Gastric electrical stimulation for treatment of clinically severe gastroparesis.

BACKGROUND: Severe, drug-resistant gastroparesis is a debilitating condition. Several, but not all, patients can get significant relief from nausea and vomiting by gastric electrical stimulation (GES). A trial of temporary, endoscopically delivered GES may be of predictive value to select patients for laparoscopic-implantation of a permanent GES device. MATERIALS AND METHODS: We conducted a clinical audit of consecutive gastroparesis patients, who had been selected for GES, from May 2008 to January 2012. Delayed gastric emptying was diagnosed by scintigraphy of ≥50% global improvement in symptom-severity and well-being was a good response. RESULTS: There were 71 patients (51 women, 72%) with a median age of 42 years (range: 14-69). The aetiology of gastroparesis was idiopathic (43 patients, 61%), diabetes (15, 21%), or post-surgical (anti-reflux surgery, 6 patients; Roux-en-Y gastric bypass, 3; subtotal gastrectomy, 1; cardiomyotomy, 1; other gastric surgery, 2) (18%). At presentation, oral nutrition was supplemented by naso-jejunal tube feeding in 7 patients, surgical jejunostomy in 8, or parenterally in 1 (total 16 patients; 22%). Previous intervention included endoscopic injection of botulinum toxin (botox) into the pylorus in 16 patients (22%), pyloroplasty in 2, distal gastrectomy in 1, and gastrojejunostomy in 1. It was decided to directly proceed with permanent GES in 4 patients. Of the remaining, 51 patients have currently completed a trial of temporary stimulation and 39 (77%) had a good response and were selected for permanent GES, which has been completed in 35 patients. Outcome data are currently available for 31 patients (idiopathic, 21 patients; diabetes, 3; post-surgical, 7) with a median follow-up period of 10 months (1-28); 22 patients (71%) had a good response to permanent GES, these included 14 (68%) with idiopathic, 5 (71%) with post-surgical, and remaining 3 with diabetic gastroparesis. CONCLUSIONS: Overall, 71% of well-selected patients with intractable gastroparesis had good response to permanent GES at follow-up of up to 2 years.

A laparoscopic vagus-preserving Merendino procedure for early esophageal adenocarcinoma.

INTRODUCTION: Laparoscopic vagal preserving oesophagectomy is a recognised treatment option for high-grade dysplasia of the oesophagus. A jejunal interposition, as described by Alvin Merendino in 1955, aims to substitute the lower oesophageal sphincter, thereby treating physiological disorders such as reflux oesophagitis. METHODS: We aimed to combine these procedures in the treatment of an otherwise healthy patient, who presented with high-grade dysplasia on surveillance endoscopy, with particular reference to technical feasibility and to Quality of Life as assessed by the Gastrointestinal Quality of Life Index (GIQLI). RESULTS: We performed a laparoscopic vagus preserving Merendino procedure with sentinel lymph node biopsy. The patient made an entirely uncomplicated recovery and was discharged on day 7. His pathological specimen reported intramucosal carcinoma and high-grade dysplasia within Barrett's oesophagus. 0/4 lymph nodes were involved. His GIQLI scores preoperatively, at 2 and 4 weeks postoperatively, were 111, 98 and 105, respectively. His weight at the corresponding times was 69.8, 63.2 and 62.7 kg. CONCLUSION: A laparoscopic vagal preserving Merendino procedure is technically feasible. It also offers a physiologically advantageous procedure for the patient.

Neoadjuvant chemotherapy and surgery for esophageal adenocarcinoma: prognostic value of circumferential resection margin and stratification of N1 category.

BACKGROUND: In the UK, it is standard practice to treat esophageal adenocarcinoma with neoadjuvant chemotherapy (no radiation) and surgery. We examined the prognostic value of the status of the circumferential resection margin (CRM) and stratification of the N1 category into 1-4 nodes or > or = 5 nodes. METHODS: Between 2000 and 2006, 105 patients with radiologically staged T3, T4 or N1 esophageal adenocarcinoma had preoperative chemotherapy. One hundred and one patients had an Ivor Lewis operation with two-field lymphadenectomy, three had a transhiatal operation and one had a three-incision operation. CRM was assessed by painting the specimen with India ink and transverse sections at 5-10 mm intervals. The CRM was considered positive (CRM+) if malignant cells were within 1 mm of the inked margin. RESULTS: There were 87 men. The median age was 61 years (range 37-81 years). Median lymph node yield was 28 (4-77); 86 patients (83%) had > or = 18 nodes. Seventy-four patients (70%) had N1 disease, with 1-4 involved nodes in 41 patients (39%) and > or = 5 nodes in 33 patients (31%). The CRM was positive in 38 patients (36%). On multivariate analysis, nodal metastasis [N0 versus N1; hazard ratio (HR) 3.3, 3-year survival 80% versus 40%; P = 0.004], CRM status (CRM- versus CRM+: HR 2.6, 3-year survival 64% versus 26%; P = 0.002) and vascular invasion (V0 versus V1: HR 2.2, 3-year survival 67% versus 39%; P = 0.014) retained independently significant prognostic value. N1 patients with 1-4 nodes had longer survival than those with > or = 5 nodes (56% versus 21%; P < 0.001). CONCLUSIONS: CRM involvement and stratification of the N1 category are independent prognostic factors after multimodal therapy for esophageal adenocarcinoma.

Comparison of oncological outcomes after laparoscopic transhiatal and open esophagectomy for T1 esophageal adenocarcinoma.

INTRODUCTION: This study compared pathological characteristics and patterns of disease recurrence for patients with pT1 esophageal adenocarcinoma treated with either laparoscopic transhiatal esophagectomy or open esophagectomy. METHODS: From January 2000-December 2006, 44 patients had pT1 esophageal adenocarcinoma after esophagectomy. No patients had neoadjuvant treatment. Twenty-four patients had an Ivor Lewis operation, 4 had an open transhiatal and 16 had a laparoscopic transhiatal operation. RESULTS: There were 37 men. The median age was 64 years (range 35-80 years). Median lymph node yield was 19 (10-51) after an Ivor Lewis operation, 16 (3-28) after an open transhiatal operation and 15 (4-41) after a laparoscopic transhiatal operation. There were two in-hospital deaths (5%), both following open Ivor Lewis operation. All patients in the laparoscopic group had N0 disease; none received adjuvant treatment. Two patients (7%) in the open group had N1 disease, of whom one patient received adjuvant chemotherapy. Eleven patients had submucosal invasion. Alive patients had median follow-up of 36 months (range 5-87 months). One patient in the laparoscopic group had recurrence at 22 months. This patient had poorly differentiated N0 disease which was limited to the mucosa and died at 24 months. Two patients in the open group developed recurrence, at 6 months (N0 disease with submucosal invasion) and 8 months (N1 disease with submucosal invasion) and died at 7 and 14 months, respectively. Both patients had poorly differentiated tumours. The second patient with N1 disease is alive and well at 14 months. Estimated survival (Kaplan-Meier) at 3 years was 93%. CONCLUSIONS: As compared with open transthoracic esophagectomy, there is no oncological detriment in the treatment of pT1 esophageal adenocarcinoma by laparoscopic transhiatal esophagectomy. The incidence of recurrence is small (7%) but can occur even in patients with tumour limited to the mucosa or N0 disease.

Comparison of early outcomes for laparoscopic ventral hernia repair between nonobese and morbidly obese patient populations.

BACKGROUND: Obesity predisposes to incisional herniation and increased the incidence of recurrence after conventional open repair. Only sparse data on the safety and security of laparoscopic ventral hernia repair (LVHR) for morbidly obese patients are available. This study compared the incidence of perioperative complications and early recurrence after LVHR between morbidly obese and non-morbidly obese patients. METHODS: The case records of consecutive patients who underwent LVHR between December 2002 and August 2007 were reviewed. Patients with a body mass index (BMI) lower than 35 kg/m2 were compared with morbidly obesity patients who had a BMI of 35 kg/m2 or higher. RESULTS: The study included 168 patients (87 men) with a median age of 55 years (range, 24-92 years). Two conversions to open repair (1.2%) were performed, both for non-morbidly obese patients. Of the 168 patients, 42 (25%) were morbidly obese (BMI range, 35.0-58.0 kg/m2) and 126 (75%) were non-morbidly obese (BMI range, 15.5-34.9 kg/m2). The groups showed no significant differences in age, gender, number or size of fascial defects, operative time, length of hospital stay, or incidence of perioperative complications. At a median follow-up period of 19 months (range, 6-62 months), 20 patients (12%) had recurrent hernias. The incidence of recurrence was significantly associated with the size of the fascial defect and the size of the mesh, but not with morbid obesity. CONCLUSION: No significant difference in the incidence of perioperative complications or recurrence after LVHR was observed between the morbidly obese patients and the non-morbidly obese patients.

Single-stage conversions from failed gastric band to sleeve gastrectomy versus Roux-en-Y gastric bypass: results from the United Kingdom National Bariatric Surgical Registry.

BACKGROUND: For patients in whom laparoscopic adjustable gastric band has failed, conversion to Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are both options for further surgical treatment. There are limited data comparing these 2 procedures. The National Bariatric Surgery Registry is a comprehensive United Kingdom-wide database of bariatric procedures, in which preoperative demographic characteristics and clinical outcomes are prospectively recorded. OBJECTIVES: To compare perioperative complication rate and short-term outcomes of patients undergoing single-stage conversion of gastric band to Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy. SETTING: United Kingdom national bariatric surgery database. METHODS: From the National Bariatric Surgical Registry data set, we identified 141 patients undergoing single-stage conversion from gastric band to either gastric bypass (113) or sleeve gastrectomy (28) between 2009 and 2014, and analyzed their clinical outcomes. RESULTS: With respect to perioperative outcomes gastric bypass was associated with a higher incidence of readmission or reintervention postoperatively (16 versus 0; P = .04). There was no difference in percentage excess weight loss between sleeve gastrectomy and gastric bypass at final follow-up at 1 year (52.1% versus 57.1% respectively; P = .4). CONCLUSIONS: Conversion from band to sleeve or bypass give comparable good early excess weight loss; however, conversion to sleeve is associated with a better perioperative safety profile.

Obesity surgery makes patients healthier and more functional: real world results from the United Kingdom National Bariatric Surgery Registry.

BACKGROUND: The National Bariatric Surgery Registry (NBSR) is the largest bespoke database in the field in the United Kingdom. OBJECTIVES: Our aim was to analyze the NBSR to determine whether the effects of obesity surgery on associated co-morbidities observed in small randomized controlled clinical trials could be replicated in a "real life" setting within U.K. healthcare. SETTING: United Kingdom. METHODS: All NBSR entries for operations between 2000 and 2015 with associated demographic and co-morbidity data were analyzed retrospectively. RESULTS: A total of 50,782 entries were analyzed. The patients were predominantly female (78%) and white European with a mean age of 45 ± 11 years and a mean body mass index of 48 ± 8 kg/m2. Over 5 years of follow-up, statistically significant reductions in the prevalence of type 2 diabetes, hypertension, dyslipidemia, sleep apnea, asthma, functional impairment, arthritis, and gastroesophageal reflux disease were observed. The "remission" of these co-morbidities was evident 1 year postoperatively and reached a plateau 2 to 5 years after surgery. Obesity surgery was particularly effective on functional impairment and diabetes, almost doubling the proportion of patients able to climb 3 flights of stairs and halving the proportion of patients with diabetes related hyperglycemia compared with preoperatively. Surgery was safe with a morbidity of 3.1% and in-hospital mortality of .07% and a reduced median inpatient stay of 2 days, despite an increasingly sick patient population. CONCLUSIONS: Obesity surgery in the U.K. results not only in weight loss, but also in substantial improvements in obesity-related co-morbidities. Appropriate support and funding will help improve the quality of the NBSR data set even further, thus enabling its use to inform healthcare policy.

Surveillance Is Important After Surgical Excision of Giant Fibrovascular Polyps of the Esophagus.

Giant fibrovascular polyps of the esophagus are rare benign tumors arising from the cervical esophagus or hypopharynx. Radiologic and endoscopic investigation may struggle to identify a stalk or to delineate the tumor as luminal or submucosal in origin. Excision is advised, although the diagnosis, and therefore the optimal operative approach, may not be apparent until the time of operation. Individual case reports describe the technical success of surgical excision but rarely include follow-up. Our case series highlights the range of approaches for surgical excision and also the importance of long-term follow-up because of the risk of recurrence and potential for airway obstruction.

Risk factors, DNA damage, and disease progression in Barrett's esophagus.

Esophageal adenocarcinoma develops on a background of Barrett's esophagus. A number of risk factors have been linked to both conditions, including gastroesophageal reflux and smoking. However, the molecular mechanisms by which these factors influence disease progression remain unclear. One possibility is that risk factors generate promutagenic DNA damage in the esophagus. The comet assay was used to measure DNA damage in esophageal (Barrett's and squamous) and gastric mucosa of Barrett's patients with (n = 24) or without (n = 50) associated adenocarcinoma or high-grade dysplasia in comparison with control patients (squamous mucosa) without Barrett's esophagus (n = 64). Patients completed a questionnaire detailing exposure to some of the known risk factors for Barrett's esophagus and adenocarcinoma. In Barrett's esophagus patients, DNA damage was higher in Barrett's mucosa compared with normal esophageal and gastric mucosa (P < 0.001). In addition, the highest quartile of DNA damage in Barrett's mucosa was associated with an increased risk (odds ratio, 9.4; 95% confidence interval, 1.1-83.4; P = 0.044) of developing adenocarcinoma or high-grade dysplasia compared with DNA damage levels in the lowest quartile. Smoking was associated with higher DNA damage in squamous epithelium in all patient groups (P < 0.01) and in Barrett's mucosa (P < 0.05) in Barrett's esophagus patients only. In controls only, current reflux was associated with higher DNA damage, whereas anti-inflammatory drug use resulted in lower levels. Collectively, these data imply a genotoxic insult to the premalignant Barrett's mucosa that may explain the genetic instability in this tissue and the progression to adenocarcinoma. There is an indication for a role for smoking in inducing DNA damage in esophageal mucosa but an understanding of the role of reflux requires further investigation.

Diagnostic variation and outcome for high-grade gastric epithelial dysplasia.

HYPOTHESIS: High-grade dysplasia (HGD) of the gastric epithelium is associated with high prevalence of invasive carcinoma, and distinction by endoscopic biopsy is difficult. DESIGN: Cohort study, 1996 to 2003. SETTING: Tertiary care center. PATIENTS: Consecutive sample of 22 patients with initial diagnosis of gastric HGD by endoscopic biopsy. Biopsy specimens were separately reviewed by 3 experienced pathologists. Clinical management was individually decided. MAIN OUTCOME MEASURES: Strength of interpathologist agreement (kappa) and final pathological diagnosis. RESULTS: The diagnosis was revised to intramucosal carcinoma in 14% to 32% of patients or suspicious for invasive carcinoma in 23% to 41%. The strength of agreement between any 2 pathologists for distinguishing between dysplasia and invasive carcinoma was fair (kappa = 0.35-0.36). A diagnosis of intramucosal carcinoma or suspicious for invasive carcinoma by 2 pathologists correlated strongly with subsequent detection of invasive carcinoma. Three patients underwent gastrectomy for HGD, and invasive carcinoma was detected in all (2 patients, T1 N0; 1 patient, T2 N0). Six patients had invasive carcinoma on endoscopic surveillance at a median of 15 months (range, 3-34 months) after diagnosis of HGD and underwent endoscopic mucosal resection (2 patients, T1 NX), gastrectomy (2 patients, T1 N0), or no resection (2 patients). Another patient had metastatic gastric adenocarcinoma despite having a diagnosis of only HGD by endoscopy. Seven patients (32%) died of unrelated causes, without invasive carcinoma, at a median of 19 months (range, 1-38 months). Three patients were alive with persistent HGD at 26 to 61 months. Two patients had no dysplasia on follow-up. CONCLUSIONS: Experienced pathologists often disagreed in distinguishing invasive carcinoma from HGD in gastric biopsy specimens. One third of patients with gastric HGD died of causes unrelated to cancer. Invasive carcinoma was detected in 67% of the remainder.

Mucosal biomarkers of colorectal cancer risk do not increase at 6 months following sleeve gastrectomy, unlike gastric bypass.

OBJECTIVE: The hypothesis that sleeve gastrectomy (SG) is not associated with an increase in mucosal colorectal cancer (CRC) biomarkers, unlike Roux-en-Y gastric bypass (RYGB), was tested. DESIGN AND METHODS: Rectal mucosa, blood, and urine were obtained from morbidly obese patients (n = 23) before and after (median 28 months) SG, as well as from nonobese controls (n = 20). Rectal epithelial cell mitosis and apoptosis, crypt size/fission, and pro-inflammatory gene expression were measured, as well as systemic inflammatory biomarkers, including C-reactive protein (CRP). RESULTS: The mean pre-operative body mass index in SG patients was 65.7 kg/m2 (24.7 kg/m2 in controls). Mean excess weight loss post-SG was 38.2%. There was a significant increase in mitosis frequency, crypt size, and crypt fission (all P < 0.01) in SG patients versus controls, as well as evidence of a chronic inflammatory state (raised CRP and mononuclear cell p65 NFκB binding), but there was no significant change in these biomarkers after SG, except CRP reduction. Macrophage migration inhibitory factor mRNA levels were increased by 39% post-SG (P = 0.038). CONCLUSIONS: Mucosal biomarkers of CRC risk do not increase at 6 months following SG, unlike RYGB. Biomarkers of rectal crypt proliferation and systemic inflammation are increased in morbidly obese patients compared with controls.

Long-term follow-up after laparoscopic sleeve gastrectomy: 8-9-year results.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity as a definitive bariatric procedure despite the sparse long-term follow-up data. On the basis of extensive experience with the open Magenstrasse and Mill operation, we began practice of LSG in 2000. The objective of the present study was to analyze 8-9 years of our follow-up data for LSG at a university hospital in the United Kingdom. METHODS: From January 2000 to December 2001, 20 patients underwent LSG. A 32F bougie was used for calibration in all cases. RESULTS: The preoperative median body mass index was 45.8 kg/m(2) (range 35.8-63.7), and 9 patients (45%) were superobese (body mass index ≥ 50 kg/m(2)). For LSG as a definitive bariatric procedure, 8-9-year follow-up data were available for 13 patients. Of the remainder, 4 patients underwent revision surgery and 3 were lost to follow-up after 2 years. For the entire cohort, the median excess weight loss (EWL) was 73% (range 13-105%) at 1 year, 78% (range 22-98%) at 2 years, 73% (range 28-90%) at 3 years, and 68% (range 18-85%) at 8 or 9 years (P = .074). Of the 13 LSG-only patients with 8-9 years of follow-up, 11 (55% of the starting cohort) had >50% EWL at 8 or 9 years. No significant difference was found in the initial body mass index between the LSG-only patients with >50% EWL and others (45.9 kg/m(2), range 35.8-59.4 versus 45.7 kg/m(2), range 38.9-63.7, respectively; P = .70). The LSG-only patients with >50% EWL had a marginally significantly greater EWL at 1 year compared with the others (76%, range 48-103% versus 45%, range 13-99%, respectively; P = .058). CONCLUSION: At 8-9 years of follow-up, 55% of patients had >50% EWL from LSG as a definitive bariatric procedure.

Use of the obesity surgery mortality risk score to predict complications of laparoscopic bariatric surgery.

BACKGROUND: This study aimed to evaluate the role of the Obesity Surgery Mortality Risk Score (OS-MRS) to predict the risk of post-operative adverse events, in addition to death, from any laparoscopic bariatric procedure. METHODS: The OS-MRS was applied to consecutive patients at a single hospital during October 2008-September 2009. The composite end point comprised one or more of the following adverse events: mortality, re-intervention, re-admission to hospital, venous thromboemobolism, or blood transfusion. RESULTS: There were 381 patients (men, 19%). The median age was 43 years (range, 19-67 years), with 42% patients aged ≥45 years. The median weight was 126 kg (75-295 kg) and median BMI 46 kg/m(2) (30-84 kg/m(2)); 37% had BMI ≥50 kg/m(2). Twenty-seven percent of patients had hypertension and 3% had a past history of venous thromboembolism. The OS-MRS classes were A (60.1%), B (35.9%), or C (4.0%). Operations comprised adjustable gastric band (37%), Roux-en-Y gastric bypass (54%), sleeve gastrectomy (8%), or biliopancreatic diversion (1%). Of the operations, 1.6% were revisional procedures. An adverse outcome occurred in 19 patients, with distribution in 3.5% of class A patients, 5.8% of class B, and 20.0% of class C (A vs. B, P = 0.451; A vs. C, P = 0.002; B vs. C, P = 0.025). There was one death: OS-MRS class C. On multivariate analysis, OS-MRS (class C vs. A or B; Odds Ratio [OR], 4; P = 0.050) and type of operation (band vs. bypass or sleeve; OR, 9.2; P = 0.033) were independently predictive of the composite end point. CONCLUSION: OS-MRS and type of the bariatric operation are independently predictive of the risk of post-operative adverse events.

Spinal Epidural Abscess Presenting with Paraplegia Following Delayed Presentation of Traumatic Esophageal Perforation without Spinal Fracture: Lessons to be Learnt.

We describe a case of esophageal perforation following blunt chest trauma with delayed presentation as paraplegia secondary to spinal epidural abscess formation. The case highlights the importance of the awareness of the possibility of esophageal injury in patients following road traffic collisions.

Anastomotic leakage after esophagectomy for cancer: a mortality-free experience.

BACKGROUND: Leakage is a serious complication of esophagectomy and is historically associated with high mortality. This study aimed to describe the morphology and strategies for clinical management of leakage after esophagectomy. STUDY DESIGN: A database prospectively maintained from July 2002 to July 2005 at a referral unit for foregut cancer was used to identify patients with leakage of saliva or gastrointestinal contents after esophagectomy and reconstruction with stomach. Contrast swallow was routinely performed on postoperative day 7. Leakage was diagnosed and classified by well-defined criteria. RESULTS: There were 99 men and 27 women, yielding an institutional volume of 42 esophagectomies per year. There was no in-hospital mortality from any cause. Actual 1-year survival was 87%. An Ivor Lewis operation was performed on 103 patients (82%); 4 patients had leakage within 5 days of operation and all had immediate rethoracotomy. An additional 8 patients with Ivor Lewis operation had leakage after day 5, and this was detected by contrast swallow in only 3 patients; 2 patients had no intervention, 4 patients had radiology-guided drainage, 1 had thoracoscopy, and 1 had rethoracotomy. Leakage was from the actual esophagogastric anastomosis in eight patients, from the linear gastric staple line in three patients, or from gastric necrosis in one patient. Twenty-three patients had a transhiatal or three-stage operation; leakage was from the actual anastomosis in five patients or gastric necrosis in one patient. CONCLUSIONS: After Ivor Lewis esophagectomy, leakage was from the actual anastomosis in two-thirds of patients or from the gastric conduit in the remaining one-third. Prompt reoperation is recommended for early postoperative leakage. Most patients with leakage after day 5 can be treated nonoperatively.

Randomized crossover study that used methylene blue or random 4-quadrant biopsy for the diagnosis of dysplasia in Barrett's esophagus.

BACKGROUND: Barrett's esophagus is generally accepted to be a premalignant condition. Previous studies have suggested the use of methylene blue (MB) chromoendoscopy to aid the identification of dysplasia in Barrett's esophagus surveillance programs, but a recent study has raised the concern that MB might induce oxidative damage of DNA. OBJECTIVE: The aim of this study was to compare MB directed biopsies (MBDB) with our current standard, which is random 4 quadrant biopsies (RB). DESIGN: A randomized prospective crossover study. SETTING: Single center. PATIENTS: Patients with a diagnosis of dysplasia identified in Barrett's esophagus within a 2-year period before entering the study. INTERVENTIONS: Either 4 random quadrant biopsies taken every 2 cm through the length of the Barrett's esophagus or MBDB from unstained or heterogenously stained mucosa. MAIN OUTCOME MEASUREMENTS: The number of patients with a diagnosis of dysplasia by each intervention. LIMITATIONS: Thirty-six percent of eligible patients declined the invitation to participate. RESULTS: Thirty patients completed the crossover study. The median length of Barrett's esophagus was 5 cm (interquartile range [IQR] 3-9 cm). At baseline histology, grades were as follows: 17 low-grade dysplasia (LGD), 3 high-grade dysplasia (HGD), and 10 no dysplasia. At completion, there were 10 LGD, 8 HGD, and 12 no dysplasia. Overall, dysplasia was identified in 17 of 18 patients by RB and in 9 of 18 by MBDB (McNemar test, p = 0.02). CONCLUSIONS: Our study showed MBDB to be significantly less sensitive in detecting dysplasia than RB in Barrett's esophagus. Hence, we discourage its use during routine surveillance of Barrett's esophagus.

TNM and Japanese staging systems for gastric cancer: how do they coexist?

Two staging systems for gastric cancer, International Union Against Cancer (UICC)/TNM and the Japanese classification, have been used widely for clinical practice and research. The two systems started independently in the 1960s, and underwent several revisions and amendments in order to approach each other, but have become more divergent in the latest editions because of characteristics based on different philosophies. The TNM system adopted a number-based system for N-staging that provides easy and accurate prognostic stratification. Comparative studies have shown that the TNM system has greater prognostic power than the Japanese classification. It contains, however, no treatment guidance and should primarily be used as a guide to prognosis. In contrast, the Japanese classification has been designed as a comprehensive guide to treatment, originally for surgeons and pathologists, and today for oncologists and endoscopists as well. Its anatomical-based N-staging was established based on analysis of lymphadenectomy effectiveness, and naturally provides direct surgical guidance. Clinicians should understand the roles of each system and must not mix the systems or terminology when they report their study results.