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Biomedical subjects

N Hayes

Publications and source records attributed to N Hayes.

At least 19 recordsLinked to original sources
PubMed2006

Use of alarm symptoms to select dyspeptics for endoscopy causes patients with curable esophagogastric cancer to be overlooked.

BACKGROUND: In August 2004, the United Kingdom Department of Health advisory body published dyspepsia referral guidelines for primary care practitioners. These guidelines advised empiric treatment with antisecretory medications and referral for endoscopy only in the presence of alarm symptoms. The current study aimed to evaluate the effect of these guidelines on the detection of esophagogastric cancer. METHODS: The study reviewed a prospectively compiled database of 4,018 subjects who underwent open access gastroscopy during the years 1990 to 1998. The main outcome measures for the study were cancer detection rates, International Union Against Cancer (UICC) stage, and survival. RESULTS: Gastroscopy identified esophagogastric carcinoma in 123 (3%) of the 4,018 subjects. Of these 123 patients, 104 (85%) with esophagogastric cancer had "alarm" symptoms (anemia, mass, dysphagia, weight loss, vomiting) and would have satisfied the referral criteria. The remaining 15% would not have been referred for initial endoscopic assessment because their symptoms were those of uncomplicated "benign" dyspepsia. The patients with "alarm" symptoms had a significantly more advanced tumor stage (metastatic disease in 47% vs 11%; p < 0.001), were less likely to undergo surgical resection (50% vs 95%; p < 0.001), and had a poorer survival (median, 11 vs 39 months; p = 0.01) than their counterparts without such symptoms. CONCLUSIONS: The use of alarm symptoms to select dyspeptics for endoscopy identifies patients with advanced and usually incurable esophagogastric cancer. Patients with early curable cancers often have only dyspeptic symptoms, and their diagnosis will be delayed until the symptoms of advanced cancer develop.

Adult↗
PubMed2005

Sentinel node biopsy to evaluate the metastatic dissemination of oesophageal adenocarcinoma.

BACKGROUND: The aim of this study was to determine the feasibility and accuracy of sentinel lymph node (SLN) biopsy for oesophageal adenocarcinoma. METHODS: Fifty-seven patients with adenocarcinoma of the lower oesophagus (n = 40) or gastric cardia (n = 17) underwent endoscopic peritumoral injection of (99m)Tc-radiolabelled nanocolloid before en bloc resection with extended lymphadenectomy. SLNs were identified during surgery using a handheld gamma probe and the pattern of radioactive uptake was quantified after operation. All 1667 resected lymph nodes were examined immunohistochemically for micrometastases. RESULTS: SLNs were identified in all 57 patients. They contained metastases (n = 32) or micrometastases (n = 3) in 35 of 37 node-positive patients and there were two false-negative studies. The overall accuracy of SLN biopsy was 96 per cent and SLNs were more likely to contain tumour than other lymph nodes (P < 0.001). Tumour-infiltrated nodal stations had a higher proportion of radioactive uptake (P < 0.001). Lower oesophageal tumours had a greater proportion of SLNs (P = 0.018), radioactive uptake (P < 0.001) and malignant nodes (P = 0.004) in the mediastinum than gastric cardia tumours. CONCLUSION: The sentinel node concept is applicable to oesophageal adenocarcinoma and could be used to tailor the extent of lymphadenectomy. There is a close relationship between patterns of radioactive uptake and lymphatic tumour dissemination, which differ for lower oesophageal and gastric cardia tumours.

Adenocarcinoma↗
PubMed2005

Cancer-related disparities: weathering the perfect storm through comprehensive cancer control approaches.

During the last two decades extraordinary progress in developing and using effective cancer prevention strategies, early detection interventions, and cancer treatments has been made. This progress has resulted in an overall decline in mortality rates for all cancers combined. Nonetheless, cancer is the second most common cause of death in the United States. Although cancer is a diagnosis that many survive, cancer experiences across populations may vary considerably. These differences in cancer experiences have created an unequal disease burden that presents distinct professional and moral challenges to our nation. Many cancer control plans suggest specific strategies that prioritize eliminating cancer-related disparities. This article describes certain cancer-related disparities in the United States and gives several examples of how communities and disenfranchised populations are using comprehensive cancer control (CCC) approaches to eliminate these disparities. One or two interventions are highlighted in each example.

Delivery of Health Care↗
PubMed2004

Prospective study of routine contrast radiology after total gastrectomy.

BACKGROUND: The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation. METHODS: Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy. RESULTS: Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak. CONCLUSION: There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Adult↗
PubMed2003

Human model of duodenogastro-oesophageal reflux in the development of Barrett's metaplasia.

BACKGROUND: Patients with an intrathoracic oesophagogastrostomy after subtotal oesophagectomy experience profound duodenogastro-oesophageal reflux (DGOR). This study investigated the degree of mucosal injury and histopathological changes in oesophageal squamous epithelium after subtotal oesophagectomy with gastric interposition in relation to the extent of postoperative DGOR. METHODS: Serial endoscopic assessment and systematic biopsy at the oesophagogastric anastomosis was undertaken in 40 patients following curative radical subtotal oesophagectomy and reconstruction with a gastric conduit subjected to a pyloroplasty. Thirty patients subsequently underwent combined 24-h ambulatory pH and bilirubin monitoring. RESULTS: Grade I-III oesophagitis was identified in 14 patients and oesophageal columnar epithelium in 19 patients. Biopsies from columnar regeneration revealed cardiac-type epithelium in ten patients and intestinal metaplasia in nine. Seven patients followed serially showed progression from cardiac-type epithelium to intestinal metaplasia. The incidence of Barrett's metaplasia was similar irrespective of the histological subtype of the resected tumour. Patients with oesophageal columnar epithelium had significantly higher acid (P = 0.015) and bilirubin (P = 0.011) reflux. CONCLUSION: Severe DGOR occurs following subtotal oesophagectomy and provides an environment for the acquisition of Barrett's metaplasia via a sequence of cardiac epithelium and eventual intestinal metaplasia.

Adult↗
PubMed2001

An HIV-1 transgenic rat that develops HIV-related pathology and immunologic dysfunction.

We report, to our knowledge, the first HIV type 1 (HIV-1) transgenic (Tg) rat. Expression of the transgene, consisting of an HIV-1 provirus with a functional deletion of gag and pol, is regulated by the viral long terminal repeat. Spliced and unspliced viral transcripts were expressed in lymph nodes, thymus, liver, kidney, and spleen, suggesting that Tat and Rev are functional. Viral proteins were identified in spleen tissue sections by immunohistochemistry and gp120 was present in splenic macrophages, T and B cells, and in serum. Clinical signs included wasting, mild to severe skin lesions, opaque cataracts, neurological signs, and respiratory difficulty. Histopathology included a selective loss of splenocytes within the periarterial lymphoid sheath, increased apoptosis of endothelial cells and splenocytes, follicular hyperplasia of the spleen, lymphocyte depletion of mesenteric lymph nodes, interstitial pneumonia, psoriatic skin lesions, and neurological, cardiac, and renal pathologies. Immunologically, delayed-type hypersensitivity response to keyhole limpet hemocyanin was diminished. By contrast, Ab titers and proliferative response to recall antigen (keyhole limpet hemocyanin) were normal. The HIV-1 Tg rat thus has many similarities to humans infected with HIV-1 in expression of viral genes, immune-response alterations, and pathologies resulting from infection. The HIV-1 Tg rat may provide a valuable model for some of the pathogenic manifestations of chronic HIV-1 diseases and could be useful in testing therapeutic regimens targeted to stages of viral replication subsequent to proviral integration.

Animals↗
PubMed2001

Diagnosis and management of a mediastinal leak following radical oesophagectomy.

BACKGROUND: The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a stapled intrathoracic anastomosis. METHODS: Some 291 consecutive patients underwent two-phase subtotal oesophagectomy with gastric interposition for malignancy. Patients with clinical suspicion of a leak were investigated with contrast radiology and flexible upper gastrointestinal endoscopy. RESULTS: Nineteen patients (6.5 per cent) developed a proven mediastinal leak at a median of 8 (range 3-30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had widespread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology was normal. In six patients the diagnosis of leakage followed an apparently normal routine contrast examination on day 5-8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intravenous antibiotics and antifungal therapy, nasogastric decompression and enteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical picture; they were managed with repeat thoracotomy and either revision of the conduit or resection and exclusion. Despite early intervention four of the six patients died. CONCLUSION: Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology and endoscopic evaluation. Isolated anastomotic leaks can be managed successfully with non-operative treatment, whereas more extensive leaks from the gastric conduit require revisional surgery which carries a high mortality rate.

Aged↗
PubMed2001

The pattern of metastatic lymph node dissemination from adenocarcinoma of the esophagogastric junction.

BACKGROUND: The incidence of adenocarcinoma of the esophagogastric junction is rapidly increasing, and the extent of lymphadenectomy for such tumors remains controversial. The aim of this study was to identify the pattern of dissemination by examination of all lymph nodes retrieved from resected tumors of the esophagogastric junction. METHODS: The endoscopic and pathologic reports of patients who underwent RO resection for adenocarcinoma of the esophagogastric junction between January 1996 and November 1999 were examined. Patients with type 1 tumors (distal esophagus) underwent subtotal esophagectomy with 2-field lymphadenectomy. Patients with type 2 (gastric cardia) tumors underwent transhiatal D2 total gastro-esophagectomy. Lymph node groups were dissected from the main specimens and examined separately. RESULTS: One hundred and four type 1 and 48 type 2 tumors were studied. Median nodal recovery was 23 lymph nodes (type 1, 22 lymph nodes; type 2, 23 lymph nodes). Seventy-eight percent of the type 1 tumors with nodal metastases had dissemination in both the abdomen and mediastinum. The common abdominal sites were the paracardiac and the left gastric stations. Within the mediastinum, paraesophageal, paraaortic and tracheobronchial metastases were more often encountered. Type 2 tumors had positive lymph nodes most frequently in the left and right paracardiac, lesser curve (N1 group), and left gastric (N2 group) territories. Nodal status correlated with increasing depth of tumor invasion (P =.002). CONCLUSIONS: The pattern of nodal dissemination for cardia tumors concurs with that described by other studies. The current definition of nodal fields in the abdomen and mediastinum for esophageal tumors relates to experience with squamous carcinomas. Our results demonstrate a different pattern of dissemination for junctional esophageal adenocarcinomas. The nodal stations to be resected in radical lymphadenectomies for such tumors should be redefined.

Adenocarcinoma↗
PubMed2001

Peri-operative risk factors for acute lung injury after elective oesophagectomy.

Acute lung injury after oesophagectomy is well recognized but the risk factors associated with its development are poorly defined. We analysed retrospectively the effect of a number of pre-, peri- and post-operative risk factors on the development of lung injury in 168 patients after elective oesophagectomy performed at a single centre. The acute respiratory distress syndrome (ARDS) developed in 14.5% of patients and acute lung injury in 23.8%. Mortality in patients developing ARDS was 50% compared with 3.5% in the remainder. Features associated with the development of ARDS included a low pre-operative body mass index, a history of cigarette smoking, the experience of the surgeon, the duration of both the operation and of one-lung ventilation, and the occurrence of a post-operative anastomotic leak. Peri-operative cardiorespiratory instability (measured by peri-operative hypoxaemia, hypotension, fluid and blood requirements and the need for inotropic support) was also associated with ARDS. Acute lung injury after elective oesophagectomy is associated with intraoperative cardiorespiratory instability.

Analysis of Variance↗
PubMed2000

Prescription of proton pump inhibitors before endoscopy. A potential cause of missed diagnosis of early gastric cancers.

BACKGROUND: Early gastric cancer is frequently seen with nonspecific dyspeptic symptoms and subtle endoscopic features. Treatment at this stage of the disease produces a high chance of cure. If the diagnosis is missed at this early stage, then the prognosis may be much poorer depending on the subsequent delay in reaching a diagnosis. OBJECTIVES: To report the healing effect of proton pump inhibitors on early gastric cancer. METHODS: This article reports a case series of 7 patients with ulcerated early gastric cancers indistinguishable as malignant gastric ulcers at endoscopy who were inadvertently prescribed a short course of a proton pump inhibitor prior to a second confirmatory endoscopy. The cases studied were patients with dyspeptic symptoms referred from primary care physicians for upper gastrointestinal endoscopy. RESULTS: In each case the patient became asymptomatic, the endoscopic signs seen at the first endoscopy had resolved, and the lesions could not be recognized even by an experienced endoscopist. If the proton pump inhibitors had been prescribed by the referring physician before the first endoscopy, the diagnosis probably would have been missed. These cases demonstrate the potentially serious masking effect of prescribing a short course of these drugs before making an endoscopic diagnosis. Even though the patient has been referred for endoscopy, the endoscopist may fail to identify the lesion and thus miss the diagnosis. CONCLUSIONS: Primary care physicians must resist the pressures to prescribe proton pump inhibitors before endoscopy, particularly in patients older than 45 years, if the diagnostic yield of gastric cancer in the early curable stages is to be maximized.

Adult↗
PubMed2000

Benign anastomotic stricture following transthoracic subtotal oesophagectomy and stapled oesophago-gastrostomy: risk factors and management

AIMS: Benign anastomotic stricture (BAS) is a common cause of dysphagia following oesophagectomy. The aim of this study was to assess the incidence of BAS, identify risk factors for its development and evaluate the results of postoperative endoscopic dilatation. METHODS: A consecutive series of 234 patients undergoing oesophagectomy with a stapled intrathoracic oesophagogastric anastomosis (Autosuture CEEA gun) between April 1990 and April 1999 were studied. BAS was defined as dysphagia with anastomotic narrowing (XQ200 endoscope) and no suspicion of recurrence. Statistical analysis was by the chi2 and Mann-Whitney U tests. RESULTS: The postoperative mortality rate was 5 per cent (12 of 234) and the anastomotic leak rate 3 per cent (six of 234). One-third of patients (70 of 222) who survived surgery re-presented with dysphagia; 5 per cent (11 of 222) were found to have proven local recurrence and 27 per cent (59 of 222) BAS. The median time to development of BAS was 92 (range 24-210) days. BAS formation was significantly related to the size of the staple gun employed: 21 mm, 80 per cent (eight of ten); 25 mm, 32 per cent (25 of 78); 28 mm, 23 per cent (19 of 81); 31 mm, 19 per cent (seven of 37) and 34 mm, 0 per cent (none of five) (chi2 = 18.3, 4 d.f., P < 0.01). All patients underwent radiographically controlled endoscopic dilatation with no complications. Recurrent BAS occurred in over half of these patients (32 of 59), who had a median of 2 (range 2-17) recurrences all resolving within 532 (mean interval 68) days. Recurrent BAS formation was also significantly related to the size of the staple gun employed (chi2 = 11.6, 4 d.f., P < 0.05). Following the introduction of the Autosuture 'tilt-top' device in July 1995 the median size of gun used rose from 25 to 28 mm with an overall decrease in the incidence of BAS from 33 to 21 per cent (chi2 = 4.0, 1 d.f., P < 0.05). All patients with anastomotic leaks survived and none subsequently developed BAS. Similarly, no association was found between the development of BAS and the anastomotic site (measured from incisors), tumour subtype, resection margin length, sex, age or preoperative cardiorespiratory status. CONCLUSIONS: Staple gun size is an important risk factor for BAS formation and 'tilt-top' devices enable the use of a larger head with a subsequently lower incidence of BAS. Endoscopic dilatation is an effective treatment for BAS which rarely recurs and always resolves within 18 months.

Journal Article↗
PubMed2000

Management of spontaneous rupture of the oesophagus

AIMS: Spontaneous rupture of the oesophagus (SRO) is a rare and often fatal event. The aim of this study was to evaluate the presentation, management and outcome of SRO in a single unit. METHODS: Data were collected on all patients presenting with SRO over a 5-year period with respect to presenting features, diagnostic investigations and subsequent management. Statistical analysis was by Student's t test, chi2 and Fisher's exact tests. RESULTS: Fourteen patients were identified, 12 men and two women with a median age of 64 (range 18-78) years; eight were tertiary referrals. Thirteen of 14 patients presented with chest or upper abdominal pain following vomiting or retching and 13 had an abnormal initial chest radiograph; only one presented with Mackler's triad of pain, vomiting and surgical emphysema. The median delay to diagnosis was 21 (range 1-84) h; this delay did not significantly affect outcome (P = 0.16). An endoscopic assessment and contrast swallow were performed in all patients. Nine of ten patients with a demonstrable leak and full-thickness tear were managed surgically and the four patients with no leak were managed conservatively (P = 0.005); surgical management consisted of thoracotomy, lavage, repair of the perforation and a feeding jejunostomy. Seven patients had a repair over a T tube and two had a primary repair. All conservatively managed patients had contained, controlled or intramural perforations and two also required a feeding jejunostomy. Patients requiring surgery had a longer hospital stay (mean(s.d.) 57.9(34.8) versus 22.2(30.7) days; P = 0.081) and a significantly longer intensive care unit stay (P = 0.044). The overall mortality rate from SRO was 14 per cent (two patients); no deaths occurred in the conservatively managed group. CONCLUSIONS: SRO continues to be diagnosed late despite a classical history and/or abnormal chest radiograph. Endoscopic assessment of perforations is safe and in combination with a contrast swallow can confidently predict patients with contained or controlled rupture in whom non-operative management is successful.

Journal Article↗
PubMed2000

Prognostic significance of peri-operative blood transfusion following radical resection for oesophageal carcinoma.

INTRODUCTION: Peri-operative allogeneic blood transfusion may exert an immunomodulatory effect and has been associated with early recurrence and decreased survival following resection for several gastro-intestinal malignancies. The aim of this study was to evaluate the prognostic influence of transfusion requirements following radical oesophagectomy for cancer. METHODS: A consecutive series of 235 patients undergoing subtotal oesophagectomy with two-field lymphadenectomy in a single centre from April 1990 to June 1999 were studied. RESULTS: The median age was 64 years (30-79) with a male to female ratio of 3:1. The predominant histological subtype was adenocarcinoma (n = 154) compared to squamous carcinoma (n = 81). To avoid the influence of surgical complications data were excluded from the 5.5% of patients suffering in-hospital mortality. In the remaining patients, median blood loss was 900 ml (200-5500) with 46% (103/222) requiring transfusion (median 3 units, range 2-21). Median survival of non-transfused patients was 36 months compared to only 19 months for those receiving transfusion (log-rank = 4.44; 1 df, P = 0.0352). Non-transfused patients had significantly higher 2 and 5-year survival rates of 62% and 41% respectively in contrast to only 40% and 25% in those receiving blood transfusion. Even after stratification of results according to disease stage or the presence of major complications, survival was significantly worse in those receiving transfusion. Multivariate analysis demonstrated that in addition to nodal status, > 4 units transfusion was an independent prognostic indicator. CONCLUSION: Post-operative transfusion is associated with a significantly worse prognosis following radical oesophagectomy. Meticulous haemostasis and avoidance of unnecessary transfusion may prove oncologically beneficial.

Adenocarcinoma↗
PubMed1999

Total gastrectomy with extended lymphadenectomy for "curable" stomach cancer: experience in a non-Japanese Asian center.

BACKGROUND: Gastrectomy with extended lymphadenectomy is the advocated treatment in Japan for patients with "curable" stomach cancer. Attempts in units elsewhere adopting this approach failed to show any survival advantage, and the high operative mortality has prevented global acceptance of the operation. This study examines the safety and efficacy of radical gastrectomy in a Far East center outside Japan. STUDY DESIGN: A consecutive series of 121 patients with gastric cancer who fulfilled criteria for radical surgery had total gastrectomy with extended lymphadenectomy equivalent to D3 dissection over a 6-year period in a single unit. RESULTS: The operation carried a morbidity of 50%, with a perioperative mortality of 5%. Survival was best predicted by tumor stage: 5-year survival for patients with intact gastric serosa was 64%, versus 10% for those with serosal penetration (p < 0.001). The majority of documented metastases occurred by transperitoneal route in serosa-positive patients, but via the hematogenous mechanisms in those who were serosa-negative. CONCLUSIONS: Radical gastrectomy with extended lymphadenectomy carries high operative morbidity. Increased mortality occurred because of loco-regional recurrence in patients with T3/T4 diseases. Novel approaches including neoadjuvant treatment or regional therapy should be explored.

Adenocarcinoma↗
PubMed1999

Peritoneal cytology in the surgical evaluation of gastric carcinoma.

Many patients undergoing surgery for gastric carcinoma will develop peritoneal metastases. A method to identify those patients at risk of peritoneal recurrence would help in the selection of patients for adjuvant therapy. Peritoneal cytology has received little attention in the West, but may prove a useful additional means of evaluating patients with gastric cancer. The aims of this study were to evaluate sampling techniques for peritoneal cytology in patients with gastric cancer, to assess the prognostic significance of free peritoneal malignant cells and to discover the effect of the operative procedure on dissemination of malignant cells. The study is based on 85 consecutive patients undergoing surgical treatment of gastric cancer and followed up for 2 years or until death. Peritoneal cytology samples were collected at laparoscopy, and at operation prior to resection by intraperitoneal lavage and serosal brushings. After resection, samples were taken by peritoneal lavage, imprint cytology of the resected specimen and post-operatively by peritoneal irrigation via a percutaneous catheter. Malignant cells were diagnosed by two independent microscopists. Preoperative peritoneal lavage yielded malignant cells in 16 out of 85 cases (19%). The yield of free malignant cells was increased by using serosal brushings (by four cases) and imprint cytology (by two cases); all of the cases had evidence of serosal penetration. One serosa-negative case exhibited positive cytology in the post-resection peritoneal specimen in which the preresection cytology specimen was negative. Survival was worse in the cytology-positive group (chi2 = 25.1; P< 0.0001). Among serosa-positive patients, survival was significantly reduced if cytology was positive, if cases yielded by brushings and imprint cytology were included (log-rank test = 8.44; 1 df, P = 0.004). In conclusion, free peritoneal malignant cells can be identified in patients with gastric cancer who have a poor prognosis; the yield can be increased with brushings and imprint cytology in addition to conventional peritoneal lavage. Evaluation of peritoneal cytology by these methods may have a role in the selection of patients with the poorest prognosis who may benefit most from adjuvant therapy.

Adult↗
PubMed1999

Percutaneous endoscopic duodenostomy: the relief of obstruction in advanced gastric carcinoma.

Nausea and vomiting in patients with advanced gastric malignancy and mechanical obstruction are distressing and difficult to manage. We describe a patient with linitis plastica and gastric stasis who was treated with a percutaneous endoscopic duodenostomy as the stomach could not be used for percutaneous endoscopic gastrostomy (PEG) formation. A Conflo PEG tube was inserted into the second part of the duodenum using the Ponsky-Gauderer technique without complication. The patient experienced excellent symptomatic relief and tolerated enteral nutrition extremely well, regaining some weight. This manoeuvre can produce effective symptom palliation allowing the patient to be managed at home during the terminal phase of their illness.

Administration, Cutaneous↗