J. Wayman

Human model of duodenogastro-oesophageal reflux in the development of Barrett's metaplasia†

Patients with an intrathoracic oesophagogastrostomy after subtotal oesophagectomy experience profound duodenogastro‐oesophageal reflux (DGOR). This study investigated the degree of mucosal injury and histopathological changes in oesophageal squamous epithelium after subtotal oesophagectomy with gastric interposition in relation to the extent of postoperative DGOR.

Peritoneal cytology in the surgical evaluation of gastric carcinoma

SummaryMany patients undergoing surgery for gastric carcinoma will develop peritoneal metastases. A method to identify those patients at risk of peritoneal recurrence would help in the selection of patients for adjuvant therapy. Peritoneal cytology has received little attention in the West, but may prove a useful additional means of evaluating patients with gastric cancer. The aims of this study were to evaluate sampling techniques for peritoneal cytology in patients with gastric cancer, to assess the prognostic significance of free peritoneal malignant cells and to discover the effect of the operative procedure on dissemination of malignant cells. The study is based on 85 consecutive patients undergoing surgical treatment of gastric cancer and followed up for 2 years or until death. Peritoneal cytology samples were collected at laparoscopy, and at operation prior to resection by intraperitoneal lavage and serosal brushings. After resection, samples were taken by peritoneal lavage, imprint cytology of the resected specimen and post-operatively by peritoneal irrigation via a percutaneous catheter. Malignant cells were diagnosed by two independent microscopists. Preoperative peritoneal lavage yielded malignant cells in 16 out of 85 cases (19%). The yield of free malignant cells was increased by using serosal brushings (by four cases) and imprint cytology (by two cases); all of the cases had evidence of serosal penetration. One serosa-negative case exhibited positive cytology in the post-resection peritoneal specimen in which the preresection cytology specimen was negative. Survival was worse in the cytology-positive group (χ2 = 25.1; P < 0.0001). Among serosa-positive patients, survival was significantly reduced if cytology was positive, if cases yielded by brushings and imprint cytology were included (log-rank test = 8.44; 1 df, P = 0.004). In conclusion, free peritoneal malignant cells can be identified in patients with gastric cancer who have a poor prognosis; the yield can be increased with brushings and imprint cytology in addition to conventional peritoneal lavage. Evaluation of peritoneal cytology by these methods may have a role in the selection of patients with the poorest prognosis who may benefit most from adjuvant therapy.

The pattern of recurrence of adenocarcinoma of the oesophago-gastric junction

Knowledge of the pattern of recurrence of surgically treated cases of adenocarcinoma of the oesophago-gastric junction is important both for better understanding of their biological nature and for future strategic planning of therapy. The aim of this study is to demonstrate and compare the pattern of dissemination and recurrence in patients with Type I and Type II adenocarcinoma of oesophago-gastric junction. A prospective audit of the clinico-pathological features of patients who had undergone surgery with curative intent for adenocarcinoma of oesophago-gastric junction between 1991 and 1996 was undertaken. Patients were followed up by regular clinical examination. Clinical evaluation was supported by ultrasound, computerised tomography, radio-isotope bone scan, endoscopy and laparotomy each with biopsy and histology where appropriate. One hundred and sixty-nine patients with oesophago-gastric junction tumours (94 Type I and 75 Type II) have been followed up for a median of 75.3 (57–133) months. One hundred and three patients developed proven recurrent disease. The median time to recurrence was 23.3 (14.2–32.4) months for Type I and 20.5 (11.6–29.4) for Type II cancers. The most frequent type of recurrence was haematogenous (56% of Type I recurrences and 54% of Type II) of which 56% were detected within 1 year of surgery. The most frequent sites were to liver (27%), bone (18%) brain (11%) and lung (11%). Local recurrence occurred in 33% of Type I cancer and 29% of Type II recurrences. Nodal recurrence occurred in 18 and 25% of Type I and Type II cancer recurrences, most frequently to coeliac or porta hepatis nodes (64%). Only 7% of Type I and 15% of Type II cancer recurrences were by peritoneal dissemination. Type I and Type II adenocarcinoma of the oesophago-gastric junction have a predominantly early, haematogenous pattern of recurrence. There is a need to better identify the group of patients with small metastases at the time of diagnosis who are destined to develop recurrent disease in order that they may be spared surgery and those with micro metastases in order that they can be offered multi-modality therapy including early post operative or neo-adjuvant chemotherapy.

Monitoring the changing pattern of esophago-gastric cancer: data from a UK regional cancer registry

Objectives: The aim of this study was to evaluate the reliability and adequacy of the existing system of cancer registration in the United Kingdom to monitor past and future trends in esophago-gastric cancer incidence. Methods: The Northern and Yorkshire UK Cancer Registry was interrogated for all cases of esophageal and gastric cancer occurring between 1984 and 1993. Data concerning year of registration, subsite, histology, sex, and ages were recorded and analyzed. Results: A total of 22,300 cases were identified from an estimated population of 6.7 million. The overall age- and sex-standardized incidence of gastric cancer fell over the 10-year period from 12.8 to 10.5 per 100,000 (p < 0.001) while esophageal cancer increased from 4.6 to 5.4 cases per 100,000 (p = 0.006). Adenocarcinoma of the gastric cardia increased in proportion from 29.1% to 52.2% (p < 0.0001), 70.4% of esophageal and 71% of gastric cancer registrations were recorded without details of subsite. For 25% of esophageal cancers and 36% of gastric cancers there was no histological information. Conclusions: While the trend toward an increasing incidence of adenocarcinoma at the esophago-gastric junction reported in earlier studies appears to be confirmed, the high incidence of imprecise subsite reporting of cancer registry data illustrated in this study should make us look critically at the findings of other cancer registry data. Recognition of cancer of the esophago-gastric junction as distinct from other gastric and esophageal subsites may improve accuracy of recording and allow cancer registry data to more accurately monitor the changes in esophago- gastric cancer incidence in subsequent analyses.

Use of alarm symptoms to select dyspeptics for endoscopy causes patients with curable esophagogastric cancer to be overlooked

BackgroundIn August 2004, the United Kingdom Department of Health advisory body published dyspepsia referral guidelines for primary care practitioners. These guidelines advised empiric treatment with antisecretory medications and referral for endoscopy only in the presence of alarm symptoms. The current study aimed to evaluate the effect of these guidelines on the detection of esophagogastric cancer.MethodsThe study reviewed a prospectively compiled database of 4,018 subjects who underwent open access gastroscopy during the years 1990 to 1998. The main outcome measures for the study were cancer detection rates, International Union Against Cancer (UICC) stage, and survival.ResultsGastroscopy identified esophagogastric carcinoma in 123 (3%) of the 4,018 subjects. Of these 123 patients, 104 (85%) with esophagogastric cancer had “alarm” symptoms (anemia, mass, dysphagia, weight loss, vomiting) and would have satisfied the referral criteria. The remaining 15% would not have been referred for initial endoscopic assessment because their symptoms were those of uncomplicated “benign” dyspepsia. The patients with “alarm” symptoms had a significantly more advanced tumor stage (metastatic disease in 47% vs 11%; p < 0.001), were less likely to undergo surgical resection (50% vs 95%; p < 0.001), and had a poorer survival (median, 11 vs 39 months; p = 0.01) than their counterparts without such symptoms.ConclusionsThe use of alarm symptoms to select dyspeptics for endoscopy identifies patients with advanced and usually incurable esophagogastric cancer. Patients with early curable cancers often have only dyspeptic symptoms, and their diagnosis will be delayed until the symptoms of advanced cancer develop.

The response of early gastric cancer to proton-pump inhibitors.

To the Editor: Early diagnosis is paramount in the successful treatment of gastric cancer.1 We have found that empirical treatment with a proton-pump inhibitor can delay the diagnosis as occurred i...

Self-expanding metal stents in the palliation of small bowel stenosis secondary to recurrent gastric cancer☆☆☆★

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Gastric Cancer Surgery – A Balance of Risk and Radicality

INTRODUCTION The aim of this study was to determine whether tailoring the extent of resection would allow radical gastric cancer surgery to be performed safely in a UK population. PATIENTS AND METHODS A total of 180 consecutive patients (median age 70 years; male:female ratio 2:1) undergoing resection for gastric adenocarcinoma with curative intent were studied. Extent of lymphadenectomy was based upon pre-operative and intra-operative staging, and balanced against the patients age and fitness. RESULTS In the study group, 83 patients underwent subtotal or distal partial gastrectomy and 97 patients underwent total or proximal partial gastrectomy. Operative procedures were: D1 lymphadenectomy (n = 62); modified (spleen and pancreas pre-serving) D2 lymphadenectomy (n = 73); D2 lymphadenectomy (n = 42); and extended resection (n = 3). TNM classification was: stage 1 (n = 45); stage 2 (n = 37); stage 3 (n = 61); and stage 4 (n = 37). Of the patients, 48 developed postoperative complications including 17 patients with a major surgical complication. The in-hospital mortality was 1.7% (3 of 180). Predicted mortality according to POSSUM and P-POSSUM was 21.4% and 7.8%, respectively. Disease-specific 5-year survival according to stage was 85.4%, 64.2%, 33.3%, and 6.9%. CONCLUSIONS By tailoring the extent of resection and balancing risk and radicality, gastric cancer surgery can be performed with low mortality in Western patients.

Evaluation of local invasion by oesophageal carcinoma--a prospective study of prone computed tomography scanning.

The aim of this study was to assess the value of prone computed tomography compared with the traditional supine position, in the assessment of invasion of adjacent mediastinal structures by oesophageal cancer. A prospective, single blind case-case comparative study of signs of local tumour invasion was conducted. Sixty nine consecutive patients undergoing computed tomography for preoperative staging of oesophageal carcinoma were studied. Computed tomography scanning of the thorax was performed in the standard supine followed by prone position; in 39 patients the computed tomography findings were correlated with the surgical findings. Four established radiological signs used to assess mediastinal invasion were scored in each case. Based on the radiological scoring system, there was a significant down staging in the probability of aortic invasion in 12 of the 69 cases (p<0.05). A similar improvement in accuracy was seen in the cases undergoing surgery; of the 38 cases who did not have aortic invasion at operation, 10 cases were scored as high for aortic invasion on the supine scans compared with only three on the prone position (p<0.05). Prone scanning was not of significant additional value in the assessment of major airway or pericardial invasion. Modification of the computed tomography protocol to include scanning in the prone position will improve the accuracy of the preoperative staging of patients with oesophageal malignancy and reduce the chance of overstaging disease. Especially in centres where endoscopic ultrasound is not available, our modification may reduce the chance of denying patients potentially curative operations.

Benign anastomotic stricture following transthoracic subtotal oesophagectomy and stapled oesophago-gastrostomy: risk factors and management

Benign anastomotic stricture (BAS) is a common cause of dysphagia following oesophagectomy. The aim of this study was to assess the incidence of BAS, identify risk factors for its development and evaluate the results of postoperative endoscopic dilatation.