N. Ravi

Prospective evaluation of quality of life in patients with localized oesophageal cancer treated by multimodality therapy or surgery alone.

Health‐related quality of life (HRQL) outcomes are important in assessing new approaches to the treatment of cancer. Neoadjuvant therapy is being used increasingly before surgery in patients with localized oesophageal cancer. This prospective non‐randomized study evaluated HRQL in patients treated by preoperative chemotherapy and radiation therapy followed by surgery (multimodal therapy) or by surgery alone.

Factors Influencing The Development of Barrett's Epithelium in The Esophageal Remnant Postesophagectomy

BACKGROUND:Barretts esophagus results from chronic reflux of both acid and bile. Reflux of gastric and duodenal contents is facilitated through the denervated stomach following esophagectomy, but the development of Barretts changes in this model and the relationship to gastric and esophageal physiology is poorly understood.AIMS:To document the development of new Barretts changes, i.e., columnar metaplasia or specialized intestinal metaplasia (SIM) above the anastomosis, and relate this to the recovery of gastric acid production, acid and bile reflux, manometry, and symptoms.PATIENTS AND METHODS:Forty-eight patients at a median follow-up of 26 months (range = 12–67) postesophagectomy underwent endoscopy with biopsies taken 1–2 cm above the anastomosis. The indication for esophagectomy had been adenocarcinoma (n = 27), high-grade dysplasia (n = 2), and squamous cell cancer (n = 19). Physiology studies were performed in 27 patients and included manometry (n = 25), intraluminal gastric pH (n = 24), as well as simultaneous 24-hour esophageal pH (n = 27) and bile monitoring (n = 20).RESULTS:Duodenogastric reflux increased over time, with differences between patients greater than and less than 3 years postesophagectomy for acid (p= 0.04) and bile (p= 0.02). Twenty-four patients (50%) developed columnar metaplasia and of these 13 had SIM. The prevalence of columnar metaplasia did not relate to the magnitude of acid or bile reflux, to preoperative neoadjuvant therapies, or to the original tumor histology. The duration of reflux was most significant, with increasing prevalence over time, with SIM in 13 patients at a median of 61 months postesophagectomy compared with 20 months in the 35 patients who were SIM-negative (p< 0.006). Supine reflux correlated with symptoms.CONCLUSIONS:The development of Barretts epithelium is frequent after esophagectomy, is time-related, reflecting chronic acid and bile exposure, and is not specific for adenocarcinoma or the presence of previous Barretts epithelium. This model may represent a useful in vivo model of the pathogenesis of Barretts metaplasia and tumorigenesis.

Evolving progress in oncologic and operative outcomes for esophageal and junctional cancer: Lessons from the experience of a high-volume center

OBJECTIVE Modern series from high-volume esophageal centers report an approximate 40% 5-year survival in patients treated with curative intent and postoperative mortality rates of less than 4%. An objective analysis of factors that underpin current benchmarks within high-volume centers has not been performed. METHODS Three time periods were studied, 1990 to 1998 (period 1), 1999 to 2003 (period 2), and 2004 to 2008 (period 3), in which 471, 254, and 342 patients, respectively, with esophageal cancer were treated with curative intent. All data were prospectively recorded, and staging, pathology, treatment, operative, and oncologic outcomes were compared. RESULTS Five-year disease-specific survival was 28%, 35%, and 44%, and in-hospital postoperative mortality was 6.7%, 4.4%, and 1.7% for periods 1 to 3, respectively (P < .001). Period 3, compared with periods 1 and 2, respectively, was associated with significantly (P < .001) more early tumors (17% vs 4% and 6%), higher nodal yields (median 22 vs 11 and 18), and a higher R0 rate in surgically treated patients (81% vs 73% and 75%). The use of multimodal therapy increased (P < .05) across time periods. By multivariate analysis, age, T stage, N stage, vascular invasion, R status, and time period were significantly (P < .0001) associated with outcome. CONCLUSIONS Improved survival with localized esophageal cancer in the modern era may reflect an increase of early tumors and optimized staging. Important surgical and pathologic standards, including a higher R0 resection rate and nodal yields, and lower postoperative mortality, were also observed.

Management of spontaneous rupture of the oesophagus (Boerhaave’s syndrome): Single centre experience of 18 cases

BackgroundSpontaneous oesophageal rupture (Boerhaave’s syndrome) is rare, and carries a high attendant risk of mortality.MethodsA retrospective eight-year review from a tertiary unit.ResultsEighteen patients were managed, with a mean age of 57 (39–88 years). Eight patients presented early and underwent surgery, seven with primary closure and one with exclusion and diversion. There was one death in this group. Ten patients were managed conservatively. In this group, two underwent an oesophagectomy because of failed conservative measures, and four had an endoprosthesis inserted. One patient died in this group on the first admission, but two patients with stents in situ died from massive bleeding relating to an aorto-oesophageal fistula at 39 days and 189 days respectively following presentation.ConclusionsSurgical intervention remains the gold standard when the diagnosis is made early For late diagnoses, this series suggests caution in the use of endoprostheses.

Original article: Outcomes in achalasia from a surgical unit where pneumatic dilatation is first-line therapy

The management of achalasia remains controversial, with little consensus on the optimal patient treatment pathway. In our own esophageal unit, we offer pneumatic dilatation as the initial therapy in most patients as first-line therapy. In this study, we aimed to examine the safety and efficacy of our own approach to the management of patients with a diagnosis of achalasia, examining symptomatic outcomes, patient satisfaction, and need for further intervention, as well as examining patient factors associated with treatment failure. Sixty-seven consecutive patients underwent pneumatic dilatation as first-line therapy (53% male, mean age 46 years). All attended regular outpatient follow-up (mean 37, range 3-132 months). Twenty-five percent of patients required a second intervention because of symptom recurrence, at a median period of 4.5 months. Symptomatic outcomes were excellent or good in 80%. Significant predictors of treatment failure and poor symptom score included a younger age at the time of diagnosis and increased esophageal diameter on barium swallow. This study suggests that pneumatic dilatation is a safe and effective approach as first-line therapy in patients with newly diagnosed achalasia.

D2 lymphadenectomy in the management of gastric cancer.

AbstractBackground Gastric carcinoma is a significant cause of death in Ireland. Surgery offers the best option of cure, but the five-year survival following resection remains dismal at 10–15%. Experience from Japan and from some Western units suggest that an extended (D2) lymphadenectomy in association with gastrectomy increases the prospect of cure, but concern about the morbidity and mortality of this operation and lack of evidence from randomised studies has limited its acceptance. Aims This study reports the experience of a specialist upper gastrointestinal unit with D2 gastrectomy in a four-year audit. Methods Sixty-two resections were performed for gastric cancer. Results Nineteen patients were deemed unsuitable for the D2 procedure and underwent a more limited lymphadenectomy (DO or D1). Forty-three patients underwent D2 resection, 12 with an oesophagogastrectomy, 22 with total gastrectomy and nine with a sub-total distal resection. Eight patients undergoing D2 resection had extended resections, five with splenectomy and three with a distal pancreatectomy. Post-operative complications occurred in 31% of patients. Thirty-day and 90-day mortality were zero. Median survival was 822 days in the D2 group (range 120–1,320). Conclusions These results show that a D2 gastrectomy can be performed with a low morbidity and mortality and a median survival of greater than two years.

PWE-018 Superiority of actual compared with close (<1 mm) circumferential resection margin involvement in the pathological staging of oesophageal and junctional cancer

Introduction An involved circumferential resection margin (CRM), defined as tumour cells within 1 mm of the CRM, is of established prognostic significance in rectal cancer. In the oesophagus, which unlike rectum lacks a defined mesentery, controversy exists, with the UK Royal College of Pathologists (RCP) recommending the 1 mm definition, while the College of American Pathologists (CAP) advise that only an involved margin defines an incomplete (R1) resection. Methods CAP and RCP CRM status were recorded prospectively in a comprehensive prospective data-base from May 2003 to May 2011. Factors impacting on survival were assessed by univariate and multivariate analysis. Kaplan–Meier survival curves for CRM + compared with CRM- groups by RCP and CAP criteria were computed. Results RCP and CAP CRM status was available for 316 patients. Overall, positive margins were recorded in 33% (n=103) and 10% (n=33) using the RCP and CAP criteria, respectively. Specific analysis focused on 143 patients with pT3 tumours. Mean follow-up was 19.8 months (range 1.6–79.5 months). RCP criteria diagnosed 60.8% (n=87) of pT3 tumours as positive; however, by CAP criteria, 18% (n=27) were positive. A significantly higher proportion of CAP positive CRMs were associated with lymph node metastases (p=0.05). Using RCP criteria there was no significant difference in survival in patients with positive and negative CRM margins (p=0.201). However, CRM involvement by CAP criteria was associated with poor survival (p=0.003). Multivariate analysis revealed nodal invasion and CAP CRM positive disease as independent prognostic variables (p=0.047 and p=0.028 respectively). Conclusion Comparison of the RCP and CAP criteria indicates that CAP is superior, consistent with recent data.1 It may be best to include both assessments in prospective data-bases, but this data suggests that actual rather than close CRM involvement significantly impacts outcome, and may be factored into prognostic calculation and possibly the design of future adjuvant trials. Competing interests None declared. Reference 1 Deeter M, Dorer R, Kuppusamy MK, et al. Assessment of criteria and clinical significance of circumferential resection margins in esophageal cancer. Arch Surg 2009;144:618–24.

Original article: Outcomes in achalasia from a surgical unit where pneumatic dilatation is first-line therapy: Pneumatic dilatation for achalasia

The management of achalasia remains controversial, with little consensus on the optimal patient treatment pathway. In our own esophageal unit, we offer pneumatic dilatation as the initial therapy in most patients as first-line therapy. In this study, we aimed to examine the safety and efficacy of our own approach to the management of patients with a diagnosis of achalasia, examining symptomatic outcomes, patient satisfaction, and need for further intervention, as well as examining patient factors associated with treatment failure. Sixty-seven consecutive patients underwent pneumatic dilatation as first-line therapy (53% male, mean age 46 years). All attended regular outpatient follow-up (mean 37, range 3-132 months). Twenty-five percent of patients required a second intervention because of symptom recurrence, at a median period of 4.5 months. Symptomatic outcomes were excellent or good in 80%. Significant predictors of treatment failure and poor symptom score included a younger age at the time of diagnosis and increased esophageal diameter on barium swallow. This study suggests that pneumatic dilatation is a safe and effective approach as first-line therapy in patients with newly diagnosed achalasia.

Boerhaave’s syndrome: fourteen cases of spontaneous oesophageal rupture with varying management strategies in a single centre

ConclusionsSurgical intervention remains the gold standard for cases which are diagnosed promptly. Where the diagnosis is delayed utilization of covered oesophageal stents is a viable option. In single institutions, management strategies can be customised, thus reducing overall mortality.

The importance of post-operative pH monitoring following antireflux surgery in Barrett’s oesophagus

ConclusionsNissen fundoplication provides excellent long-lasting relief of symptoms in Barrett’s oesophagus patients. Post-operative 24-hour pH studies establish that acid reflux has been abolished. Abnormal post-operative studies may be associated with dysplasia and adenocarcinoma in the long-term and emphasise the need for longterm follow-up.