The British journal of surgery
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The ideal perioperative analgesia should provide effective pain relief, avoid the detrimental effects of the stress response, be simple to administer without the need for intensive monitoring, and have a low risk of complications. ⋯ Epidural analgesia enhances recovery after gastrointestinal surgery. The results support the development of structured regimens of early postoperative feeding and mobilization to exploit the potential for thoracic epidural analgesia to reduce hospital stay after gastrointestinal surgery.
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Trials in surgery pose some special problems. This paper examines these with reference to 10 years of methodological research sponsored by the UK National Health Service Research and Development programme. ⋯ Like surgery itself, the methodological toolkit for evaluation of surgical procedures continues to evolve. The rules of statistical and scientific probity provide plenty of scope for imaginative design solutions for surgical trials.
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Southern Hebei Province has one of the highest incidences of oesophageal cancer in the world. This study describes a single-centre experience with oesophagectomy for this condition. ⋯ The rate of postoperative complications and deaths following oesophagectomy for cancer has fallen steadily over the past five decades but long-term survival remains disappointing. Improved survival is likely to be dependent on earlier diagnosis and adjunctive therapies.
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Gastrointestinal stromal tumours (GISTs), previously classified as benign or malignant smooth muscle tumours, are the most common mesenchymal tumours of the gastrointestinal tract. GISTs express a growth factor receptor with tyrosine kinase activity, termed KIT. Mutations of KIT are common in malignant GISTs and lead to constitutional activation of tyrosine kinase function, which causes cellular proliferation and resistance to apoptosis. GISTs are notoriously unresponsive to chemotherapy and, until the recent introduction of the KIT inhibitor imatinib, there has been no effective therapy for advanced, metastatic disease. ⋯ The 5-year survival rate after complete resection of GISTs is approximately 50 per cent. The median duration of survival for patients with a metastatic GIST is approximately 20 months, and 9-12 months for patients with local recurrence. Phase II trials have investigated the effect of imatinib on irresectable or metastatic GISTs. In these trials more than 50 per cent of patients responded to imatinib within a few months and approximately 12 per cent had disease progression. Uptake of [(18)F]fluoro-2-deoxy-D-glucose demonstrated by positron emission tomography has been found to be reduced after starting imatinib. The potential for cure and the optimal length of treatment is currently unknown. Imatinib is the first effective systemic therapy for metastatic and locally irresectable GISTs. Large multi-institutional clinical trials to investigate the efficacy of imatinib as adjuvant or neoadjuvant therapy for GISTs are now required.
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Mortality is the most tightly defined and used adverse event for audit and performance monitoring in surgery. However, to identify cause and therefore scope for improvement, accurate and timely data are required. The aim of this study was to perform a systematic review of the quality of measurement, reporting and monitoring of mortality as an outcome after surgery. ⋯ A comprehensive data collection system is needed for improving clinical performance, with ownership, but not necessarily data collection, resting with the surgeons concerned. Recording of risk factors and deaths after discharge from hospital is essential, whatever data collection system is used.