Birth asphyxia and cerebral palsy

resection,2 and in Britain we may well be dealing mostly with patients whose disease has infiltrated into surrounding tissue. The early disease in Japan may be different from that in Britain because the survival in Japanese patients (95%) is so much better than that in British patients (70%) that it cannot be explained purely on the basis of removing more affected nodes-and even RI resection in Japan still produces an 88% five year survival.2 4 Nearly halfof the few early lesions that are encountered in Britain are type III lesions (excavated and mimicking benign ulcers) compared with less than 5% in Japan, which again suggests a different type of early disease.2'4 Another difference may be that only 16% of Japanese patients have lesions in the cardia (which carry a poorer prognosis stage for stage than those in the body and antrum) compared with 30% in one series reported from Britain.49 The British Medical Research Council is now running a trial to compare extended lymphadenectomy with conventional gastrectomy. Eligible cases are those up to the Japanese stage III, in which the liver and peritoneum are clear of the disease but the serosa has been breached or there is metastasis to the second tier of lymph nodes' (MRC cooperative surgical trial for gastric cancer, protocol, Ninewells Hospital, Dundee). In Japan patients with stomach cancer are younger than in Britain; in addition, the Japanese have less obesity and a lower incidence of arterial disease, and postoperative deep vein thrombosis is almost unknown. There will inevitably be a learning curve for surgeons undertaking the tricky dissection of friable, haemorrhagic fat and lymphatic tissue close to vital structures. It may also be difficult to set aside the extra operative time needed without the service to other patients deteriorating. Despite these difficulties we need to identify which, if any, patients in Britain will benefit from an extended lymphadenectomy, and the MRC trial should achieve this. But diagnosis of the condition also needs attention. Some encouraging results have come from the West Midlands, where 48 new cases of gastric cancer were detected among 2820 patients with dyspepsia who were screened; eight of these were early cases (A Jewkes, meeting of the British Stomach Cancer Group, Manchester, 1988). This approach screens only patients with symptoms, but in Japan also most patients have symptoms. The resource implications of repeatedly screening all patients aged over 50 with dyspepsia are daunting, but only with a drive toward early diagnosis and, probably to a lesser extent, better surgery may the results of treating gastric cancer be improved. And the Japanese have shown that improvement is possible. PETER J MILEWSKI Consultant in General Surgery Withybush Hospital, Haverfordwest, Pembrokeshire SA61 2PZ JOHN BANCEWICZ Reader in Surgery University Department of Surgery, Hope Hospital, Salford M6 8HD