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Biomedical subjects

I G Martin

Publications and source records attributed to I G Martin.

At least 19 recordsLinked to original sources
PubMed1997

Assessment of microsatellite alterations in young patients with gastric adenocarcinoma.

BACKGROUND: Genetic factors are probably important in the development of gastric carcinoma in young patients (younger than 40 years). The authors investigated early onset primary gastric adenocarcinomas for the presence of microsatellite instability, which is a phenotypic marker for the hereditary nonpolyposis colon carcinoma syndrome. METHODS: DNA was extracted from archival microdissected carcinoma and corresponding normal tissue from 10 British gastric carcinoma patients age 19 to 39 years at the time of diagnosis. A panel of 12 microsatellite loci were amplified by fluorescent polymerase chain reaction and analyzed using an automated DNA sequencer. RESULTS: There was no evidence of microsatellite instability. In contrast, allelic imbalance was recorded at D3S966, D3S1076, D10S197, D11S904, P53, NM23, and DCC microsatellite loci. CONCLUSIONS: The authors reported ten cases of early onset gastric carcinoma that demonstrated allelic imbalance but no evidence of instability at microsatellite loci. It is unlikely that defective DNA mismatch repair is important in this group of young patients.

Adenocarcinoma↗
PubMed1997

Delays in the diagnosis of oesophagogastric cancer: a consecutive case series.

OBJECTIVES: To examine the time taken to diagnose oesophageal or gastric cancer, identify the source of delay, and assess its clinical importance. DESIGN: Study of all new patients presenting to one surgical unit with carcinoma of the oesophagus or stomach. SETTING: University department of surgery in a large teaching hospital. SUBJECTS: 115 consecutive patients (70 men, mean age 66 years) with carcinoma of the oesophagus (27) or stomach (88). MAIN OUTCOME MEASURES: Interval from the onset of symptoms to histological diagnosis, final pathological stage of the tumour, and whether potentially curative resection was possible. RESULTS: The median delay from first symptoms to histological diagnosis was 17 weeks (range 1 to 168 weeks). 25% (29/115) of patients had a delay of over 28 weeks (median 39 weeks). Total delay was made up of the following components: delay in consulting a doctor (29%), delay in referral (23%), delay in being seen at hospital (16%), and delay in establishing the diagnosis at the hospital (32%). No relation was found between delay in diagnosis and tumour stage in patients with gastric cancer, but for oesophageal cancer those with stage I and II disease were diagnosed within 7 weeks compared with 21 weeks (P < 0.02) for those with stage III and IV disease. CONCLUSIONS: Long delays still occur in the diagnosis of patients with cancer of the stomach or oesophagus. Streamlined referral and investigation pathways are needed if patients with gastric and oesophageal carcinomas are to be diagnosed early in the course of the disease.

Aged↗
PubMed1996

Radical thoracoscopic esophagectomy for cancer.

BACKGROUND: Much of the morbidity of conventional esophagectomy for cancer is thought to relate to the thoracotomy wound and while transhiatal esophagectomy removes the need for a thoracotomy, it is not oncologically sound. Videothoracoscopy could potentially provide an oncologically sound means for resecting the thoracic esophagus without the need for a thorcotomy. METHODS: Between June 1991 and June 1994, thoracoscopic mobilization of the thoracic esophagus combined with radical lymphadenectomy was attempted in 24 patients as part of three-stage esophagectomy for cancer (5 squamous and 19 adenocarcinomas). Mean age was 59 years (range 43-76). Eight patients were ASA grade I, 10 were ASA II, and 6 ASA III. Two patients had early lesions (T1N0) but all other cancers were T2 or T3. Dissection of the thoracic esophagus was attempted via a right-sided approach, followed by a laparotomy and a cervical incision. RESULTS: The thoracoscopic procedure was successful in 22 patients; it was abandoned in one patient with dense pleural adhesions and in another with inoperable tumor. Mean duration of the thoracic component was 184 min(120-330). There were three post-operative deaths. Ten further patients had major complications. Median post-operative stay was 18 days(9-129). Mean node harvest was 13 nodes(6-28). Two-year survival (cancer specific) was 33%. CONCLUSIONS: Radical thoracoscopic mobilization of the esophagus is feasible, but the potential for complications remains high and requires further study.

Adenocarcinoma↗
PubMed1996

Laparoscopic cholecystectomy in pregnancy. A safe option during the second trimester?

BACKGROUND: Laparoscopic cholecystectomy is now the standard treatment for symptomatic gallstones; while symptomatic gallstones during pregnancy are not frequent they are by no means rare. The role of laparoscopic cholecystectomy during pregnancy is controversial but initial reports suggest it is both safe and feasible. METHODS: During a consecutive series of 500 laparoscopic cholecystectomies, 3 patients have undergone laparoscopic cholecystectomy during pregnancy. The 3 patients were 16-27 weeks pregnant with an average age of 32 years. The indication for laparoscopic cholecystectomy was severe pain in two patients and gallstone pancreatitis in one patient. Following standard obstetric anesthesia, laparoscopic cholecystectomy was performed. Open cannulation was used to establish peritoneal access, following which "standard," four-port laparoscopic cholecystectomy was performed without complication. The insufflation pressure used was 8-10 mmHg CO2 and a liver retractor was employed to facilitate access. RESULTS: In each case the postoperative recovery was rapid and uneventful for both mother and fetus. The patients were discharged on the first or second postoperative day. CONCLUSIONS: Laparoscopic cholecystectomy during the second trimester of pregnancy is both safe and feasible provided both suitable surgical and anesthetic expertise are available. Even up to the end of the second trimester there is sufficient access for the technique to be employed.

Adult↗
PubMed1996

Laparoscopic splenectomy. The suspended pedicle technique.

BACKGROUND: Elective splenectomy is often performed for hematological diseases, some of which cause only moderate enlargement of the spleen. The avoidance of an extensive upper abdominal incision is desirable in such cases and laparoscopic splenectomy offers significant potential advantages over the open operation if it can be performed safely and economically. METHODS: Eight consecutive patients underwent laparoscopic splenectomy. The operation was carried out with the patient at 40 degrees in the right lateral position so that rotating the operating table would make a full right lateral position possible. After fenestration of the gastrocolic omentum and division of the short gastric vessels, this position allowed the spleen to be pushed up under the diaphragm to facilitate access to the splenic vessels and the hilum. Vessels were divided individually between clips. RESULTS: All eight cases were completed laparoscopically. Mean length of operation was 259 min (range 230-285). Postoperative stay ranged from 2 to 7 days (median 4 days). There was no mortality, although minor complications did occur in three patients. CONCLUSIONS: We found laparoscopic splenectomy to be a safe and feasible procedure for the elective removal of the moderately enlarged spleen.

Adult↗
PubMed1995

Bile leakage following laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) is now the treatment of choice for gallstones, but there has been concern that bile leakage with LC is more frequent than after open cholecystectomy (OC). We have analyzed our experience of this complication with regard to both its incidence and management. From a consecutive series of 500 LC, in which both operative cholangiography and drainage of the gallbladder bed were routine, bile leakage was identified in ten patients (2%). There was no bile duct injury. Nine of the ten patients presented with bile in the drain within 24 h of operation and one patient presented 1 week after operation with a subphrenic collection. Of the ten patients, five settled spontaneously. Of the five remaining patients, two needed laparotomy--one for a subphrenic collection not responding to percutaneous drainage and one for biliary peritonitis. One patient was treated by relaparoscopy and suture of a duct of Luschka and one patient had successful percutaneous drainage of an infected collection; the fifth patient who presented with a late subphrenic collection of bile was shown at endoscopic retrograde cholangiopancreatography (ERCP) to have a cystic duct stump leak and was treated with an endoscopic stent. Bile leakage is seen more frequently after LC than OC for reasons that are currently unclear. We believe that the use of routine gallbladder bed drainage is justified for this reason alone. The majority of bile leaks settle either spontaneously or with minimally invasive intervention.

Adult↗
PubMed1995

Fundus-first laparoscopic cholecystectomy.

Removal of the gallbladder with commencement of dissection at the fundus is well recognized as a safe technique during difficult "open" cholecystectomy because it minimizes the risks of damage to the structures in or around Calot's triangle. We report here the routine employment of liver retractors and fundus-first dissection during laparoscopic cholecystectomy (LC) as an alternative to techniques previously described. Retraction of the liver and "fundus-first" dissection was used in 53 patients who underwent laparoscopic cholecytectomy. There were 16 male and 37 female patients. Seven were operations performed during an acute admission and 20 had moderate or severe adhesions involving the gallbladder. Thirteen patients had a preexisting abdominal incision. The procedure was successful in 52 patients (98%), but in one patient it was converted to open operation because of dense adhesions. Median duration of operation was 90 min (range 35-240 min). There was no mortality and two complications (persistent right upper quadrant pain for 2 weeks after operation and bile leakage from the gallbladder bed). The facility to retract the liver and carry out a fundus-first dissection extends techniques developed for "open" surgery into the laparoscopic arena. It offers the surgeon the safety and versatility during laparoscopic cholecystectomy that it confers during conventional open surgery.

Acute Disease↗
PubMed1995

Why do some patients experience poor functional results after anterior resection of the rectum for carcinoma?

PURPOSE: The aim of this study was to examine the dynamic inter-relationship of the anal sphincter, residual rectum, and neorectum after low anterior resection for rectal carcinoma. METHODS: Seventy-three patients underwent laboratory tests of anorectal function a median of ten (range 1-100) months after operation. All patients completed quality of life questionnaires and had the level of their anastomoses determined by rigid sigmoidoscopy. Forty-four patients (60 percent) had some form of disturbance of bowel function, which was classified as "poor" function if bowel frequency was four or more in 24 hours and if there was also either fecal leakage or urgency of defecation. Manometric data were analyzed using stepwise logistic regression analysis. RESULTS: Only two factors were found to be significantly and independently associated with poor bowel function, namely, the pressure recorded in the upper part of the anal sphincter in response to distention of the neorectum (15 (7-24) cm of water in patients with poor function vs. 29 (15-58) cm in patients with good function; P < 0.005) and the level of the anastomosis above the anal sphincteric high pressure zone (2.5 (2-3.5) cm in patients with poor function vs. 6 (4-12) cm in patients with good function; P < 0.005). CONCLUSION: Continence after anterior resection is related to an appropriate "sampling" response in the anal sphincter to activity within the neorectum. This in turn, is directly related to length of the residual rectum, which is, therefore, of crucial importance to function.

Aged↗
PubMed1995

Helicobacter pylori and recurrent ulceration after highly selective vagotomy.

OBJECTIVE: To examine the relationship between Helicobacter pylori and recurrent ulceration after highly selective vagotomy (HSV). SETTING: Academic Department of Surgery at a teaching hospital. PATIENTS: Thirty-eight patients (26 men and 12 women) were studied 2-21 years after HSV. Seven patients had recurrent ulceration. Each patient underwent tests of acid secretion before and 1 week after HSV together with later endoscopic examination of the stomach and duodenum. Four biopsies were taken from the duodenum and gastric antrum. RESULTS: There was no statistical difference in acid output between patients with and those without recurrent ulceration (peak acid output 46.9 versus 55.8 mmol/h, respectively; not significant) before operation. After operation, insulin stimulated acid secretion was significantly higher in patients who later developed recurrent ulceration (0.26 versus 4.1 mmol/h, respectively; P < 0.02). The endoscopic biopsies were tested for H. pylori infection (90 versus 86% for patients without and those with recurrent ulceration, respectively; not significant), gastric metaplasia within the duodenum (23 versus 14% for patients without and those with recurrent ulceration, respectively; not significant), antral gastritis (86 versus 71% for patients without and those with recurrent ulceration, respectively; not significant) and antral intestinal metaplasia (52 versus 43% for those without and those with recurrent ulceration, respectively; not significant). CONCLUSION: H. pylori infection is not influenced by HSV and ulcer recurrence is determined by the completeness of vagotomy rather than by H. pylori status.

Adult↗
PubMed1994

Role of circumferential margin involvement in the local recurrence of rectal cancer.

Local recurrence after resection for rectal cancer remains common despite growing acceptance that inadequate local excision may be implicated. In a prospective study of 190 patients with rectal cancer, we examined the circumferential margin of excision of resected specimens for tumour presence, to examine its frequency and its relation to subsequent local recurrence. Tumour involvement of the circumferential margin was seen in 25% (35/141) of specimens for which the surgeon thought the resection was potentially curative, and in 36% (69/190) of all cases. After a median 5 years' follow-up (range 3.0-7.7 years), the frequency of local recurrence after potentially curative resection was 25% (95% CI 18-33%). The frequency of local recurrence was significantly higher for patients who had had tumour involvement of the circumferential margin than for those without such involvement (78 [95% CI 62-94] vs 10 [4-16]%). By Cox's regression analysis tumour involvement of the circumferential margin independently influenced both local recurrence (hazard ratio = 12.2 [4.4-34.6]) and survival (3.2 [1.6-6.53]). These results show the importance of wide local excision during resection for rectal cancer, and the need for routine assessment of the circumferential margin to assess prognosis.

Adult↗
PubMed1994

Immunoproliferative small intestinal disease: Mediterranean lymphoma and alpha heavy chain disease.

Gastrointestinal lymphoma, uncommon in the West, is far more prevalent in developing countries where it falls into two groups: 'Western'-type lymphomas, similar to those seen in developed countries, and the so-called Mediterranean-type lymphoma. It is now accepted that Mediterranean lymphoma represents, in the majority if not in all cases, the late stage of alpha heavy chain disease (alpha-HCD). This disease is characterized by abnormal secretion of an immunoglobulin fragment; alpha-HCD and Mediterranean lymphoma constitute two ends of a spectrum of pathology now classified as immunoproliferative small intestinal disease (IPSID). IPSID is associated predominantly with poor socioeconomic conditions; patients present with progressive malabsorption in the second and third decades of life. Diagnosis is established by small bowel biopsy, with or without high serum levels of the alpha heavy chain protein. Treatment consists of an initial staging laparotomy, with debulking of lymphomatous deposits if appropriate, followed by chemotherapy or radiotherapy. Overall prognosis is poor but the recent use of doxorubicin-based chemotherapy offers some hope for the future.

Diagnosis, Differential↗
PubMed1994

Goseki grading in gastric cancer: comparison with existing systems of grading and its reproducibility.

A novel grading method which utilises intra-cellular mucin content and tubular differentiation (the Goseki grade) has been applied to 181 gastric cancers removed in potentially curative resections, and compared to conventional tumour grading (well, moderate, poor differentiation) and the Lauren, Ming and WHO classifications. The Goseki grade is significantly related to patient survival and, unlike the existing approaches, remains so after allowing for tumour stage in multivariate analyses. Potential relationships between the Goseki grade, direct tumour spread, lymph node involvement and survival have been investigated. Prognosis is particularly related to mucin content; 55% of patients with mucin-rich tumours dying within 5 years compared to 29% of those with mucin-poor cancers. A smaller proportion of mucin-poor cancers show lymph node involvement (N1 and N2) than mucin-rich tumours (52% v. 73%) and a smaller proportion of cancers showing good tubular differentiation exhibit widespread lymph node involvement (N2) than tubule-poor cancers (11% v. 28%). However, these differences did not achieve statistical significance. When compared to the existing classification or grading methods, the Goseki grade was found to be highly significantly correlated with the WHO and Lauren classifications and to conventional grading, but not to the Ming classification. These inter-relations are largely dependent upon tubular differentiation. There was no relationship between Goseki grade and the lymphocytic response around the tumour margin. Inter-observer agreement on the WHO type and the Lauren, Ming and Goseki grading methods was tested on 70 randomly selected cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗
PubMed1994

Goseki histological grading of gastric cancer is an important predictor of outcome.

TNM (tumour, node, metastases) staging has thus far been the most important guide to prognosis in patients with gastric cancer. Histological grading, in contrast, has not provided any additional information. Recently a novel grading system based on tubular differentiation and mucus production has been proposed, which was correlated with patterns of tumour spread found at necropsy. This study set out to assess its value as a determinant of survival after gastric resection. In a consecutive series of 211 patients who had potentially curative resection for gastric cancer, five histological grading systems were assessed: the Lauren type, the WHO type, degree of differentiation, the type of tumour border, and the lymphocytic response to the tumour and compared with the Goseki grading (I-IV). When T and N stage were taken into account, using Cox's proportional hazards model, only the Goseki grading added further to the ability to predict survival. The proportional hazards ratios were: node negative v node positive 6.5 T1 v T3 2.45; Goseki I v Goseki IV 3.1. Five year survival of patients with mucus rich (Goseki II and IV) T3 tumours was significantly worse than that of patients with mucus poor (Goseki I and III) T3 tumours (18% v 53%, p < 0.003). Goseki grading identifies subgroups of patients with a poorer prognosis than is predicted by TNM staging alone. It could prove useful in the selection of patients for adjuvant therapy after potentially curative resection for gastric cancer.

Aged↗
PubMed1993

Gastric cancer: a curable disease in Britain.

OBJECTIVE: To determine whether more vigorous efforts aimed at earlier diagnosis allied to radical surgical resection lead to improved survival of patients with gastric cancer. DESIGN: Prospective audit of all cases of gastric cancer treated during 1970-89. SETTING: Department of surgery, general hospital. SUBJECTS: 493 consecutive patients with gastric adenocarcinoma. MAIN OUTCOME MEASURES: Operative mortality, postoperative morbidity, and five year survival after radical potentially curative resection. RESULTS: 207 (42%) patients underwent potentially curative resection. The proportion of all patients in whom this was possible increased significantly (p < 0.01) from 31% in the first five year period to 53% in the last five year period. The proportion of patients who had early gastric cancer rose from 1% to 15% (p < 0.01) and stage I disease rose from 4% to 26% (p < 0.001). After potentially curative resection, mortality 30 days after operation was 6%. Operative mortality decreased from 9% in the 1970s to 5% in the 1980s. Likewise, the incidence of serious postoperative complications decreased from 33% in the 1970s to 17% in the 1980s (p < 0.01). Five year survival was 60% in patients who underwent curative resection, 98% in patients with early gastric cancer, and 93%, 69%, and 28% in stage I, II, and III disease respectively. By the late 1980s five year survival after operation was about 70%. CONCLUSIONS: These findings suggest that an increasing proportion of patients with gastric cancer could be diagnosed at a relatively early pathological stage when about two thirds are curable by means of radical surgery.

Adenocarcinoma↗
PubMed1993

Minimally invasive treatment for common bile duct stones.

The impact of endoscopic surgery on the management of stones in the common bile duct (CBD) was studied. All patients with proven common duct stones managed by a single consultant during a 21-month period were included. Of a total of 60 patients, 48 were referred because of symptoms or signs of calculi in the CBD and 12 were found to have common duct stones although symptoms were related primarily to the gallbladder. Of the 48 patients referred with common duct stones, 41 (85 per cent) were successfully treated by endoscopic retrograde cholangiography (ERC) and endoscopic sphincterotomy (ES) (complications were cholangitis (one patient), mild acute pancreatitis (one), impacted retrieval basket (one)). Of the remaining seven patients, two underwent open exploration (one after failed laparoscopic exploration) and five had successful laparoscopic duct exploration. One patient underwent laparoscopic exploration of the CBD but subsequently died. Of the patients with primary gallbladder symptoms, eight underwent preoperative ES, one was treated by laparoscopic duct exploration, one by conversion to open operation and in two patients duct stones were removed at postoperative ERC. The overall mortality rate was 2 per cent and the incidence of complications 12 per cent. Open exploration of the CBD was performed in three patients (5 per cent). This experience suggests that open duct exploration will become increasingly infrequent and may be replaced by endoscopic surgery in the majority of patients.

Adult↗