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J A Gossage

Publications and source records attributed to J A Gossage.

9 recordsLinked to original sources
PubMed2006

Neoadjuvant chemotherapy for locally advanced carcinoma of the lower oesophagus and oesophago-gastric junction.

AIMS: To evaluate a single unit's experience with neoadjuvant chemotherapy for treating locally advanced non-metastatic initially resectable and unresectable oesophago-gastric cancer. METHODS: The medical records of all patients with either locally advanced carcinoma of the lower oesophagus or cardia treated with neoadjuvant chemotherapy between August 1999 and January 2003 were reviewed. RESULTS: Sixty-four patients with initially resectable tumours (T2-3 or N+) and 38 patients with initially unresectable tumours (T4 or M1a) received neoadjuvant chemotherapy (83% combination Epirubicin, Cisplatin and 5-Fluorouracil). Symptomatic grade III/IV toxicity was observed in 33% of patients. Chemotherapy was not completed in 20 patients because of death (5.9%) and inadequate tumour response/toxicity (13.7%). Forty-three patients (67.3%) with initially resectable tumours and 19 patients (50%) with initially unresectable tumours underwent surgery. CONCLUSIONS: Chemotherapy in this study was associated with appreciable toxicity. Patients with initially unresectable locally advanced disease can be downstaged with neoadjuvant chemotherapy.

Adenocarcinoma↗
PubMed2006

Symptomatic responses to neoadjuvant chemotherapy for carcinoma of the oesophagus and oesophagogastric junction: are they worth measuring?

AIMS: Neoadjuvant chemotherapy is used to downstage locally advanced oesophagogastric cancer. This study assessed whether changes in dysphagia and weight correlated with radiological and pathological assessment of response and surgical decision-making. MATERIALS AND METHODS: All patients with locally advanced carcinoma of the lower oesophagus or oesophagogastric junction treated with neoadjuvant ECF (epirubicin, cisplatin, and 5-fluorouracil) chemotherapy from January 2000 to January 2003 were included in this study. Patients were considered to be operable depending upon their chemotherapy response. Weight and swallowing were assessed before and after chemotherapy. Statistical analysis was carried out using ANOVA, unpaired t test and Fisher's exact test. RESULTS: Seventy-eight patients (male-female ratio: 6.8: 1; median age: 62.2 years; range: 44.1-78.0 years) underwent a median of three cycles (range: 1-7) of neoadjuvant ECF chemotherapy. Forty patients (51%) gained weight, and swallowing improved in 53 patients (68%). Radiological changes (based on computed tomography) were assessed according to WHO criteria: complete response (5%), partial response (27%), stable disease (46%) and progressive disease (15%). Patients whose swallowing improved gained significantly more weight (P < 0.0001). Swallowing (P = 0.0009) was significantly improved in radiological responders but not weight (P = 0.06); when radiological non-responders were separated into stable and progressive disease, patients with progressive disease were identified as failing to gain weight (P = 0.005). Both swallowing (P < 0.0001) and weight gain (P < 0.0001) were better in patients undergoing surgery. The use of changes of weight (P = 0.42) and swallowing (P = 0.61) failed to separate pathological responders from nonresponders in the subset of patients undergoing surgery. CONCLUSIONS: Weight gain and improved swallowing are good but not absolute indicators of radiological response to chemotherapy and patient selection for surgery. However, changes in these variables are not sufficiently sensitive to identify pathological responders from non-responders.

Adenocarcinoma↗
PubMed2006

Left thoracoabdominal esophagogastrectomy: still a valid operation for carcinoma of the distal esophagus and esophagogastric junction.

The left thoraco-abdominal (LTA) esophago-gastrectomy is rarely performed and yet provides excellent exposure of the esophageal hiatus. The aim of this study was to review the outcome of LTA esophago-gastrectomy within a single unit. Patients were selected for an LTA esophago-gastrectomy (January 2000 - June 2003) based upon the presence of locally advanced tumors of the distal esophagus and cardia. These patients were identified from a prospective consultant database. LTA esophagogastrectomy was technically possible in all 38 patients (34 males; median age = 63 years). In-hospital mortality was 2.6% (1 patient). Four patients (10.5%) were admitted to the intensive care unit and three (7.9%) returned to theatre. Two patients developed clinically apparent anastomotic leaks (5.3%). A potentially curative resection was performed in 34 patients (89%) but 22 (57.8%) of these patients were subsequently found to have tumor cells at or within 2 mm from the circumferential resection margin. The 1-year and 2-year overall survival rates were 70% and 52%, respectively. Long-term complications included benign anastomotic stricture (24%), delayed gastric emptying (26%) and a persistent thoracic wound sinus (15%). LTA esophagogastrectomy remains a viable approach with an acceptably low incidence of short and long-term complications.

Adenocarcinoma↗
PubMed2006

Centralisation of oesophagogastric cancer services: can specialist units deliver?

INTRODUCTION: Oesophagogastric cancer surgery is increasingly being performed in only centralised units. The aim of the study was to examine surgical outcomes and service delivery within a specialist unit. PATIENTS AND METHODS: The case notes of all patients undergoing attempted oesophagogastrectomy between January 2000 and May 2003 were identified from a prospective consultant database. RESULTS: A total of 187 patients (median age, 63 years; range, 29-83 years; M:F ratio, 3.9:1) underwent attempted oesophago-gastrectomy. Of these, 91% were seen within 2 weeks of referral and treatment was instituted after a mean of 31 days (range, 1-109 days). More patients underwent surgery (63%) than neoadjuvant therapy (56%) within 1 month of referral. The main indication for surgery was invasive malignancy in 166 patients (89%). The 30-day mortality was 0.5% (1 death) and in-hospital mortality was 1.1% (2 deaths). The median length of hospital stay was 14 days (range, 7-69 days). Significant postoperative morbidity included: pulmonary complications (36%), cardiovascular complications (16%), wound infection (13%) and clinically significant anastomotic leaks (7%). Of the study group, 28 patients (15%) were admitted to ICU with a median stay of 10 days (range, 1-44 days); this accounted for 0.9% of ICU bed availability. Twelve patients (6.4%) were returned to theatre, most commonly for bleeding. The 1-year survival rates were 78%. During 2002-2003, national waiting list targets for both hernia repair and cholecystectomy were achieved. CONCLUSIONS: Despite recent increases in workload, high volume specialist units can deliver an efficient and timely service with both good treatment outcomes and minimal impact upon elective surgical waiting lists and ICU provision.

Adult↗
PubMed2005

Neoadjuvant chemotherapy for oesophageal cancer: the need for accurate response prediction and evaluation.

Primary surgical resection for locally advanced oesophageal cancer is associated with systemic failure and poor survival due to presence of micrometastatic disease at the time of diagnosis. Neoadjuvant chemotherapy prior to surgical resection aims to downstage these locally advanced tumours. A review of reported randomised controlled trials has shown only one sufficiently powered trial with a survival advantage for cisplatin-based chemotherapy. Published meta-analyses of neoadjuvant chemotherapy trials have shown little or no overall survival benefit. A subgroup of patients with biologically favourable tumours who respond to this treatment have been consistently shown to have a survival advantage. These patients need to be differentiated from non-responders preferably at an early stage of this potentially toxic treatment. Current clinical, endoscopic and radiological methods of response evaluation are all unreliable. Response evaluation with 18FDG-PET has been shown to accurately assess the pathological response and also to predict the risk of local recurrence and overall survival. The development of integrated PET/CT imaging may enhance the accuracy of this response evaluation. In the future, molecular markers of response prediction prior to initiation of treatment may allow the development of individualised treatment strategies. New emerging chemotherapeutic agents may prove to be more effective in eradicating micrometastatic disease.

Antineoplastic Agents↗
PubMed2005

The modernisation of the surgical house officer.

INTRODUCTION: There have been considerable changes in the junior doctors' hours and working patterns over the last 4 years. The aim of this study was to assess the effect of these changes on the house officers' surgical experience and to obtain their opinions on the 'Hospital at Night' system, which has recently been introduced at our large teaching hospital. METHODS: A questionnaire was filled out by surgical house officers at the end of their surgical posts in 2001. The same questionnaire was then repeated for house officers completing the same posts in 2005. RESULTS: Pre-registration house officers now see less acute surgical admissions (mean 5 patients in 3 months in 2005 compared with 35 in 2001; P < 0.0001) and spend less time attending theatre than four years ago (mean 12 sessions in 3 months in 2001 compared with 6 in 2005). Despite the reduction in hours, they are still managing to attend educational sessions. Nine out of ten house officers felt that the 'Hospital at Night' system was unsatisfactory. They were unable to see and clerk acute surgical admissions or go to theatre because they were providing cross cover for other specialties. CONCLUSIONS: The full shift system and the introduction of the 'Hospital at Night' team have led to a reduction in acute surgical experience for surgical house officers. The General Medical Council recommendations for reducing non-educational tasks have not been fulfilled despite the evolving role of nurse practitioners.

Attitude of Health Personnel↗
PubMed2003

Intercostal drain migration post esophagectomy.

A 38-year-old man underwent an Ivor-Lewis esophagectomy for a squamous carcinoma at the lower third of his esophagus. On the fifth postoperative day one liter of turbid fluid appeared from the intercostal drain and there was a right-sided pleural effusion on the chest radiograph. A contrast swallow demonstrated a leak at the distal part of the gastric staple line. This leak was managed conservatively and subsequent contrast swallows failed to show any leakage despite the persistent drainage from the drain. At gastroscopy, the intercostal drain was seen to have eroded through the stomach wall. The drain was repositioned and the patient was discharged from hospital 5 days later. We believe this to be the first report of an intercostal drain migration into the stomach after an elective esophagectomy.

Adult↗
PubMedDate not supplied

Peripheral arterial embolism: prevalence, outcome, and the role of echocardiography in management.

The aims of this study were to review the prevalence and outcome of all surgically treated upper and lower limb emboli presenting to one vascular unit in the last 3 years and to compare transthoracic with transesophageal echocardiography for defining the source of the embolus. All patients who underwent surgical embolectomy for acute limb ischemia from January 2001 to June 2004 were reviewed. Transthoracic and transesophageal echocardiography were carried out on a subset of consecutive unselected patients. Forty-two patients, with a mean age of 80 years, underwent surgical embolectomy from January 2001 to June 2004 (M/F 1:1.8): 27 for lower limb ischemia and 15 for upper limb ischemia. Two thirds of these patients were found to be in atrial fibrillation at presentation (n = 28), of whom less than a third were receiving anticoagulants or antiplatelet agents (n = 8). The mean hospital stay was 15 days with 36 patients (86%) being fully anticoagulated before discharge from hospital. The 30-day mortality rate was 11% (n = 3/27) with 5 patients requiring fasciotomies (12%) and 3 patients requiring an amputation of the lower limb (11%). Postoperatively, 34 patients (81%) had transthoracic echocardiography (TTE), which demonstrated a source or potential source for thrombus in 19 (56%). Fifteen patients (36%) had transesophageal echocardiography (TEE), which changed the subsequent management in 3 patients. All patients in whom TEE altered clinical management would have required this investigation if standard clinical guidelines were followed. TEE did not identify any additional patients with cardiac embolic sources that were not detected by TTE. Arterial limb emboli are still prevalent, but limb salvage and mortality rates appear to be improving. Despite clear guidelines on anticoagulation for patients in atrial fibrillation, many are not receiving appropriate treatment. Transthoracic echocardiography is a good screening tool for detecting a potential cardiac source for peripheral embolism, with transesophageal echocardiography being reserved for specific indications.

Aged, 80 and over↗