Site distribution of oesophagogastric cancer.

AIMS: It has been suggested that adenocarcinomas of the lower oesophagus and gastric cardia should be reclassified as oesophagogastric junction (OGJ) cancers. This study aimed to define the frequency of OGJ cancers in a geographically defined population of 4.3 million people. METHODS: All cases of oesophageal and gastric cancer occurring in 1993 were identified by the North Western Regional Cancer Registry. A total of 1192 hospital case notes were reviewed and a study group of 1067 patients was defined. Tumour involvement was documented at individual subsites in the oesophagus and stomach, allowing for tumour presence in more than one oesophageal/gastric subsite. RESULTS: There were 627 tumours in men and 440 in women. The tumour was confined to the oesophagus in 281 (26.3%) cases and to the stomach in 454 (42.6%) cases. The tumour encroached upon or crossed the OGJ in 332 (31.1%) cases. Overall, tumours involved the cardia, OGJ, or lower oesophagus in 633 (59.3%) cases; in 179 (18.5%) cases the tumour involved the lower oesophagus but not the OGJ, and in another 122 (11.4%) cases the cardia was involved but not the OGJ. CONCLUSIONS: Oesophagogastric cancers in this population predominantly involve the OGJ, lower oesophagus, and/or cardia.

Argon beam plasma coagulation in the management of cancers of the esophagus and stomach.

BACKGROUND: Esophagogastric cancer often presents at an advanced stage, or in patients unfit for resection. These patients may benefit from local ablation to provide both symptom and disease control. METHODS: A series of 48 consecutive patients with esophagogastric cancer were treated with endoscopic argon beam plasma coagulation (ABPC) at a specialist unit. RESULTS: Of 16 unfit patients who presented with early cancers, four are disease-free and all are asymptomatic at a median of 21 months after treatment. In 13 of 14 patients with occluded esophageal stents, the esophageal lumen was restored. In 18 patients with advanced cancers, ABPC was employed to debulk two gastric outlet and eight esophageal tumors. Argon was employed successfully to control bleeding in three of five patients. In advanced disease, dysphagia was relieved in only one of three patients. CONCLUSIONS: Endoscopic ABPC controls symptoms and may control early esophageal and gastric cancers in unfit patients. ABPC allows restoration of the lumen in stent overgrowth and control of bleeding from advanced gastric neoplasms; however, its role in debulking large tumors is less clear.

Abnormal neurophysiology in patients with oesophageal motility disorders.

BACKGROUND: The pathology of oesophageal motility disorders is poorly understood. Oesophageal manometry provides only a descriptive assessment of luminal pressure changes. This study applied the investigative methods of the neurophysiologist to gain insight into the pathophysiology of these disorders. METHODS: Twelve healthy volunteers and 28 patients with oesophageal motility disorders underwent oesophageal manometry and balloon stimulation studies. Cortical evoked potentials (CEPs) in response to electrical stimulation of the oesophagus and oesophageal motor evoked potentials (MEPs) to transcranial magnetic stimulation of the cerebral cortex were recorded. RESULTS: Only two patients had abnormalities with a primary defect in muscle function. Fifteen had abnormal responses to balloon stimulation with normal CEPs and MEPs, suggesting a defect in the intrinsic nerves of the oesophagus. Five with achalasia did not respond to balloon stimulation and had abnormal CEPs and MEPs, suggesting widespread neural defects. The remainder had a variety of abnormal responses suggesting possible defects in receptor sensitivity, central processing or sensory neuropathy. There was no correlation between the manometric diagnosis and abnormal neurophysiology, except in patients with achalasia. CONCLUSION: Neurophysiological testing suggests that oesophageal motility disorders are most commonly due to a variety of neural defects.

The cost effectiveness of metal oesophageal stenting in malignant disease compared with conventional therapy.

Expanding metal oesophageal stents are being used more commonly to palliate patients with inoperable oesophageal carcinoma. Many reports have so far documented their clinical effectiveness, however, their high acquisition cost has caused on-going concern when compared with the cost of conventional therapies. We reviewed 64 consecutive patients with inoperable oesophageal carcinoma, half of whom had received our conventional method of palliation using a variety of techniques including, BICAP diathermy, alcohol injection and Atkinson tube insertion. The other half (32 patients) were treated with expandable metal stents -- Gianturco Z stents (Cook UK Ltd) and uncovered Ultraflex stents (Microvasive, Boston Scientific). The physical amount of resources consumed were identified and measured (number of diagnostic and support procedures, days as in patients, number of day cases or outpatient attending) and an average NHS cost was applied to this resource use. All costs were summated over the period of palliation from the date of the first intervention with palliative intent until death. Although the patients in this study were not randomized, the two groups were matched to ensure comparability in clinical manifestation (uncomplicated biopsy proven oesophageal carcinoma) and the average age of patients from each group. A difference was identified between the length of survival in both patient groups and the analysis was corrected for this by estimating a cost per day of palliative support. Patients palliated with metal stents underwent fewer procedures and spent fewer days in hospital during the time period from presentation until death even when corrected for differences in survival. Patient outcome (effectiveness of palliation) was measured by recording mean dysphagia scores which were recorded before and after palliation. Metal stents were found to lead to a significantly higher improvement in dysphagia in comparison to conventional therapy. In addition, the mortality related to metal oesophageal stents was lower than Atkinson tube insertion. The average cost of palliation was much lower in the metal stent group (mean = pound sterling 2817) compared with the cost in those palliated conventionally (mean = pound sterling 4566). However, once this was corrected for survival the difference in the cost of palliation on a per diem basis was reduced (metal stents = pound sterling 60 per day, conventional group = pound sterling 72 per day). The results of our study indicate that the initial high cost of metal stents is more than outweighed by resource savings elsewhere in the hospital by virtue of reduced need for re-intervention and shorter length of hospital in patient stay. Such cost savings taken in combination with the improved clinical effectiveness and low mortality related to metal stents provide significant support for introducing their use into clinical practice.

Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Surgical Co-operative Group.

Controversy still exists on the optimal surgical resection for potentially curable gastric cancer. Much better long-term survival has been reported in retrospective/non-randomized studies with D2 resections that involve a radical extended regional lymphadenectomy than with the standard D1 resections. In this paper we report the long-term survival of patients entered into a randomized study, with follow-up to death or 3 years in 96% of patients and a median follow-up of 6.5 years. In this prospective trial D1 resection (removal of regional perigastric nodes) was compared with D2 resection (extended lymphadenectomy to include level 1 and 2 regional nodes). Central randomization followed a staging laparotomy. Out of 737 patients with histologically proven gastric adenocarcinoma registered, 337 patients were ineligible by staging laparotomy because of advanced disease and 400 were randomized. The 5-year survival rates were 35% for D1 resection and 33% for D2 resection (difference -2%, 95% CI = -12%-8%). There was no difference in the overall 5-year survival between the two arms (HR = 1.10, 95% CI 0.87-1.39, where HR > 1 implies a survival benefit to D1 surgery). Survival based on death from gastric cancer as the event was similar in the D1 and D2 groups (HR = 1.05, 95% CI 0.79-1.39) as was recurrence-free survival (HR = 1.03, 95% CI 0.82-1.29). In a multivariate analysis, clinical stages II and III, old age, male sex and removal of spleen and pancreas were independently associated with poor survival. These findings indicate that the classical Japanese D2 resection offers no survival advantage over D1 surgery. However, the possibility that D2 resection without pancreatico-splenectomy may be better than standard D1 resection cannot be dismissed by the results of this trial.

Palliation in oesophageal neoplasia.

Oesophageal cancer is an increasingly common disease in the UK. Sadly, the overall results of treatment remain poor with overall 5 year survival of approximately 10%. More than 50% of patients receive purely palliative care from the outset. Of those having potentially curative treatment, 40% will not survive the first year and 70% will not survive 5 years. Good quality palliation is, therefore, required for the majority of patients.

Identification of the optimal parameters for recording cortical evoked potentials to human oesophageal electrical stimulation.

Cortical evoked potentials in response to stimulation of the oesophagus may prove to be a powerful technique for assessing the oesophageal afferent pathway in health and disease. However, in order to maximize the potential of this technique it is essential that the optimal parameters for recording oesophageal CEP are established. The aim was to determine the optimal parameters required to record reproducible CEP. CEP were recorded from the vertex in eight subjects (age range 23-44 years). Electrical stimulation was performed 5 cm above the lower oesophageal sphincter using a bipolar ring electrode at 0.2 Hz. Protocol 1: to determine the stimulation intensity which generates the largest amplitude and shortest latency, two runs of 50 stimuli were applied at increasing intensities. Protocol 2: to determine the number of stimuli for optimal signal to noise ratio, 10 runs of 50 stimuli were recorded. Individual runs were averaged. Protocol 3: to determine the optimal inter-run interval, CEP evoked by 200 stimuli were averaged using randomly chosen inter-run intervals. Protocol 4: CEP reproducibility using parameters determined from Protocols 1-3 was assessed in three subjects on three separate occasions. The results were as follows: Protocol 1; P1 latency was shortest and P1-N1 amplitude largest at an intensity of 75% above threshold. Protocol 2; optimal signal-to-noise was achieved by averaging four runs of 50 stimuli. Protocol 3; the optimal interstudy interval was 10 min. Protocol 4; highly reproducible CEP were obtained in all individuals. Using these optimal parameters, it is possible to obtain highly reproducible oesophageal CEP to ES which can now be used for clinical study.

The clinical effectiveness of the Gianturco oesophageal stent in malignant oesophageal obstruction.

Between January 1994 and December 1996 72 patients were treated with 76 Gianturco oesophageal stents for oesophageal obstruction or perforation. The patients were followed prospectively in order to determine the effectiveness in improving dysphagia, to establish long term patency, survival times and complications. The mean dysphagia score prior to stenting was 3, improving to a mean score of 1 after stenting. Swallowing failed to improve in three patients. No serious complications were seen at stent insertion. Patients tolerated the procedure well with no complications in 63%. The most frequent immediate complication was chest pain occurring in 15 patients (21%). This settled in all patients with appropriate analgesia, however, four patients required long-term pain relief. In no cases was the chest pain due to perforation. Re-intervention was required in 16.7% of patients, the commonest cause being tumour overgrowth, and this was seen primarily in patients with long survival. The migration rate was low, despite the fact that 45 of 76 stents had been placed with the distal end in the stomach. Only four stents (5.6%) migrated completely, all of which had been deployed across the cardia. In our series the use of the Gianturco oesophageal stents for provided effective palliation of malignant oesophageal obstruction.

Simple laparoscopic gastropexy as the initial treatment of paraoesophageal hiatal hernia.

BACKGROUND: Paraoesophageal hiatal hernia is relatively rare compared with sliding hernia but it is associated with serious complications. Its clinical management presents a major challenge since many patients are elderly and unfit for a formal repair. This paper describes a laparoscopic method aimed at reducing the complications of open repair. METHODS: Thirteen patients treated for symptomatic paraoesophageal hernia were included in the study. Eleven patients successfully underwent a simple laparoscopic modification of the Boerema anterior gastropexy. Two patients required an open anterior gastropexy through a minilaparotomy because of incomplete reduction of the hernia. A five-puncture technique was used. The stomach and any other contents of the sac were reduced into the abdomen and the stomach was firmly fixed to the fascia of the anterior abdominal wall with GORE-TEX sutures tied extracorporeally. RESULTS: There was one postoperative death due to spontaneous intrathoracic perforation of the posterior aspect of the stomach in an elderly woman with severe cardiac disease. There was no postoperative morbidity. Eight of the ten patients who went home following laparoscopic gastropexy have remained asymptomatic on follow-up. In three patients, two in the laparoscopic group and one in the open group, symptoms recurred. CONCLUSION: While anterior gastropexy has a significant incidence of recurrent herniation, the clinical results of this simple procedure in a high-risk population support its use as the initial surgical option.

Postoperative morbidity and mortality after D1 and D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group.

BACKGROUND: In Japan the surgical approach to treatment of potentially curable gastric cancer, including extended lymphadenectomy, seems in retrospective surveys to give better results than the less radical procedures favoured in Western countries. There has, however, been no evidence from randomised trials that extended lymphadenectomy (D2 gastric resection) confers a survival advantage. This question was addressed in a trial involving thirty-two surgeons in Europe. METHODS: In a prospective randomised controlled trial, D1 resection (level 1 lymphadenectomy) was compared with D2 resection (levels 1 and 2 lymphadenectomy). Central randomisation (200 patients in each arm) followed a staging laparotomy. FINDINGS: The D2 group had greater postoperative hospital mortality (13% vs 6.5%; p=0.04 [95% Cl 9-18% for D2, 4-11% for D1] and higher overall postoperative morbidity (46% vs 28%; p<0.001); their postoperative stay was also longer. The excess postoperative morbidity and mortality in the D2 group was accounted for by distal pancreaticosplenectomy and splenectomy. In the whole group (400 patients), survival beyond three years was 30% in patients whose gastrectomy included en-bloc pancreatico-splenic resection versus 50% in the remainder. INTERPRETATION: D2 gastric resections are followed by higher morbidity and mortality than D1 resections. These disadvantages are consequent upon additional pancreatectomies and distal splenectomies, and in long-term follow-up the higher mortality when the pancreas and spleen are resected may prove to nullify any survival benefit from D2 procedures.

Yield pressure: a new concept in the evaluation of GERD?

This study evaluates the yield pressure at the gastroesophageal junction in a group of 73 patients undergoing diagnostic endoscopy and in another group of 82 patients during the course of manometry for suspected GERD. The group included 17 patients who had previously undergone a successful Nissen fundoplication and eight patients who had a failed Nissen fundoplication. Air is insufflated into the stomach, and a water perfused pressure transducer is used to detect intragastric pressure. The pressure at which the cardia was seen to open at endoscopy, or when a common cavity phenomenon was detected at manometry, was taken as the opening pressure. Yield pressure was calculated as the difference between the opening pressure of the cardia and the resting gastric pressure. Results indicated a significant decrease in yield pressure in 65 patients with esophagitis compared with 65 patients with no evidence of reflux or esophagitis. A significant inverse correlation was found between yield pressure and the size of the hiatus hernia noted in these patients. There was also a correlation between valvular appearance of the cardia at endoscopy and the yield pressure. A progressive decrease in yield pressure occurred with an increasing deterioration in the physical appearance of the valve. There was no significant relationship found between yield pressure and lower esophageal sphincter (LES) pressure or intra-abdominal length. A small but significant relationship was found between yield pressure and acid exposure of the lower esophagus. The 17 patients with a successful Nissen showed a significantly increased yield pressure to supranormal values. In contrast, the eight patients with a failed Nissen had yield pressures within the range of the patients with esophagitis. In eight patients, yield pressure was measured by both manometry and endoscopy and showed no significant differences between the two methods.

Endoscopic appearance of the gastroesophageal valve and competence of the cardia.

The endoscopic appearance of the gastroesophageal valve, viewed by the retroflexed gastroscope, has been studied in 51 patients with and without reflux esophagitis. Esophagitis was graded according to its severity, and the yield pressure (YP) was measured in all patients to assess the competence of the cardia. There was a close relationship between the YP and the grades of the gastroesophageal valve. YP was significantly lower in patients with endoscopic oesophagitis than in patients with no evidence of reflux esophagitis (p <0.0001). An increased abnormality of the gastroesophageal valve was associated with all grades of esophagitis and with a low YP. The valve mechanism at the cardia has an important role in determining its competence. YP is possibly a measure of the flap valve component of the gastroesophageal junction.

Dysphagia due to secondary achalasia as an early manifestation of squamous cell carcinoma.

A 59-year-old man, a smoker, presented with features of airflow obstruction due to squamous cell carcinoma of central airways mimicking chronic obstructive airways disease. He also had pronounced dysphagia. Computed tomographic and magnetic resonance imaging scans showed mediastinal tumour invasion but no direct oesophageal involvement. Oesophageal manometry studies revealed that dysphagia was due to the oesophageal motility disorder, secondary achalasia.

Yield pressure, anatomy of the cardia and gastro-oesophageal reflux.

The yield pressure at which the cardia opens in response to gastric distension was measured in 155 subjects with and without gastro-oesophageal reflux (GOR) and after Nissen fundoplication. Yield pressure was measured by endoscopy or during oesophageal manometry. The median pressure was significantly lower in subjects with GOR than in those without (P < 0.0001). After successful Nissen fundoplication this pressure increased to supranormal values (P < 0.0001). There was a close relationship between yield pressure and the presence and size of hiatus hernia and also between yield pressure and the valvular appearance of the cardia at endoscopy. There was a significant correlation between yield pressure and oesophageal acid exposure. However, no relationship was observed between yield pressure and lower oesophageal sphincter pressure or intra-abdominal length. These results suggest that yield pressure is useful for assessment of the competence of the cardia, particularly after antireflux surgery. The competence of the cardia is greatly influenced by its anatomical structure.

Topographic mapping of cortical potentials evoked by distension of the human proximal and distal oesophagus.

We describe cortical potentials evoked by balloon distension of the proximal and distal oesophagus in 8 healthy right handed volunteers. Oesophageal stimulation was performed using a pump which rapidly inflated a 2 cm silicone balloon positioned either 3 cm distal to the upper oesophageal sphincter or 5 cm proximal to the lower oesophageal sphincter, at a frequency of 0.2 Hz, using inflation volumes which produced a definite but not painful sensation. Oesophageal evoked cortical potentials were recorded in all subjects with an initial negative and positive component (N1 and P1), followed by a second negative and positive component (N2 and P2) in 6 subjects. The morphology and the scalp topography of the N1 component elicited by proximal and distal oesophageal stimulation suggests activation of the primary somatosensory cortex and/or the insular. There was also evidence for hemispheric dominance for the N1 potential which was independent of handedness. The frontal emphasis of the proximal oesophageal N1 component, in contrast to the central emphasis of the distal oesophageal N1 component, suggests that different neuronal populations were activated by stimulation of the two sites. The frontal emphasis of the ensuing P1 component from both oesophageal sites suggests that it originates in a separate precentral source. The topography of the N2 components obtained by stimulation of either oesophageal site was similar to that of the N1 component, suggesting that they originate in similar areas of the cortex. The P2 component evoked by stimulation of both oesophageal sites was localised at the vertex. The inter- and intra-subject variation in the morphology of the N2 and P2 components suggests that secondary cortical processes related to cognition may be involved in their generation.