Oesophageal cancer staging using
endoscopic ultrasound. Vickers J, Alderson D. Br J Surg
1998; 85: 994-998.
Endoscopic ultrasound is being increasingly used for high
resolution imaging of gastrointestinal pathology. Its role in both the
local and nodal staging of cancers has attracted recent interest. There
have been no reported UK studies of its value in the staging of
oesophageal cancer. The aim of this study was to determine the accuracy of
endoscopic ultrasound for the local tumour and lymph node staging in
patients with oesophageal cancer compared with surgical and histological
assessment. Fifty consecutive patients underwent pre-operative endoscopic
ultrasound. The extent of the disease was staged both by the surgeon at
operation and on the final histological specimen. Endoscopic ultrasound
was 92% accurate at T staging and 86% accurate at N staging. Ultrasound
was superior to surgical operative assessment. Endoscopic ultrasound
appeared to be reliable for both local tumour and lymph node staging of
oesophageal cancer. It was able to identify patients in whom a cure may be
possible and also those who may benefit from adjuvant therapy. It also
identified those with invasion into adjacent organs and thus prevented
Symptomatic benefit from eradicating
Helicobacter pylori infection in patients with nonulcer dyspepsia.
McColl K, Murray L, El-Omar E et al. N Eng J Med 1998;
Dyspepsia affects 20-40% of the population. In those in
whom upper GI endoscopy is normal they are regarded as having nonulcer or
functional dyspepsia. Eradication of H. pylori has been shown to be
beneficial in those with a proven duodenal or gastric ulcer. The role of
H. pylori eradication in those with nonulcer dyspepsia is unclear.
In this study 914 patients with dyspepsia were assessed. Almost two-thirds
were excluded due mainly to the presence of a peptic ulcer or being H.
pylori negative. 330 patients who were H. pylori positive and
had a normal endoscopy were randomised to either triple therapy
(omeprazole 20 mg bd, amoxycillin 500 mgs tds, metronidazole 400 mg tds)
for 2 weeks or omeprazole alone. At one month, 88% of triple therapy
patients and 5% of omeprazole patients were H. pylori negative. At
one year 21% of the triple therapy groups and 7% of the omeprazole group
had complete resolution of their symptoms. It was concluded that in
patients with nonulcer dyspepsia who are H. pylori positive triple
therapy treatment is more likely to resolve symptoms than omeprazole
alone. This study has implication for the provision of endoscopy services
in that it could be argued that in young patients with dyspeptic symptoms
who are H. pylori positive on non-invasive testing, upper GI
endoscopy is not required as the treatment would be the same whether an
ulcer was identified or not.
Eradication of Helicobacter pylori
prevents recurrence of ulcer after simple closure of duodenal ulcer
perforation. Ng E K W, Lam Y H, Sung J J Y et al.
Ann Surg 2000; 231: 153-158.
The optimal surgical treatment for perforated duodenal
ulcer remains controversial. Simple oversewing is associated with a
significant risk of long-term recurrence. Up to one-third of
patients develop further ulceration and on-third of these patients will
require further surgery. As a result acid-reduction procedure have
been advocated and surgically this has often been achieved by a truncal
vagotomy. This increases both the operation time and risk of
post-operative complications. Alternatively acid suppression can be
achieved post-operatively by pharmacological treatments. H.
pylori eradication is of proven benefit in patients with uncomplicated
or bleeding duodenal ulceration. It role following surgery for ulcer
perforation is unclear. A significant proportion of patients with
perforated duodenal ulcers are H. pylori positive. The aim of
this study was to evaluate whether H. pylori eradication reduces
the risk of ulcer recurrence following simple oversew of a perforated
duodenal ulcer. In a prospective, randomised study of 129 patients
with perforated duodenal ulceration 104 (81%) were shown to be H.
pylori positive during intraoperative gastroscopy and CLO test.
The 91 patients that underwent simple oversewing of the ulcer were
randomised to receive either quadruple therapy (bismuth, tetracycline,
metronidazole and omeprazole) or post-operative omeprazole alone.
Endoscopy was repeated at 8 weeks, 16 weeks and one year. The
primary endpoint was ulcer healing or relapse at one year. In total
51 patients received eradication therapy and 48 patients received
omeprazole alone. Ninety patients underwent follow up endoscopy at
the prescribed times. From these patients, 43/44 (98%) who underwent
eradication therapy and 8/46 (17%) taking omeprazole alone were H.
pylori negative. The initial ulcer healing (82% vs. 87%) was
similar in the two groups. At one year ulcer relapse was
significantly reduced (5% vs 38%) in the eradication group. It was
concluded that H. pylori eradication reduces ulcer recurrence in
patients with H. pylori associated perforated duodenal ulceration.
Immediate acid-reduction surgery is unnecessary.
Effects of intravenous omeprazole on
recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.
Lau J Y W, Sung J J Y, Lee K K C et al. N Eng J Med
2000; 343: 310-316.
Endoscopic treatment is often effective for controlling
bleeding from peptic ulcers but recurrent haemorrhage occurs in 15-20% of
patients. Rebleeding is associated with a high mortality rate.
The role of acid suppression following endoscopic treatment of upper
gastrointestinal haemorrhage is unclear with no convincing evidence that
that H2 antagonists reduce the risk of further haemorrhage or mortality.
Several studies have evaluated the effect of proton pump inhibitors on the
risk of recurrent haemorrhage but most have had methodological
deficiencies. The aim of this study was to conduct a randomised
double-blind placebo controlled trial to assess whether the adjuvant use
of a high-dose proton pump inhibitor after endoscopic treatment of
bleeding peptic ulcers would reduce the rate of recurrent bleeding.
Patients with actively bleeding ulcers or ulcers with non-bleeding visible
vessels were treated with adrenaline injection and thermocoagulation.
After haemostasis had been achieved patients were randomised to either an
omeprazole infusion or placebo for 72 hours. After the infusion all
patients received oral omeprazole for eight weeks. The primary end
point was rebleeding within 30 days of endoscopy. In total 120
patients were randomised in to each group. Rebleeding occurred in 8
(6.7%) patients in the omeprazole group and in 27 (22.5%) patients in the
placebo group (Hazard ratio 3.9; 95% CI 1.7-9.0). Most rebleeding
occurred within the first three days - i.e. during the infusion period.
There was no difference in the need for surgery or mortality between the
two groups. It was concluded that following endoscopic treatment of
bleeding peptic ulcers a high-dose of a proton pump inhibitor
significantly reduced the risk of recurrent haemorrhage.
Oesophageal resection for high-grade
dysplasia in Barrett's oesophagus. Zaninotto G, Parenti A R,
Ruol A, Costantini M, Mergliano S, Ancona E. Br
J Surg 2000; 87: 1102-1105.
Although endoscopic surveillance programmes for Barrett's
oesophagus have been widely established, the diagnosis of high-grade
dysplasia in biopsies is relatively rare. As the natural history of
high-grade dysplasia is unclear the optimal management of this problem is
at present unknown. The available options include continued
endoscopic surveillance, treatment limited to the Barrett's mucosa (e.g.
endoscopic mucosectomy) or a more aggressive therapy such as
oesophagectomy. All of these options have particular advantages and
disadvantages. The aim of this study was to determine the prevalence
of associated cancer undetected by endoscopy in patients with Barrett's
high-grade dysplasia and to assess whether an endoscopic protocol
with multiple biopsies could improve the diagnostic accuracy. In
addition the morbidity and mortality associated with oesophageal resection
for high-grade dysplasia were studied. Between 1982 and 1998, 15
patients were identified who had high-grade dysplasia within an area of
Barrett's oesophagus. Seven patients underwent primary resection
soon after diagnosis. The other eight patients underwent a second
endoscopy during which a median of 12 biopsies were taken. All
later underwent oesophageal resection. Invasive adenocarcinoma was
identified in 5 (33%) patients with no difference between the two groups.
There were no perioperative deaths. Early morbidity was seen in
eight patients and late morbidity in in four patients. The actuarial
survival rate was 80% at five years. It was concluded that patients
with high-grade dysplasia had a 33% probability of harbouring invasive
oesophageal carcinoma. A second endoscopy failed to identify the
invasive cancer. Oesophagectomy can be performed with no mortality
and remains the rational treatment in patients considered fit for
Prognostic significance of peri-operative
blood transfusion following radical resection for oesophageal carcinoma.
Dresner S M, Lamb P J, Shenfine J, Hayes N, Griffin S M. Eur J
Surg Oncol 2000; 26: 492-497.
It has recently become apparent that peri-operative
allogeneic blood transfusion is associated with a clinically relevant
immunosuppressive effect. In some situations, such as after organ
transplantation, this may be clinically advantageous but it may also have
a deleterious effect on patients undergoing surgery for malignant disease.
Several reports have highlighted an association between between
peri-operative blood transfusion and an increase in recurrence rates and
reduced survival following surgery for several gastrointestinal
malignancies. The aim of this study was to clarify the prognostic
significance of perioperative blood transfusion following oesophagectomy
in a specialist centre. A consecutive series of 235 patients
undergoing subtotal oesophagectomy with a two-field lymphadenectomy
between April 1990 and June 1999 were studied. The median age was 64
years (30-79) with a male to female ratio of 3:1. The predominant
histological type was adenocarcinoma (n=154). To avoid the influence
of surgical complications the 5.5% of patients suffering in-hospital
mortality were excluded. In the remaining patients the median blood
loss was 900 ml (200-5500) with 46% (n=103) of patients requiring a blood
transfusion (median 3 units, range 2-21). Median surgical of
non-transfused patients was 36 months compared to 19 months for those
receiving a blood transfusion (log-rank=4.44; 1df, p=0.03).
Non-transfused patients had a significantly higher 2 and 5-year survival
rate. Even after stratification of results according to disease
stage or the development of complications, survival was significantly
worse in those requiring a blood transfusion. Multivariate analysis
demonstrated that in addition to nodal status, transfusion of more than 4
units of blood was an independent prognostic factor. It was
concluded that peri-operative transfusion is associated with a
significantly worse prognosis following radical oesophagectomy and that
meticulous haemostasis and avoidance of unnecessary transfusion may prove
characterization by site of origin and hormone production. Onaitis M
W, Kirshbom P M, Hayward T Z et al. Ann Surg
2000; 232: 549-556.
Carcinoid tumours are relatively uncommon neuroendocrine
lesions arising from amine precursor uptake and decarboxylation (APUD)
cells. Those arising from the gastrointestinal tract are usually
classified according to their site of origin as foregut, midgut or hindgut
tumours. One of the unique features of these tumours is their
ability to produce protein and peptide hormones, the most characteristic
of which is serotonin. Hormonal measurements show that foregut and midgut
tumours produce the highest levels. Systemic serotonin release is
believed to produce many of the symptoms of the carcinoid syndrome
including diarrhoea, flushing, wheezing and right-sided heart disease.
Published data has described prognostic features of carcinoid tumours as
site of origin, age, sex, disease stage and presence of high hormonal
levels at presentation. The aim of this study was to define the
relationship between presenting variables and prognosis among carcinoid
tumours arising at different gastrointestinal sites. A prospective
database of carcinoid patients maintained in a university teaching
hospital for 30 years was interrogated to identify presenting symptoms,
hormonal data, pathological features and survival. Carcinoid tumours
arising in different locations had different presentations. Rectal
carcinoids presented significantly more often with gastrointestinal
bleeding. Midgut carcinoids presented more often with carcinoid
syndrome. Patients with midgut tumours had significantly higher
hormonal levels. Although age, stage, site of origin and urinary
5-HIAA levels all predicted survival on univariate analysis only the later
three were independent prognostic factors on multivariate analysis.
Of patients with metastatic disease at diagnosis, those with midgut
tumours had improved survival. It was concluded that although region
of origin is an important prognostic factor, stage at presentation is more
predictive of survival. Pancreatic and midgut carcinoids are
metastatic at origin more often than those arising at other sites.
Laparoscopic Heller myotomy for
achalasia. Hunt D R, Wills V L. Aust NZ J Surg
2000; 70: 582-586.
Achalasia is a rare condition with an incidence of
approximately one per 100,000 per year. It is characterised by
incomplete relaxation of the lower oesophageal sphincter and disordered
oesophageal body peristalsis. Both endoscopic and surgical
treatments are aimed at disrupting the lower oesophageal sphincter.
This is most commonly achieved by endoscopic balloon dilatation with
surgical myotomy reserved for endoscopic failures. Surgical
treatments may also be combined with an anti-reflux procedure.
Minimally invasive surgical procedures have potential advantages over
traditional open operations. The aim of this study was to examine
the evolution of the operative technique, postoperative outcome and the
effect of the 'learning curve' in 70 patients undergoing laparoscopic
Heller's myotomy between 1992 and 1999. Pre and perioperative data
regarding all patients was prospectively entered into a database.
Patients were followed up clinically or by a biennial postal questionnaire
obtaining information regarding dysphagia, heartburn, regurgitation and
chest pain. Surgery was performed as a primary procedure in 20
patients, after failed endoscopic treatment in 48 cases and after failed
fundoplication in 2 patients. The myotomy was combined with a 360
degree fundoplication in 57 patients and with an anterior fundoplication
in 13 patients. Mucosal perforation occurred in 11 cases.
Conversion to an open procedure was required in 7 cases. At a mean
follow-up of 3 years, symptom scores were significantly improved for
dysphagia, regurgitation and chest pain. The 'learning curve'
contributed significantly to the length of the procedure and the need for
re-operation. It was concluded that laparoscopic Heller myotomy is a
technically challenging procedure but one that provided good palliation of
the symptoms associated with achalasia.
Long-term outcome of medical and surgical
therapies for gastroesophageal reflux disease. Spechler S J,
Lee E, Ahnen D et al. JAMA 2001; 285:
Gastroesophageal reflux disease (GORD) is one of the
commonest disorders of the alimentary tract with approximately 20% of
adults experiencing symptoms of GORD each week. Modern medical and
surgical anti-reflux therapies are highly effective in controlling
symptoms of GORD but little is know of the efficacy of these measures in
preventing long-term complications such as peptic stricture, Barrett's
oesophagus and oesophageal carcinoma. Whilst good short-term results have
been reported following both open and laparoscopic fundoplication, the
long-term outcome of surgery is unknown. In the 1980s the Department
of Veteran Affairs Cooperative Studies Program conducted a randomised
trial of medical and surgical anti-reflux therapies in 247 patients with
complicated GORD. For the two-year duration of the study surgery
(open fundoplication) was found to be better then medical therapy
(antacids, H2 blockers and sucralfate). To determine the long-term
outcome of GORD therapies a follow-up study of this well-define cohort was
of patients was performed. Mean follow up was 10.6 years for
medical patients and 9.1 years for surgical patients. Overall, 239
(97%) of the original cohort were found with 79 patients having died.
Of the 160 survivors (157 men, 3 women), 129 participated in the follow-up
study. The main outcome measures were use of anti-reflux medication,
GORD activity index (GRACI) score, grade of oesophagitis, frequency of
treatment of stricture, frequency of subsequent anti-reflux operation,
36-item Short Form health survey (SF-36) score, survival and incidence of
adenocarcinoma. Overall, 92% of medical patients and 62% of surgical
patients reported the regular use of anti-reflux medication (p<0.001).
After discontinuation of anti-reflux medication, mean GRACI scores were
significantly lower in the surgical group (p=0.003). There was,
however, no significant difference in the frequency of oesophagitis or
rate of stricture formation. Patients with Barrett's oesophagus at
baseline developed oesophageal adenocarcinoma at a rate of 0.4% whereas
these cancers developed in patients without Barrett's oesophagus at an
annual rate of 0.07%. There was no difference between the two groups
in the incidence of oesophageal carcinoma. It was concluded that
anti-reflux surgery should not be advised with the expectation that
patients with GORD will no longer need to take anti-secretory medication
or that the procedure will prevent cancer amongst those with GORD and
Laparoscopic peritoneal lavage in
staging gastric and oesophageal cancer. Bryan R T, Cruickshank
N R, Needham S J et al. Eur J Surg Oncol 2001;
Accurate staging of gastric, oesophageal and
gastro-oesophageal cancer is essential to avoid unnecessary extensive
surgery in patients in whom only palliation is appropriate. This
requires a multimodal approach utilizing endoscopy, CT and diagnostic
laparoscopy. Upper GI endoscopy is usually the initial investigation
leading to the diagnosis with confirmation achieved by a biopsy specimen.
CT is commonly used to further assess local invasion, nodal status and the
presence of either liver metastases or gross peritoneal disease.
Staging laparoscopy is often used to complement the CT scan to further
increase the accuracy of disease staging. It allows assessment of
the primary tumour, local invasion and the detection of liver and nodal
metastases which may not be apparent on CT. It is most useful in
detecting small peritoneal metastases. Peritoneal dissemination is
the most frequently observed type of recurrence following gastric and
oesophageal cancer surgery and arises from transcoelomic spread from the
primary tumour. The presence of free peritoneal tumours cells
(FPTCs) detected at the time of laparoscopy or laparotomy carries a poor
prognosis. Various methods of peritoneal lavage for the detection of
FPTCs have been described. The aim of this study was to evaluate the
prognostic value of a technique for peritoneal lavage used in Birmingham.
Between March 1997 and February 1999, 88 staging laparoscopies were
performed in patients eligible for an attempted curative resection of a
gastric, oesophageal or gastro-oesophageal cancer. During
laparoscopy the pelvis was irrigated with 200 ml normal saline with 100 ml
aspirated and examined cytologically. Patients were followed up
until September 1999. Overall, 11 patients had FPTC-positive
cytology with a median survival from laparoscopy of 122 days (95% CI
82-161) with only a single patient surviving for more than one year.
In the FPTC-negative group, median survival was 378 days (95% CI 256,-).
Log-rank chi-squared = 16.7 p<0.001. It was concluded that the
presence of FPTCs detected by this technique is a contraindication to
attempted curative resection and that in this group of patients palliation
by either medical or surgical methods is appropriate.
Effectiveness of laparoscopic
fundoplication for gastro-oesophageal reflux. Khoursheed M A,
Al-Asfoor M, Al-Shamali et al. Ann R Coll Surg Eng 2001;
Gastro-oesophageal reflux (GORD) is a common condition,
symptoms of which can be effectively controlled in most patients with
either life-style modification and medical therapy. However, a small
percentage of patients remain symptomatic despite optimal medical therapy.
These patients may benefit from antireflux surgery. Since the first
report of laparoscopic fundoplication in 1991, several centres have
reported their experiences and with up to 95% being symptom-free and
satisfied with the outcome of their surgery. These results are
similar to those seen following open surgery. The aim of this study was
evaluate the effectiveness of laparoscopic fundoplication in a middle
eastern population. Between 1995 and 1998, 74 patients who failed
medical treatment for GORD were treated by laparoscopic fundoplication.
The Toupet procedure (270 degree wrap) was used in 66 patients and a
Nissen fundoplication (360 degree wrap) was used in 8 patients. The
patients were followed up for a mean of 15 (range 3-33) months. Most
of the patients were male (n=65). The mean age of the patients was
36 (range 17-60) years. Overall, 94% were symptom-free following
antireflux surgery. Five patients considered the procedure a
failure. Of these, 3 patients developed symptoms of recurrent
reflux. Two patients developed complications (gas bloat and
dysphagia) which warranted taking down of the fundoplication
laparoscopically. Two patients developed small incisional hernias at
the site of a 10 mm port. It was concluded that laparoscopic
fundoplication is safe and effectively relieves reflux symptoms in
patients who have failed medical treatment.
Effect of Helicobacter pylori
eradication on the ulcer recurrence rate after simple closure of
perforated duodenal ulcer: retrospective and prospective randomised
controlled studies. Kate V, Ananthakrishnan N, Badrinath
S. Br J Surg 2001; 88: 1054-1058.
Primary treatment of a perforated duodenal ulcer involves
patch closure which can be combined with definitive ulcer surgery.
Simple closure is associated with unacceptably high recurrence rates where
as definitive surgery may have long-term side-effects in patients who
might otherwise have been cured by simple closure. Trials of the use
of either H2 blocking drugs or proton pump inhibitors to reduce ulcer
recurrence after simple patch closure has produced conflicting results.
Attention has recently focused on the role of H. pylori and the
effect of eradication on the natural history of perforated duodenal ulcer.
The aim of this study was to determine the prevalence of H. pylori
in patients with perforated duodenal ulcer and to correlate the H.
pylori status with the short, medium and long-term ulcer recurrence
rates following simple closure. Some 202 patients were followed
prospectively for 2 years after simple closure of a perforated duodenal
ulcer (prospective group). A second group of 60 patients were
reviewed 5 years or more after simple closure (retrospective group).
The prevalence of H. pylori in patients with perforated duodenal
ulcer was compared with that in controls. Patients in the
prospective group were randomised to receive either ranitidine alone or
quadruple therapy (ranitidine, colloidal bismuth, metronidazole,
tetracycline) after operation. The incidence of H. pylori
infection after the two treatments and the association with residual or
recurrent ulceration was studied. The prevalence of H. pylori
infection in patients with perforated duodenal ulcer was not significantly
different to that in controls. However, at every time interval of
follow-up in both the prospective and retrospective groups the H.
pylori infection rate was higher in patients with recurrent or
residual ulceration. It was concluded that eradication of H.
pylori after simple closure of a perforated duodenal ulcer should
reduce the incidence of residual and recurrent duodenal ulceration.
Chemoradiotherapy after surgery compared
with surgery alone for adenocarcinoma of the stomach or gastroesophageal
junction. MacDonald J S, Smalley S R, Benedetti J et
al. N Eng J Med 2001; 345: 725-730.
Any potentially curative treatment for stomach cancer
requires gastric resection. However, most patients are not cured by
surgery alone. The high rate of relapse (up to 70%) after resection
makes it important to consider adjuvant treatment for patients with
stomach cancer. Adjuvant chemotherapy (without radiotherapy) has not
resulted in improved survival compared with surgery alone. The aim
of this study was to investigate the effect of surgery plus postoperative
adjuvant chemoradiotherapy on the survival of patients with resectable
adenocarcinoma of the stomach and gastroesophageal junction.
Overall, 556 patients with resected adenocarcinoma were randomly assigned
to surgery plus postoperative chemoradiotherapy or surgery alone.
Adjuvant therapy consisted of fluorouracil plus leucovorin for 5 days,
followed by 45Gy radiotherapy for 5 weeks with further fluorouracil and
leucovorin at the beginning and end of the chemotherapy. One month
after completion of radiotherapy two further cycles of chemotherapy were
given. The median survival in the surgery-only group was 27 months
compared with 36 months in the chemoradiotherapy group. The hazard
ratio for death was 1.35 (95% CI; 1.09-1.66. p=0.005). The
hazard ratio for relapse was 1.52 (95% CI; 1.23-1.86. p<0.001).
Three patients (1%) died form the toxic effects of the chemoradiotherapy.
It was concluded that postoperative chemoradiotherapy should be considered
for all patients at high risk for recurrence of adenocarcinoma of the
stomach and gastroesophageal junction who have undergone curative
Surgical resection with or without
preoperative chemotherapy in oesophageal cancer: a randomised controlled
trial. MRC Oesophageal Cancer Working Party. Lancet
2002; 359: 1727-1733.
The outlook for patients with oesophageal cancer who
undergo surgical resection with curative intent is still poor with only
20-30% surviving to two years. Factors contributing to this poor
outlook include the presence of locally advanced disease and undiagnosed
metastases at presentation. As a result there has been recent
interest in the use of systemic chemotherapy in addition to local surgical
treatment and radiotherapy. The aim of this study was to assess whether
preoperative chemotherapy could improve survival, dysphagia and
performance status in patients undergoing surgical resection for
oesophageal cancer. Overall, 802 previously untreated patients with
resectable oesophageal cancer of any cell type were randomly allocated to
either two cycles of cisplatin with a fluorouracil infusion over three
weeks followed by surgical resection (CS group. n=400) or surgical
resection alone (S group. n=402). Patients could be give
preoperative radiotherapy irrespective of their randomisation. The
primary outcome measure was survival and analysis was on an intention to
treat basis. Resection was complete in 233 (60%) of 390 assessable
patients in the CS group and 215 (54%) of 397 assessable patients in the S
group (p<0.0001). Postoperative complications were reported in 146
(41%) of patients in the CS group and 161 (42%) patients in the S group.
Overall survival was better in the CS group (HR=0.79; 95% CI 0.67-0.93.
p=0.004). Median survival was 512 days in the CS group and 405 in the
S group (difference 107 days. 95% CI 30-196) and 2-year survival rates
were 43% and 34% (difference 9%; CI 3-14). It was concluded that two
cycles of preoperative cisplatin and fluorouracil improves survival
without additional serious adverse events in the treatment of patients
with resectable oesophageal cancer.
Hepatitis B e antigen and the risk of
hepatocellular carcinoma. Yang H-I, Lu S-N, Liaw Y-F et al.
N Eng J Med 2002; 347: 168-174.
Chronic hepatitis B virus infection is a serious clinical
problem because of its world wide distribution and potential for adverse
sequelae, including hepatitis, cirrhosis and hepatocellular carcinoma.
It is particularly prevalent in the Asian-Pacific region, where patients
usually acquire the infection at the time of birth or in early childhood.
The presence of the hepatitis B e antigen (HBeAg) in serum indicates
active viral replication in hepatocytes. HBeAg is thus a surrogate
marker for the presence of hepatitis B virus DNA. The aim of this
study was to determine the relationship between positivity for hepatitis B
surface antigen (HBsAg) and HBeAg and the development of hepatocellular
carcinoma. In 1991 and 1992, 11,893 men in Taiwan, aged 30-65 years
and without evdience of hepatocellular carcinoma, were enrolled in the
study. Serum samples were obtained and tested for HBsAg and HBeAg by
radioimmunoassay. The diagnosis of hepatocellular carcinoma was
ascertained through data linkage with the computerised National Cancer
Registry in Taiwan and with death certificates. A multiple
regression analysis was performed to determine the relative risks of
hepatocellular carcinoma among men who were positive for HBsAg alone or
HBsAg and HBeAg, as compared with those who were negative for both.
Overall, there were 111 cases of newly diagnosed hepatocellular carcinoma
during 92,359 person-years of follow-up. The incidence rate of
hepatocellular carcinoma was 1169 cases per 100,000 person-years amongst
men who were positive for both HBsAg and HBeAg, 324 per 100,000
person-years for those who were positive for HBsAg only and 39 per 100,000
person-years for those who were negative for both. After adjustment
for age, sex, the presence or absence of antibodies to hepatitis C virus,
cigarette smoking, and use or nonuse of alcohol, the relative risk of
hepatocellular carcinoma was 9.6 (95% CI 6.0-15.2) among men who were
positive for HBsAg alone and 60.2 (CI 95% 35.5-102.1) amongst those who
were positive for both HbsAg and HBeAg, as compared with men who were
negative for both. It was concluded that positivity for HBeAg is
associated with an increased risk of hepatocellular carcinoma.
Inoperable adenocarcinoma of the
oesophagogastric junction: a comparative study of laser coagulation
versus self-expanding metallic stents with special reference to cost
analysis. Sihvo E I T, Pentikainen T, Luostarinen M E,
Ramo O J, Salo J A. Eur J Surg Oncol 2002; 28:
The incidence of adenocarcinoma near the
gastro-oesophageal junction is increasing. Over 60% of these
patients have incurable disease at presentation either because of advanced
stage of disease or poor general physical condition. Altogether, 10%
or fewer of these patients will be cured of their disease so for the
majority, the main aims of treatment are palliation of dysphagia,
prevention of aspiration and improvement of the quality of life. The
role of palliative surgery is limited but no one method of endoscopic
palliation has proved to be superior. These include oesophageal
stents - either rigid plastic or self-expanding metallic stents (SEMS) and
local tumour ablative techniques such as laser therapy. Neither
clinical nor financial comparisons yet exist between SEMS and laser
therapy. The aim of this study was to compare the relative lifetime
costs and clinical results of Nd-YAG laser to those of SEMS as alternative
forms of primary palliation of dysphagia for adenocarcinoma near the
oesophagogastric junction. A retrospective review was undertaken of
52 patients with distal oesophageal or oesophagogastric adenocarcinoma who
underwent palliative treatment for dysphagia; 32 treated with laser
therapy and 20 with SEMS. The clinical outcome and cumulative costs
were analysed. Although patients palliated with SEMS underwent fewer
procedures (1.9 vs. 3.4. p=0.0048), they spent as many days
in hospital (12.9 vs. 15.1 p=0.370) and required as high overall
coats of therapy as those treated with laser therapy. In addition
patients treated with SEMS had higher morbidity rates (30% vs. 6%.
p=0.043), hospital mortality (20% vs. 3%. p=0.0066) and
30-day mortality (40% vs. 3.1%. p=0.0011) than did patients with
laser therapy, with no evidence of SEMS being the more effective treatment
modality. It was concluded that in patients with adenocarcinoma in
the distal oesophagus or at the oesophagogastric junction, compared with
SEMS laser therapy palliates dysphagia effectively with lower morbidity
and mortality and without increased costs or hospital stay.
Routine use of laparoscopic repair for
perforated peptic ulcer. Siu W T, Chau C H, Law K
B et al. Br J Surg 2004; 91: 481-484
Despite reports on the feasibility of laparoscopic repair
of perforated peptic ulcer in 1990, it has not been widely adopted.
Three randomised clinical trials of laparoscopic versus open repair have
demonstrated comparable to better outcomes in the laparoscopic group,
revealing benefits in terms of reduced wound pain, analgesic requirement,
decreased hospital stay and earlier resumption of daily activities.
The aim of this study was to evaluate the safety and efficacy of
laparoscopic repair for perforated peptic ulcer in routine clinical
practice. A prospective analysis of 172 patients who underwent
laparoscopic repair of perforated peptic ulcer between 1997 and 2003 was
performed. The mean age was 54 years (range 14-93 years).
Overall, 165 patients underwent omental patch closure of the perforation.
There were 6 Polya gastrectomies and one excision of the ulcer. 37
patients (22%) required conversion to an open operation. The mean
operating time was 65 (14-180) minutes. The median stay was 6 days.
Complications occurred in 28 patients (16%) resulting in three operations.
Six patients with intra-abdominal collections were managed by percutaneous
drainage. Two patients who underwent conversion developed wound
infections. Overall, 14 patients (8%) died, 11 of whom were ASA
grade III or IV. It was concluded that laparoscopic repair of
perforated peptic ulcer is a safe emergency procedure in routine clinical
practice for patients with perforated peptic ulcer.
Randomised clinical trial of
laparoscopic versus open fundoplication for gastro-oesophageal
reflux. Nilsson G, Wenner J, Larsson S et al.
Br J Surg 2004; 91: 552-559.
Laparoscopic surgery for gastro-oesophageal reflux disease
(GORD) was introduced to reduce postoperative pain and increase patients'
acceptance of surgery. Recently, its long-term acceptance has been
questioned. A recent study has suggested that failure and
dissatisfaction were significantly more common after laparoscopic than
open surgery. The aim of this study was to compare the long-term
results of laparoscopic and open antireflux surgery in a randomised trial
by investigating subjective and objective outcomes. Overall, 60
patients were randomised to either laparoscopic or open 360 degree
fundoplication. Subjective evaluation was by disease-specific and
generic questionnaires and structure interviews. Objective
evaluation was by endoscopy, oesophageal manometry and 24-hour pH
monitoring. These were performed before operation and one month, 6
months and 5 years after surgery. Two patients in the laparoscopic
group had reoperations for hiatal stricture and one patient in the
open group had repair of an incisional hernia. One patient in each
group underwent surgery for intestinal obstruction. There were no
differences in the subjective outcomes of diet, sleep, medication,
patients satisfaction and symptoms of GORD at 5 years. There no
differences in objective outcomes determined by endoscopy, manometry or
24-hour pH monitoring. Well-being was decreased in all patients
prior to surgery but was restored to normal or above-normal values after
fundoplication, regardless of the type of surgery. Seven of 28
patients in the open group had complaints regarding the scar. It was
concluded that elimination of GORD symptoms improved well-being and
eliminated the need for daily acid suppression in most patients no matter
which procedure was employed. These results were apparent one month
after operation and were still valid 5 years later.
Randomised clinical trial of morbidity
after D1 and D3 surgery for gastric cancer. Wu C W,
Hsiung C A, Lo S S et al. Br J Surg 2004;
Cancer of the stomach is the second commonest cancer in
the world. Currently surgery if the only curative primary treatment,
but survival rates are dismal. Recent studies from Japan and several
Western centres have noted an improved survival in patients who have
undergone extensive lymph node dissection with curative resection.
Two large randomised surgical trials in Holland and the UK, however,
reported no survival benefit and higher morbidity and mortality rates
after D2 gastric resection. Better survival in Japan may reflect
great staging accuracy and improved stage-specific survival rates owing to
stage migration. The aim of this study was to examine the difference
in morbidity between D1 and D3 dissections and the impact on mortality
rates. A randomised comparison was undertake of 221 patients
undergoing gastric cancer surgery. Overall, 110 patients underwent
D1 surgery and 111 underwent D3 surgery. The morbidity was higher
after D3 than after D1 surgery (17% vs. 7%. p = 0.012).
The difference was largely related to abdominal abscess (8% after D1
versus none after D1). The D3 group had an anastomotic leak rate of
4.5% whereas these was no leakage in the D1 group (p=0.060).
All anastomotic leaks were minor and were managed non-operatively with
nutritional support. Patients who had a D3 resection had longer
operating times, greater blood loss and postoperative drain outputs and
more patients needed blood transfusion. There were no deaths in either
group. The hospital stay was longer after D3 than after D1 surgery.
It was concluded that extended lymphadenectomy for gastric cancer is
associated with more complications than limited lymphadenectomy but does
not lead to significant mortality.
Role of endoscopic ultrasonography in
the preoperative staging of gastric carcinoma. Javaid G, Shah
O J, Dar M A et al. ANZ J Surg 2004; 74:
Preoperative staging of tumour extent in upper
gastrointestinal malignancy greatly facilitates the planning of therapy.
The advent of endoscopic ultrasonography (EUS) has significantly improved
the diagnosis and staging of upper gastrointestinal cancer. The aim
of this study was to evaluate whether preoperative EUS accurately predicts
the tumour stage in gastric carcinoma. EUS was performed
preoperatively on 112 patients with gastric cancer. All 112 patients
underwent surgery. The results of the EUS was compared with the
postoperative histological stage. EUS was correct in determining the
primary tumour (T) and regional lymph node (N) staging in 83% and 64% of
patients respectively. EUS was correct in determining the absence of
lymph node metastasis in 88% but was not reliable in determining
metastasis in one to six regional nodes (N1) and metastasis in 7 to 15
regional nodes (N2) stages; (62% and 33% respectively). Of 26
patients with N1 stage, 10 had false negative results, whereas 11 patients
in stage N2 were diagnosed endoscopically as stage N1. The
sensitivity and specificity were 67% and 89% respectively. It was
concluded that EUS staging is the most accurate method for discriminating
between potentially resectable (T1 to T3) and potentially non-resectable
(T4) cases of gastric cancer.
Randomised clinical trial of
laparoscopic versus open fundoplication for gastro-oesophageal reflux
disease. Ackroyd R, Watson D I, Majeed A W et al.
Br J Surg 2004; 91: 975-982.
Antireflux surgery is the treatment of choice for moderate
to sever gastro-oesophageal reflux disease, particularly in patients with
reflux symptoms that have not responded to medical therapy or who do not
wish to continue medical treatment indefinitely. The most commonly
performed procedure is the Nissen 360 degree fundoplication, with
long-term success achieved in around 90% of patients. Over the past
decade, the development of laparoscopic techniques has changed the way in
which antireflux surgery is performed. The aim of this study was to
compare laparoscopic and open fundoplication for gastro-oesophageal reflux
in the setting of a randomised controlled trial. Overall, 99
patients were randomised to either laparoscopic (n=52) or open (n=47)
Nissen fundoplication. Patients with oesophageal dysmotility, those
requiring a concurrent abdominal procedure and those who had undergone
previous antireflux surgery were excluded. Independent assessment of
dysphagia, heartburn and patient satisfaction was performed 1,3, 6 and 12
months after surgery using multiple standardised clinical grading systems.
Objective measurement of oesophageal acid exposure and lower oesophageal
sphincter pressure before and after surgery, and endoscopic assessment of
postoperative anatomy was performed. Operating time was longer on
the laparoscopic group (median 82 vs. 46 min). Postoperative pain,
analgesia requirement, time to solid food intake, hospital stay and
recovery time were reduced in the laparoscopic group. Perioperative
outcomes, postoperative dysphagia, relief of heartburn and overall
satisfaction were equally good at all follow-up intervals. Reduction
in oesophageal acid exposure, increase in lower oesophageal sphincter tone
and improvement in endoscopic appearance were the same for the two groups.
It was concluded that the laparoscopic approach to Nissen fundoplication
improved early postoperative recovery with an equally good outcome up to
An 11-year experience of enterocutaneous
fistula. Hollington P, Mawdsley J, Lim W et al.
Br J Surg 2004; 91: 1646-1651.
Enterocutaneous fistula is a feared complication of
abdominal surgery. Such fistulae usually occur soon after surgery,
although inflammatory bowel disease, diverticulitis, radiotherapy, trauma,
ischaemic bowel and malignancy commonly contribute. Favourable outcome
relies on early control of sepsis, adequate nutritional support and skin
protection. Enterocutaneous fistulae have traditionally been
associated with a high risk of morbidity and death, related to sepsis,
malnutrition, fluid, electrolytes or metabolic disturbances. This
study was a retrospective review of enterocutaneous fistula management
over an 11-year period in major tertiary referral centre. Most
fistulas occurred secondary to abdominal surgery and a high proportion
(53%) occurred in association with inflammatory bowel disease. A low
rate of spontaneous healing was observed (20%). The healing rate
after definitive fistula surgery was 82%, although more than one attempt
was required to achieve surgical closure in some patients.
Definitive fistula resection resulted in a mortality rate of 3%. In
addition, one patient died after laparotomy for intra-abdominal sepsis and
an additional 24% died from complications of fistulation, giving and
overall fistula-related mortality rate of 11%. It was concluded that
early recognition and control of sepsis, management of fluid and
electrolyte imbalances, meticulous wound care and nutritional support
appear to reduce the mortality rate and allow spontaneous fistula closure
in some patients. Definitive surgical management is performed only
after restitution of normal physiology, usually after at least 6 months.
Predictors of operative death after
oesophagectomy. Abunasra H, Lewis S, Beggs L et al.
Br J Surg 2005; 92: 1029-1033.
Oesophagectomy remains the mainstay of treatment in
patients with potentially resectable oesophageal cancer. The post
operative death rate has decreased significantly over the past two
decreased in experienced centres. This has been attributed to
improvements in anaesthesia, standardisation and refinement of surgical
technique, better management of postoperative complications and strict
preoperative selection of patients with adequate physiological reserve for
surgical resection. The aim of this study was to define risk factors
for death after oesophageal resection for malignant disease. Between
1990 and 2003, 773 oesophagectomies for oesophageal cancer were performed.
Continuous variables were categorised into quartiles for analysis.
Predictors of operative mortality were identified by univariate and
multiple logistic regression analysis. The operative mortality was
4.8%. In univariate analysis, advanced age, reduced FEV1, reduced
FVC, presence of diabetes and tumour located in the upper third of the
oesophagus were associated with higher mortality rate. Multivariate
analysis identified age, tumour position and FEV1 as independent
predictors of death. It was concluded that advanced age, impaired
preoperative respiratory function and a tumour high in the oesophagus are
associated with a significant increased risk of death after oesophagectomy
Is there a role for palliative
gastrectomy in patients with Stage IV gastric cancer. Saidi R F,
ReMine S G, Dudrick et al. World J Surg 2006; 30:
Surgical resection is the only curative treatment for
gastric cancer. Although the role of palliative gastrectomy in
patients with advanced gastric cancer is unclear, several studies have
suggested that resection may provide some survival benefit. However,
the extended survival after palliative gastrectomy in other studies has
been associated with significant postoperative morbidity, prolonged
hospital stay and poor quality of life. The aims of palliative
gastrectomy are often to enable oral food intake, stop bleeding or relieve
pain. The aim of this study was to evaluate patient outcome after
palliative gastric resection for metastatic gastric cancer. Over a
10 year period, a total of 105 patients with Stage IV gastric cancer were
identified of which 81 (77%) had no resection and 24 (23%) underwent
palliative gastric resection. Mean survival in those without
resection who underwent chemotherapy (with or without radiation) treatment
was 5.9 months (95% CI 4.2 - 7.6 months). For those with resection
and adjuvant treatment, mean survival was 16.3 months (95% CI 4.3-28.8
months). Kaplan-Meier survival analysis showed significantly better
survival in those with resection and adjuvant therapy (log-rank test. p=0.01).
Mortality and morbidity rates of those undergoing resection was 9% and 33%
respectively, which did not differ statistically from those undergoing
curative resection during the same time period. However, the
duration of hospital stay was significantly higher in those with Stage IV
disease. It was concluded that palliative resection combined with
adjuvant treatment may improve survival in a selected group of patients
with Stage IV gastric cancer. Palliative gastrectomy plus systemic
therapy should be compared with systemic treatment alone in a randomised