British Journal of Surgery

Emergency ligation of bleeding oesophageal varices using the Milnes Walker technique was performed in 38 patients. Haemorrhage continued or recurred in hospital in 11 patients, all of whom subsequently died. A further 10 patients died in hospital following operation from hepatic failure and a variety of other causes. Five patients were finally considered suitable for elective shunt surgery, but of 12 patients who were discharged without a further operation, only 2 have re-bled. Although the overall 6-month survival was 32 per cent, in patients with good preoperative liver function this rose to 71 per cent, and the simple scoring system for grading the severity of disturbance of liver function was found to be of value in predicting the outcome of surgery.

Since the results of emergency ligation of bleeding oesophageal varices in our hands have been so disappointing we are currently using it less and are trying the mesenteric caval jump graft as an emergency operation for the control of bleeding varices.

Five cases are described where minute foci of adenocarcinoma have been demonstrated in the mesorectum several centimetres distal to the apparent lower edge of a rectal cancer. In 2 of these there was no other evidence of lymphatic spread of the tumour. In orthodox anterior resection much of this tissue remains in the pelvis, and it is suggested that these foci might lead to suture-line or pelvic recurrence. Total excision of the mesorectum has, therefore, been carried out as a part of over 100 consecutive anterior resections. Fifty of these, which were classified as ‘curative’ or ‘conceivably curative’ operations, have now been followed for over 2 years with no pelvic or staple-line recurrence.

Authors writing on oesophageal cancer include adenocarcinoma to a variable extent–between 1 and 75 per cent–but the true incidence of this histological type is about 1 per cent. Most adenocarcinomas are gastric in origin, involving the lower oesophagus, have a lower operative mortality than in the middle or upper one-third of the oesophagus and poorer prognosis than squamous cell carcinoma, but there is no alternative treatment to surgery. Squamous cell carcinoma of the oesophagus, separated incompletely but as far as possible, has been analysed by reviewing data on 83 783 patients in 122 papers. After trying to standardize the data, it appears that of 100 patients with the condition, 58 will be explored and 39 have the tumour resected, of whom 13 will die in hospital. Of the 26 patients leaving hospital with the tumour excised, 18 will survive for 1 year, 9 for 2 years and 4 for 5 years. Oesophageal resection for squamous cell carcinoma has the highest operative mortality of any routinely performed surgical procedure today.

During the past 10 years, postoperative mortality associated with surgical treatment of oesophageal carcinoma has been reduced by one-half. However, it appears that all efforts to improve long-term survival with extensive excisional procedures and adjuvant chemotherapy and radiotherapy have failed. Fifty-six of 100 patients presenting to the surgeon with an oesophageal carcinoma have resectable disease. Recent studies suggest that seven of them will die from postoperative complications and 49 patients will be discharged from the hospital after an average of 3 weeks. Of these patients, 27 will survive the first, 12 the second, and ten the fifth year. Although it may be possible to further reduce postoperative complications and mortality, the chances of improving the long-term prognosis of patients with oesophageal carcinoma seem small.

The incidence of lymphoedema was studied in 200 patients following a variety of treatments for operable breast cancer. Lymphoedema was assessed in two ways: subjective (patient plus observer impression) and objective (physical measurement). Arm volume measurement 15 cm above the lateral epicondyle was the most accurate method of assessing differences in size of the operated and normal arm. Arm circumference measurements were inaccurate. Subjective lymphoedema was present in 14 per cent whereas objective lymphoedema (a difference in limb volume > 200 ml) was present in 25.5 per cent. Independent risk factors contributing towards the development of subjective late lymphoedema were the extent of axillary surgery (P < 0.05), axillary radiotherapy (P < 0.001) and pathological nodal status (P < 0.10). The risk of developing late lymphoedema was unrelated to age, menopausal status, handedness, early lymphoedema, surgical and radiotherapeutic complications, total dose of radiation, time interval since presentation, drug therapy, surgery to the breast, radiotherapy to the breast and tumour T stage. The incidence of subjective late lymphoedema was similar after axillary radiotherapy alone (8.3 per cent), axillary sampling plus radiotherapy (9.1 percent) and axillary clearance alone (7.4 per cent). The incidence after axillary clearance plus radiotherapy was significantly greater (38.3 per cent, P < 0.001). Axillary radiotherapy should be avoided in patients who have had a total axillary clearance.