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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.)

Background: Feeding jejunostomy is frequently performed in patients undergoing oesophageal surgery, but can lead to serious complications. This prospective randomized trial compared the efficacy and complications of feeding jejunostomy with those of nasoduodenal tube feeding in oesophageal surgery., Methods: Over an 18-month period, 150 consecutive patients undergoing oesophageal resection were randomized to participate in the trial. Enteral access was by jejunostomy in 79 patients and by nasoduodenal tube in 71. Enteral feeding was started on the first day after surgery., Results: Full enteral feeding took 3 days to be established in both groups. Minor catheter-related complications occurred in 28 patients (35 per cent) in the jejunostomy group, and in 21 (30 per cent) in the nasoduodenal group (P = 0.488). One patient had jejunostomy leakage that required reoperation. Enteral nutrition was given for a median of 11 days in the jejunostomy group and for 10 days in the nasoduodenal group. Nine patients who had a jejunostomy and five with a nasoduodenal tube did not tolerate full enteral feeding (P = 0.411)., Conclusion: Nasoduodenal tube feeding is safe and efficient after oesophageal resection., (Copyright 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: The extent to which adenocarcinoma of the cardia with lymph node metastasis in the upper mediastinum is amenable to cure by radical surgery is open to debate. It remains unclear whether these relatively distant metastases have an effect on long-term survival. The aim of this study was to identify the incidence of such positive nodes and evaluate their prognostic significance., Methods: Some 50 patients with adenocarcinoma of the gastric cardia and substantial invasion of the oesophagus (junctional type II), who underwent an extended transthoracic oesophagectomy as part of a prospective randomized trial between 1994 and 2000, were studied., Results: Eleven patients (22 per cent) had lymph node metastasis in the proximal field of the chest. These patients had more positive nodes overall (P = 0.020) and a shorter median survival (P = 0.009) than those without such metastasis. Multivariate analysis identified positive nodes in the proximal field as an independent predictor of poor survival., Conclusion: 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.

Background: The unknown natural history and risk of complications of large haemangiomas may pose therapeutic dilemmas. The authors describe their experience with the management of giant haemangiomas., Methods: Patients with a giant haemangioma were identified by a survey of the hospital database. Forty-nine patients with a haemangioma of at least 4 cm in diameter presented between January 1990 and December 2000. Medical records were analysed retrospectively., Results: Eleven patients had surgical treatment and 38 were managed conservatively. The median diameter of the tumours was 8.0 cm in surgically treated patients and 6.0 cm in the group managed by observation. Surgery-related morbidity occurred in three patients, and abdominal complaints persisted in three of ten patients with a symptomatic lesion. During a median follow-up of 52 months, 12 non-operated patients had mild abdominal complaints, considered to be unrelated to the lesion. In these patients symptoms either diminished or became minimal during follow-up. Complications did not occur., Conclusion: Observation of giant haemangiomas can be performed safely. The authors advocate resection of cavernous liver haemangiomas only in patients with persistent severe symptoms.

Background: Although studies have shown that early oral feeding after abdominal surgery is feasible, many surgeons still advocate a careful, slow introduction of postoperative oral feeding. This study was conducted to investigate whether patient-controlled postoperative feeding is possible in patients undergoing colonic or aortic surgery., Methods: A randomized clinical trial compared patient-controlled postoperative oral feeding (PC group) with a fixed regimen (FR group). Patients in the PC group (n = 56) received oral feeding when they requested it; patients in the FR group (n = 49) started a normal diet on day 5. Endpoints were time to tolerance of a diet similar to the preoperative diet, reinsertion of a nasogastric tube, complications and duration of hospitalization., Results: Median time to resumption of a normal diet was 3 days in the PC group and 5 days in the FR group (P < 0.001). Reinsertion of a nasogastric tube was required in nine patients in each group (P not significant). The incidence of complications was similar in both groups: 12 of 56 in the PC group and 13 of 49 in the FR group. There was no significant difference in duration of hospital stay between the groups., Conclusion: Most patients tolerate a normal diet on the third day after operation. Patient-controlled postoperative feeding is safe and leads to earlier resumption of a normal diet.

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).

Background: As the morbidity and mortality rates associated with emergency resection in patients with a ruptured hepatocellular adenoma are high, the authors have favoured initial non-operative management in haemodynamically stable patients., Methods: A retrospective study was performed to evaluate the treatment of ruptured hepatocellular adenoma., Results: Over a 21-year interval, 12 patients presented with a ruptured hepatocellular adenoma. Haemodynamic observation and support was the initial management in all 12 patients. Three underwent urgent laparotomy and gauze packing because of haemodynamic instability; no emergency liver resection was necessary. Eight patients had definitive surgery; three developed postoperative complications but none died. Regression of the tumour was observed in three of four patients treated conservatively., Conclusion: The initial management of a ruptured hepatocellular adenoma should be haemodynamic stabilization. Definitive resection is required for rebleeding or for tumours exceeding 5 cm in diameter. A conservative approach may well be justified in case of regression of an asymptomatic adenoma.

Background: Photosensitized patients are exposed to bright lights when undergoing intraoperative photodynamic therapy or fluorescence measurements. Acrylate yellow filters might reduce unwanted tissue damage., Methods: To investigate the protective value of these filters, the spectral power distribution of the operating lights and light energy densities with and without an acrylate yellow filter were measured. Subsequently the effects of light exposure on the survival of a human hepatocellular carcinoma cell line and the photodamage induced in pig tissues after the administration of 5-aminolaevulinic acid were also studied., Results: The light energy density in the ultraviolet and blue region of the light spectrum emitted by the operating light was reduced up to 50 per cent by the acrylate yellow filter. The survival of photosensitized cells was longer and photodamage induced in pig tissues was less when exposed to filtered light., Conclusion: Photodamage induced by operating lights can be reduced by filtering out ultraviolet and blue light by means of acrylate yellow filters.

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.

Background: After potentially curative resection of oesophageal cancer and prevertebral gastric tube reconstruction, approximately one-quarter of patients develop secondary dysphagia due to locoregional recurrence. In half of them dysphagia can be prevented by using an extra-anatomical reconstruction route. The present randomized study was conducted to compare the technical and functional results after prevertebral and retrosternal gastric tube reconstruction., Methods: Sixty patients underwent resection of a carcinoma of the oesophagus or gastro-oesophageal junction with curative intent. Subsequently, these patients were randomly allocated to either prevertebral (n = 30) or retrosternal (n = 30) gastric tube reconstruction. Early and late complications and functional results were carefully monitored., Results: Creation of the retrosternal tunnel was not accompanied by any perioperative complications. Postoperative recovery, anastomotic leakage and benign stricture formation were not significantly different between the two groups. Functional results, as measured by scintigraphic gastric emptying, quantitative and qualitative oral food intake, and changes in body-weight were similar in the two groups., Conclusion: After subtotal oesophagectomy retrosternal gastric tube reconstruction can be performed easily and safely, and gives functional results similar to those obtained with prevertebral reconstruction. In patients at high risk for developing secondary malignant dysphagia the extra-anatomical route is the reconstruction of first choice.

Background: The ideal method for staging tumours of the oesophagus and gastric cardia is not known. This paper was designed to assess the value of laparoscopy and laparoscopic ultrasonography in the staging of oesophageal and cardial carcinoma., Methods: From October 1993 to January 1996, 60 patients in whom no metastases were seen on gastroscopy, ultrasonography of the abdomen and supraclavicular region, helical computed tomography of the chest and abdomen or endosonography were scheduled for laparoscopy and laparoscopic ultrasonography., Results: Some 40 patients had carcinoma of the oesophagus, in one of whom liver metastases were found at laparoscopy and proven histologically. On laparoscopic ultrasonography metastases were found in four patients but were impossible to biopsy. These lymph node metastases were confirmed at exploratory laparotomy. Twenty patients had carcinoma of the gastric cardia; distant metastases were found in four at laparoscopy. On laparoscopic ultrasonography metastases were present in four further patients, all proven by biopsy., Conclusion: In this study laparoscopy was not an effective staging technique for oesophageal carcinoma. The inclusion of laparoscopic ultrasonography was of little benefit. A problem that was encountered was biopsy under laparoscopic guidance. In carcinoma of the gastric cardia, laparoscopy was more effective; adding laparoscopic ultrasonography doubled the number of patients seen to have metastatic disease.

Budd-Chiari syndrome is the generic term for different forms of hepatic venous outflow obstruction resulting in a clinical picture of portal hypertension and hepatomegaly. Three levels of venous outflow obstruction may be recognized, affecting respectively the small intrahepatic (IVC). Each level of obstruction is related to a different aetiology. Clinical manifestations range from mild symptoms to acute or chronic end-stage liver disease. Treatment is surgical in the great majority of patients. Occlusion of the IVC may be treated by removal of the caval obstruction in selected patients. Hepatic outflow obstruction may be circumvented by different forms of shunting from the portal or upper mesenteric vein to the IVC or right atrium, depending on the level of obstruction and the difference in venous pressure. For the rare patient presenting with acute or chronic end-stage liver failure, hepatic transplantation may be a life-saving procedure.

The recurrence pattern after 'limited' resection for oesophageal carcinoma was analysed to determine whether more extensive local excision of tumour in combination with radical lymphadenectomy improves locoregional disease control and long-term survival. A total of 143 patients who underwent limited surgery with curative intent between 1983 and 1989 were studied: 90 with squamous cell carcinoma (group 1) and 53 with adenocarcinoma (group 2) of the thoracic oesophagus. One patient was lost to follow-up. Tumour recurrence occurred in 40 patients (44 per cent) in group 1 and 35 (66 per cent) in group 2. Locoregional recurrence in isolation occurred in 11 per cent of patients in group 1 and 8 per cent of those in group 2; locoregional recurrence was detected in combination with tumour elsewhere in 19 and 28 per cent respectively. In conclusion, one-third of patients at the most might potentially have benefited from more radical local tumour resection. Theoretical advantages such as a prolonged disease-free interval and definite cure should be weighed against the higher risk of serious complications. More extensive procedures should therefore be performed only in controlled clinical studies.

Perforation of the oesophagus was retrospectively analysed in 59 patients. Cause and extent of perforation, localization, quality of the oesophageal wall and therapeutic modes were subjected to univariate analysis. The perforations of the intrathoracic oesophagus (39) were also subjected to multivariate analysis. Perforation of the cervical oesophagus is seldom lethal and can be adequately treated conservatively in the majority of cases. Perforations of the intrathoracic oesophagus can be divided into two groups, with or without simultaneous perforation of the parietal pleura. The optimal treatment for the group with pleural perforation seems to be resection of the oesophagus and secondary reconstruction, although primary closure is indicated in selected early cases. Perforations of the intrathoracic oesophagus confined to the mediastinum can be adequately treated conservatively in most patients. Perforation of the intra-abdominal oesophagus should be treated like any other intra-abdominal visceral perforation, by closure or diversion, even if this results in resection of the oesophagus.

During a 7-year period 20 patients underwent operation for a graft-enteric fistula after implantation of an intra-abdominal vascular prosthesis months or years before. Eighteen patients had gastrointestinal blood loss as their first symptom; 12 were in shock on admission. Fourteen patients had a fistula between the proximal anastomosis and the duodenum. Graft excision followed by axillobifemoral bypass was performed in 10 patients and four patients underwent local repair. A fistula between the distal anastomosis and the bowel was found in the remaining six patients and a local repair was carried out. Proximal graft-enteric fistula carries a particularly high postoperative mortality rate of more than 50 per cent.