During a routine audit of postoperative care we identified a high incidence of hyponatraemia following anatomical lung resection for cancer. It is recognised that lung tumours, but not usually non-small cell cancer (NSCLC), can cause hyponatraemia. We wished to determine whether peri- and/or intraoperative factors contributed to the occurrence of postoperative hyponatraemia. The regional thoracic surgery database was searched for all anatomical non-small cell lung cancer resections performed during the period January 2011 to December 2012. Ninety-seven patients were identified. Parameters relating to patient characteristics, tumour features and perioperative care were examined. A multivariate analysis was performed to determine what factors indicated high risk for hyponatraemia and what management practices could be addressed to reduce its incidence. Hyponatraemia occurred in 44 patients in our cohort (45.4%). The major factor, which showed an association with hyponatraemia was the use of epidural analgesia, 31/62 (50%) as opposed to paravertebral catheter, 13/35 (37%), (P = 0.002). Staging of lung cancer (Stage I and II vs III and IV), presence of central vs peripheral tumour, gender, age, diuretic therapy, complications and postoperative admission to critical care unit were not seen to be statistically different between the two groups. No deaths occurred as a result of hyponatremia. All cases of hyponatremia observed in the study responded to fluid restriction. Length of hospital stay was longer in epidural patients (9.6 vs 7.7 days, P = 0.027). This study demonstrated an increased risk of hyponatraemia in patients receiving thoracic epidural. In cases where the avoidance of large fluid volumes or electrolyte disturbances is critical, the use of a paravertebral infusion may be a safe, effective option. All authors have declared no conflicts of interest.

e14571 Background: Combined positron emission tomography with computed tomography(PETCT) using [18F] 2-fluoro-2-deoxy-D-glucose (FDG) is an important modality for staging oesophageal cancer and may also predict pathological response to chemotherapy. We therefore conducted this retrospective review to assess the relationship between metabolic response measured by FDG-PETCT imaging following neoadjuvant chemotherapy in oesophageal cancer and survival. Methods: Oesophageal cancer patients presenting to Northern Ireland Cancer Centre between January 2003 to December 2008, who had FDG-PETCT assessment for staging and also following neoadjuvant chemotherapy before surgery were included. Routine FDG-PETCT findings were collated and metabolic response (≥ 35% reduction in the tumour standard uptake values[SUV]), evaluated. Pathologic response was assessed and stratified into five histological tumour regression grades (TRG1-5). TRG 1 and 2 groups were classified as pathological responders. Overall survival and event-free survival were obtained. Results: 81 patients with a median age of 66 years (28-77) were identified. 66 (81%) had oesophageal carcinoma and 15 (19%) had Siewart type I or type II oesophageal-gastric junction (OGJ) carcinomas. Metabolic response was identified in 67 (82.3%) of patients. After a median follow up of 25.0 months, the median overall survival in metabolic responders has not been reached. In the metabolic non responders the median overall survival was 15.7 months (p 0.005), (HR = 2.66, 95%CI 1.31-5.41) and median event-free survival was also 15.7 months (p 0.023), (HR = 2.14, 95%CI 1.09-4.21). Pathological response was seen in 14 (17.9%) and this correlates poorly with metabolic response. There is no statistically significant relationship between pathologic response and survival. Conclusions: Metabolic nonresponse to neoadjuvant chemotherapy measured by FDG-PETCT appears to be associated with a poor survival. Further work will seek to identify a molecular signature for lack of response to preoperative chemotherapy in order to minimise exposure of patients to toxic treatment where they are unlikely to benefit. No significant financial relationships to disclose.

Objectives: Sputum retention after lung surgery is a potentially lethal condition, which can progress to atelectasis, pneumonia and respiratory failure requiring ventilatory support. Previous studies have concentrated on the treatment of postoperative respiratory complications but few have studied the risk factors for sputum retention. This prospective study was designed to identify the risk factors which may lead to the development of sputum retention after lung surgery. Methods: Three hundred sixty-one patients underwent lung surgery between January 1997 and December 1999 in a specialist Thoracic Surgery Unit (pneumonectomy, lobectomy, wedge or segmental resection, bullectomy, etc). Preoperative and intraoperative data collected prospectively included potential risk factors: chronic obstructive airway disease (COAD), forced expiratory volume in 1 s (FEV1) < 50%, current smokers, ischaemic heart disease (IHD), cerebrovascular disease (CVA), resection of phrenic or recurrent laryngeal nerve, or absence of regional analgesia. Univariate and multivariate analysis was per-formed. Results: Sputum related complications occurred in 108 patients (30%). There were 17 deaths of which nine were due to complications related to sputum retention. Univariate analysis confirmed current smokers (n = 128), COAD (n = 103), IHD (11 = 41), prior history of CVA (n = 16), FEV1 < 50% (n = 48), and absence of regional anaesthesia as significant risk factors (P < 0.01). The multivariate analysis confirmed current smokers, IHD and absence of regional anaesthesia as risk factors. Conclusions: A subgroup of lung surgery patients at high risk for postoperative sputum retention can be predicted by the presence of one of the following criteria: current smokers, history of COAD, CVA, or IHD, and absence of regional analgesia. Prophylactic measures should be considered in this group to reduce the incidence of sputum retention. (C) 2002 Elsevier Science B.V. All rights reserved.

Background and Study Aims: Self-expanding metal stents have become accepted palliation for inoperable malignant oesophageal obstruction, the cost of the devices being offset against the ease of insertion and the reduced complication rate. However, re-intervention is often required for obstruction, malposition, migration and tumour progression. The marginal cost of re-stenting is generally higher than other modalities. This study aims to determine the rate of re-intervention and the effectiveness of the various intervention modalities.Patients and Methods: A population of 165 patients, treated in a tertiary referral oesophageal centre, (132 with oesophageal cancer, 31 with mediastinal metastases from other tumours, two with benign conditions) whose initial stent placement was performed between January 1994 and December 1998 was followed-up through July 1999 or till death.Results: A total of 75 re-interventions were required in 44 patients and were successful in 51 (68%). Rigid oesophagoscopy and removal of food bolus was successful in three out of three, dilation in one of 11, rigid oesophagoscopy and physical debridement in 12 of 17 and laser debridement in 12 of 20. Re-stenting was the primary re-intervention in 10 cases and was ultimately necessary in 14 patients with 11 self-expanding metal stents, three Celestin) who had previously undergone other forms of re-intervention. It was not successful in one case. The median survival following first re-intervention was 9.8 weeks (compared with 14.3 weeks for initial stenting) and was longer in those receiving radiotherapy (23.6 weeks) or chemotherapy (14.4 weeks).Conclusions: While repeated stenting is usually successful, debridement and laser vaporization are viable alternatives for proximal tumour overgrowth or ingrowth in the upper or middle third of the oesophagus. Distal tumour growth or ingrowth at the oesophagogastric junction are best treated with a second stent. Repeated treatment is justified, as survival following first re-intervention is comparable to that after initial stenting, particularly in those patients who are able to undergo chemotherapy or radiotherapy.

OBJECTIVE:Anastomotic recurrence is a major cause of late mortality following oesophago-gastrectomy (OG) for carcinoma of the oesophagus and oesophago-gastric junction using either the Ivor Lewis or left thoraco-abdominal approach with intra-thoracic anastomosis. The aim of this study was to determine whether the more extensive total thoracic oesophagectomy (TTO) with cervical anastomosis would reduce the anastomotic recurrence rate while maintaining acceptable operative morbidity and mortality.METHODS:From January 1988 to December 1996, 108 total thoracic oesophagectomies and 66 oesophago-gastrectomies were performed with curative intent in 174 patients (125 males, mean age 62.4 years) with carcinoma (squamous cell carcinoma in 34 and adenocarcinoma in 140) of the middle (31 patients) and lower (44 patients) oesophagus and oesophago-gastric junction (99 patients).RESULTS:Minor complications occurred in 37 (34%) total thoracic oesophagectomy and 18 (27%) oesophago-gastrectomy patients, major complications in 15 (14%) and 5 (8%) and peri-operative death in 5 (4.6%) and 7 (11%) patients, respectively. Anastomotic leakage occurred in 10 (9%) total thoracic oesophagectomy and 5 (8%) oesophago-gastrectomy patients, and was fatal in 1 (1%) and 4 (6%). There was no incidence of tumour at or within 5 mm of the proximal limit in the total thoracic oesophagectomy group and this was reflected in the complete absence of anastomotic recurrence. In the oesophago-gastrectomy group there was a positive proximal resection margin in 13 (20%) and 13 anastomotic recurrences (22% of peri-operative survivors). The 5-year survival (including operative mortality) was 29% for total thoracic oesophagectomy compared with 21% for the other techniques (P = 0.028 log rank test). Median survival was 25.2 months after total thoracic oesophagectomy and 15.8 after oesophago-gastrectomy.CONCLUSIONS:Total thoracic oesophagectomy can be performed in oesophageal cancer patients with comparable morbidity to that of lesser resections. Incomplete proximal resection and anastomotic recurrence did not occur in this series of 108 total thoracic oesophagectomies and this is reflected in an increased medium term survival. The improved survival is most apparent for tumours of the oesophago-gastric junction.

BACKGROUND:Resection is the treatment of choice for lung cancer, but may cause impaired cardiopulmonary function with an adverse effect on quality of life. Few studies have considered the effects of thoracotomy alone on lung function, and whether the operation itself can impair subsequent exercise capacity. METHODS:Patients being considered for lung resection (n = 106) underwent full static and dynamic pulmonary function testing which was repeated 3-6 months after surgery (n = 53). RESULTS:Thoracotomy alone (n = 13) produced a reduction in forced expiratory volume in one second (FEV1; mean (SE) 2.10 (0.16) versus 1.87 (0.15) l; p<0.05). Wedge resection (n = 13) produced a non-significant reduction in total lung capacity (TLC) only. Lobectomy (n = 14) reduced forced vital capacity (FVC), TLC, and carbon monoxide transfer factor but exercise capacity was unchanged. Only pneumonectomy (n = 13) reduced exercise capacity by 28% (PVO2 23.9 (1.5) versus 17.2 (1.7) ml/min/kg; difference (95% CI) 6.72 (3.15 to 10.28); p<0.01) and three patients changed from a cardiac limitation to exercise before pneumonectomy to pulmonary limitation afterwards. CONCLUSIONS:Neither thoracotomy alone nor limited lung resection has a significant effect on exercise capacity. Only pneumonectomy is associated with impaired exercise performance, and then perhaps not as much as might be expected.

Because there now exists an awareness among all those involved in the provision of injury services, from govemment down to the ‘coalface’ workers, of the importance of ‘getting it right first time’ in injury management, changes will occur in the systems in which injury patients are treated. Predicting these changes and making provision for them is a major challenge. In particular, we envisage that the facility in accident and emergency departments to perform advanced radiological imaging and minimally invasive thoracoscopic procedures will change the face of routine management of thoracic injury. Chest injuries lead directly to one-quarter of all deaths from trauma and contribute to a further one-quarter. While the vast majority of blunt chest injuries can be treated conservatively, many penetrating wounds produce lacerations which are optimally managed by active intervention. With the establishment of trauma centres and the emergence of specialist injury surgeons and cardiothoracic surgeons with a specific commitment to treating injuries, new techniques and new technology currently used for elective surgery are being adapted for use in the emergency situation. In the pre-hospital phase the presence of medical or highly trained paramedical personnel should allow better assessment so that the injured patient is transferred directly to the most suitable centre, that centre having been radioed to inform of the anticipated arrival. The approplrate injury specialists can be summoned and patient data transmitted en rottfe for expert opinion. Avoidable delays at the site of injury and prolonged stays in an ill-equipped A&E department will ultimately be eliminated, with many transfers going directly to theatre. The A&E department of tomorrow will have an integrated resuscitation, imaging and operating room. Spiral CT scanners, angiography and endo-oesophageal ultrasound will be available to assess thoracic, abdominal, cerebral, aortic and peripheral vascular injuries. Where there is no experienced thoracic injury expertise on site, digitised images of radiological studies, video pictures of the victim and two-way audiovisual link-ups will make it possible to access a nationwide network of experienced opinion for unusual or difficult problems. Thoracoscopic specialist intervention may be carried out remotely using robotic systems.

In the late 1970's the options for treatment of oesophageal cancer were limited. When cure was thought possible, resection was performed by the Ivor Lewis or oesophagogastrectomy techniques. Mortality was high, local recurrence rates disappointing, and long-term survival poor. For those patients whose tumours could not be resected, palliative intubation required open operation with high morbidity, and gave poor quality of life. In 1994, selective screening is diagnosing cancers early, more extensive resections are possible with lower mortality, and fewer local recurrences. Adjuvant therapy is increasing the operability rates. Gradually the facade of poor prognosis is being etched away, so that more patients are being given better quality of life, and cure is a distinct possibility. Palliation can be achieved endoscopically by dilatation, intubation or laser ablation combined with local external beam radiation. Mortality for palliative procedures is now considerably reduced.

BACKGROUND:Flexible oesophagoscopy is regarded as superior to rigid oesophagoscopy on the basis of perforation rates as an end point. This advantage may be more apparent than real because no comparison has been made in a diagnostic setting in patients with carcinoma of the oesophagus with both perforation rate and diagnostic efficacy as indices.METHODS:A retrospective analysis was carried out on data on 336 diagnostic oesophagoscopies in patients with carcinoma of the oesophagus, comparing rigid with flexible oesophagoscopy.RESULTS:Both rigid and flexible oesophagoscopies were performed without perforation when they were used for diagnosis only. Rigid biopsy achieved a diagnostic success rate of 99.3%, compared with 80.5% for flexible oesophagoscopy.CONCLUSIONS:Diagnostic oesophagoscopy can be achieved without perforation with either instrument, but the chance of diagnosing carcinoma was significantly greater with the rigid instrument.

The efficacy and safety of rigid oesophagoscopy in diagnostic and therapeutic settings in a consecutive series of 404 patients with oesophageal carcinoma were studied and compared to that for flexible oesophagoscopy in the same group. In addition, we examined the same parameters in a smaller group who had undergone radiotherapy with subsequent malignant stricturing. We performed 328 rigid procedures and 118 flexible procedures in a single regional surgical referral unit over a 7 year period. The combined perforation rate was 1.3%, with an overall mortality of 1% from 446 procedures.We conclude that rigid oesophagoscopy in the presence of carcinoma retains an important diagnostic and therapeutic role which can be achieved with low incidence of perforation in high-risk patients.