及时、准确地诊断隆乳术后并发症提供客观的诊断依据。方法：用超声高频探头检查假体隆乳术后出现异常临床表现的62例患者124只乳房，并择期行手术治疗，结合临床表现和术中所见进行分析。结果：超声诊断假体包膜挛缩27只（含局部过度增生1只），假体充填物渗漏、血肿、感染伴纤维囊形成35只，假体破裂伴纤维囊形成11只；超声诊断结果与术后诊断结果完全符合。结论：超声可以及时、准确地为隆乳术后并发症的诊断提供客观依据，并可用来对隆乳术后的情况作长期的动态随访观察。     

THE CLINICAL ROLE OF SHOULDER ULTRASOUND

Background : Rotator cuff surgery is facilitated by accurate pre-operative information regarding the presence and size of cuff tears, and the extent of any cuff retraction or lamination. Methods : A total of 117 consecutive patients who underwent shoulder ultrasound followed by surgical management were assessed, and the pre-operative ultrasound diagnoses were correlated with the operative findings. Results : Ultrasound was found to be reliable for the detection of full-thickness cuff tears (positive predictive value 96%). In the assessment of partial thickness tears, ultrasound produced few false positives, but failed to diagnose a significant proportion of these lesions. Lamination and other interstitial cuff pathology were not reliably detected by ultrasound. In the diagnosis of subacromial impingement, ultrasound produced few false positives (positive predictive value 95%), but did produce a significant number of false negative results (negative predictive value 66%). Conclusions : Ultrasound is cheaper than MRI and arthrography, and is both non-invasive and ‘dynamic’. It is reliable in the diagnosis of full-thickness cuff tears and is a useful adjunct in the diagnosis of cuff impingement and partial thickness tears, but is very much operator-dependent.     

改良内镜乳头括约肌切开治疗乳头狭窄临床研究

为评价内镜乳头括约肌切开(EST)对乳头狭窄的临床疗效。以54例乳头狭窄病人为研究对象,随机分为二组,施行改良EST(内镜乳头括约肌梭形切开)和常规EST,行2年内的临床追踪观察。结果显示改良组乳头形态呈锁孔状,对照组为挛缩裂隙状;改良组临床症状复发7.4％,对照组为33.3％,二者有显著性差异(P<0.05);二组近期并发症无显著性差异(P>0.05);提示内镜乳头括约肌梭形切开治疗乳头狭窄疗效可靠,且简单方便。