Effect of simvastatin on physiological and biological outcomes in patients undergoing esophagectomy: a randomized placebo-controlled trial.

OBJECTIVE: To test whether simvastatin improves physiological and biological outcomes in patients undergoing esophagectomy. BACKGROUND: One-lung ventilation during esophagectomy is associated with inflammation, alveolar epithelial and systemic endothelial injury, and the development of acute lung injury (ALI). Statins that modify many of the underlying processes are a potential therapy to prevent ALI. METHODS: We conducted a randomized double-blind placebo-controlled trial in patients undergoing esophagectomy. Patients received simvastatin 80 mg or placebo enterally for 4 days preoperatively and 7 days postoperatively. The primary end point was pulmonary dead space (Vd/Vt) at 6 hours after esophagectomy or before extubation. Inflammation was assessed by plasma cytokines and intraoperative exhaled breath condensate pH; alveolar type 1 epithelial injury was assessed by plasma receptor for advanced glycation end products and systemic endothelial injury by the urine albumin-creatinine ratio. RESULTS: Thirty-nine patients were randomized; 8 patients did not undergo surgery and were excluded. Fifteen patients received simvastatin and 16 received placebo. There was no difference in Vd/Vt or other physiological outcomes. Simvastatin resulted in a significant decrease in plasma MCP-1 on day 3 and reduced exhaled breath condensate acidification. Plasma receptor for advanced glycation end products was significantly lower in the simvastatin-treated group, as was the urine albumin-creatinine ratio on day 7 postsurgery. ALI developed in 4 patients in the placebo group and no patients in the simvastatin group although this difference was not statistically significant (P=0.1). CONCLUSIONS: In this proof of concept study, pretreatment with simvastatin in esophagectomy decreased biomarkers of inflammation as well as pulmonary epithelial and systemic endothelial injury.

Guidelines on the radical management of patients with lung cancer.

A joint initiative by the British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland was undertaken to update the 2001 guidelines for the selection and assessment of patients with lung cancer who can potentially be managed by radical treatment.

The association between alcohol and reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma.

BACKGROUND & AIMS: Alcohol consumption may increase gastroesophageal reflux symptoms, cause damage to the esophageal mucosa, and/or promote carcinogenesis. However, reports about the association between alcohol and reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma are conflicting. METHODS: Information relating to alcohol consumption, at age 21 and 5 years before the interview date, was collected from 230 reflux esophagitis, 224 Barrett's esophagus, and 227 esophageal adenocarcinoma patients and 260 frequency-matched population controls. Logistic regression analyses were used to compare alcohol consumption in the 3 case groups to controls with adjustment for potential confounders. RESULTS: Population controls reporting gastroesophageal reflux symptoms were less likely than controls without symptoms to drink alcohol 5 years before the interview date (odds ratio [OR], 0.44, 0.20-0.99). No associations were observed between total alcohol consumption 5 years before the interview date and reflux esophagitis, Barrett's esophagus, or esophageal adenocarcinoma (OR, 1.26, 0.78-2.05; OR, 0.72, 0.43-1.21; and OR, 0.75, 0.46-1.22, respectively). Wine was inversely associated with reflux esophagitis (OR, 0.45, 0.27-0.75). Total alcohol consumption at age 21 years was significantly associated with reflux esophagitis (OR, 2.24, 1.35-3.74) but not with Barrett's esophagus or esophageal adenocarcinoma (OR, 1.06, 0.63-1.79 and OR, 1.27, 0.77-2.10, respectively). CONCLUSIONS: Alcohol consumption in early adulthood may lead to the development of reflux esophagitis. More recent alcohol consumption does not appear to confer any increased risk of reflux esophagitis, Barrett's esophagus, or esophageal adenocarcinoma. In fact, wine consumption may reduce the risk of these 3 esophageal disorders.

Dietary antioxidant and mineral intake in humans is associated with reduced risk of esophageal adenocarcinoma but not reflux esophagitis or Barrett's esophagus.

The role of antioxidants in the pathogenesis of reflux esophagitis (RE), Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC) remains unknown. We evaluated the associations among dietary antioxidant intake and these diseases. We performed an assessment of dietary antioxidant intake in a case control study of RE (n = 219), BE (n = 220), EAC (n = 224), and matched population controls (n = 256) (the Factors Influencing the Barrett's Adenocarcinoma Relationship study) using a modification of a validated FFQ. We found that overall antioxidant index, a measure of the combined intake of vitamin C, vitamin E, total carotenoids, and selenium, was associated with a reduced risk of EAC [odds ratio (OR) = 0.57; 95% CI = 0.33-0.98], but not BE (OR = 0.95; 95% CI = 0.53-1.71) or RE (OR = 1.60; 95% CI = 0.86-2.98), for those in the highest compared with lowest category of intake. Those in the highest category of vitamin C intake had a lower risk of EAC (OR = 0.37; 95% CI = 0.21-0.66; P-trend = 0.001) and RE (OR = 0.46; 95% CI = 0.24-0.90; P-trend = 0.03) compared with those in the lowest category. Vitamin C intake was not associated with BE, and intake of vitamin E, total carotenoids, zinc, copper, or selenium was not associated with EAC, BE, or RE. In conclusion, the overall antioxidant index was associated with a reduced risk of EAC. Higher dietary intake of vitamin C was associated with a reduced risk of EAC and RE. These results suggest that antioxidants may play a role in the pathogenesis of RE and EAC and may be more important in terms of progression rather than initiation of the disease process.

Glycemic index, carbohydrate and fiber intakes and risk of reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma.

OBJECTIVE: To examine the association between dietary glycemic index (GI), glycemic load (GL), total carbohydrate, sugars, starch, and fiber intakes and the risk of reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. METHODS: In an all-Ireland study, dietary information was collected from patients with esophageal adenocarcinoma (n = 224), long-segment Barrett's esophagus (n = 220), reflux esophagitis (n = 219), and population-based controls (n = 256). Multiple logistic regression analysis examined the association between dietary variables and disease risk by tertiles of intake and as continuous variables, while adjusting for potential confounders. RESULTS: Reflux esophagitis risk was positively associated with starch intake and negatively associated with sugar intake. Barrett's esophagus risk was significantly reduced in people in the highest versus the lowest tertile of fiber intake (OR 0.44 95%CI 0.25-0.80). Fiber intake was also associated with a reduced risk of esophageal adenocarcinoma, as was total carbohydrate intake (OR 0.45 95%CI 0.33-0.61 per 50 g/d increase). However, an increased esophageal adenocarcinoma risk was detected per 10 unit increase in GI intake (OR 1.42 95%CI 1.07-1.89). CONCLUSIONS: Our findings suggest that fiber intake is inversely associated with Barrett's esophagus and esophageal adenocarcinoma risk. Esophageal adenocarcinoma risk is inversely associated with total carbohydrate consumption but positively associated with high GI intakes.

Cyclooxygenase-2 and inducible nitric oxide synthase gene polymorphisms and risk of reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma.

The incidence of esophageal adenocarcinoma has increased in recent years, and Barrett's esophagus is a recognized risk factor. Gastroesophageal reflux of acid and/or bile is linked to these conditions and to reflux esophagitis. Inflammatory disorders can lead to carcinogenesis through activation of "prosurvival genes," including cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS). Increased expression of these enzymes has been found in esophageal adenocarcinoma, Barrett's esophagus, and reflux esophagitis. Polymorphic variants in COX-2 and iNOS genes may be modifiers of risk of these conditions. In a population-based case-control study, we examined associations of the COX-2 8473 T>C and iNOS Ser(608) Leu (C>T) polymorphisms with risk of esophageal adenocarcinoma, Barrett's esophagus, and reflux esophagitis. Genomic DNA was extracted from blood samples collected from cases of esophageal adenocarcinoma (n = 210), Barrett's esophagus (n = 212), and reflux esophagitis (n = 230) and normal population controls frequency matched for age and sex (n = 248). Polymorphisms were genotyped using TaqMan allelic discrimination assays. Odds ratios and 95% confidence intervals were obtained from logistic regression models adjusted for potential confounding factors. The presence of at least one COX-2 8473 C allele was associated with a significantly increased risk of esophageal adenocarcinoma (adjusted odds ratio, 1.58; 95% confidence interval, 1.04-2.40). There was no significant association between this polymorphism and risk of Barrett's esophagus or reflux esophagitis or between the iNOS Ser 608 Leu polymorphism and risk of these esophageal conditions. Our study suggests that the COX-2 8473 C allele is a potential genetic marker for susceptibility to esophageal adenocarcinoma.

No association between hOGG1, XRCC1, and XPD polymorphisms and risk of reflux esophagitis, Barrett's esophagus, or esophageal adenocarcinoma: results from the factors influencing the Barrett's adenocarcinoma relationship case-control study.

Reflux of gastric contents can lead to development of reflux esophagitis and Barrett's esophagus. Barrett's esophagus is a risk factor for esophageal adenocarcinoma. Damage to DNA may lead to carcinogenesis but is repaired through activation of pathways involving polymorphic enzymes, including human 8-oxoguanine glycosylase 1 (hOGG1), X-ray repair cross-complementing 1 (XRCC1), and xeroderma pigmentosum group D (XPD). Of the single nucleotide polymorphisms identified in these genes, hOGG1 Ser 326 Cys, XRCC1 Arg 399 Gln, and XPD Lys 751 Gln are particularly common in Caucasians and have been associated with lower DNA repair capacity. Small studies have reported associations with XPD Lys 751 Gln and esophageal adenocarcinoma. XRCC1 Arg 399 Gln has been linked to Barrett's esophagus and reflux esophagitis. In a population-based case-control study, we examined associations of the hOGG1 Ser 326 Cys, XRCC1 Arg 399 Gln, and XPD Lys 751 Gln polymorphisms with risk of esophageal adenocarcinoma, Barrett's esophagus, and reflux esophagitis. Genomic DNA was extracted from blood samples collected from cases of esophageal adenocarcinoma (n = 210), Barrett's esophagus (n = 212), reflux esophagitis (n = 230), and normal population controls frequency matched for age and sex (n = 248). Polymorphisms were genotyped using TaqMan allelic discrimination assays. Odds ratios and 95% confidence intervals were obtained from logistic regression models adjusted for potential confounding factors. There were no statistically significant associations between these polymorphisms and risk of esophageal adenocarcinoma, Barrett's esophagus, or reflux esophagitis.

Nonsteroidal anti-inflammatory drugs and the esophageal inflammation-metaplasia-adenocarcinoma sequence.

Observational studies suggest that nonsteroidal anti-inflammatory drugs (NSAIDs) reduce the risk of esophageal adenocarcinoma, but it is not known at what stage they may act in the esophageal inflammation-metaplasia-adenocarcinoma sequence. In an all-Ireland case-control study, we investigated the relationship between the use of NSAIDs and risk of reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Patients with esophageal adenocarcinoma, long-segment Barrett's esophagus and population controls were recruited from throughout Ireland. Esophagitis patients were recruited from Northern Ireland only. Data were collected on known and potential risk factors for esophageal adenocarcinoma and on the use of NSAIDs, including aspirin, at least 1 year before interview. Associations between use of NSAIDs and the stages of the esophageal inflammation-metaplasia-adenocarcinoma sequence were estimated by multiple logistic regression. In total, 230 reflux esophagitis, 224 Barrett's esophagus, and 227 esophageal adenocarcinoma and 260 population controls were recruited. Use of aspirin and NSAIDs was associated with a reduced risk of Barrett's esophagus [odds ratio [OR; 95% confidence interval (95% CI)], 0.53 (0.31-0.90) and 0.40 (0.19-0.81), respectively] and esophageal adenocarcinoma [OR (95% CI), 0.57 (0.36-0.93) and 0.58 (0.31-1.08), respectively]. Barrett's esophagus and esophageal adenocarcinoma patients were less likely than controls to have used NSAIDs. Selection or recall bias may explain these results and the results of previous observational studies indicating a protective effect of NSAIDs against esophageal adenocarcinoma. If NSAIDs have a true protective effect on the esophageal inflammation-metaplasia-adenocarcinoma sequence, they may act early in the sequence.

Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma.

In the developed and developing countries, corrosive injury to the gastrointestinal system as a consequence of either accidental ingestion or as a result of self-harm has become a less common phenomenon compared to decades ago. This could partly be attributed to the tighter legislation imposed by the government in these countries on detergents and other corrosive products and general public awareness. Most busy upper gastrointestinal surgical units in these countries, especially in the developed countries will only encounter a small number of cases per year. Up to date knowledge on the best management approach is lacking. In this article, we present our experience of two contrasting cases of corrosive injury to the upper gastrointestinal tract in our thoracic unit in the last 2 years and an up-to-date Medline literature search has been carried out to highlight the areas of controversies in the management of corrosive injuries of the upper gastrointestinal tract. We concluded that the main principle in managing such patients requires a good understanding of the pathophysiology of corrosive injury in order to plan both acute and future management. Each patient must be evaluated individually as the clinical picture varies widely. Signs and symptoms alone are an unreliable guide to injury.

Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system.

OBJECTIVE: The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population. METHODS: In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups. RESULTS: Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS. CONCLUSIONS: The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.

Primary diffuse B-cell lymphoma presenting as a solitary chest-wall lesion.

Primary lymphoma presenting as a solitary lesion of the chest wall is extremely rare, as the majority of chest-wall tumours arise from metastasis. We demonstrate a case report of a 67-year-old male who underwent investigations for a chronic left-sided pleural effusion. A computed tomography scan demonstrated a large chest-wall lesion, without rib destruction. He subsequently underwent fine needle aspirations and excisional biopsy for a histological diagnosis.

Lung surgery: identifying the subgroup at risk for sputum retention.

OBJECTIVES: Sputum retention after lung surgery is a potentially lethal condition, which can progress to atelectasis, pneumonia and respiratory failure requiring ventilatory support. Previous studies have concentrated on the treatment of postoperative respiratory complications but few have studied the risk factors for sputum retention. This prospective study was designed to identify the risk factors which may lead to the development of sputum retention after lung surgery. METHODS: Three hundred sixty-one patients underwent lung surgery between January 1997 and December 1999 in a specialist Thoracic Surgery Unit (pneumonectomy, lobectomy, wedge or segmental resection, bullectomy, etc). Preoperative and intraoperative data collected prospectively included potential risk factors: chronic obstructive airway disease (COAD), forced expiratory volume in 1 s (FEV1)<50%, current smokers, ischaemic heart disease (IHD), cerebrovascular disease (CVA), resection of phrenic or recurrent laryngeal nerve, or absence of regional analgesia. Univariate and multivariate analysis was performed. RESULTS: Sputum related complications occurred in 108 patients (30%). There were 17 deaths of which nine were due to complications related to sputum retention. Univariate analysis confirmed current smokers (n=128), COAD (n=103), IHD (n=41), prior history of CVA (n=16), FEV1<50% (n=48), and absence of regional anaesthesia as significant risk factors (P<0.01). The multivariate analysis confirmed current smokers, IHD and absence of regional anaesthesia as risk factors. CONCLUSIONS: A subgroup of lung surgery patients at high risk for postoperative sputum retention can be predicted by the presence of one of the following criteria: current smokers, history of COAD, CVA, or IHD, and absence of regional analgesia. Prophylactic measures should be considered in this group to reduce the incidence of sputum retention.

Glomus tumor of the mediastinum.

Glomus tumors are rare benign myoepithelial neoplasms that can present with intractable pain. We report the case of a 59-year-old gentleman who presented with upper abdominal and chest pain caused by a posterior mediastinal glomus tumor arising from the spinal column, which required surgical resection. As glomus tumors usually develop in the limbs, this case highlights the complexity of diagnosis and treatment of glomus tumors when they present in rare locations.

Endoscopic stent insertion versus primary operative management for spontaneous rupture of the esophagus (Boerhaave syndrome): an international study comparing the outcome.

Spontaneous rupture of the esophagus (Boerhaave syndrome) is an extremely rare, life-threatening condition. Traditionally surgery was the treatment of choice. Endoscopic stent insertion offers a promising alternative. The aim of this study was to compare the results of primary surgical therapy with endoscopic stenting. A British and a German high-volume center for esophageal surgery participated in this retrospective study. At the British center, operative therapy (primary repair or surgical drainage) was routinely carried out. Endoscopic stent insertion was the primary treatment option at the German center. Only patients with nonmalignant, spontaneous rupture of the esophagus (Boerhaave syndrome) were included. Demographic characteristics, comorbidity, clinical course, and outcome were analyzed. The study comprises 38 patients with a median age of 60 years. Time between rupture and treatment was less than 24 hours in 22 patients. Overall mortality was four of 38. Diagnosis greater than 24 hours was associated with higher risk for fatal outcome (odds ratio [OR], 4.64; 95% confidence interval [CI], 0.33 to 265.79). The surgery (S) and the endoscopic stent group (E) included 20 and 13 cases, respectively. Esophagectomy was unavoidable in three cases and two were managed conservatively. There were no significant differences in age, time to diagnosis less than 24 hours, intensive care unit days, hospital stay, sepsis, renal failure, slow respiratory weaning, or presence of comorbidity between the two groups. In 11 of 13 in the stent group, operative intervention (video-assisted thoracic surgery, thoracotomy, mediastinotomy) was eventually mandatory and three of 13 even required repeated surgery. The rate of reoperation in the surgery group was six of 20. Mortality was two of 13 (E) versus one of 20 (S). The odds for fatal outcome were 3.3 times higher in the stent group than in the surgery group (OR, 3.32; 95% CI, 0.15 to 213.98). Management of Boerhaave syndrome by means of endoscopic stent insertion offers no advantage regarding morbidity, intensive care unit or hospital stay, and is associated with frequent treatment failure eventually requiring surgical intervention. Furthermore, endoscopic stenting shows a higher risk for fatal outcome than primary surgical therapy.

Prognostic factors in malignant pleural mesothelioma: role of talc pleurodesis.

OBJECTIVE: To examine baseline characteristics associated with survival in patients with malignant pleural mesothelioma. METHODS: 122 patients with histologically proven malignant pleural mesothelioma during the period 2000-2010 were studied. Survival was evaluated by the Kaplan-Meier method with the logrank test. Cox regression analysis was used to estimate the hazard ratios for possible prognostic factors. RESULTS: 105 (86%) patients had complete survival follow-up; 91 died and 14 (13.3%) were alive at the end of the observation period starting from the day of diagnosis. The median survival was 286 days (95% confidence interval: 212-359). Talc pleurodesis was performed in 59 patients, and 17 had surgical interventions (2 chest wall resections, 2 extrapleural pneumonectomies, and 13 decortications). Chemotherapy was used in 41 patients, port-site radiation in 68, and combined therapy in 26. Cox regression analysis identified talc pleurodesis (p=0.04), chemotherapy (p<0.001), port-site radiation (p<0.001), and combined chemotherapy and port-site radiation (p<0.006) as favorable prognostic factors after adjusting for age, sex, histologic subtype, smoking, and performance status. CONCLUSIONS: Surgical intervention including decortications and extrapleural pneumonectomy had no effect on survival in this series. Chemotherapy and radiation to port sites independently and in combination were associated with improved overall survival in malignant pleural mesothelioma patients. Talc pleurodesis was an independent determinant of survival, but further studies are warranted.

Lung cancer resection rates have increased significantly in females during a 15-year period.

OBJECTIVE: The aim was to carry out a comparative study of lung cancer incidence and resection rates following the introduction of positron emission tomography-computed tomography (PET-CT) and the reorganisation of Cancer Services in Northern Ireland. METHODS: Data were retrieved from the Regional Thoracic Service Database and Northern Ireland Cancer Registry (NICR) covering the period 1994-2008. The two databases are maintained independently. A total of 13288 lung cancer cases and 1575 lung resections were identified. Secondary tumours were excluded. The incidence of lung tumours and procedures performed was available for each individual year. The incidence of lung cancer was taken from the NICR. The NICR confirmed the diagnosis of lung cancer using international guidelines and cancer was confirmed by histology, cytology, radiological investigations and post-mortem examinations. Poisson regression was used to model the incidence and resections per year; logistic regression was used to model the yearly rate of resections per incidence case. The 15-year period was divided into three periods to assess trends in surgical resection, but the surgical resection rate (SRR) was calculated on a yearly basis. RESULTS: The regional incidence of lung cancer in Northern Ireland (NI) females has increased (1.7% per annum P<0.01, Poisson regression), but this increase has not been seen in males. The incidence of lung cancer patients, who underwent resection at the regional Thoracic Surgery Unit, increased for females (4.4% per annum, P<0.01, Poisson regression), but not for males. The proportional rate of resection (number of resections in a given year/incidence in that year) has changed significantly over the study period for females but not males (the odds ratio per unit year was 1.029, P<0.01, logistic regression). The average age of females increased by 0.2 year (P<0.01) annually; there was no significant increase in the age of males over this period. There was no significant overall rise in the number of patients diagnosed with non-small-cell lung cancer (NSCLC). The percentage of all lung cancer patients who were discussed at multidisciplinary team (MDT) meetings rose from 19% in 1996 to 64% in 2006. The percentage of patients aged over 75 years discussed at an MDT increased from 12% in 1996 to 58% in 2006. The number of females presenting with NSCLC and the number of people presenting with stage I and II disease did not change over the time frame. More patients aged above 70 years had an operation in group III. These accounted for over 50% of the increase in operations between the first and last group. The number of females in this group rose by 92% compared with group I. Significantly, more patients aged over 80 years had an operation in group III than in group I; however, there was significantly more males treated surgically aged over 80 years than females; P=0.001. CONCLUSIONS: The resection rate is currently higher in females than males, and has significantly increased during the study period. The incidence in female lung cancer has risen but it is still below male incidence rates. It seems unlikely that one single factor has brought about this increase. With better education among medical practitioners and the public, more lung cancer cases have been considered for surgery by surgeons. There has been an overall increase in patients presented at MDTs involving thoracic surgeons. For whatever reason, it appears that many lung cancer cases in females had previously not been presented to surgeons prior to the introduction of MDT meetings practice guidelines. The development of MDT meetings throughout NI along with the close involvement of the Thoracic Surgical Unit from the inception of all MDTs seems the most likely factor leading to a change in lung cancer resection rates.

A surgeon's case volume of oesophagectomy for cancer does not influence patient outcome in a high volume hospital.

The aim of this study is to assess if individual case volume of oesophageal resections influences the operative mortality rate in a high volume hospital. Between June 1994 and June 2006, 252 total thoracic oesophageal resections (75% male, mean age 63 years) were performed by five surgeons in tertiary referral centre. Operative approach was standardised in all cases and consisted of left thoracolaparotomy, resection of all intrathoracic and abdominal oesophagus and left cervical incision for anastomosis. Operative mortality, defined as in-hospital death irrespective of length of stay, was compared among consultants and also trainees. A total of 207 operations were performed by five consultants with nine deaths (4.3%) compared to two deaths after 45 operations by 17 trainees (4.4%) [Fisher's exact test, P=0.61 (CI=0.84-1.26)]. Individual case volume for consultants ranged from 5 to 10.5 cases/years [chi2-test, P=0.34 (CI=0.89-1.29)] with 0-5.4% mortality rate [chi2-test, P=0.24 (CI=0.96-1.19)]. Overall hospital volume ranged from 17 to 57 cases/years. This study confirms that surgeons with appropriate training in oesophageal resection may get good results despite lower individual case volumes when a standardised approach is taken in an institution with a high case volume.

Bilateral thoracoscopic sympathectomy: results and long-term follow-up.

The aim of this study is to evaluate the efficacy of bilateral thoracoscopic sympathectomy in alleviating symptoms and improving quality of life in patients with hyperhidrosis or facial blushing and to investigate the occurrence, severity and possible underlying factors to compensatory sweating after surgery. One hundred and sixty-three patients in a single institution underwent bilateral thoracoscopic sympathectomy with a mean follow-up period of 51 (5-140) months. Indications were for palmar hyperhidrosis (41%), axillary hyperhidrosis (17%), combined palmar and axillary hyperhidrosis (27%) and facial blushing+/-facial hyperhidrosis (15%). Success rates were palmar 98.5%, axillary 96.4%, palmar and axillary 97.7% and facial blushing+/-facial hyperhidrosis 84%. Compensatory sweating occurred in 77% of patients and its severity was related to the severity of the primary complaint. Recurrence rates were palmar 4.6%, axillary 7.4%, palmar and axillary 9.3% and facial blushing+/-facial hyperhidrosis 4.7% at a mean of 22 (3-72) months. An improvement in quality of life was seen in 85% and a diminution of quality of life was noted in 5% due to compensatory sweating. This large mature series demonstrates that bilateral thoracoscopic division of the sympathetic chain as opposed to resection can be performed effectively in patients with success rates higher than 90% and low recurrence rates.

A population-based association study of SNPs of GSTP1, MnSOD, GPX2 and Barrett's esophagus and esophageal adenocarcinoma.

Oxidative stress appears to be important in the pathogenesis of Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC). Single-nucleotide polymorphisms (SNPs) of antioxidant enzyme genes may play a part in determining individual susceptibility to these diseases. The Factors Influencing the Barrett's Adenocarcinoma Relationship (FINBAR) study is a population-based, case-control study of BE and EAC in Ireland. DNA from EAC (n = 207), BE (> or =3 cm BE at endoscopy with specialized intestinal metaplasia on biopsy, n = 189) and normal population controls (n = 223) were analyzed. Several SNPs spanning the genes for glutathione S-transferase P1 (GSTP1), manganese superoxide dismutase (MnSOD) and glutathione peroxidase 2 (GPX2) were genotyped using multiplex polymerase chain reaction and SNaPshottrade mark. The chi(2) test was used to compare genotype and allele frequencies between case and control subjects. Linkage disequilibrium between SNPs was quantified using Lewontin's D' value and haplotype frequency estimates obtained using Haploview. Eleven SNPs were genotyped (six for GSTP1, three for MnSOD and two for GPX2); all were in Hardy-Weinberg equilibrium. None was significantly associated with EAC or BE even before Bonferroni correction. Odds ratios for EAC for individual SNPs ranged from 0.68 [95% confidence interval (CI) 0.43-1.08] to 1.25 (95% CI 0.73-2.16), and for BE from 0.84 (95% CI 0.52-1.30) to 1.30 (95% CI 0.85-1.97). SNPs in all three genes were in strong linkage disequilibrium (D' > 0.887) but haplotype analysis did not show any significant association with EAC or BE. SNPs involving the GSTP1, MnSOD and GPX2 genes were not associated with BE or EAC. Further studies aimed at identifying susceptibility genes should focus on different antioxidant genes or different pathways.