Biomedical subjects

W G Lewis

Publications and source records attributed to W G Lewis.

At least 19 recordsLinked to original sources

PubMed2007

Prognostic significance of body mass indices for patients undergoing esophagectomy for cancer.

The aim of this study was to determine the role of body mass index (BMI) in a Western population on outcomes after esophagectomy for cancer. Two hundred and fifteen consecutive patients undergoing esophagectomy for esophageal cancer of any cell type were studied prospectively. Patients with BMIs > 25 kg/m were classified as overweight and compared with control patients with BMIs below these reference values. Ninety-seven patients (45%) had low or normal BMIs, 86 patients (40%) were overweight, and a further 32 (15%) were obese. High BMIs were associated with a higher incidence of adenocarcinoma versus squamous cell carcinoma (83%vs. 14%, P = 0.041). Operative morbidity and mortality were 53% and 3% in overweight patients compared with 49% (P = 0.489) and 8% (P = 0.123) in control patients. Cumulative survival at 5 years was 27% for overweight patients compared with 38% for control patients (P = 0.6896). In a multivariate analysis, age (hazard ratio [HR] 1.492, 95% CI 1.143-1.948, P = 0.003), T-stage (HR 1.459, 95% CI 1.028-2.071, P = 0.034), N-stage (HR 1.815, 95% CI 1.039-3.172, P = 0.036) and the number of lymph node metastases (HR 1.008, 95% CI 1.023-1.158, P = 0.008), were significantly and independently associated with durations of survival. High BMIs were not associated with increased operative risk, and long-term outcomes were similar after R0 esophagectomy.

Adenocarcinoma↗

PubMed2006

Colonoscopy first for iron-deficiency anaemia: a Numbers Needed to Investigate approach.

BACKGROUND: British Society of Gastroenterology guidelines recommend that gastrointestinal investigations should be considered in males and post-menopausal women presenting with iron-deficiency anaemia (IDA). AIM: To compare the diagnostic yields and clinical effectiveness of upper and lower gastrointestinal (GI) investigation in detecting malignancy among patients presenting with IDA. DESIGN: Retrospective review of case notes, endoscopy records and radiology reports. METHODS: We reviewed the results of 3798 investigations in 2600 patients presenting to our hospital with IDA from October 1995 to December 2003. The findings of the 2318 gastroscopies were compared with those of the 896 colonoscopies and the 584 barium enemas. Patients diagnosed with GI malignancy were identified and their outcomes determined. RESULTS: Gastroscopy identified 44 patients with newly-diagnosed upper GI cancer (18 oesophageal, 26 gastric). Thus for patients being gastroscoped for IDA, the Numbers Needed to Investigate (NNI) to detect each cancer was 53. Five-year survival for these 44 patients was 10%, so the NNI to identify each curable upper GI malignancy was 527. Colonoscopy or barium enema identified 111 (7.5%) patients with newly diagnosed colorectal cancer, giving a NNI of 13. Their 5-year survival was 35%, giving a NNI to identify each curable colorectal cancer patient of 38. DISCUSSION: Potentially curable gastrointestinal malignancy was diagnosed over 13 times more commonly using colonoscopy or barium enema vs. gastroscopy. For patients presenting with IDA, our findings favour investigating the lower GI tract first, or performing both gastroscopy and colonoscopy during the same endoscopy list.

Adolescent↗

PubMed2006

Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer.

We aim to compare the outcomes of patients undergoing R0 esophagectomy by a multidisciplinary team (MDT) with outcomes after surgery alone performed by surgeons working independently in a UK cancer unit. An historical control group of 77 consecutive patients diagnosed with esophageal cancer and undergoing surgery with curative intent by six general surgeons between 1991 and 1997 (54 R0 esophagectomies) were compared with a group of 67 consecutive patients managed by the MDT between 1998 and 2003 (53 R0 esophagectomies, 26 patients received multimodal therapy). The proportion of patients undergoing open and closed laparotomy and thoracotomy decreased from 21% and 5%, respectively, in control patients, to 13% and 0% in MDT patients (chi2 = 11.90, DF = 1, P = 0.001; chi2 = 5.45, DF = 1, P = 0.02 respectively). MDT patients had lower operative mortality (5.7%vs. 26%; chi2 = 8.22, DF = 1, P = 0.004) than control patients, and were more likely to survive 5 years (52%vs. 10%, chi2 = 15.05, P = 0.0001). In a multivariate analysis, MDT management (HR = 0.337, 95% CI = 0.201-0.564, P < 0.001), lymph node metastases (HR = 1.728, 95% CI = 1.070-2.792, P = 0.025), and American Society of Anesthesiologists grade (HR = 2.207, 95% CI = 1.412-3.450, P = 0.001) were independently associated with duration of survival. Multidisciplinary team management and surgical subspecialization improved outcomes after surgery significantly for patients diagnosed with esophageal cancer.

Adenocarcinoma↗

PubMed2005

Prognostic significance of alarm symptoms in patients with gastric cancer.

BACKGROUND: The aim of this study was to determine the incidence and spectrum of alarm symptoms in patients with newly diagnosed gastric cancer, and to examine the relationship between symptoms and outcome. METHODS: Three hundred consecutive patients with gastric adenocarcinoma were studied prospectively. The outcomes of 40 patients (13.3 per cent) without alarm symptoms (21 men; median age 69 years) were compared with those of the 260 patients (86.7 per cent) with alarm symptoms (175 men; median age 72 years). RESULTS: It was possible to perform an R0 gastrectomy more often in patients without alarm symptoms (21 patients; 52 per cent) than in those with alarm symptoms (71 patients; 27.3 per cent) (chi(2) = 10.35, 1 d.f., P = 0.001). The cumulative survival rate at 5 years was 38 per cent for patients without alarm symptoms versus 15.0 per cent for those with alarm symptoms (chi(2) = 10.18, 1 d.f., P = 0.001). In a multivariate analysis, distant metastasis (hazard ratio (HR) 2.73 (95 per cent confidence interval (c.i.) 2.04 to 3.66); P < 0.001), overall stage of cancer (HR 1.83 (95 per cent c.i. 1.53 to 2.19); P < 0.001) and persistent vomiting at diagnosis (HR 1.66 (95 per cent c.i. 1.26 to 2.18); P < 0.001) were independently associated with length of survival. CONCLUSION: Alarm symptoms are absent in a significant minority of patients with gastric cancer at diagnosis; these patients stand a better chance of curative surgery and long-term survival than those with alarm symptoms.

Adenocarcinoma↗

PubMed2005

The European Working Time Directive: One for all and all for one?

BACKGROUND: The European Working Time Directive (EWTD) became law in Britain on October 1, 1998. As a result, the maximum period that may be spent as a resident in hospitals is 56 hours per week and after August 2009, 48 hours per week. The aim of this study was to determine the views of senior house officers (SHOs), specialist registrars (SpRs), and general consultant surgeons (CONs) in Wales on the influence of the EWTD on surgical training and clinical experience. METHODS: In this cohort study, a postal questionnaire was sent to 150 SHOs in surgical specialties, 50 general surgical SpRs, and all 84 CONs in the Welsh Deanery. RESULTS: The response rates were 81%, 78%, and 71% for SHOs, SpRs, and CONs, respectively. The vast majorities at all grades (88% SHOs, 100% SpRs, and 96% CONs) were unhappy with the introduction of EWTD legislation to clinical medicine. Most felt that EWTD legislation will have a negative effect on clinical experience (96% SHOs, 97% SpRs, 96% CONs); patient care (83% SHOs, 85% SpRs, 96% CONs); and training (94% SHOs, 100% SpRs, 93% CONs). Furthermore, a large proportion felt surgical training should be exempt from EWTD regulations (76% SHOs, 87% SpRs, 89% CONs). A significant proportion at each grade was opposed to the introduction of shifts in order to comply with regulations (78% SHOs, 87% SpRs, 89% CONs), and an alarming number have considered leaving the National Health Service when the regulations are enforced (29% SHOs, 41% SpRs, 33% CONs). CONCLUSION: This study shows that, in Wales at least, a vast majority of surgical trainees and consultants alike are opposed to the introduction of the EWTD and believe it will have a detrimental effect on training, patient care, and doctors' lives outside of medicine.

Adult↗

PubMed2004

Prospective comparison of D1 vs modified D2 gastrectomy for carcinoma.

To compare the outcomes after D1 gastrectomy with those after modified D2 gastrectomy (preserving pancreas and spleen) performed by specialist surgeons for gastric cancer in a large UK NHS Trust. In all, 118 consecutive patients with gastric adenocarcinoma were referred by postcode, to undergo either a D1 gastrectomy (North Gwent (RJ), n=36, median age 76 years, 21 m) or a modified D2 gastrectomy (South Gwent (WL), n=82, 70 years, 57 m). Operative mortality in the two groups of patients was similar (D1 8.3% vs D2 7.3%, chi2 0.286, DF 1, P=0.593). Overall cumulative survival at 5 years was 32% after D1 gastrectomy compared to 59% after D2 gastrectomy (chi2 4.25, DF 1, P=0.0392). In patients with stage III cancers, survival was 8% after D1, compared with 33% after D2 gastrectomy (chi2 6.43, DF 1, P=0.0112). In a multivariate analysis, T stage (hazard ratio 2.339, 95% CI 1.683-2.995, P=0.01), N stage (hazard ratio 4.026, 95% CI 3.536-4.516, P=0.0001) and the extent of lymphadenectomy (hazard ratio 0.258, 95% CI -0.426-0.942, P=0.0001) were independently associated with durations of survival. In conclusion, modified D2 gastrectomy can improve survival four-fold for patients with stage III gastric cancer, without significantly increasing morbidity and mortality when compared with a D1 gastrectomy.

Adenocarcinoma↗

PubMed2004

Comparison of special interest computed tomography, endosonography and histopathological stage of oesophageal cancer.

AIMS: To assess the strength of agreement between the perceived pre-operative stage of oesophageal tumours as determined by spiral computed tomography (CT) and endoscopic ultrasound (EUS), both alone and in combination, with the histopathological stage. METHODS: Sixty patients with oesophageal cancer underwent both pre-operative CT and EUS performed by two consultant radiologists with a special interest in upper gastrointestinal radiology. The strength of the agreement between the radiological stage and the histopathological stage was determined by means of the weighted Kappa statistic (Kw). RESULTS: Sensitivity for T and N stages was 58% and 79% for CT, and 72% and 91% for EUS. Specificity for T and N stages was 80% and 84% for CT, and 85% and 68% for EUS. Kw for T and N stages was 0.455 (p=0.0001) and 0.603 (p=0.0001) for CT compared with 0.604 (p=0.0001) and 0.610 (p=0.0001) for EUS. In patients when CT and EUS agreed regarding the T and N stages, the strength of agreement between the radiological and the histopathological stage was greater (Kw T 0.613 (p=0.0001), Kw N 0.781 (p=0.0001)). CONCLUSION: CT and EUS are complimentary techniques for the staging of oesophageal tumours, and these results reinforce the importance of specialist radiology in stage directed management.

Adenocarcinoma↗

PubMed2003

Illumination of x-rays: the usual lights exposed.

AIMS: Faced with pressure of work and limited resource, doctors frequently use the nearest available light to examine x-ray films. The aim of this study was to examine the relative intensities of hospital light sources, and to compare these with the light intensity guidelines (1500 to 3000 candelas) of the British Institute of Radiology. METHODS: The relative intensities of seven hospital light sources were examined using a standard light meter at a constant 30 cm from the source. A control group of 10 individual consultant's x-ray viewing boxes were compared with six other ward based light sources. RESULTS: Only two light sources approached the British Institute of Radiology light intensity x-ray viewing criteria: the x-ray viewing boxes of consultant radiologists with a median light intensity of 3503 candelas (chi(2)=13.3, df 1; p=0.0001), and daylight from north facing windows with a median of 1464 candelas when overcast (chi(2)=8.571, df 1; p=0.003) and 4669 candelas in sunshine (chi(2)= 6.364, df 1; p=0.0001). CONCLUSION: Few hospital light sources met the British Institute of Radiology guidelines. The long held high regard of artists for northern light appears justified even in the environment of a British district general hospital.

Humans↗

PubMed2003

Surgical time and motion: the intermediate equivalent revisited.

The relationship between operative time, the intermediate equivalent value (IEV) and the complexity of common general surgical operations was examined. Correlation was found between the BUPA schedule values for procedures categorized as intermediate and major, but complex major vascular reconstruction and oesophagogastric resection for cancer occupied significantly more theatre time than the four intermediate equivalents allocated by the Collins or BUPA schedule. Moreover, anaesthetic preparation time for complex major surgery in the latter surgical subspecialities contributed at least one further intermediate value. Re-evaluation of the ideal IEV weighting of all surgical operations including anaesthetic input from larger similar audits would allow more accurate audits of surgeons' work-load, and also facilitate transparent intensive management of operating theatre resource.

Consultants↗

PubMed2002

Special interest radiology improves the perceived preoperative stage of gastric cancer.

AIM: The aim of this study was to compare the accuracy of spiral computed tomography (CT) performed by a specialist radiologist within a multi disciplinary team (MDT) framework with that of radiologists working outside of this framework. MATERIALS AND METHODS: One hundred and ten patients [median age 70 (35-86)yr, 71m] underwent either a preoperative CT performed by the MDT specialist consultant radiologist (n=60) or a CT performed by one of 13 other consultant radiologists (n=50). The strength of the agreement between the CT stage and the histopathological stage was determined by the weighted Kappa statistic (Kw). RESULTS: Sensitivity for T, N and M stage were 64%, 65% and 25% for MDT specialist CT, compared with 24%, 24% and 5% for control CT. Specificity for T, N and M stage were 68%, 59% and 95% for MDT specialist CT compared with 79%, 94% and 93% for control CT. Kw for T, N and M stage were 0.314, 0.350 and 0.255 for MDT specialist CT compared with 0.088, 0.102 and -0.019 for control CT. Unsuspected metastases were found in 12 patients staged by MDT specialist CT compared with 19 patients staged by control CT (Chi2=4.366, df=1,p =0.037). CONCLUSION: Improved patient selection for surgery should maximize use of limited resource.

Adenocarcinoma↗

PubMed2001

Oesophagogastric cancer and surgical subspecialisation: how much work?

The aim of this study was to assess the volume of work generated by one consultant (out of a surgical unit of seven) managing all the upper gastrointestinal malignancy in a district general hospital serving a population of 480,000. A 3-year period was prospectively audited and the volume of out-patient and in-patient workload assessed with particular reference to resource management and levels of surgical staffing. Oesophagogastric cancer accounted for a mean of 61 new cases per year, representing 5.3% of new patient referrals. Assuming that a complex major operation for an oesophagogastric cancer equates to four intermediate equivalent values (IEVs), then this translated to a mean operative workload of 186 IEVs per year, representing 16.7% of the total elective operative workload of 1140 IEVs per year. Thus, all the oesophagogastric cancer was managed by a single firm as a speciality in a district general hospital over this 3-year period, though a relatively small proportion of new patients with oesophagogastric cancer translated into a significantly greater burden on the resources of consultant manpower and operating theatre time.

Esophageal Neoplasms↗

PubMed2000

The effect of pelvic ileal reservoir volume and antiperistaltic reflux on emptying efficiency.

PURPOSE: The emptying efficiency of four different designs of pelvic ileal reservoir was compared using two different techniques of measurement. METHOD: Thirty-four patients were studied one year after restorative proctocolectomy. In each the ileal reservoir was filled with methyl cellulose paste labeled with 51chromium-chromate and technetium Tc 99m-diethylenetriamine pentaacetic acid. Percentage evacuation was calculated from 1) the difference in 51chromium activity between the recovered effluent and the total paste administered and 2) gamma camera measurements of technetium Tc 99m-diethylenetriamine pentaacetic acid activity within the ileal reservoir before and after evacuation. RESULTS: Median evacuation using the 51chromium method was 84, 90, 70, and 75 percent for the W40, W30, J40, and J30 reservoirs respectively. The results were not significantly different from those obtained using the gamma camera: 83, 87, 67, and 71 percent (P = not significant). Patients with either type of W reservoir evacuate isotope-labeled paste more efficiently than patients with J40 reservoirs (P < 0.05 and P < 0.001, respectively) but not J30 reservoirs (P = not significant). However, if the actual volume of paste evacuated during a visit to the lavatory is measured, it is greatest for J40 reservoirs (median, 300 ml compared with 258 ml for W40, 289 ml for W30, and 268 ml for J30; P = not significant). CONCLUSIONS: Gamma camera measurement of ileal reservoir emptying is as accurate as our previous standard technique and provides a qualitative record of pouch evacuation, which may reveal reasons for inefficient emptying. The gamma camera images reveal that the difference in emptying percentage between W and J pouches is because of reflux of paste into the afferent ileum occurring more frequently in J pouches than in W pouches. The effect of this phenomenon on emptying is more than compensated for by the increase in reservoir capacity created by the reflux.

Adolescent↗

PubMed1997

One-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis: a note of caution.

PURPOSE: This study was designed to determine the safety of omitting a temporary defunctioning ileostomy in restorative proctocolectomy for ulcerative colitis. METHOD: One hundred consecutive patients with ulcerative colitis were treated electively by restorative proctocolectomy and pouch-anal anastomosis, without mucosal stripping; 50 had a defunctioning ileostomy added, and 50 underwent a one-stage procedure without ileostomy. RESULTS: There was no operative mortality. The incidence of postoperative complications was similar in the two groups of patients. Life-threatening complications, however, were more common among patients who did not have a defunctioning ileostomy, of whom 11 developed pelvic sepsis and 7 required reoperation. Among patients with an ileostomy, seven developed pelvic sepsis but none required reoperation (P < 0.02). Emergency reoperations were required in 11 patients without an ileostomy but in only 1 patient with an ileostomy (P < 0.01). CONCLUSION: One-stage restorative proctocolectomy without a defunctioning ileostomy is associated with increased risk to life. Its routine use cannot be recommended.

Adolescent↗

PubMed1996

Does eversion of the anorectum during restorative proctocolectomy influence functional outcome?

PURPOSE: The aim of this study was to determine the effect of eversion of the anorectum during restorative proctocolectomy (RP) for ulcerative colitis on functional outcome. METHODS: One hundred seventeen patients underwent RP with stapled end-to-end ileal pouch-anal anastomosis (EEA), without resection of the anal mucosa. Sixty-four underwent EEA with eversion of the anorectum, and 53 underwent EEA without eversion. Each patient underwent paired studies of anorectal function before and a median of 12 months after RP. RESULTS: One year after RP, median (interquartile range) maximum resting pressure was 69 (range, 51-88) cmH2O in those patients who underwent eversion vs. 80 (range, 64-90) cmH2O in patients without eversion (P < 0.04). Threshold sensation in the upper, middle, and lower thirds of the anal canal were 9.1, 7.4, and 6.8 mA after eversion vs. 6.9, 4.9, and 3.8 mA without eversion (P = 0.003, P < 0.001, P < 0.001, respectively). Before operation, all patients had a rectoanal inhibitory reflex; however, after RP, 54 of 64 patients in the eversion group and 50 of 53 patients with a stapled EEA without eversion had an inhibitory reflex (P = not significant). Leakage of mucus was experienced by 11 patients who underwent eversion, compared with 9 patients without eversion. Fifty-six of 64 patients with eversion could defer defecation for more than 30 min compared with 43 of 53 patients without eversion. Twenty-two of 64 patients in the eversion group retained perfect discrimination between flatus and feces compared with 38 of 54 without eversion (P < 0.001). Level of the anastomosis was 1 (range, 0.5-3) cm above dentate line after eversion compared with 1.5 (range, 0-6) cm without eversion. CONCLUSION: Clinical outcome after RP with eversion was not as good as outcome after stapled EEA without eversion. Such a conclusion requires confirmation in a prospective control trial.

Adult↗

PubMed1996

Prospective controlled trial of duplicated (J) versus quadruplicated (W) pelvic ileal reservoirs in restorative proctocolectomy for ulcerative colitis.

AIMS: A prospective randomised controlled trial was conducted to find out what influence the design of the pelvic reservoir had on the functional outcome. PATIENTS AND METHODS: Sixty patients received either a duplicated (J) or a quadruplicated (W) reservoir, constructed with either 30 or 40 cm of ileum. Each patient underwent laboratory tests of anorectal function before and one year after operation. RESULTS: One year after operation, 57 patients were available for assessment: each had good anal continence, though eight experienced minor leakage of mucus, and all were able to defer defecation for more than 15 minutes. Median bowel frequency in 24 hours (IQR) in patients with J reservoirs (5 (4-7)) did not differ significantly from that of patients with W reservoirs (5 (4-6)). Likewise, bowel frequency in patients with the smaller (30 cm) reservoirs did not differ significantly from bowel frequency in patients with the larger (40 cm) reservoirs. However, patients with large W40 reservoirs had the lowest bowel frequency of the four groups (median 4 per 24 hours, p = NS). The capacity and compliance of the W40 reservoirs were greater than those of the other types of reservoir, but the differences were not statistically significant. CONCLUSIONS: These findings provide support for the use of a relatively small (30 cm), duplicated (J) ileal reservoir, which is simple to construct with linear stapling instruments.

Adolescent↗

PubMed1996

Morbidity of varicose vein surgery: auditing the benefit of changing clinical practice.

During two consecutive study periods (24 months and 16 months), 997 patients (1322 legs) with varicose veins underwent surgical treatment in Huddersfield Royal Infirmary, using a variety of surgical techniques. The average length of stay was 1.5 days, and 95.5% of patients had a hospital stay of less than 2 days. Complications occurred in seven inpatients. A further 16 patients developed complications requiring readmission to hospital (10 minor and intermediate; 6 major). The complication rate appeared to be operator-dependent: an increased complication rate (particularly major complications) occurred after surgery by junior surgeons. Major complications included femoral vein injury (1 patient), postoperative deep venous thrombosis (4 patients), pulmonary embolism (1 patient) and groin lymphatic fistula requiring reoperation (1 patient). Between the first and second study period, a change in policy regarding the type of bandaging used and the use of postoperative antiembolic stockings occurred and appears to have reduced the incidence of thromboembolic complications from 0.7% to 0.2%. Varicose vein surgery is not without major complications though, fortunately, there was no mortality in this series. These complications can be minimised with good surgical technique and better supervision of surgical trainees. Modification of postoperative management can further enhance the safety of this procedure.

Adult↗

PubMed1995

Factors that influence functional outcome after coloanal anastomosis for carcinoma of the rectum.

Thirty consecutive patients had laboratory assessment of anorectal function after rectal excision and stapled coloanal anastomosis for rectal carcinoma. Eleven patients experienced perfect continence but 19 had faecal leakage with or without urgency of defaecation. Median (interquartile range) function was related to the pressures generated in the anal sphincter at rest (good versus poor function: 80 (63-91) versus 51 (23-60) cmH2O, P < 0.01), during maximum squeeze (160 (126-203) versus 102 (58-112) cmH2O, P < 0.01) and during reflex inhibition (58 (23-63) versus 36 (18-54) cmH2O, P < 0.05). Poor function was significantly commoner in women than in men (P < 0.01). These findings suggest that occult damage may have occurred to the anal sphincter before low anterior resection. Careful preoperative evaluation with manometry and endoanal ultrasonography may detect such damage and allow selection of patients for colopouch reconstruction.

Adult↗

PubMed1995

Clinical and physiological evaluation of anorectal eversion during restorative proctocolectomy.

Fifty patients had a restorative proctocolectomy with stapled end-to-end ileoanal anastomosis by the eversion technique. Median (interquartile range) maximum resting anal pressure was 90 (73-116) cmH2O before restorative proctocolectomy and 71 (51-88) cmH2O 1 year after surgery (P < 0.001). Median maximum squeeze pressure was 141 (110-185) cmH2O before surgery and 146 (118-186) cmH2O 1 year after surgery (P not significant). Median thresholds for sensation in the lower third of the anal canal before and 1 year after surgery were 5.3 and 7.1 mA, respectively (P = 0.006). One year after restorative proctocolectomy, all patients were continent, although two experienced leakage of mucus requiring a pad. Forty-two patients (84 per cent) could discriminate between faeces and flatus. Eversion of the anorectum during restorative proctocolectomy impairs the motor and sensory functions of the anal sphincter. Most patients achieved satisfactory anal continence, however, despite these physiological changes.

Adolescent↗