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Copyright of British Journal of Surgery is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The UK Medical Research Council ST03 trial compared perioperative epirubicin, cisplatin and capecitabine (ECX) chemotherapy with or without bevacizumab (B) in gastric and oesophagogastric junctional cancer. No difference in survival was noted between the arms of the trial. The present study reviewed the standards and performance of surgery in the context of the protocol‐specified surgical criteria. Methods: Surgical and pathological clinical report forms were reviewed to determine adherence to the surgical protocols, perioperative morbidity and mortality, and final histopathological stage for all patients treated in the study. Results: Of 1063 patients randomized, 895 (84·2 per cent) underwent resection; surgical details were available for 880 (98·3 per cent). Postoperative assessment data were available for 873 patients; complications occurred in 458 (52·5 per cent) overall, of whom 71 (8·1 per cent) developed complications deemed to be life‐threatening by the responsible clinician. The most common complications were respiratory (211 patients, 24·2 per cent). The anastomotic leak rate was 118 of 873 (13·5 per cent) overall; among those who underwent oesophagogastrectomy, the rate was higher in the group receiving ECX‐B (23·6 per cent versus 9·9 per cent in the ECX group). Pathological assessment data were available for 845 patients. At least 15 nodes were removed in 82·5 per cent of resections and the median lymph node harvest was 24 (i.q.r. 17–34). Twenty‐five or more nodes were removed in 49·0 per cent of patients. Histopathologically, the R1 rate was 24·9 per cent (208 of 834 patients). An R1 resection was more common for proximal tumours. Conclusion: In the ST03 trial, the performance of surgery met the protocol‐stipulated criteria. Registration number: NCT00450203 (http://www.clinicaltrials.gov). [ABSTRACT FROM AUTHOR]

Background: Textbook outcome is a multidimensional measure representing an ideal course after oesophagogastric cancer surgery. It comprises ten perioperative quality‐of‐care parameters and has been developed recently using population‐based data. Its association with long‐term outcome is unknown. The objectives of this study were to validate the clinical relevance of textbook outcome at a hospital level, and to assess its relation with long‐term survival after treatment for oesophagogastric cancer. Methods: All patients with oesophageal or gastric cancer scheduled for surgery with curative intent between January 2009 and June 2015 were selected from an institutional database. A Cox model was used to study the association between textbook outcome and survival. Results: A textbook outcome was achieved in 58 of 144 patients (40·3 per cent) with oesophageal cancer and in 48 of 105 (45·7 per cent) with gastric cancer. Factors associated with not achieving a textbook outcome were failure to achieve a lymph node yield of at least 15 (after oesophagectomy) and postoperative complications of grade II or more. After oesophagectomy, median overall survival was longer for patients with a textbook outcome than for patients without (median not reached versus 33 months; P = 0·012). After gastrectomy, median survival was 54 versus 33 months respectively (P = 0·018). In multivariable analysis, textbook outcome was associated with overall survival after oesophagectomy (hazard ratio 2·38, 95 per cent c.i. 1·29 to 4·42) and gastrectomy (hazard ratio 2·58, 1·25 to 5·32). Conclusion: Textbook outcome is a clinically relevant measure in patients undergoing oesophagogastric cancer surgery as it can identify underperforming parameters in a hospital setting. Overall survival in patients with a textbook outcome is better than in patients without a textbook outcome. [ABSTRACT FROM AUTHOR]

Background The significance of extracapsular lymph node involvement ( LNI) is unclear in patients with oesophageal cancer who have undergone neoadjuvant treatment followed by oesophagectomy. The aim of this study was to assess the incidence and prognostic significance of extracapsular LNI in a large multicentre series of consecutive patients with oesophageal cancer treated by neoadjuvant chemotherapy or chemoradiotherapy and surgery. Methods Data from a consecutive series of patients treated at two European centres were analysed. All patients with squamous cell carcinoma or adenocarcinoma of the oesophagus or gastro-oesophageal junction, who received neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy with curative intent, were included. Results Between January 2000 and September 2013, 704 patients underwent oesophagectomy after neoadjuvant therapy. A median of 28 (range 5-77) nodes per patient was recovered. Some 347 patients (49·3 per cent) had no LNI ( ypN0). Of the remaining 357 patients (50·7 per cent) with LNI ( ypN1-3), extracapsular LNI was found in 190 (53·2 per cent). Five-year overall survival rates were 62·7 per cent for patients with N0 disease, 44·9 per cent for patients without extracapsular spread and 14·0 per cent where extracapsular LNI was identified ( P < 0·001). Multivariable analyses demonstrated the presence of extracapsular LNI as an independent prognostic factor. Conclusion The presence of extracapsular LNI after neoadjuvant therapy carries a poor prognosis. [ABSTRACT FROM AUTHOR]

Background The value of conventional prognostic factors is unclear in the era of multimodal treatment for oesophageal cancer. This study aimed to quantify the impact of neoadjuvant chemoradiotherapy ( nCRT) and surgery on well established prognostic factors, and to develop and validate a prognostic model. Methods Patients treated with nCRT plus surgery were included. Multivariable Cox modelling was used to identify prognostic factors for overall survival. A prediction model for individual survival was developed using stepwise backward selection. The model was internally validated leading to a nomogram for use in clinical practice. Results Some 626 patients who underwent nCRT plus surgery were included. In the multivariable model, only pretreatment cN category and ypN category were independent prognostic factors. The final prognostic model included cN, ypT and ypN categories, and had moderate discrimination (c-index at internal validation 0·63). Conclusion In patients with oesophageal or oesophagogastric cancer treated with nCRT plus surgery, overall survival can best be estimated using a prediction model based on cN, ypT and ypN categories. Predicted survival according to this model showed only moderate correlation with observed survival, emphasizing the need for new prognostic factors to improve survival prediction. [ABSTRACT FROM AUTHOR]

Background This population-based study aimed to evaluate trends in surgical approach for screen-detected cancer versus interval breast cancer, and to determine the factors associated with positive resection margins. Methods Screening mammograms of women aged 50-75 years, who underwent biennial screening in a Dutch breast-screening region between 1997 and 2011, were included. Patient and tumour characteristics were compared between women who underwent mastectomy or breast-conserving surgery ( BCS) for screen-detected or interval cancer, and women with a negative or positive resection margin after BCS. Results Some 417 013 consecutive screening mammograms were included. A total of 2224 screen-detected and 825 interval cancers were diagnosed. The BCS rate remained stable (mean 6·1 per 1000 screened women; P = 0·099), whereas mastectomy rates increased significantly during the study from 0·9 (1997-1998) to 1·9 (2009-2010) per 1000 screened women ( P < 0·001). The proportion of positive resection margins for invasive cancer was 19·6 and 7·6 per cent in 1997-1998 and 2009-2010 respectively ( P < 0·001), with significant variation between hospitals. Dense breasts, preoperative magnetic resonance imaging, microcalcifications, architectural distortion, tumour size over 20 mm, axillary lymph node metastasis and treating hospital were independent risk factors for mastectomy. Interval cancer, image-guided tumour localization, microcalcifications, breast parenchyma asymmetry, tumour size greater than 20 mm, lobular tumour histology, low tumour grade, extensive invasive component and treating hospital were independent risk factors for positive resection margins. Conclusion Mastectomy rates doubled during a 14-year period of screening mammography and the proportion of positive resection margins decreased, with variation among hospitals. The latter observation stresses the importance of quality control programmes for hospitals treating women with breast cancer. [ABSTRACT FROM AUTHOR]

Background Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non-operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre. Methods All patients with oesophageal perforation managed in a single oesophagogastric unit in the UK between January 2002 and December 2012 were identified. Gastric perforations and anastomotic leaks were excluded. Data were verified using an endoscopy database, electronic and paper records. Aetiology of perforation, management and outcomes were analysed. Results There were 101 adult patients with oesophageal perforation. Complete records were not available for five patients and they were excluded from the analysis. The median age was 69·5 years. Thoracic perforations were present in 84 per cent of patients. There were 51 spontaneous perforations, 41 iatrogenic and four related to foreign bodies. Oesophageal malignancy was present in 11 patients. Forty-four patients were managed surgically, 47 without operation and five patients were considered unfit for active treatment. The in-hospital mortality rate for treated patients was 24 per cent and median length of hospital stay was 31·5 days. Conclusion The management of oesophageal perforation requires specialist multidisciplinary input. It is best provided in an environment familiar with the range of treatment modalities. Management decisions should be guided primarily by the degree of contamination rather than the aetiology of the defect. The routine use of stents is unproven and controversial. [ABSTRACT FROM AUTHOR]

Background A gross proximal oesophageal margin greater than 5 cm is considered to be necessary for curative surgery of adenocarcinoma of the oesophagogastric junction. This study investigated whether a shorter proximal margin might suffice in the context of total gastrectomy for Siewert type II and III tumours. Methods The gross proximal margin was measured on stretched specimens just after resection. Relationships between gross proximal margin lengths and clinicopathological features were investigated in patients with Siewert type II and III adenocarcinoma of the oesophagogastric junction treated by R0-1 surgical resection. For survival analyses, only patients who had undergone R0 resection for pathological (p) T2-4 N0-3 M0 tumour via a transhiatal approach were evaluated. Results Of the 140 patients, 120 had a total gastrectomy. Two patients (1·4 per cent) had histologically positive proximal margins and another two (1·4 per cent) developed anastomotic recurrence. Of 100 patients with pT2-4 N0-3 M0 tumours who underwent gastrectomy via a transhiatal approach, those with gross proximal margins larger than 20 mm appeared to have better survival than those with shorter margins ( P = 0·027). Multivariable analysis demonstrated that a gross proximal margin of 20 mm or less was an independent prognostic factor (hazard ratio ( HR) 3·56, 95 per cent confidence interval 1·39 to 9·14; P = 0·008), as was pathological node status ( HR 1·76, 1·08 to 2·86; P = 0·024). Conclusion Gross proximal margin lengths of more than 20 mm in resected specimens seem satisfactory for patients with type II and III adenocarcinoma of the oesophagogastric junction treated by transhiatal gastrectomy. [ABSTRACT FROM AUTHOR]

Background Postoperative complications may have an adverse effect not only on short-term but also long-term outcome among patients having surgery for cancer. A retrospective series of patients who had surgery for colorectal liver metastases (CLM) was used to assess this association. Methods Patients who had surgery with curative intent for CLM from 2000 to 2009 were included. The impact of postoperative complications, patient characteristics, disease stage and treatment on long-term survival was analysed using multivariable Cox regression models. Results A total of 251 patients were included. The median age was 58 (interquartile range 51-68) years and there were 87 women (34·7 per cent). A minor or major postoperative complication developed in 41 and 14 patients respectively, and five patients (2·0 per cent) died after surgery. The 5-year recurrence-free (RFS) and overall survival rates were 19·5 and 41·9 per cent respectively. Multivariable analysis revealed that postoperative complications independently predicted shorter RFS (hazard ratio (HR) 2·36, 95 per cent confidence interval 1·56 to 3·58) and overall survival (HR 2·34, 1·46 to 3·74). Other independent predictors of shorter RFS and overall survival included lymph node metastasis, concomitant extrahepatic disease, a serum carcinoembryonic antigen level of at least 100 ng/dl, and the use of radiofrequency ablation (RFS only). The severity of complications also correlated with RFS ( P = 0·006) and overall survival ( P = 0·001). Conclusion Postoperative complications were independently associated with decreased long-term survival after surgery for CLM with curative intent. The prevention and management of postoperative adverse events may be important oncologically. [ABSTRACT FROM AUTHOR]

Background: The extent of lymphadenectomy in patients with Siewert type II adenocarcinoma of the oesophagogastric junction is controversial. The aim of this study was to investigate lymph node involvement around the left renal vein. Methods: Lymph node involvement and prognosis in patients with Siewert type II cancers treated by R0-1 surgical resection were investigated, with regard to lymphadenectomy around the left renal vein. Based on the incidence of involvement at each node, the node stations were divided into three tiers (first tier, more than 20 per cent involvement; second tier, 10-20 per cent involvement; third tier, less than 10 per cent involvement). Results: Of 150 patients with type II oesophagogastric adenocarcinoma, 94 had left renal vein lymphadenectomy. The first lymph node tier included nodes along the lesser curvature, right cardia, left cardia and left gastric artery, with involvement of 28·0-46·0 per cent and a 5-year survival rate of 42-53 per cent in patients with positive nodes. The nodes around the lower mediastinum, left renal vein, splenic artery and coeliac axis constituted the second tier, with involvement of 12·7-18 per cent and a 5-year survival rate of 11-35 per cent. With regard to the left renal vein, the incidence of involvement was 17 per cent and the 5-year rate survival rate was 19 per cent. Multivariable analysis showed that left renal vein lymphadenectomy was an independent prognostic factor in patients with pathological tumour category pathological T3-4 disease (hazard ratio 0·51, 95 per cent confidence interval 0·26 to 0·99; P = 0·048). Conclusion: Left renal vein nodal involvement is similar to that seen along the splenic artery, in the lower mediastinum and coeliac axis, with similar impact on patient survival. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Major surgery for cancer has become safer, including for elderly patients with co-morbidity. The aim of this study was to investigate the association between patient characteristics, resection rates and survival among patients with oesophageal or gastric cancer. Methods: The prospective Dutch population-based Eindhoven Cancer Registry for oesophagogastric cancers diagnosed between 1995 and 2009 was studied retrospectively for patient characteristics including co-morbidity. Logistic regression analysis was performed to assess the likelihood of resection in patients with tumour node metastasis (TNM) stage I-III lesions. Cox proportional hazard analysis was used to estimate hazard ratios (HRs) for survival. Results: The database contained information on 923 patients with oesophageal squamous cell carcinoma, 1181 with distal oesophageal, 942 with cardia and 3177 with subcardia cancer. Of patients with TNM stage I-III disease, 20·8 per cent (557 of 2680 patients) did not undergo resection. Age 70 years or above was associated with a lower likelihood of resection for distal oesophageal (odds ratio (OR) 0·24, 95 per cent confidence interval (c.i.) 0·14 to 0·41) and gastric (cardia: OR 0·41, 0·22 to 0·76; subcardia: OR 0·68, 0·48 to 0·97) cancer. The 30-day mortality rate increased with age (4·7 per cent in patients aged less than 70 years versus 11·9 per cent in those aged 70 years or more; P < 0·001) and co-morbidity (no co-morbidity, 3·6 per cent; 1 co-morbidity, 8·6 per cent; 2 or more co-morbidities, 11·2 per cent; P = 0·015). Surgery (compared with no surgery) was independently associated with better survival for all tumour types. After adjustment for treatment differences, age 70 years or above and presence of two or more co-morbidities were independently associated with poorer survival, especially in patients with subcardia carcinoma (age 70 years or more: HR 1·27, 95 per cent c.i. 1·17 to 1·48; co-morbidity: HR 1·33, 1·21 to 1·62). Conclusion: Surgical compared with non-surgical treatment of oesophagogastric cancer was associated with better survival, but postoperative mortality was increased in patients of advanced age and with greater co-morbidity. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Intrathoracic anastomotic leak is a major cause of postoperative mortality and morbidity after resection for oesophageal cancer. Little is known about persisting symptoms after this complication. In this Swedish nationwide cohort study, it was hypothesized that intrathoracic anastomotic leak makes patients more susceptible to persisting eating difficulties, odynophagia, dysphagia, trouble swallowing saliva and reflux. Methods: Patients who underwent oesophagectomy for oesophageal cancer, and had reconstruction with a gastric conduit and an intrathoracic anastomosis, between April 2001 and December 2005 were included. Symptoms were measured using an oesophageal cancer-specific health-related quality-of-life questionnaire (QLQ-OES18), developed by the European Organization for Research and Treatment of Cancer. Multivariable logistic regression models were used to calculate risk estimates for symptoms, expressed as odds ratio (OR) with 95 per cent confidence interval, 6 months after intrathoracic anastomotic leakage. Results: Among the 277 patients included in the study, the 29 patients with an intrathoracic anastomotic leak had a fourfold increased risk (OR 4·05, 1·47 to 11·16) of eating difficulties and a more than twofold greater risk (OR 2·59, 1·15 to 5·82) of odynophagia, 6 months after surgery, compared with patients without a leak. There was a twofold increased risk of trouble swallowing, but this was not statistically significant (OR 1·98, 0·58 to 6·67). Conclusion: Patients with an intrathoracic anastomotic leak after oesophageal cancer surgery were at increased risk of eating difficulties and odynophagia 6 months after surgery. Higher risks of reflux and dysphagia were not found among patients with anastomotic leak. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article presents a study which examined the possible adverse effects of anastomotic leak on the long-term survival of patients with stomach cancer. A review was made on an electronic database of patients with resectable gastric cancer treated at university surgical centers. Results revealed that patients diagnosed with anastomotic leakage experienced increased incidences of surgical and general complications and higher mortality rates.

The article presents a study which examines the effectiveness of self-expanding plastic stents in oesophageal anastomotic leaks treatment. It mentions that 21 of the 22 patients studied have gained resolution of the leak after 23 days through the combined treatment with stenting and drainage. However, stent migration happened in 5 patients and one patient has died. The result of the study suggests that effective drainage and stenting can treat oesophageal anastomotic leaks and reduce mortality.

The article examines the safety and effectiveness of endoscopic procedures for gastro-esophageal reflux. Literature databases were searched. Randomized controlled trials and non-randomized comparative studies were included in the search. Outcomes for the patients were analyzed. According to the article, there is insufficient evidence to determine the safety and effectiveness of endoscopic procedures for gastro-esophageal reflux, particularly in the long-term.

The article evaluates the introduction of targeted preoperative bone scintigraphy. It reveals that bone is frequently the first site of identifiable distant metastatic spread. Bone scintigraphy has been recommended to exclude metastatic disease before radical treatment of advanced esophageal carcinoma.

The article examines the incidence and degree of extracapsular lymph node involvement (LNI) in a consecutive series of patients with adenocarcinoma of the ampulla of Vater, who underwent resection with curative intent. Median overall survival was 30 and 18 months in patients with intracapsular and extracapsular LNI, respectively. Extracapsular LNI and tumor differentiation were independent prognostic factors for survival.

The article presents a study which compared the health-related quality of life (HRQL) among patients with adenocarcinoma of the gastro-oesophageal junction who were treated by either total gastrectomy (TG) or transthoracic oesophagectomy (TTO). The authors found that HRQL deteriorated greatly after TTO than after TG in terms of role and social function, global quality of life and fatigue. They also found increased symptom scores for pain and diarrhoea in both groups.

The article presents a study which evaluated the Physiological and Operative Severity Score for the enUmeration of Mortality adjusted for oesophagogastric surgery (O-POSSUM). It analyzed data on patients who underwent oesophagectomy in a center for adenocarcinoma or squamous cell carcinoma of the oesophagus. Results showed that 24 patients died in hospital and the predicted ratio for in-hospital mortality was 0.29. It was concluded that O-POSUUM overpredicted in-hospital mortality threefold.

Background: Tumour node metastasis (TNM) staging predicts survival on the basis of the pathological extent of a tumour. The aim of this study was to develop a prognostic model with improved survival prediction after oesophagectomy. Methods: Consecutive patients who had potentially curative oesophagectomy for adenocarcinoma of the oesophagus or gastro-oesophageal junction were included. Cox regression analyses were performed to examine the association between risk factors and time to death from oesophageal cancer. The concordance index, calculated after bootstrapping, was used to measure accuracy. A nomogram was designed for use in clinical practice. Results: Oesophageal cancer-specific survival Pates for the 364 included patients who underwent oesophagectomy between 1993 and 2003 were 75.8, 54.9 and 39.2 per cent at 1, 2 and 5 years respectively. A prognostic model using all prognostic variables outperformed TNM staging (concordance index 0.79 versus 0.68 respectively; P < 0.001). A reduced model derived after backward elimination, containing only T stage, lymph node ratio and extracapsular lymph node involvement, also outperformed TNM staging (concordance index 0.77; P < 0.001). Conclusion: A prognostic model developed to predict disease-specific survival after oesophagectomy was superior to TNM staging. More reliable prognostic information might lead to different approaches to patient follow-up. [ABSTRACT FROM AUTHOR]

Background: Sentinel lymph node biopsy (SLNB) is the standard procedure for axillary staging in patients with primary operable breast cancer and uninvolved axillary nodes. These patients increasingly have breast-conserving surgery (BCS), and 5 to 10 per cent develop ipsilateral breast tumour recurrence during follow-up. If axillary nodes remain clinically uninvolved after a previous negative SLNB the question remains whether second SLNB is a suitable option. Methods: Between January 2000 and October 2006, 202 patients who had previously had BCS and a negative SLNB developed an ipsilateral breast tumour recurrence. Of these, 65 women with clinically negative axillary nodes were offered a second SLNB; 57 had received adjuvant radiotherapy after BCS. Results: In 63 women, preoperative lymphoscintigraphy showed an axillary sentinel node (identification rate 97 per cent). In five, this was associated with extra-axillary migration. Sentinel node metastases were detected in seven women; in two this was the only metastasis. At a median follow-up of 45.9 months, no axillary recurrence had occurred in the women who had not had axillary dissection. Conclusion: Second SLNB after previous BCS and negative SLNB plus adjuvant radiotherapy may be offered to selected women with ipsilateral breast tumour recurrence. [ABSTRACT FROM AUTHOR]

Background: Cricopharyngeal myotomy for oropharyngeal dysphagia is designed to improve symptoms, but the operation can result in significant morbidity and even death. Methods: A retrospective analysis was carried out of all complications and deaths among 253 patients who had cricopharyngeal myotomy performed by a single surgeon. Results: A single wound infection developed among 15 patients with neurological dysphagia. The same patient subsequently required laryngeal exclusion and tracheostomy. Of 139 patients treated for dysphagia secondary to muscular dystrophy, haematoma formation or infection occurred in four, and eight patients developed postoperative pulmonary complications, four of whom died from respiratory distress syndrome. Two patients with myogenic dysphagia required laryngeal exclusion with a permanent tracheostomy. Infection of the wound or retropharyngeal space was the main problem in 90 patients with a pharyngo-oesophageal diverticulum, affecting 9 per cent of the patients. Fistula was documented in three patients overall (1.2 per cent). Systemic morbidity unrelated to the technique occurred in 26 patients (10.3 per cent). Conclusion: Pulmonary aspiration and lethal respiratory distress occurred only in patients with myogenic dysphagia. Local infection was the main complication in those with pharyngo-oesophageal diverticulum. Persistent aspiration can lead to laryngeal exclusion or resection with permanent tracheostomy. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to determine the effect of neoadjuvant radiochemotherapy (RCT) on postoperative complications and survival after surgery for locally advanced oesophageal squamous cell carcinoma. Methods: Postoperative course and survival were compared in 144 patients who had neoadjuvant RCT and 80 control patients who had surgery alone for locally advanced oesophageal squamous cell carcinoma (radiological stage T3, N0 or N1, M0). Results: The two groups were comparable in terms of American Society of Anesthesiologists grade, age, sex, weight loss, turnout location, presence of lymph node metastasis and surgical approach. Postoperative mortality rates were 6.3 and 9 per cent (P = 0.481), with morbidity rates of 40.3 and 41 per cent (P = 0.887) in the RCT and control group respectively. Complete resection (R0) rates were 74.3 and 48 per cent respectively (P < 0.001). Significant downstaging was observed in the RCT group (P < 0.001), with 16.0 per cent of patients having a complete pathological response. Median survival was 29 versus 15 months, and the 5-year survival rate 37 versus 17 per cent (P = 0.002) in RCT and control groups respectively. Conclusion: Neoadjuvant RCT significantly enhanced R0 resection and survival rates in patients with stage T3 oesophageal squamous cell carcinoma, with no increase in postoperative mortality and morbidity rates. [ABSTRACT FROM AUTHOR]

Background: Health-related quality of life (HRQL) outcomes are important in assessing new approaches to the treatment of cancer. Neoadjuvant therapy is being used increasingly before surgery in patients with localized oesophageal cancer. This prospective non-randomized study evaluated HRQL in patients treated by preoperative chemotherapy and radiation therapy followed by surgery (multimodal therapy) or by surgery alone. Methods: Data from European Organization for Research and Treatment of Cancer quality of life questionnaires QLQ-30 and QLQ-OES24 were collected prospectively. Questionnaires were completed at diagnosis, after chemoradiotherapy where applicable, and at 3, 6 and 12 months after surgery. Results: The study included 202 consecutive patients with oesophageal cancer considered suitable for curative (R0) resection at the time of staging. Eighty-seven patients received chemotherapy combined with external-beam radiotherapy before surgery. At baseline, 75 (86 per cent) of 87 patients in the multimodal group completed questionnaires, compared with 72 (62.6 per cent) of 115 in the surgery-alone group. There were no significant differences in baseline global HRQL scores between groups. Preoperative chemoradiotherapy significantly reduced physical (P = 0.004) and role (P = 0.007) functioning before surgery, despite a significant (P = 0.043) improvement in the dysphagia score. Oesophageal resection had a negative impact on global, functional and symptom HRQL scores at 3 months in both groups. Most variables had recovered by 6 months fu the two groups, but at 12 months physical and role functioning remained impaired in the surgery-alone group, and social functioning and financial worries in the multimodal group. Conclusion: Although the multimodal regimen had a negative impact on HRQL before surgery, postoperative quality of life in patients who had multimodal therapy was similar to that in those who had surgery alone. [ABSTRACT FROM AUTHOR]

The article aims to establish the incidence and prognostic significance of lymph node metastasis in the proximal field of the chest in patients undergoing transthoracic esophagectomy for adenocarcinoma of the cardia with substantial invasion of the esophagus. The results show that patients had more positive nodes and a shorter medial survival compared to those without metastasis. Positive nodes are identified by multivariate analysis in the proximal field as an independent predictor of poor survival. The study suggests that lymph node metastasis in the proximal field of the chest is common and is an indicator of poor prognosis in patients with adenocarcinoma of the cardia.

Determines the feasibility and accuracy of sentinel lymph node biopsy for esophageal adenocarcinoma. Surgical procedure; Sentinel node identification; Postoperative examination of lymph nodes; Distribution of radioactive uptake; Relationship between overall radioactive uptake and lymphatic dissemination.

Investigates the value of positron emission tomography in the diagnosis of recurrent esophageal carcinoma. Locoregional recurrence observed; Sensitivity of fluorodeoxyglucose (FDG)-positron emission tomography (PET) higher than that of computed tomography in detecting locoregional recurrence.

Reviews relates literature regarding postoperative mortality rate following esophagectomy for the period 1990-2000. Number of papers included in the review; Fall in the operative mortality rates following esophagectomy; 30-day mortality rate and the in-hospital mortality rate.

Focuses on the types of surgical treatment for pharyngeal pouch. Pathophysiology, history, and surgery of pharyngeal pouch; Emphasis of the treatment to cricopharyngeal myotomy; Result of minimally invasive techniques; Advantages of the endoscopic approach.

Evaluates the effectiveness of neoadjuvant therapy for oesophagogastric cancer. Potential of metabolic response evaluation during neoadjuvant treatment for oesophagogastric cancer; Rationale for multimodal therapy.

Background: Reflux of gastric and duodenal content after oesophagectomy with gastric conduit reconstruction is a common problem and largely considered an inevitable consequence of surgery. Cervical burning and regurgitation, often more pronounced when supine, can be troublesome and even disabling, interfering substantially with quality of life. The aim of this study was to identify the factors contributing to reflux after oesophagectomy and evaluate measures to prevent or control it. Methods: A Medline search using the terms 'gastro-oesophageal reflux', 'oesophagectomy' and 'antireflux surgery' was conducted. Additional references and search pathways were sourced from the bibliographies of articles located. Results and conclusion: Reflux after oesophagectomy is a significant problem, with both clinical and pathological consequences. Simple measures to facilitate gastric emptying, such as creating a gastric tube, performing a pyloric drainage procedure and using gastric motility agents, may produce a reduction in symptoms but do not alone control reflux itself. A variety of surgical reconstructions have been used, many of which are either difficult to fashion or not suitable when a radical resection has been performed. A modified fundoplication at the anastomosis seems to be the simplest technique and may be relatively effective in controlling symptoms. The impact of strategies to reduce reflux on quality of life and on pathological sequelae of reflux in the oesophageal remnant remains to be evaluated. [ABSTRACT FROM AUTHOR]

Background: The choice of surgical strategy for patients with adenocarcinoma of the oesophagogastric junction is controversial. This study was performed to analyse the surgical results of a 20-year experience with these lesions. Methods: From January 1981 to January 2001, 126 patients with adenocarcinoma of the cardia underwent resection in the authors' institution. The treatment of choice was oesophagectomy for type I tumours, and extended gastrectomy for type II and III lesions. Morbidity, mortality and survival were determined retrospectively. Results: Fifty-six patients (44·4 per cent) had type I tumours, 44 (34·9 per cent) type II and 26 (20·6 per cent) type III. Primary resection was performed in 113 patients (89·7 per cent). Oesophagectomy with resection of the proximal stomach was carried out in 65 patients (51·6 per cent) and extended total gastrectomy with transhiatal resection of the distal oesophagus in 61 (48·4 per cent). In-hospital mortality and morbidity rates were 4·8 and 34·1 per cent respectively. The overall 3- and 5-year survival rates were 40·9 and 25·1 per cent respectively, and were not affected by the surgical approach. Survival was significantly associated with R0 resection, pathological node-positive category, postoperative complications and tumour differentiation. Conclusion: Postoperative mortality, morbidity and long-term survival did not appear to be affected by surgical approach. Further prospective studies are needed to confirm the equivalence between transthoracic and transabdominal approaches. [ABSTRACT FROM AUTHOR]

Summary Background The extent of lymph node dissection can affect tumour node metastasis staging. The resulting ‘stage migration’ might hamper stage-by-stage comparison between different forms of oesophageal resection. The aim of this study was to assess the diagnostic impact of extended en bloc lymphadenectomy in staging (adeno)carcinoma of the mid/distal oesophagus or gastric cardia. Methods This was a prospective study of 74 patients (67 men and seven women; median age 63 (range 40–78) years) who underwent extended oesophagectomy between 1994 and 2000. Results A median of 31 (range 15–78) lymph nodes was resected (and identified), with a median of 5 (range 0–31) positive nodes. Twenty-seven patients (36 per cent) had tumour-positive nodes in extended fields: 15 patients (20 per cent) in the abdomen and 15 patients (20 per cent) in the mediastinum. Subcarinal nodes were most affected (19 per cent). Extended resection led to tumour upstaging in 17 patients (23 per cent); two patients had isolated positive subcarinal nodes and 15 other tumours became M1a owing to positive nodes near the coeliac axis, hepatic artery or splenic artery. Tumour positivity in paratracheal or aortopulmonary nodes occurred in 8 per cent of patients, without influencing staging. Conclusion Extended en bloc lymphadenectomy altered staging in 17 of 74 patients (23 per cent) with adenocarcinoma of the oesophagus or cardia, mainly into M1a owing to positive coeliac nodes (20 per cent). Presented in abstract form to United European Gastroenterology Week, Brussels and the British Association of Surgical Oncology, London, November 2000. [ABSTRACT FROM AUTHOR]

Summary Background After Nissen fundoplication, troublesome dysphagia develops in 5–10 per cent of patients. The mechanism of dysphagia has not been fully resolved, in spite of a number of studies focusing on oesophageal motility and lower oesophageal sphincter (LOS) dynamics. Tightness and length of the wrap have had considerable attention, without giving a fully satisfactory explanation of the pathophysiological mechanism. Methods Eighteen patients with persistent dysphagia after Nissen fundoplication needing reoperation were studied. Eighteen patients, matched for age and sex, without dysphagia after Nissen fundoplication were used as controls. Reoperation consisted of conversion of a 360° into a 270° wrap. Barium swallow, endoscopy, oesophageal manometry and 24-h pH monitoring were performed before and after (re)operation. Results Peristaltic amplitude, velocity and duration of contraction were not significantly influenced by operation. In 16 of 18 patients with dysphagia, LOS relaxation was incomplete and the residual relaxation pressure was significantly higher than that in the group without dysphagia (P < 0·01). No correlation was found between LOS pressure and peristaltic amplitude, nor between LOS pressure and ramp pressure in the distal oesophagus. After reoperation, basal LOS pressure decreased significantly (P < 0·01) and LOS relaxation was complete in all but three patients; residual relaxation pressure decreased (P < 0·01) and was significantly lower than that after uncomplicated Nissen fundoplication. In the latter group, LOS pressure, residual relaxation pressure and ramp pressure increased significantly after operation (P < 0·01). Conclusion A return to complete LOS relaxation and a decrease in residual relaxation pressure play an important role in resolving dysphagia. [ABSTRACT FROM AUTHOR]

Summary Background Oesophageal cancer carries a poor prognosis. The 5-year survival rate following resection ranges from 10 to 35 per cent. Recent evidence suggests that the addition of non-surgical treatments to surgery may improve resection rates, reduce the risk of recurrence and improve survival. This review examines the role of preoperative chemoradiotherapy (CRT) in oesophageal cancer. Methods A Medline-based literature review (1980–2000) was performed using the key words ‘neoadjuvant or preoperative’ and ‘chemoradiotherapy or radiochemotherapy’. Additional literature was obtained from original papers and published meeting abstracts. Results Forty-six non-randomized and six randomized trials of preoperative CRT were found. Resection rates, pathological complete response (pCR), treatment-related mortality rates and relapse patterns are documented. Improved 5-year survival rates approaching 60 per cent may be achieved following pCR. Three of the six randomized trials show a benefit in either overall survival or disease-free survival compared with surgery alone. Treatment-related toxicity can be significant. Conclusion Preoperative CRT may improve survival. Emerging evidence suggests that CRT alone can achieve similar survival rates to surgery alone. New imaging modalities may help to select which patients require surgery. Larger randomized trials of preoperative CRT or chemotherapy are needed to define optimal regimens and produce higher pCR rates with acceptable toxicity. [ABSTRACT FROM AUTHOR]

Summary Background The purpose of this study was to investigate whether the presence of lymph node micrometastasis in pathological lymph node-negative (pN0) oesophageal squamous cell carcinoma had prognostic value. Methods Some 1840 lymph nodes were obtained from 50 patients with pN0 oesophageal squamous cell carcinoma who underwent curative resection of the primary tumour with systematic lymphadenectomy. These lymph nodes were examined immunohistochemically with anticytokeratin antibody (AE1/AE3). Lymph node micrometastases newly detected by immunohistochemistry were classified as micrometastasis. Additionally, lymph node micrometastases were classified into three stages: stage 1, one individual AE1/AE3-positive cell; stage 2, multiple individual positive cells; stage 3, one or multiple positive clusters. Results Micrometastases were detected in 20 patients (40 per cent). A higher stage of micrometastasis was associated with greater pathological tumour (pT) size (P = 0·023). Recurrent tumours developed in nine patients. However, the frequency of recurrence was similar in patients with, or without, micrometastasis (five of 20 and four of 30 patients respectively; P = 0·25). Twenty-three of 30 patients without micrometastasis survived, whereas 15 of 20 patients with micrometastasis were still alive (5-year overall survival 75 and 78 percent respectively, P = 0·91). Twenty-six of 30 patients without micrometastasis had no recurrence, whereas 15 of 20 patients with micrometastasis had no recurrence (5-year relapse-free survival 86 and 73 per cent respectively, P = 0·37). There was no significant difference in prognosis with respect to the stages of micrometastasis. Multivariate analysis also showed that micrometastasis was not an independent prognostic factor (P = 0·73). Conclusion Immunohistochemical detection of lymph node micrometastasis may be an indicator of lymphatic dissemination of tumour cells. However, the... [ABSTRACT FROM AUTHOR]

Summary Background The aim of the study was to identify all patients who presented with oesophagogastric malignancy within a single National Health Service region (Wales) over 1 year, and to follow the cohort for 5 years. Management and outcome were analysed to identify current practice and draft guidelines for Wales. Methods Patients were identified from hospital records. Details were recorded in structured format for analysis. Results Analysable data were obtained for 910 of 916 patients. The overall incidence was 31·4 per 100 000 population. Treatment was by resection 298 (33 per cent), palliation 397 (44 per cent) or no treatment 215 (24 per cent). The 30-day mortality rate was 12 per cent and the in-hospital mortality rate was 13 per cent. Some 226 patients (25 per cent) were alive at 2 years. Resection conferred a significant survival advantage over palliation (P < 0·001) and no treatment. Anastomotic leakage occurred in 16 patients (5 per cent), of whom eight died in hospital. ‘Open and close’ operations were common (23 per cent), laparoscopy was infrequent (16 per cent), and many surgeons undertook small caseloads. Operating on fewer than six patients per year increased the mortality rate after partial gastrectomy (P < 0·05) and was associated with a trend to a higher mortality rate after mediastinal and cardia surgery. Operating on more than 70 per cent of patients seen resulted in a significantly higher mortality rate (P < 0·01) irrespective of case volume. Conclusion Tumour resection conferred a survival advantage. Wider use of laparoscopy is advocated. Improved selection for surgery should result in a lower mortality rate. [ABSTRACT FROM AUTHOR]

Summary Background Primary thrombosis and chronic allograft nephropathy are important causes of early and late graft loss, respectively, following renal transplantation. This study examined the potential for aspirin therapy to reduce these complications. Methods A consecutive series of 105 cadaveric renal transplants treated with aspirin 150 mg daily for the first 3 months after transplantation was compared with an untreated historical control group (n = 121). Protocol needle-core biopsies were performed on all transplants in both groups at 1 week and 12 months after transplantation. Needle-core allograft biopsies were performed at 3, 6 and 12 months after transplantation, and serum creatinine was measured at each outpatient attendance for the duration of follow-up. Results There was a significantly lower rate of primary allograft thrombosis in patients treated with aspirin (none of 105) compared with that in the control group (six (5 per cent) of 121; P = 0·03). There were no differences in renal function or 2-year allograft survival between the two groups. Aspirin-treated patients had a lower incidence of chronic allograft nephropathy at 1 year than controls although this did not reach statistical significance (16 versus 26 per cent; P = 0·075). There were no major bleeding complications in either group in association with peptic ulcer disease or following renal transplant biopsy. Conclusion Aspirin reduced the rate of early graft thrombosis of renal transplants in this series but did not improve renal function or graft survival. A trend towards a lower rate of chronic allograft nephropathy was noted with aspirin treatment. These findings require confirmation in a prospective randomized trial. [ABSTRACT FROM AUTHOR]

Background: Adenocarcinomas of the distal third of the oesophagus and the gastric cardia have similar characteristics but different staging criteria are being used. In the present study the question is addressed whether these tumours should be regarded and staged as one clinical entity. Methods: From January 1987 to January 1997, 252 patients with an adenocarcinoma of the oesophagus (n = 111) or gastric cardia (n = 141) underwent transhiatal resection. Pathology, pathological tumour node metastasis (pTNM) stage and survival were analysed retrospectively, and a comparison was made between tumours of the oesophagus and gastric cardia. Results: Barrett’s epithelium was diagnosed in 54 per cent of oesophageal adenocarcinomas compared with 13 per cent of adenocarcinomas of the gastric cardia (P < 0·001). Oesophageal carcinomas had a more favourable pT stage, fewer positive locoregional lymph nodes (pN1–2 56 versus 62 per cent; P = 0·3), but more distant metastases accounted for by positive lymph nodes around the coeliac axis (pM1 19 versus 4 per cent; P < 0·001). Five-year overall survival (26 versus 27 per cent; P = 0·9) and survival according to tumour stage were no different between the groups. Multivariate analysis showed that the location of the primary tumour was not an independent prognostic factor. Conclusion: Adenocarcinomas of the distal oesophagus and gastric cardia should be regarded as one clinical entity. Uniform staging criteria for both malignancies are recommended. [ABSTRACT FROM AUTHOR]