M. van Blankenstein

Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD).

BACKGROUND: It has been suggested that the incidence of inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohns disease (CD), is three or more times higher in northern than in southern Europe. The aim of this EC funded study was to investigate this apparent variation by ascertaining the incidence of IBD across Europe. METHODS: For the period 1 October 1991 to 30 September 1993 all new patients diagnosed with IBD were prospectively identified in 20 European centres according to a standard protocol for case ascertainment and definition. FINDINGS: Altogether 2201 patients aged 15 years or more were identified, of whom 1379 were diagnosed as UC (including proctitis), 706 as CD, and 116 as indeterminate. The overall incidence per 100,000 at ages 15-64 years (standardised for age and sex) of UC was 10.4 (95% confidence interval (95% CI) 7.6 to 13.1) and that of CD was 5.6 (95% CI 2.8 to 8.3). Rates of UC in northern centres were 40% higher than those in the south (rate ratio (RR) = 1.4 (95% CI 1.2 to 1.5)) and for CD they were 80% higher (RR = 1.8 (95% CI 1.5 to 2.1)). For UC the highest reported incidence was in Iceland (24.5, 95% CI 17.4 to 31.5) and for CD, Maastricht (The Netherlands; 9.2, 95% CI 6.5 to 11.8) and Amiens (north west France; 9.2, 95% CI 6.3 to 12.2). The lowest incidence of UC was in Almada (southern Portugal) (1.6, 95% CI 0.0 to 3.2) and of CD in Ioannina (north west Greece) (0.9, 95% CI 0.0 to 2.2). An unexpected finding was a difference in the age specific incidence of UC in men and women with the incidence in women but not men declining with age. INTERPRETATION: The higher overall incidence rates in northern centres did not seem to be explained by differences in tobacco consumption or education. Nevertheless, the magnitude of the observed excess for both conditions is less than expected on the basis of previous studies. This may reflect recent increases in the incidence of IBD in southern Europe whereas those in the north may have stabilised.

Oesophageal cancer is an uncommon cause of death in patients with Barrett's oesophagus

BACKGROUND: Barretts oesophagus carries a 30-fold to 40-fold increased risk of oesophageal cancer. It is unknown whether endoscopic surveillance programmes reduce mortality from oesophageal cancer. METHODS: A cohort study was undertaken of all 166 patients in whom the diagnosis Barretts oesophagus had been established between 1973 and 1986. RESULTS: One hundred and fifty five of 166 patients could be traced (93%). During a mean follow up of 9.3 years (amounting to 1440 patient years) eight patients had developed oesophageal cancer at random intervals (one case in 180 patient years). All but one of the tumours were diagnosed at endoscopy for symptoms, three in the stage of carcinoma in situ. Risk factors for the development of oesophageal cancer were extensive Barretts oesophagus exceeding 10 cm (p = 0.02) and Barretts ulcer at the time of intake (p = 0.009). Seventy six patients were alive; three had undergone surgery for oesophageal cancer and were without recurrence respectively, 12.8 years, 12.1 years, and 7 months postoperatively. Seventy nine patients had died; five of them had developed oesophageal cancer, but in only two cases this had been the cause of death (2.5%). CONCLUSIONS: Oesophageal cancer is an uncommon cause of death in patients with Barretts oesophagus. The patients of this cohort would not have benefited from an endoscopic surveillance programme.

Electrogastrographic study of gastric myoelectrical activity in patients with unexplained nausea and vomiting.

Using cutaneous electrodes an electrogastrographic study was made of gastric myoelectrical activity in both the fasting and postprandial states in 48 patients with unexplained nausea and vomiting and in 52 control subjects. A gastric emptying study, using a radio-labelled solid phase meal, was carried out in 30 of these 48 patients. A follow up study was done after one year. In 48% of the patients abnormal myoelectrical activity was found which was characterised by: instability of the gastric pacemaker frequency; tachygastrias in both the fasting and postprandial states; the absence of the normal amplitude increase in the postprandial electrogastrogram. This last characteristic was correlated with a delayed gastric emptying of solids. The present study shows that with electrogastrography in a heterogeneous group of patients with unexplained nausea and vomiting a subgroup can be discerned with abnormal myoelectrical activity. Our findings suggests that this abnormal myoelectrical activity is related to these symptoms.

Adenocarcinoma in Barrett's oesophagus: an overrated risk.

Barretts oesophagus is a risk factor for the development of oesophageal cancer and for this reason annual endoscopic surveillance has been proposed. In this retrospective study of all patients with Barretts oesophagus diagnosed in a 12 year period carcinoma had developed in only four patients. The incidence of oesophageal cancer in this series was one in 170 patient years, which means a 30-fold increase compared with the general population. The survival of patients with Barretts oesophagus was not different, however, from an age and sex matched control population. It is concluded that systematic endoscopic surveillance of patients with Barretts oesophagus is not indicated.

Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: Risk factors and management

UNLABELLED Benign stricture formation at the cervical anastomosis after transhiatal esophagectomy with gastric tube interposition is an important source of morbidity. In a large group of patients (n = 269) who had undergone transhiatal esophagectomy with gastric tube interposition, we examined surgical and nonsurgical risk factors for the development of benign strictures at the cervical anastomosis. In addition, we evaluated the results of endoscopic bougie dilation in patients in whom an anastomotic stricture developed. RESULTS During follow-up, 114 patients (42%) had a benign anastomotic stricture. Only a history of cardiac disease (P = 0.03), postoperative leakage at the anastomosis (p = 0.002), and a stapled rather than a hand-sewn anastomosis (p = 0.04) were found to be independent risk factors for the development of a stricture. In 27 of 60 patients with anastomotic leakage, contrast swallow examination demonstrated only a leak at the anastomosis. Endoscopic bougie dilation of anastomotic strictures was successful in 78% of patients after a median of three dilation sessions (range 1 to 28). In 3% of patients dilations were still being performed, and 19% of patients had died before normal swallowing had been achieved. In two of 519 (0.4%) dilation sessions a major complication occurred. CONCLUSIONS (1) Patients with preoperative cardiac disease are at an increased risk for anastomotic stricture. (2) Even in patients having no symptoms, a contrast swallow can detect anastomotic leakage that results in an increased risk for the development of anastomotic strictures. (3) The benefit of the stapler device for anastomosis remains to be determined. (4) Endoscopic bougie dilation with the patient mildly sedated is a safe and effective method for the treatment of anastomotic strictures.

Outcome of surgical treatment of adenocarcinoma in Barrett's oesophagus.

A retrospective study was performed of an 11 year period (1978-88) to analyse the survival of 112 patients (85 men and 27 women, mean age 63 years) with adenocarcinoma in a columnar lined (Barretts) oesophagus in respect of surgical treatment, tumour staging, and histological grading. Presenting symptoms were dysphagia (60%) and pain (25%). Only six patients were previously known to have a columnar lined oesophagus. Eighty five patients (76%) underwent partial resection of the oesophagus and cardia. Postoperative mortality was 6%. After resection (n = 85), the 5 year survival was 24%. Survival was significantly better for patients without regional lymph node metastases (stage 0, I, IIA (n = 61): 5 year survival 30%) and even better if the tumour was restricted to the submucosa (stage 0, I (n = 12): 5 year survival 63%). Survival was not influenced by the histological grade of the tumour. Staging based on infiltration of the oesophageal wall and lymph node spread is valuable in determining the prognosis for patients with adenocarcinoma in Barretts oesophagus.

Achalasia complicated by oesophageal squamous cell carcinoma: a prospective study in 195 patients.

To determine the incidence of oesophageal carcinoma in patients with achalasia and to establish the efficacy of endoscopic surveillance, 195 consecutive patients with achalasia (90 men and 105 women, mean age 52 years), who were treated by pneumatic dilatation in our institution between 1973 and 1988 were prospectively studied. None of the patients had undergone cardiomyotomy. Follow up totalled 874 person years after pneumatic dilatation. In this period three patients developed an oesophageal squamous cell carcinoma. The mean age at diagnosis of the oesophageal carcinoma was 68 years (37, 77, and 89 years). The mean period between the onset of dysphagia and the diagnosis of the tumour was 17 years (19, 28, and 5 years); the mean interval between the diagnosis of achalasia and carcinoma was 5.7 years (5, 8, and 4 years). The incidence of oesophageal squamous cell carcinoma in this series (3.4/1000 patients per year) is significantly higher than the statistically expected incidence (0.104/1000 patients per year) using age and sex specific incidence data from the population of the Netherlands (Poisson statistics: p less than 0.001). The risk of developing oesophageal squamous cell carcinoma in patients with achalasia is therefore increased 33 fold. Periodic endoscopy showed the potential for detecting early stage oesophageal carcinoma in two cases but a larger study with a longer follow up is required to determine the efficacy of endoscopic screening in improving the prognosis for patients with achalasia who develop oesophageal squamous cell carcinoma.

The role of radiotherapy in the treatment of bile duct carcinoma

Forty-two patients with irresectable bile duct carcinoma (n = 31) or with microscopic evidence of tumor rest after aggressive surgery for bile duct carcinoma (n = 11) were given radiotherapy consisting intentionally of external-beam therapy and intraluminal 192Iridium (192Ir) wire application(s) following bile drainage procedures. The treatment was well tolerated; complications were mainly infectious and related to the success of the drainage. A median survival of 10 months was achieved for the group as a whole. Patients treated following microscopically incomplete resection survived longer than patients with an irresectable tumor (15 vs 8 months median survival, p = 0.06). Gross lymph node involvement also proved to be a prognostic factor.

Dysplasia and aneuploidy as markers of malignant degeneration in Barrett's oesophagus. The Rotterdam Oesophageal Tumour Study Group.

The role of dysplasia and aneuploidy as markers in columnar epithelium for malignant degeneration in Barretts oesophagus was compared in a case control study comprising 38 patients with benign Barretts oesophagus and 50 patients with Barretts oesophagus associated with adenocarcinoma. Tissue specimens of columnar epithelium were reviewed for the presence of specialised columnar epithelium and the grade of dysplasia. Ploidy was determined using the method for formalin fixed paraffin wax embedded tissue described by Hedley. There was no significant difference in the frequency of specialised columnar epithelium between both groups. Dysplasia was found more often in columnar epithelium associated with adenocarcinoma compared with benign Barretts oesophagus (p < 0.001). Multivariate analysis using logistic regression showed an increased risk of malignancy in Barretts oesophagus in case of dysplasia (odds ratio 9.4, p = 0.003 for mild dysplasia and 33.1, p < 0.001 for moderate or severe dysplasia). Ploidy was not statistically significantly correlated with dysplasia. Aneuploidy or increased G2/tetraploidy proved to be an independent risk factor for younger patients (age < 65 years: odds ratio 44.7, p = 0.003). In conclusion, dysplasia and aneuploidy or increased G2/tetraploidy in columnar epithelium are independent risk factors for malignant degeneration. Patients with these risk factors should be offered a more intensive screening programme.

Effects of highly selective vagotomy on gastric myoelectrical activity

Changes in gastric myoelectrical activity following highly selective vagotomy were studied in 12 patients by means of electrogastrography (EGG) using cutaneous electrodes. Measurements were made before, 10 days after, and six months after operation. Eight patients undergoing cholecystectomy served as controls. Preoperatively all controls and patients had normal recordings. In the cholecystectomized patients no significant changes were found postoperatively. Ten days after highly selective vagotomy the normal initial postprandial dip in gastric ECA frequency and the subsequent increase in frequency and power were not seen. Tachygastrias were observed in three patients. Six months after operation the normal frequency and power responses to a test meal had returned, but both the fasting and postprandial ECA frequencies were raised significantly. It is concluded that highly selective vagotomy is associated with abnormalities in myoelectrical activity, in particular in the postprandial state, most of which are reversible with time.