Kenneth G. M. Park

Hospital volume does not influence long-term survival of patients undergoing surgery for oesophageal or gastric cancer

Guidelines suggest that surgery for oesophageal and gastric cancer should be conducted in large cancer centres. This national study examined the relationship between hospital volume and outcome in Scotland.

Surgical Aspects of Subungual Malignant Melanomas

The incidence, treatment, and survival of subungual malignant melanomas in Scotland is reviewed from the Scottish Melanoma Group database. Between 1979 and 1989, 100 cases of subungual melanoma were identified (2.8% of all malignant melanomas in Scotland). The tumors tended to be locally advanced at the time of presentation (mean Breslow depth, 4.7 mm ± 3.0 mm), and this is reflected in an overall 5-year survival of 41%. There was no difference in the survival of patients treated with local/proximal interphalangeal (PIP) joint amputation compared with those having more proximal amputations. Because nearly 70% of these tumors arose on the thumb or hallux, it is concluded that, provided adequate clearance could be obtained, less radical excision should be performed for these lesions to maintain maximum function.

Accuracy of laparoscopic ultrasonography in the staging of upper gastrointestinal malignancy

Laparoscopic ultrasonographic staging was compared prospectively with conventional computed tomography (CT) and ultrasonographic staging of 24 lower-third oesophageal tumors and 20 gastric malignancies. Following laparoscopic ultrasonography, seven patients regarded as being resectable after conventional imaging were excluded from surgical exploration because of ascites with peritoneal deposits (four patients), liver metastases (one), advanced local disease (one) and poor tolerance of general anaesthesia (one). Preoperative T and N stages were compared with the pathological staging following resection in 34 patients. Laparoscopic ultrasonography was significantly more accurate than conventional CT and ultrasonography in assessment of the primary tumour (91 versus 64 per cent, P < 0.01) and nodal status (91 versus 62 per cent, P < 0.05). The addition of laparoscopic ultrasonography to conventional procedures for staging upper gastrointestinal malignancy improved the overall accuracy of staging. Although this may have future implications for the selection of patients for multimodality treatment, management decisions are currently based on laparoscopic findings, which in this study resulted in a resection rate of 97 per cent.

The impact of operative approach for oesophageal cancer on outcome: The transhiatal approach may influence circumferential margin involvement

AIM Surgery for oesophageal cancer remains the only means of cure for invasive tumours. It is claimed that the surgical approach for these cancers impacts on morbidity and may influence the ability to achieve tumour clearance and therefore survival, however there is no conclusive evidence to support one approach over another. This study aims to determine the impact of operative approach on tumour margin involvement and survival. METHODS Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of five-year follow up. Analysis focused on the three commonest approaches (Ivor Lewis n = 140, transhiatal n = 68, left thoraco-laparotomy n = 142) for oesophageal cancer. RESULTS Operative approach had no significant impact on post-operative morbidity, mortality, overall margin involvement and survival. Transhiatal approach resulted in significantly more circumferential margin involvement (p = 0.019), and the presence of circumferential margin involvement significantly reduced five-year survival (median survival 13 months) compared to no margin involvement (median survival 25 months, p = 0.001). CONCLUSION Surgical approach for oesophageal cancer had no significant effect on morbidity, post-operative mortality and five-year survival. Non-selective use of the transhiatal approach is associated with a significantly greater circumferential margin involvement, with positive circumferential margin impacting adversely on 5-year survival.

Positron emission tomography for monitoring response to neoadjuvant therapy in patients with oesophageal and gastro-oesophageal junction carcinoma

AIMS The aim of this review is to consolidate our knowledge on an important and rapidly expanding area of expertise. Numerous methods for predicting response (in terms of pathological response and survival) to neoadjuvant therapy (chemotherapy/chemo-radiotherapy) in oesophageal and junctional cancers have been proposed. This review concerns itself only with the use of positron emission tomography for such a purpose. At present there are no standardised criteria amongst PET trials as to what determines a response according to PET, what is the optimal time to perform PET in relation to the timing of neoadjuvant therapy, and what is the ideal method of quantifying PET tracer uptake. METHODS An electronic search was performed of PubMed, Ovid and Embase websites to identify studies, in the English language, using the search terms: PET; oesophageal; oesophago-gastric; survival; cancer; response; chemotherapy and chemo-radiotherapy. The reference lists were searched manually to identify further relevant studies. RESULTS Twenty-two studies were identified, all using (18)FDG as the tracer, using PET to predict response in terms of pathological response and survival following neoadjuvant therapy (chemotherapy/chemo-radiotherapy). PET had a varying degree of success in predicting both pathological response and survival outcomes, with only one study using PET to influence management decisions. CONCLUSIONS PET seems a promising technique, but large-scale conclusions are hindered by small study numbers, lack of criteria as to what constitutes a response and markedly differing PET imaging times. A large randomised trial concerning a homogeneous group of patients and tumours is required before PET might be used to influence management.

The impact of operative approach on outcome of surgery for gastro-oesophageal tumours

BackgroundThe choice of operation for tumours at or around the gastro-oesophageal junction remains controversial with little evidence to support one technique over another. This study examines the prevalence of margin involvement and nodal disease and their impact on outcome following three surgical approaches (Ivor Lewis, transhiatal and left thoraco-laparotomy) for these tumours.MethodsA retrospective analysis was conducted of patients undergoing surgery for distal oesophageal and gastro-oesophageal junction tumours by a single surgeon over ten years. Comparisons were undertaken in terms of tumour clearance, nodal yield, postoperative morbidity, mortality, and median survival. All patients were followed up until death or the end of the data collection (mean follow up 33.2 months).ResultsA total of 104 patients were operated on of which 102 underwent resection (98%). Median age was 64.1 yrs (range 32.1–79.4) with 77 males and 25 females. Procedures included 29 Ivor Lewis, 31 transhiatal and 42 left-thoraco-laparotomies. Postoperative mortality was 2.9% and median survival 23 months. Margin involvement was 24.1% (two distal, one proximal and 17 circumferential margins). Operative approach had no significant effect on nodal clearance, margin involvement, postoperative mortality or morbidity and survival. Lymph node positive disease had a significantly worse median survival of 15.8 months compared to 39.7 months for node negative (p = 0.007), irrespective of approach.ConclusionSurgical approach had no effect on postoperative mortality, circumferential tumour, nodal clearance or survival. This suggests that the choice of operative approach for tumours at the gastro-oesophageal junction may be based on the individual patient and tumour location rather than surgical dogma.

Optimal gastric pouch reconstruction post-gastrectomy

BackgroundGastric pouches have the potential to improve nutrition following total gastrectomy, compared with standard reconstruction. However, a consensus view of clinical benefit is not available, at least partly due to a lack of standardization of pouch design or size. This study was undertaken to identify optimal conditions for pouch design.MethodsA mathematical model was established and a porcine model constructed to evaluate the pressure/volume dynamics of the pouch. A “J” pouch was constructed at anastomotic lengths of 5, 10, 15, and 20 cm. Each pouch was distended with saline and the pressure/volume relationship established.ResultsMathematically, increasing the anastomotic length of the pouch to 15 cm increases the volume significantly; thereafter, there is minimal benefit of increasing the pouch length further. For smaller pouches (5 and 10 cm) a 350-to 400-ml volume (approximate meal volume in the elderly) is never achieved until higher pressures (45 cmH2O) are applied. However, in the larger pouches (15 and 20 cm) a 350-to 400-ml volume is readily achieved at basal pressures of 15 cmH2O.ConclusionSmaller pouches never achieve adequate volumes at basal pressures; accordingly, it is unlikely that they will lead to any clinical benefit. Further in-vivo studies should therefore be based upon 15-cm pouch designs.

F-18-FDG and C-11-choline positron emission tomography in human esophago-gastric cancer : prediction of response to therapy

Background To determine the utility of F-18-FDG and C-11-Choline uptake, in patients with esophageal and esophago-gastric junction tumors who are to undergo either neo-adjuvant or palliative chemotherapy, in predicting response (pathological and survival). Methods Eighteen patients with biopsy proven cancer were recruited prospectively. Patients underwent PET imaging before and during the first cycle of chemotherapy (seven and 14 days) with both F-18-FDG and C-11-Choline. Tracer uptake was quantified using Standardized Uptake Values. Pathological tumor response was determined using the Mandard criteria. Cellular proliferation was determined using ki-67 immunohistochemistry. Relationships between tracer uptake and response, one-year survival and cellular proliferation were determined. Results All 18 tumors were imaged by F-18-FDG PET compared to 16/18 with C-11-Choline. Change in uptake of either tracer did not correlate with pathological response. Pathological response did not influence survival (median-survival, responders = 16.1 months; non-responders = 19.0 months, p = 0.978). There was no significant correlation of change in tracer uptake with survival. C-11-Choline tumor uptake did not correlate with cellular proliferation. Conclusion F-18-FDG PET is superior for imaging of the primary tumor. Neither F-18-FDG nor C-11-Choline PET was able to predict response accurately.

Impact of anastomotic leakage on oncological outcome after rectal cancer resection (Br J Surg 2007; 94 1548–1554)

Sir We read the article by Ptok et al. with interest, in which they report the experience of the multicentre quality control study Colon/Rectum Carcinoma, conducted by the Institute for Quality Control at the Otto-von-Guericke University Magdeburg. The main finding is patients with anastomotic leakage, necessitating surgical treatment, after rectal cancer resection had a significantly higher local recurrence rate and a significantly lower 5-year disease-free survival rate than those not suffering a leak. A number of reasons for this are proposed but it does appear that one of the more obvious possibilities is neglected, i.e. surgical proficiency. Both local recurrence and anastomotic leakage rates are indicators of surgical performance. It is welldocumented that post-operative morbidity, mortality and survival vary significantly among surgeons and hospitals1,2. For example, in the Stockholm Trials, Holm et al. reported that patients with rectal cancer treated by adequately trained surgeons had significantly better oncological outcomes than those operated by less well-trained surgeons3. Therefore, it is highly possible that patients treated by surgeons who are technically better have more favourable outcomes including less anastomotic leakage, lower local recurrence rate and higher disease-free survival rate, and vice versa. Although the surgeon factor can be difficult to assess, this highly possible confounding factor certainly needs addressing, as it is a factor which is potentially remediable. C. S. Lim and K. G. M. Park Department of General Surgery, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK DOI: 10.1002/bjs.6217

Letter 1: Value of endoscopic ultrasonography as a predictor of long‐term survival in oesophageal carcinoma (Br J Surg 2003; 90: 1367–1372)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4‐sized paper in double spacing and should be accompanied by a disk. Copyright