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This study compared the outcome between patients who had an open and those who had a hybrid esophagectomy for T1 or T3 esophageal adenocarcinoma (eAC). No clear data are available concerning this question based on T-category. Two groups of patients with esophagectomy and high intrathoracic esophagogastrostomy for eAC were analyzed: hybrid (laparoscopy + right thoracotomy) (n = 835) and open (laparotomy + right thoracotomy) (n = 188). Outcome criteria were 30- and 90-day mortality, R0-resection rate (R0), number of resected lymph nodes (rLNs), and 5-year survival rate (5y-SR). For each type of surgery, three patient groups were analyzed: pT1-carcinoma (group-1), cT3Nx and neoadjuvant chemoradiation (group-2), and pT3N0-3 without neoadjuvant therapy (group-3). The comparison was based on a propensity score matching in relation of 1:2 for open versus hybrid. In group-1 (38 open vs 76 hybrid) R0-resection (100%), 30-day mortality (0%), 90-day mortality (2.6% vs 0%), and rLNs (median 29.5 vs 28.5) were not significantly different. The pN0-rate was 76% in the open and 92% in the hybrid group (p = 0.036). Accordingly, the 5y-SR was 69% and 87% (p = 0.016), but the prognosis of the subgroups pT1pN0 or pT1pN+ was not significantly different between open or hybrid. In group-2 (68 open vs 135 hybrid) R0-resection (97%), 30-day (0% vs 0.7%) and 90-day (4%) mortality, rLNs (28.5 vs 26), and 5y-SR (36% vs 41%) were not significantly different. In group-3 (37 open vs 75 hybrid) R0, postoperative mortality, rLNs, and 5y-SR were not significantly different. In a propensity score–matched comparison of patients with an open or hybrid esophagectomy for esophageal adenocarcinoma the quality of oncologic resection, postoperative mortality and prognosis are not different.

Background This study was conducted to validate a pretreatment (i.e. prior to neoadjuvant chemoradiotherapy) pathological staging system in the resection specimen after neoadjuvant chemoradiotherapy for esophageal cancer. The study investigated the prognostic value of pretreatment pathological T and N categories (prepT and prepN categories) in both an independent and a combined patient cohort. Methods Patients with esophageal cancer treated with neoadjuvant chemotherapy and esophagectomy between 2012 and 2015 were included. PrepT and prepN categories were estimated based on the extent of tumor regression and regressional changes of lymph nodes in the resection specimen. The difference in Akaike’s information criterion (ΔAIC) was used to assess prognostic performance. PrepN and ypN categories were combined to determine the effect of nodal sterilization on prognosis. A multivariable Cox regression model was used to identify combined prepN and ypN categories as independent prognostic factors. Results The prognostic strength of the prepT category was better than the cT and ypT categories (ΔAIC 7.7 vs. 3.0 and 2.9, respectively), and the prognostic strength of the prepN category was better than the cN category and similar to the ypN category (ΔAIC 29.2 vs. − 1.0 and 27.9, respectively). PrepN + patients who became ypN0 had significantly worse survival than prepN0 patients (2-year overall survival 69% vs. 86% in 137 patients; p = 0.044). Similar results were found in a combined cohort of 317 patients (2-year overall survival 62% vs. 85%; p = 0.002). Combined prepN/ypN stage was independently associated with overall survival. Conclusions These results independently confirm the prognostic value of prepTNM staging. PrepTNM staging is of additional prognostic value to cTNM and ypTNM. PrepN0/ypN0 patients have a better survival than prepN +/ypN0 patients.

Aims Neoadjuvant chemoradiation reduces tumour volume and improves the R0 resection rate, followed by extended survival for patients with advanced oesophageal cancer. The degree of tumour regression has high prognostic relevance. To date, there is still no generally accepted tumour regression grading system. The aim of this study was to compare the prognostic discrimination power of different histological regression grading systems: (i) the fibrosis/tumour ratio within the primary tumour (Mandard classification), (ii) the percentage of residual vital tumour cells (VTC) compared to the original primary tumour (Cologne Regression) and (iii) the ypT category, in patients with cT3 carcinoma of the oesophagus after neoadjuvant chemoradiation. Methods and results This study included 216 patients with oesophageal cancer clinically staged as cT3NxM0 and treated from 2009 to 2012 with standardised chemoradiation followed by oesophagectomy [median age 62 years, 176 (81%) male and 138 (64%) adenocarcinoma patients]. The subgroup frequencies of the three classification systems were ypT category: ypT0 = 18%, ypT1 = 14%, ypT2 = 23%, ypT3 = 44%, ypT4 = 1%; Mandard classification: TRG1 = 18%, TRG2 = 26%, TRG3 = 24%, TRG4 = 30%, TRG5 = 2%; and Cologne Regression Scale: no tumour = 18%, 1-10% VTC = 27%, 10-50% VTC = 26% and >50% VTC = 29%. The Mandard and Cologne Regression classifications showed better prognostic differentiation for the subgroups than the ypT category. The four-tiered Cologne Regression system had a good prognostic relevance. Comparing results of the re-evaluated Cologne Regression classification with the classification by routine pathological report showed very good inter-rater agreement, with kappa value 0.891. Conclusion Compared to the original primary tumour, the tumour regression grading system using the percentage of residual vital tumour has prognostic relevance.

Therapeutic decisions in esophageal adenocarcinomas (EAC) restricted to mucosa (pT1a) or submucosa (pT1b) depend mainly on classic histomorphology-based criteria like tumor grading or lymphovascular invasion with limited success. There is a strong need for reliable pre-therapeutical biomarker-based evaluation also applicable on endoscopically obtained biopsies. Patients who underwent esophagectomy due to EAC in a high volume center between 1999 and 2016 were included. Tissue microarrays (TMA) were retrospectively established from the formalin-fixed and paraffin-embedded material of the resected specimens and immunohistochemically stained using a monoclonal primary antibody specific for IMP3. IMP3 staining intensity was scored manually according to a 3-tier-scoring system (negative, weak and strong). 371 EACs were interpretable for analysis. 109 patients (29%) had early invasive (pT1a/pT1b) and 262 patients (71%) locally advanced EAC (> pT2). 259 EACs (70%) revealed positive immunostaining for IMP3 including 167 strongly and 92 weakly positive. Early EAC had significantly lower IMP3 expression compared to advanced tumor stages (p

Esophageal cancer is the eighth most common cancer globally and has the sixth worst prognosis because of its aggressiveness and poor survival. Data regarding cancer treatment in older patients is limited because the elderly have been under-represented in clinical trials. Therefore, we reviewed the existing literature regarding treatment results for elderly patients (70+ years). Areas covered: We used pubmed to analyze the actual literature according to elderly esophageal cancer patients with subheading of incidence, esophagectomy, chemoradiation or chemotherapy. The main points of interest were treatment options for patients with Barrett's esophagus or early carcinoma, advanced tumor stages, and inoperable cancer. Expert opinion: The incidence of esophageal cancer has been increasing over the past thirty years, with a rapid increase of esophageal adenocarcinoma in Western industrialized nations. Patients aged over 60 years have been particularly affected. In this review, we have shown that elderly patients with esophageal cancer have various alternatives for adequate treatment. Clinical evaluation of comorbidity is necessary to make treatment decisions. Therapeutic options for early carcinomas are endoscopic or surgical resection. For elderly patients with advanced carcinomas, preoperative chemoradiation or chemotherapy should be discussed.

Delayed gastric emptying after esophagectomy with gastric replacement can pose a significant postoperative problem, often leading to aspiration and pneumonia. The present study analyzes retrospectively the effectiveness of endoscopic pyloric dilatation for post-surgical gastric outlet obstruction. Between March 2006 and March 2010, 403 patients underwent a transthoracic en-bloc esophagectomy and reconstruction with a gastric tube and intrathoracic esophagogastrostomy. In patients with postoperative symptoms of an outlet dysfunction and the confirmation by endoscopy, pyloric dilatations were performed without preference with either 20- or 30-mm balloons. A total of 89 balloon dilatations of the pylorus after esophagectomy were performed in 60 (15.6 %) patients. In 21 (35 %) patients, a second dilatation of the pylorus was performed. 55 (61.8 %) dilatations were performed with a 30-mm balloon and 34 (38.2 %) with a 20-mm balloon. The total redilatation rate for the 30-mm balloon was 20 % (n = 11) and 52.9 % (n = 18) for the 20-mm balloon (p

Respiratory complications are responsible to a high degree for postoperative morbidity and mortality after Ivor-Lewis esophagectomy. The etiology of respiratory failure is known to be multifactorial with preoperative impaired lung function being the most important one. The aim of this study was to investigate the correlation between preoperative airway colonization (PAC) and postoperative respiratory complications.In this observational study, 64 patients with esophageal cancer were included. All patients underwent Ivor-Lewis esophagectomy with laparoscopic or open gastric mobilization. After induction of anesthesia and intubation with a double-lumen tube, bronchial exudate was collected by random endoluminal suction for further microbiological work-up. Length of postoperative mechanical ventilation (24 h, 24-72 h,72 h), re-intubation, and tracheostomy were recorded as primary and secondary study endpoints.In 13 of 64 study patients (20.3 %), pathological colonization of the bronchial airways could be proved prior to esophagectomy. Haemophilus species was the most frequently identified pathogen. PAC was associated with a longer history of smoking (p = 0.025), a lower preoperative forced expiratory volume (FEV1, p = 0.009) or vital capacity (VC, p = 0.038), a prolonged postoperative mechanical ventilation (p 0.001), and a higher frequency of re-intubation (p 0.001) and tracheostomy (p = 0.017). In the multivariate analysis, PAC was identified as an independent predictor of respiratory failure (hazard ratio 11.4, 95 % confidence interval 2.6-54, p = 0.002). Mortality in the PAC group was 30.8 % compared to 0 % in patients without PAC (p 0.0001).PAC is a significant risk factor for postoperative respiratory failure. A routine bronchoscopy and bronchoalveolar lavage as part of preoperative management prior to esophagectomy need to be discussed.

The role of glucose transporter 14 (GLUT-14/SLC2A14) in tumor biology is entirely unknown, and the significance of hypoxia inducible factor 1-alpha (HIF1-α) for gastric adenocarcinoma is controversial. The impact of GLUT-1/SLC2A1 has never been confirmed in a Caucasian cohort. Between 1996 and 2007, 124 patients underwent gastrectomy for gastric adenocarcinoma. Tumor sections were incubated with GLUT-1, GLUT-14, and HIF1-α antibodies. Expression was analyzed for correlations with histopathology, marker coexpression, and patient survival by uni- and multivariate analyses. Expressions of GLUT-1, GLUT-14, and HIF1-α were detectable in 50, 77.4, and 27.1 %, respectively. Expression of GLUT-1 was associated with pT-category (p = 0.019), pN-category (p = 0.019), tubular (WHO, p = 0.008), and intestinal (Lauren classification; p = 0.002) histologic subtypes. Expression of GLUT-14 was correlated with pT category (p = 0.043), whereas HIF1-α did not show any correlation with histopathology or survival. The median survival period was 14 months (95 % confidence interval [CI] 9.2–18.8 months) for GLUT-1-positive patients and 55 months (95 % CI 25.8–84.2; p = 0.01) for GLUT-1-negative patients. An inferior prognosis also was seen for GLUT-14-positive cases compared with GLUT-14-negative cases (p = 0.004). Thus, worst survival was seen with both GLUT-1- and GLUT-14-positive expression followed by single-positive and then double-negative cases (p = 0.004). In multivariate analysis including International Union Against Cancer (UICC) stages, R category, Lauren classification, surgery alone versus neoadjuvant/perioperative chemotherapy, and marker expression as covariates, GLUT-1 (p = 0.011) and GLUT-14 (p = 0.025) kept their prognostic independence. The study findings suggest that detection of GLUT-1 and GLUT-14 is of high prognostic value. It gives additional information to UICC stages and identifies patients with inferior prognosis. If confirmed in prospective studies, these markers need to be considered for future classification systems.

The prognostic effect of neoadjuvant treatment in advanced oesophageal cancer is still debated because most studies included undefined T-stages, different radio/chemotherapies or different types of surgery.To analyse the prognostic impact of neoadjuvant chemoradiation in patients with clinical T3 oesophageal cancer and oesophagectomy.In a retrospective study 768 patients from two centres with cT3/Nx/M0 oesophageal cancer and transthoracic en-bloc oesophagectomy were selected. Clinical staging was based on endoscopy, endosonography and spiral-CT scan. Propensity score matching using histology, location of tumour, age, gender and ASA-classification identified 648 patients (n=302 adenocarcinoma (AC), n=346 squamous cell carcinoma (SCC)) for the intention-to-treat analysis comparing group-I (n=324) patients with planned oesophagectomy and group-II (n=324) patients with planned neoadjuvant chemoradiation (40Gy, 5-FU, cisplatin) followed by oesophagectomy. The prognosis was analysed by univariate and multivariate analyses.In the intention-to-treat analysis group-I had a 17% and group-II a 28% 5-year survival rate (5-YSR) (p0.001). After excluding patients without oesophagectomy the 5-YSR of group-II increased to 30%. The results were more favourable for patients with AC (5y-SR of 38%) compared to SCC (22%) (p=0.060). In group-II patients with major response (n=128) had a 41% 5-YSR compared to 20% for those with minor response (n=155, p0,001). In multivariate analysis neoadjuvant chemoradiation was a favourable independent prognostic factor.Neoadjuvant chemoradiation followed by oesophagectomy results in 11% higher 5-YSR than surgery alone for patients with cT3/Nx/M0 oesophageal cancer. This effect is due to the substantial prognostic benefit of the major responders.

Die Erfassung von Lebensqualitat (LQ) ruckt immer mehr in den Vordergrund der klinischen Forschung. Dies zeigt sich anhand der jahrlich steigenden Anzahl von Publikationen zu diesem Thema. Ziel der Arbeit ist es, aktuelle Daten zur LQ nach viszeralchirurgischen Eingriffen darzustellen und zu bewerten. Beispielhaft werden die Ergebnisse fur je zwei maligne bzw. benigne viszeralchirurgische Krankheitsbilder dargestellt. Fur Patienten mit Tumorerkrankungen ist die Beurteilung der LQ nur in Abhangigkeit der Prognose moglich. Prospektiv randomisierte Studien beim Fruhkarzinom des Magens zum Vergleich der laparoskopischen vs. offenen Verfahren liegen aus dem asiatischen Raum vor. Daten aus den USA zeigen, dass die LQ unabhangig vom Operationsverfahren beim Magenkarzinom in der Zeit nach der Operation deutlich reduziert ist. Die LQ besserte sich bei einem Teil dieser Patienten innerhalb des ersten halben Jahres, bestand aber auch noch bei einem Drittel der Patienten nach langerer Zeit. Die Operation beim Pankreaskarzinom scheint auch bei einer R1-Resektion einen Vorteil hinsichtlich der LQ zu bringen. Fur Eingriffe bei benignen Erkrankungen wie Cholezystektomie oder Hernienoperationen sind die Fragestellungen anders und bringen nicht immer einheitliche Ergebnisse.

The aim of this study was to analyze the incidence and impact of extracapsular lymph node spread (ELNS) in pancreatic cancer (PC) and cancer of the papilla of Vater (CPV).Between 2004 and 2009, 148 patients underwent surgical therapy for PC (n = 112) and CPV (n = 36). The resected lymph nodes (LNs) were further analyzed for ELNS.In 95 (64.2%) patients, LN metastasis was present. In 45 (47.3%) of these patients, an ELNS was present on histopathology. The patients' survival was negatively affected by ELNS. For PC, the 5-year survival rate was 37% for patients with no LN metastasis compared with 4% and 0% for patients with LN metastasis (pN1) but without extracapsular LN involvement and patients with pN1 disease with extracapsular LN involvement of at least 1 LN, respectively (P0.001). In patients with CPV, the 5-year survival rate was 56% for patients with no LN metastasis and 44% and 0% for patients with pN1 disease but without extracapsular LN involvement and patients with pN1 disease with extracapsular LN involvement of at least 1 LN, respectively (P = 0.006). Multivariate analysis revealed ELNS as an independent prognostic factor of survival for both tumor types.Extracapsular LN spread is an independent negative prognostic factor in PC and CPV. In future staging systems, ELNS should be included.

Background There is an increasing trend to include patients with esophageal carcinoma invading the muscularis propria (pT2) in neoadjuvant therapy regimens. But it is unclear which patients have prognostic benefit from this strategy. The aim of this study was to assess the prognosis and prognostic factors in patients with pT2 esophageal adenocarcinoma to further optimize treatment strategies. Methods Included were patients with pT2 esophageal adenocarcinoma treated operatively at three centers specializing in upper gastrointestinal surgery. There were 159 patients (139 male) without induction therapy; median age was 64.5 years. Survival was analyzed by univariate and multivariate analysis. Results In 37% of patients (n = 59), no lymph node involvement (pN0) was detected. Overall 5-year survival rate for all patients was 37%; for pN0 patients it was 62%, and for patients with lymph node metastases (pN+) it was 24%. Median number of examined lymph nodes was 26. Extracapsular lymph node involvement (ELNI) was evident in 55 of 100 pN+ patients with a 5-year survival rate of 14%. Patients without ELNI had a 5-year survival rate of 36% ( p = 0.041). Results were comparable in all participating hospitals. Thirty-day and 90-day mortality rates of the entire collective were 2.6% and 3.8%, respectively. Multivariate analysis of prognosis revealed the lymph node ratio ( p p = 0.005) as significant parameters (pN0 hazard ratio 1 [reference]; pN+ without ELNI hazard ratio 2.2, 95% confidence interval: 1.2 to 3.8); pN+ with ELNI hazard ratio 2.5, 95% confidence interval: 1.5 to 4.5). Conclusions The prognosis of patients with esophageal adenocarcinoma invading the muscularis propria without lymph node metastasis is very good. However, in this study, about 30% had extracapsular lymph node involvement, which reflects particularly aggressive biological tumor behavior.

To identify possible predictive markers, our study aimed to characterize microRNA (miRNA) profiles of responder and nonresponder in the multimodality therapy of locally advanced esophageal cancer. Initially, a microarray-based approach was performed including eight patients with esophageal cancer. Patients received neoadjuvant chemoradiation followed by surgical resection. Major histopathological response was defined if resected specimens contained less than 10% vital tumor cells (major/minor response: 4/4 patients). Intratumoral RNA was isolated from both, pretherapeutic tissue biopsies in addition to corresponding surgical specimens. The profile of 768 miRNAs was analyzed in 16 specimens (preneoadjuvant and postneoadjuvant therapy). Selected miRNAs were than analyzed on pretherapeutic and post-therapeutic biopsies of 80 patients with esophageal cancer, who underwent multimodality therapy (major/minor response: 30/50 patients). Comprehensive miRNA profiling identified miRNAs in pretherapeutic biopsies that were significantly different between major/minor responders. Based on the microarray results, miR-192, miR-194 and miR-622 were selected and the dysregulated miRNAs were studied on an extended series of esophageal cancer patients. The expression of miR-192, miR-194 and miR-622 was significantly reduced after neoadjuvant therapy confirming the array profiling data. Importantly, the pretherapeutic intratumoral expression of miR-192 and miR-194 was significantly associated with the histopathologic response of esophageal squamous cell carcinoma to multimodal therapeutic treatment. Therefore, in patients with locally advanced esophageal cancer undergoing neoadjuvant chemoradiation followed by esophagectomy, miR-192 and miR-194 in pretherapeutic biopsies are considered as indicators of major histopathologic regression.

Introduction Nodal micrometastasis is a negative prognosticator for esophageal cancer. There is a trend toward endoscopic resection for early cancer of the esophagus without lymphadenectomy. Frequency and prognostic impact of nodal micrometastasis in early cancer of the esophagus have not been investigated so far. Patients and methods This study includes 69 patients with a pT1-stage cancer of the esophagus (SCC: n = 26, AC: n = 43), who underwent transthoracic en-bloc esophagectomy with D2-lympadenectomy between 1996 and 2004. On routine histopathological analysis 48 patients were diagnosed as pN0. Lymph nodes ( n = 1344) of these patients were further examined for the presence of isolated tumor cells with the monoclonal anti-epithelial antibody AE1/AE3. Results In lymph nodes of 7 (14.6%) out of 48 pN0-patients a positive staining for AE1/AE3 as a sign for nodal micrometastasis was found. In these patients the tumor has infiltrated the submucosal layer. In patients with tumors restricted to mucosal layer ( n = 20) no nodal micrometastasis was present. 5-year survival of pN0-patients with nodal micrometastasis was inferior compared to pN0-patients (57% vs. 82%; p = 0.002). Conclusion Almost 15% of patients with pT1 N0 M0 carcinoma of the esophagus and only those with submucosal infiltration show nodal micrometastasis. It has a significant negative impact on survival already in early esophageal cancer.

Background Although studies comparing the surgical treatment of gastric carcinoma in Japan and Western industrialized countries have revealed differing survival rates, no studies to date have been performed comparing Western and Eastern Europe. This study aimed to compare demographics and surgical practice as well as the related prognostic impact on gastric cancer patients treated in Poland and Germany. Methods This retrospective study included gastric cancer patients treated between 1999 and 2004 by surgical departments in Gdansk (Poland) and Cologne (Germany). Univariate and multivariate analyses of demographic, histopathological, surgical, and prognostic data were performed. Results Included were 117 patients from Gdansk and 130 patients from Cologne. The Cologne patients showed higher incidence rates of serious comorbidity, pT1 cancer, and distant metastasis than those from Gdansk. Indications for and frequency of selected surgical procedures differed significantly. D2-lymphadenectomy was performed in 89% of the Cologne patients, while D1-lymphadenectomy was done for 85% of the Gdansk patients. Univariate analysis yielded a 5-year survival rate of 28.3% for the Gdansk patients, and 40.3% for the Cologne patients (p = 0.056). Independent prognostic factors were pT category (p = 0.002), pN category (p

Background Despite improvements in perioperative treatments, the overall survival of patients with esophageal adenocarcinoma (EAC) remains low. In early invasive tumors (pT1) there is striking risk discrepancy for tumors with vascular invasion (L1/V1). As this tumor stage is potentially locally resectable, there is an urgent need for reliable pretherapeutical evaluation. High expression of IMP3 correlates with worse prognosis in colon and gastric cancer. In a small series of 30 patients with EAC, IMP3 is significantly associated with lymphovascular invasion. In our large cohort of EAC, we analyzed the immunohistochemical expression of IMP3 in correlation to clinical data. Methods 371 patients who underwent esophagectomy due to EAC at the Department of General, Visceral and Cancer Surgery, University of Cologne between 1999 and 2012 were included. Tissue Microarrays (TMA) were retrospectively established from the formalin-fixed, paraffin embedded material of the resected specimens and immunohistochemically stained using the primary antibody specific for IMP3. The IMP3 staining intensity was scored manually according to a 3-tier-scoring system (negative, weak and strong). Results TMAs from 371 patients were interpretable for further analysis. 109 patients (29.3%) had superficial EAC (pT1a/pT1b) while 262 (70.7%) showed locally advanced tumors (pT2 or pT3). 67 (26.7%) patients with advanced tumors and all pT1 EAC patients did not receive neoadjuvant therapy (chemotherapy or chemo-radiotherapy) prior to surgery. 259 of the 371 EAC revealed positive immunostaining for IMP3 including 167 strongly and 92 weakly positive. For patients without neoadjuvant therapy, there was a significant trend for higher IMP3 expression in early invasive tumors (pT1a/pT1b) showing significantly higher rates of IMP3 positive tumors compared to locally advanced pT3-tumors without neoadjuvant therapy (P = 0.0015). There was no difference of IMP3 expression according to neoadjuvant therapy in patients with pretreated EAC. There is a statistically significant association between IMP3 protein expression and shortened survival in early invasive pT1-esophageal carcinomas (P = 0.045). Conclusion IMP3 is a feasible marker in early invasive EAC (pT1a and pT1b) and is significantly associated with worse outcome. IMP3 indicates lymph node metastases, advanced infiltration depth and higher tumor grade. Thus IMP3 might be useful for therapeutic decisions in early invasive EAC. Disclosure All authors have declared no conflicts of interest.

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.

Anastomotic leakage is still the major surgical complication following transthoracic esophagectomy with intrathoracic esophagogastrostomy (Ivor-Lewis procedure). Modifications of this standard procedure aim to reduce postoperative morbidity and mortality.In this retrospective analysis of a 12-year period, 419 patients who had an Ivor-Lewis (IL) procedure for esophageal carcinoma were included. Due to modifications of the standard procedure, two different groups were compared with respect to their mortality and anastomotic leakage rate. In 181 patients (43.1%), esophagectomy and gastric reconstruction was performed as a one-stage procedure (classical IL group). Two hundred thirty-eight patients (56.9%) underwent a modified IL procedure that included minimally invasive gastric mobilization and a two-stage operation following ischemic conditioning of the gastric conduit.The hospital mortality rate was lower in the modified IL group without statistical significance (2.9 vs. 6.1%). Thirty-five anastomotic leaks were diagnosed postoperatively, 17 in the classical IL group (9.4%) and 18 in the modified IL group (7.6%). The rate of late leakages (after the 10th postoperative day) was higher in the modified IL group. Septic complications and mortality following anastomotic leakage were less frequent in the modified IL group. Leaks in the classical IL group predominantly required rethoracotomy, whereas leaks of the modified IL group were sufficiently treated with endoscopic stenting.Surgical modifications of the classical IL procedure, including a minimally invasive approach and ischemic conditioning of the gastric conduit, seem to reduce postoperative morbidity and mortality. However, due to the retrospective design of this study, the impact of other factors influencing the outcome cannot be ruled out.

BACKGROUND: Lymphatic spread is 1 of the most relevant prognostic factors for gastric carcinoma. The current International Union Against Cancer (UICC) pN staging system is based on the number of metastatic lymph nodes and does not take into consideration the characteristics of the metastatic lymph nodes itself. The aim of the current study was to examine the prognostic value of extracapsular lymph node involvement in gastric cancer and to find correlations with clinicopathological parameters. METHODS: Tissue samples were obtained from 159 gastric cancer patients who underwent gastrectomy with D2-lymphadenectomy in 142 (89.3%) cases and subtotal gastrectomy with D2-lymphadenectomy in 17 (10.7%) cases. The number of resected lymph nodes, number of metastatic lymph nodes, and number of metastatic lymph nodes with extracapsular lymph node involvement were determined. Extracapsular spread was defined as infiltration of cancer cells beyond the capsule of the metastatic lymph node. RESULTS: Ninety-six (60.4%) patients had lymph node metastasis. In 57 (35.8%) cases, extracapsular lymph node involvement was also detected. Extracapsular lymph node involvement was significantly associated with higher pN-category (P < .001), higher pM category (P = .048), and higher UICC stages (P = .001). According to the Kaplan-Meier log-rank statistical method, extracapsular lymph node involvement was significantly associated with poor survival (P = .001). In the multivariate analysis besides pT (P < .001) and R-category (P = .009), extracapsular lymph node involvement also remained as an independent prognostic factor (P = .003), whereas the UICC pN-category (P = .822) lost its prognostic value. CONCLUSIONS: Extracapsular lymph node involvement is associated with higher tumor stages and is an independent negative prognostic factor in gastric cancer. In future staging systems for gastric cancer, extracapsular lymph node involvement should be considered. Cancer 2010. © 2010 American Cancer Society.

A review of the literature demonstrated that clinical evaluation cannot be used to determine ‘complete response’. The different classification systems of the histopathologic response grading after neoadjuvant radiochemotherapy of esophageal carcinoma are summarized in this report. A systematic review of studies analyzing preoperative chemoradiation of squamous cell carcinoma (SCC) or adenocarcinoma (AC) of the esophagus demonstrated no significant difference in pathologic complete response (pCR) rates between the AC and SCC studies. Analyzing only the applied dose of radiation demonstrated that patients with AC required a higher dose than patients with SCC to achieve complete response. Incorporating chemotherapy administration does not markedly change the difference in required radiation dose. However, when the tumor does respond, the rate of pCR with increasing dosage of chemoradiotherapy increases more rapidly in AC patients than in SCC patients.

Objective: The purpose of this study was to evaluate the frequency of lymph node metastasis according to the depth of tumor infiltration of the mucosa and submucosa. Background Data: Currently some endoscopists extend the indication for endoscopic mucosal resection in gastric cancer to the submucosa. However, the decision between endoscopic mucosectomy or gastrectomy with lymphadenectomy for early gastric cancer depends especially on the probability of lymph node metastasis. Methods: One hundred twenty-six patients either had subtotal resection (n = 29) or total gastrectomy (n = 97) for T1 gastric cancer. The median number of resected lymph nodes was 21 (1-63). In the histopathologic analysis ofthe specimens the tumors were differentiated according to their wall penetration in the upper (ml), middle (m2), lower (m3) third of the mucosa or submucosa (sm1, sm2, sm3). The greatest diameter of the lesions, the Grading and the Goseki-, Ming-, WHO-, and Lauren classification were determined. Results: Patients with ml (n = 3) and m2 (n = 5) layer infiltration had no lymphatic metastasis compared with 13% for m3 (n = 39). The rate of lymphatic metastasis in submucosal carcinomas was 21% for sm1 (n = 29), 16% for sm2 (n = 23) and 40% for sm3 (n = 25). Carcinomas with papillary differentiation, Grading G1 or

AIM: This review comments on the diagnosis and treatment of gastric cancer in the classical -mean-ing - excluding adenocarcinoma of the -oesophagogastric junction. Algorithms of diagnosis and care with respect to tumour stage are present-ed. PREOPERATIVE DIAGNOSIS: Besides oesophagogastroduodenoscopy, endoscopic ultrasonography is necessary for the accurate diagnosis of T categories and as a selection criterion for neoadjuvant chemotherapy. Computed tomography is recom-mended for preoperative evaluation of tumours > T1, laparoscopy has become an effective stag-ing tool in T3 and T4 tumours avoiding unneces-sary laparotomies and improving the detection of small -liver and peritoneal metastases. TREATMENT: Endoscopic mucosal resection and submucosal dissection are indicated in superficial cancer confined to the mucosa with special characteristics (T1 a / no ulcer / G1, 2 / Lauren intestinal / L0 / V0 / tumour size < 2 cm). In all other cases total gastrectomy or distal subtotal gastric resection are indicated, the latter in cases of tumours located in the distal two-thirds of the stomach. Standard lymphadenectomy (LAD) is the D2 LAD without distal pancreatectomy and splenectomy. The Roux-en-Y oesophagojejunostomy is still the preferred type of reconstruction. An additional pouch reconstruction should be considered in -patients with favourable prognosis, this also -applies for the preservation of the duodenal passage by jejunum interposition. Extended organ resections are only indicated in cases where a R0-resection is possible. Hepatic resection for metachronous or synchronous liver metastases is rarely advised since 50 % of patients with liver metastases show concomitant peritoneal dis-semination of the dis-ease. DISCUSSION AND CONCLUSIONS: Undergoing gastrectomy at a high-volume centre is associated with lower in-hospital mortality and a better prognosis, however, clear thresholds for case load cannot be given. Perioperative chemotherapy and postoperative chemoradiotherapy are based on the MAGIC and MacDonald trials. Perioperative chemotherapy should be performed in patients with T3 and T4 tumours with the aim to increase the likelihood of curative R0-resection by downsizing the tumour. Adjuvant postoperative chemotherapy cannot be recommended since its benefit has so far not been -proven in randomised trials. In selected patients with incomplete lymph-node dissection and questionable R0-resection postoper-ative chemoradiotherapy may be debated.

BACKGROUND AND OBJECTIVES: Neoadjuvant therapy is applied to improve the prognosis associated with advanced gastric cancer. Only patients with a major response seem to have a survival benefit. Predictive markers to allow individualisation of treatment could be helpful. We examined the association of survivin protein expression with histopathologic response to neoadjuvant chemotherapy and prognosis in patients with gastric cancer. METHODS: Forty patients with gastric cancer received neoadjuvant chemotherapy. Afterwards, 38 patients underwent total gastrectomy, while 2 patients received definitive chemotherapy because of tumour progression. Histomorphologic regression was defined as major response when resected specimens contained

BACKGROUND: In spite of decreasing incidence rates, gastric carcinomas still belong to the top ten causes of tumour death in Germany. The aim of our study was to analyse the influence of age and comorbidity on the prognosis in patients with gastric cancer. MATERIAL AND METHODS: One-hundred and seventy-five consecutive patients with gastric cancer resected under curative intentions were included in this study. The comorbidity (Com) was evaluated with the Charlson comorbidity index (CCI) classifying four different grades of severity (CCI grade 0 = no Com, I = light Com, II = middle Com, III = severe Com). For each decade more than fifty years of age, one point was added for the calculation of the age-adjusted CCI grade. The prognosis was analysed with uni- and multivariate methods. RESULTS: Sixty-two percent of the 175 patients were males. The median age of all patients was 67 years; 18 % were younger than 50 years, 40 % between 51 and 70 years and 42 % were older than 70 years. The frequencies of comorbidity were as follows: CCI grade 0 = 32 %, I = 46 %, II = 18 % and III = 4 %. The 5-years survival rate (5y-SR) for all patients was 39 %. The univariate analysis of the prognosis showed a significant -influence (p < 0.001) of pT, pN, pM and R categories, but no significant results for age and comorbidity. However, the age-adjusted CCI grades demonstrated significantly different prognoses both in the univariate (p < 0.05) and in the multivariate analyses (p < 0.001) including the UICC stages. Patients between 50 and 70 years -without or with only minor comorbidity had the best prognosis (5y-SR = 55 %). In contrast, young patients without comorbidity had a worse prognosis comparable with that of older patients with comorbidity. CONCLUSION: The combination of high age and comorbidity are -together with the UICC stage the most relevant prognostic factors in patients with resected gastric cancer.

Background: This study investigates response and prognosis after neo-adjuvant chemoradiation (CTx/RTx) in patients with advanced esophageal carcinoma, according to histological type. Patients and methods: Patients with uT3 carcinoma of the esophagus treated with curative-intention esophagectomy from 1997 until 2006 were included in this retrospective analysis. Patients receiving preoperative CTx/ RTx (5-fluorouracil, cisplatin, 36 Gy) were compared with those with primary surgery for pT3 tumors. Therapy response after CTx/RTx was evaluated using 'Cologne Regression Grade' (minor response: >10% vital residual tumor cells (VRTCs), major response

Introduction Gastroesophageal reflux is the most important factor in the development of Barrett’s metaplasia. The effect of acid reflux is commonly accepted today, but there is controversy about the role of non-acid reflux. With introduction of combined esophageal pH-impedance monitoring, a precise diagnostic test for acid and non-acid reflux is now available. Methods Ninety two consecutive patients (33 women) off acid-suppressive therapy underwent diagnostic work-up for suspected gastroesophageal reflux disease including upper-GI endoscopy, esophageal manometry, barium swallow, and combined esophageal pH-impedance monitoring. Patients were subdivided into three groups according to symptoms and endoscopic appearance: typical symptoms without esophagitis (n = 28; NERD); erosive esophagitis (n = 52, ERD), and patients with intestinal metaplasia (n = 12, BE). Results Pathologic acid reflux during pH-metry was found in 35.7%, 63.5%, and 75.0% for NERD, ERD, and BE patients, respectively (P = 0.022). Likewise, the percentage of time pH < 4 rose significantly during upright, supine, and total phases. In contrast, combined pH-impedance monitoring showed no significant difference between groups for the number of acid reflux events and for percentage of acid bolus reflux time. However, BE patients had significantly more non-acid reflux events and a higher percentage of non-acid bolus reflux time during the supine (P = 0.043, P = 0.020, respectively), but not during the upright phase (P = 0.740, P = 0.730, respectively). Conclusion Patients with BE are exposed to increased supine non-acid reflux and to increased acid reflux during upright and supine phases. This observation supports the concept that nocturnal non-acid reflux may play a role in the pathogenesis of BE.

OBJECTIVES We examined mRNA expression of the urokinase-type plasminogen activator (uPA), its receptor (uPAR), and the plasminogen activator inhibitor 1 (PAI-1) in a panel of adenocarcinomas of the pancreas (PC) and cancers of the papilla of Vater (CPV). Expression profiles were compared with paired uninvolved normal tissues to define a possible differential role of these genes in tumorigenesis of both tumor types. METHODS Urokinase-type plasminogen activator, uPAR, and PAI-1 mRNA expression was analyzed by real-time quantitative reverse-transcriptase polymerase chain reaction (TaqMan) in 25 PC, 7 CPV, and in the paired uninvolved normal tissues. RESULTS Uninvolved normal tissue probes from PC and CPV showed similar mRNA expression profiles of uPA, uPAR, and PAI-1. Whereas expression levels of uPA (P = 0.81) and uPAR (P = 0.75) were not statistically significant different between tumor and paired normal tissues, PAI-1 levels were significantly down-regulated in tumor compared with paired normal tissue samples (Wilcoxon test; P < 0.006). No differences in mRNA expression of uPA, uPAR, and PAI-1 between PC and CPV were observed. Expression levels of the 3 genes were not associated with tumor stage, grading, or survival. CONCLUSIONS Increased mRNA expression of uPA and uPAR could not be detected in PC and CPV; however, PAI-1 mRNA expression levels are significantly down-regulated in PC, which might lead to higher activity levels of uPA components. Our data are merely hypothesis generating and should be validated in larger translational studies.

Objective The aim of the present cross-sectional study was to explore patient- and physician-specific determinants of physician empathy (PE) and to analyse the influence of PE on patient-reported long-term outcomes in German cancer patients. Methods A postal survey was administered to 710 cancer patients, who had been inpatients at the University Hospital Cologne (response rate 49.5%). PE was measured with the German translation of the consultation and relational empathy (CARE) measure, and patient-reported long-term outcomes were assessed using the major (ICD-10) depression inventory (MDI) and the EORTC quality of life (Qol) questionnaire QLQ-C30. Hypotheses were tested by structural equation modelling. Results PE had (a) a moderate indirect effect on “depression” and a smaller indirect effect on “socio-emotional-cognitive Qol” by affecting “desire for more information from the physician regarding findings and treatment options” and (b) a moderate indirect effect on “socio-emotional-cognitive Qol” and a smaller effect on “depression” via “desire for more information about health promotion”. The determinant with the greatest importance was “patient-perceived general busyness of hospital staff”: it had a strong negative influence on PE, indirectly influencing “desire for more information from the physician regarding findings and treatment options” and also patients’ “depression”. Conclusion PE seems to be an important pre-requisite for information giving by physicians and through this pathway having a preventive effect on depression and improving Qol. Conversely, physicians’ stress negatively influences these relationships. Practice implications The research findings suggest that reducing physicians’ stress at the organizational and individual may be required to enhance patient–physician communication. Empathy, as an outcome-relevant professional competence needs to be assessed and developed more intensively in medical students and physicians.

BACKGROUND: Early squamous cell carcinoma and early adenocarcinoma of the esophagus are potentially curable diseases. Limited surgical procedures are carried out as alternatives to either endoscopic mucosectomy or to radical esophagectomy for T1 esophageal cancer. In this stage the only indication for limited surgery with curative intent is in patients who have no evidence of lymph node metastasis as the procedure is not comprising an adequate lymphadenectomy. The depth of tumor infiltration into the mucosal and submucosal layers is correlated with the rate of nodal metastases and therefore with long-term prognosis. The crucial point is to define the right stage of T1 carcinoma for this type of therapy. METHODS: A review of the literature was performed to gather published data concerning the status of limited surgery for 'early' cancer of the esophagus. RESULTS: For mucosal esophageal cancer endoscopic mucosal resection is an alternative treatment option but requires intensive follow-up since the rate of complete resections is lower than in limited and in radical surgical procedures. On the other hand, low postinterventional morbidity and functional integrity of the tubular esophagus support the indication of endoscopic mucosal resection for mucosal cancer. The Merendino procedure may offer another option in the treatment of early esophageal cancer. Major advantages of this operation over endoscopic mucosectomy include the possibility of complete resection of the carcinoma and the entire Barrett segment. The lower postoperative morbidity and mortality compared to radical surgery are in favour of the Merendino resection. Vagal-sparing esophagectomy is another surgical option in esophageal cancer limited to the mucosa. However, both limited procedures are not appropriate in case of lymph node metastases. None of these techniques have been validated in prospective clinical studies. CONCLUSION: Procedures with limited radicality are technically feasible but should strictly be reserved for patients with mucosal cancer. Results of limited surgery should be validated in clinical studies compared to radical esophagectomy comparing functional and prognostic outcome.

Aims: Risk reduction for Barrett's cancer in individuals taking non-steroidal anti-inflammatory drugs has been reported. Cyclooxygenase (COX)-2, one of the inhibited enzymes, is putatively involved in Barrett's cancer pathogenesis. The aim of this study was to examine a possible association between COX-2 protein expression and the development and progression of the Barrett's metaplasia–dysplasia–carcinoma sequence and the type and degree of associated inflammatory reaction. Methods and results: Squamous epithelium, metaplastic, low-grade, high-grade dysplastic lesions and tumour tissue of 49 resection specimens from patients with Barrett's adenocarcinoma were immunohistochemically analysed. Active and chronic inflammatory reactions were classified according to the Updated Sydney System. Within the Barrett's sequence, a significant progressive increase in COX-2 expression was identified (P

In patients with esophageal carcinoma, transthoracic esophagectomy is associated with high postoperative morbidity and mortality rates. The question of this study was whether an individualized preoperative risk analysis is able to predict postoperative outcome. Based on prospectively accumulated data of 126 patients with a malignant esophageal tumor, a preoperative composite risk score using objective parameters was evaluated. All patients underwent a transthoracic en bloc esophagectomy with two-field lymphadenectomy. The risk score was correlated to the postoperative course which was classified according to the days of intensive care unit (ICU) treatment, hours of mechanical ventilation, and reoperation and readmission to the ICU. A multivariate analysis was performed to identify single risk factors. The overall morbidity rate was 55%, while the mortality rate was 5.6%. According to the composite risk score, 22.8% of the patients had a “low” risk, 53.2% had a “moderate” risk, and in 19% the preoperative risk was classified as “high”. There was a significant correlation of the preoperative risk and the postoperative course (p

Ulkuschirurgie konzentriert sich heute auf die Komplikationen der Ulkuskrankheit, insbesondere die Ulkusperforation und endoskopisch nicht kontrollierbare Ulkusblutungen. Dabei steht der laparoskopische oder offen ausgefuhrte Verschluss des gastroduodenalen Defekts bzw. die lokale Blutstillung durch Laparotomie im Vordergrund. Elektive Eingriffe wegen rezidivierender Ulcera ventriculi oder duodeni sind sehr selten geworden. Eine Indikation bei konservativ therapieresistentem Magengeschwur kann der bleibende Malignomverdacht sein, beim Zwolffingerdarmgeschwur vorwiegend die Magenausgangsstenose. Bestehen diese Indikationen, so kommen die klassischen Magenresektionsverfahren nach Billroth I bzw. Billroth II noch zur Anwendung, wahrend die Vagotomie praktisch nicht mehr eingesetzt wird. Insgesamt ist die Magenchirurgie trotz des seltenen Einsatzes heute sehr sicher geworden.

Background and study aims: The application of endoscopic mucosectomy in early esophageal cancer is limited by the presence of lymph-node metastasis. The aim of this prospective study was to analyze the rate of lymph-node involvement relative to the depth of mucosal or submucosal tumor penetration, comparing squamous-cell carcinomas and adenocarcinomas. Patients and methods: A total of 60 patients with pT1 esophageal cancer - 24 with squamous-cell carcinomas (SCCs) and 36 with adenocarcinomas - were treated with transthoracic en-bloc esophagectomy with two-field lymphadenectomy (n = 50) or transhiatal esophageal resection (n = 10). An average of 30 lymph nodes were examined, and the following characteristics were evaluated: histology, mucosal infiltration, depth of submucosal wall infiltration in three thirds (sm1, sm2, sm3), grading, resection category, ratio of metastatic to resected lymph nodes, and locations of metastatic nodes. Results: The rates of lymph-node metastasis were 0% for the 16 mucosal carcinomas and 45% for the 44 submucosal carcinomas (P< 0.01). There were no significant differences in the extent of lymph-node involvement between submucosal adenocarcinomas (41%) and submucosal SCCs (50%). Smi carcinomas were associated with a lower rate of lymph-node metastasis (SCCs 33%, adenocarcinomas 22%) than sm3 carcinomas (SCCs 69%, adenocarcinomas 78%). Two patients (9%) with submucosal SCCs and five patients (23 %) with submucosal adenocarcinomas were classified as having stage pM1 lymph. The average lymph-node ratio in patients with pN1 was 0.13 for adenocarcinomas and 0.1 for SCCs (difference not significant). In the multivariate analysis, the parameters mucosal vs. submucosal (P

The aim of this prospective study was to analyze Ming's classification in correlation with other currently used classification systems of gastric cancer. In addition, we wanted to define the prognostic significance of the Ming classification system. The present study analyzed material of 117 patients with gastric carcinoma who underwent D2-gastrectomy with curative intent. All specimens were categorized according to International Union Against Cancer (UICC) classification, World Health Organization (WHO) classification, Borrmann classification, Lauren classification, Goseki classification, Ming classification, and tumor differentiation. For analysis of correlation between the classification systems, the correlation coefficient according to Spearman was calculated. The survival curves have been calculated according to the Kaplan-Meier method. According to the Ming classification, 38.5% of the carcinomas exhibited an expanding growth pattern, and 61.5% of specimens showed an infiltrating growth pattern. The subtypes according to the Ming and Lauren classification correlated significantly (P < 0.001). WHO classification (P < 0.001), tumor differentiation (P < 0.001), and Goseki classification (P < 0.001), as well as the macroscopic classification of Borrmann (P < 0.001) and the pT and pN categories of the UICC classification exhibited a highly significant correlation with the Ming classification (P < 0.001 and 0.001, respectively). Median overall survival was 31.3 months. In Kaplan-Meier analysis, the 3-year survival rates were lower in the infiltrative tumor type when compared to the expansive tumor type according to Ming (P = 0.0847). In multivariate analysis, only the UICC system presented as an independent prognostic factor in multivariate analysis (P < 0.001). This study shows that the Ming classification correlates significantly with the currently used classification systems for gastric cancer and with the UICC staging system, especially, the pT and pN category. The 3-year survival rates were lower in the infiltrative tumor type than in the expansive tumor type according to Ming. However, the Ming classification is not an independent prognostic factor.

In Germany, esophageal carcinoma is one of the ten most frequent causes of death. Normally the disease is found in men over the age of 50. Although squamous cell carcinoma (SCC) of the esophagus has been more commonly diagnosed over the past 30 years, there is increasing incidence of esophageal adenocarcinoma (AC) in Western industrialized countries. For SCC the known etiological risk factors are nicotine and alcohol abuse. For AC, they are moderate nicotine and alcohol consumption as well as gastro-esophageal reflux and obesity.

Das Osophaguskarzinom gehort in Deutschland zu den zehn haufigsten Krebstodesursachen und betrifft hauptsachlich Manner, die alter als 50 Jahre sind. Wahrend bis vor 30 Jahren histologisch uberwiegend Plattenepithelkarzinome (PC) diagnostiziert wurden, lasst sich in den letzten Jahren in den westlichen Industrienationen eine exponentielle Zunahme der Adenokarzinome (AC) feststellen. Atiologische Faktoren fur das PC sind bekanntermasen das Rauchen und ein starker Alkoholkonsum, fur das AC werden ein lange bestehender gastroosophagealer Reflux und Ubergewicht sowie das Rauchen und in geringerem Mase der Alkoholkonsum verantwortlich gemacht. Durch die rasante Entwicklung der Endoskopietechnologie hin zu hochauflosenden Videoendoskopen und Magnifikationsendoskopen sowie neuer diagnostischer Verfahren wie die Chromoendoskopie und Minisonden-Endosonographie haben die diagnostischen Moglichkeiten insbesondere fur die Fruherkennung dieser Tumoren einen hohen Standard erreicht.

Extension of lymphadenectomy in gastric cancer is controversial, and preoperative diagnosis of lymph node metastases (LNM) is difficult. Therefore, knowledge-based systems such as the Maruyama computer program (MCP) are being developed. MCP shows good prognostic value for the compartments; however, for different lymph node groups (LNG) there are a large number of false positives. The aim of this study was to evaluate artificial neural networks (ANN) for predicting LNM in patients with gastric cancer and to compare the predictive power with that of MCP. A total of 135 consecutive patients who underwent D2 gastrectomy were included. We applied a single-layer perceptron to the data of 4302 patients from the National Cancer Center, Tokyo, and compared the results with those from the MCP. Prediction of N+ or N0 with ANN-1 (Borrmann classification, T category, and tumor size and location) had an accuracy of 79%. The predictive value for LNM in each of the LNG varied: ANN-1, 64% to 86%; MCP, 42% to 70%. We constructed another ANN by using the additional parameter of metastases in LNG 3 as an example of sentinel node. The accuracy of this ANN was 93%. Using an ANN, LNM in each LNG can be accurately predicted. Additional knowledge about one lymph node improves the results.

Esophageal squamous cell carcinomas ( n=23) and adenocarcinomas ( n=14) from German patients were tested for the presence of human papillomavirus (HPV) and Epstein-Barr-Virus (EBV) DNA. No DNA for either genital HPV or epidermodysplasia verruciformis-associated HPV was detected in any tumor. In contrast, 35% of squamous cell carcinomas and 36% of adenocarcinomas were shown to contain EBV DNA by nested polymerase chain reaction.

Objectives Because of the high prevalence of coexisting medical conditions in patients with gastrointestinal cancer, clinical investigators often need to adjust for comorbidity when assessing the effect of comorbidity on patient outcome. Comorbidity in cancer has been shown to be a major determinant in treatment selection and survival. However, none of the comorbidity studies in patients with gastric cancer reported in the literature have been performed using the Charlson comorbidity index. The purpose of this study was to examine the applicability of the CCI and usefulness of the CCI as a predictor in patients with gastric cancer and to examine whether it correlates with short- term outcome in these patients. Method Study design was a prospective study. The study population was drawn from our department and included 139 patients who underwent curative treatment of gastric cancer between 1.1.1997 and 31.12.2001. All patients were staged by the CCI for comorbidity and divided into three groups based on the comorbidity severity staging. Group 1 included patients with no comorbidity, group 2 included those with low-level comorbidity and group 3 those with severe comorbidity. Outcomes were compared based on these divisions performing uni- and multivariate analysis. Results 35 patients (25.2 %) had no, 55 (39.6 %) low and 39 (35.2 %) severe comorbidity. 28.8 % of patients showed no or mild, 14.4 % moderate and 14.4 % of patients severe postoperative complications and 5.8 % died in hospital postoperatively. 30-day-mortality was 3.6 % (n = 5). There was no statistical significant correlation between CCI and occurrence of postoperative complications, severity of postoperative course and postoperative stay in hospital. In multivariate analysis only age was an independent factor for postoperative course. Conclusion The method of classifying comorbidity by CCI provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies and in outcomes research from administrative databases. In gastric cancer, however, the CCI was found not to be a valid prognostic indicator.

Einleitung. Die Risikoabschatzung ist eine wesentliche Vorraussetzung fur die Wahl der chirurgischen Therapie.Ziel der Umfrage war daher zu untersuchen,inwieweit die praoperative Risikoerhebung Eingang in den Behandlungsablauf chirurgischer Kliniken in Deutschland gefunden hat. Methoden. Anhand eines Fragebogens wurden insgesamt 1.159 chirurgische Kliniken zum Thema befragt, durch wen und wie das praoperative Risiko erfasst wird, von welchen Faktoren der postoperative Verlauf des Patienten abhangt und ob und wie postoperative Komplikationen erfasst werden. Ergebnisse. Es wurden 636 Bogen ausgewertet. Der Einfluss bestehender Vorerkrankungen auf den Verlauf wird als gros eingestuft. Die ASA-Klassifikation wird am haufigsten verwandt.Kein praoperatives Risiko erfassen 12%. In 67% wird das Risiko durch Chirurgen und Anasthesisten gemeinsam beurteilt.Von den Kliniken werten 21% ihre postoperativen Komplikationen nicht regelmasig aus. Schlussfolgerungen. Risikoerfassung und Kontrolle postoperativer Komplikationen sind wesentliche Standbeine chirurgischer Arbeit.

Background and aims. The rising incidence of Barrett's carcinoma is a matter of major concern in Western societies. We realized a review of the literature to evaluate the impact of antireflux surgery on prevention of Barrett's carcinoma. Methods. We used MedLine- and PubMed-based review of the literature published since 1970 on surgical treatment of Barrett's esophagus. Results. There is no report in the literature that describes de novo development of Barrett's metaplasia after successful antireflux surgery. Compared with medical therapy, the risk for malignant degeneration of Barrett's metaplasia is reduced in surgical patients according to some studies. On the other hand, regression of Barrett's metaplasia after antireflux surgery is rare and Barrett's carcinoma after surgery has been observed repeatedly. The combination of antireflux surgery and ablation of metaplastic mucosa in order to obtain regression has led to encouraging preliminary results; however, experience is still limited and numerous studies currently are underway. Dysplastic Barrett's esophagus (BE) is a precancerosis and should not be treated as BE without dysplasia; strategies other than antireflux surgery need to be discussed. Conclusion. A prophylactic effect of early antireflux surgery upon de novo development of Barrett's metaplasia is probable. The impact of surgery on malignant degeneration of Barrett's epithelium remains uncertain. Data currently available show no clear benefit of antireflux surgery on cancerogenesis in patients with Barrett's metaplasia.

Bei der Bewertung der Ergebnisqualitat viszeralchirurgischer Eingriffe benigner Erkrankungen ist zwischen dem fruhpostoperativen Verlauf und den Langzeitergebnissen zu differenzieren. Im fruhpostoperativen Verlauf spielt das Auftreten operationsbedingter allgemeiner Probleme wie postoperative Nachblutung, Hamatome und Anastomoseninsuffizienz eine Rolle genauso wie die Vermeidung von Lasionen anatomischer Strukturen wie N. laryngeus recurrens oder N. vagus. Weitere Kriterien sind Blutverlust, postoperativer Schmerz, Qualitat der Operationsnarbe und soziookonomische Faktoren wie Dauer der Operation und des Krankenhausaufenthaltes, Arbeitsunfahigkeit und Kosten. Bereits im Kurzzeitverlauf kann die Elimination bzw. Reduktion der Symptome beurteilt werden, die fur die Indikation zur Operation ausschlaggebend waren. Solche persistierenden oder rezidivierenden Symptome und eventuelle Folgeerkrankungen sind die Zielkriterien fur die Bewertung des Langzeitverlaufes. Erfasst werden dabei symptomatische oder asymptomatische Rezidive, Folgeerkrankungen und die Lebensqualitat. Fur die Quantifizierung von Symptomen und Lebensqualitat sind Scoresysteme (GLQI-Score, AFP-Score, Schmerzscore) entwickelt und evaluiert worden, die heute fur die Beurteilung der Ergebnisqualitat verwendet werden konnen. Um das chirurgische Ergebnis bei einzelnen Erkrankungen exakt bewerten zu konnen, sind spezifische Kriterien zu berucksichtigen.

Background The outcome after oesophagectomy depends not only on the surgical procedure itself but can be improved by the selection of patients based on a preoperative risk score. Methods In order to compare the preoperative risk for different histological subtypes of oesophageal carcinoma, 221 patients with a squamous cell carcinoma (SCC) and 104 patients with an adenocarcinoma (AC) were enrolled in a prospective study. The preoperative assessment included socioeconomic status, alcohol and tobacco consumption, general and nutritional status, and pulmonary, cardiovascular, hepatic and renal function. Results More patients with an SCC were ‘blue collar’ and with an AC were ‘white collar’ workers (P < 0·001). Alcohol and tobacco consumption was higher in patients with an SCC (P < 0·01 and P < 0·05 respectively). The preoperative forced expiratory volume, arterial partial pressure of oxygen and the aminopyrine breath test showed more severely compromised pulmonary and hepatic function in patients with an SCC (P < 0·05 for all variables). Some 50 per cent of patients with an AC were overweight with a higher body mass index (P < 0·001). More patients with an AC had severely impaired cardiac function (P < 0·01). Conclusion Patients with SCC and AC of the oesophagus differed regarding their socioeconomic and preoperative risk factors for surgery.

Einleitung: Die Effektivitat der perioperativen Antibioticagabe ist nachgewiesen, die Prophylaxe wird jedoch haufig inadaquat angewandt. Ziel der Studie war es daher zu uberprufen, inwieweit Leitlinien in der Lage sind, die Qualitat der perioperativen Gabe von Antibiotica zu verbessern. Methoden: In einer retrospektiven Analyse stellten wir bei 280 Operationen den Ist-Zustand der Antibioticaprophylaxe hinsichtlich der Kriterienwahl des Antibioticums, Dosis, Zeitpunkt, Stop nach Operationsende und 2. Gabe bei einer Operationsdauer > 3 Std fest. Nach Leitlinienerstellung und klinikinterner Fortbildung erfolgte eine erneute Uberprufung im Rahmen einer prospektiven Beobachtungsstudie (n = 245). Gruppenunterschiede wurden mit dem χ 2-Test berechnet. Das Signifikanzniveau wurde auf p < 0,05 festgelegt. Ergebnisse: Der Anteil der indizierten, aber nicht durchgefuhrten Antibioticaprophylaxe konnte von 15,5 % auf 8,4 % (p < 0,05) reduziert werden. Die Prophylaxe wurde im Vergleich zur retrospektiven Analyse signifikant haufiger adaquat zur Anwendung gebracht (35,7 % vs. 63,5 %; p < 0,05). Dies war vor allem auf die genauere Berucksichtigung der Dosis und der Operationsdauer zuruckzufuhren. Diskussion: Krankenhausinterne Leitlinien konnen zu einer Verbesserung der perioperativen Antibioticaprophylaxe beitragen. Um ein optimales Ergebnis zu erreichen, mussen Leitlinien durch weitere Masnahmen, wie z. B. computerassistierte Programme, erganzt werden.

Background The results of surgical treatment in 41 patients with early adenocarcinoma of the oesophagus were analysed retrospectively. Methods The treatment of choice was transhiatal radical subtotal oesophagectomy (n = 38); in three patients with adenocarcinoma in the mid or upper thoracic portion of the oesophagus, right transthoracic en bloc oesophagectomy was performed. Results One patient died within 30 days and another within 90 days (4.8 per cent). All tumours were resected completely. Multicentricity of adenocarcinoma in Barrett's oesophagus was detected in six cases and high-grade dysplasia in 28. Some 31 patients had infiltration of the submucosa, whereas in ten, carcinoma was limited to the mucosa. No patient with mucosal adenocarcinoma had lymph node metastases, whereas five of the 31 with submucosal infiltration showed lymph node involvement. The 5-year survival rate of the total group of 41 patients, including postoperative mortality, was 83 per cent. All ten patients with adenocarcinoma limited to the mucosa (pT 1a ) were alive at 5 years; of 31 with submucosal infiltration (pT 1b ) 79 per cent survived to 5 years (P not significant). Patients without lymph node metastasis had a 5-year survival rate of 81 per cent, compared with 50 per cent for those in the pN 1 category (P not significant). Conclusion Oesophagectomy for early oesophageal adenocarcinoma is safe and leads to a favourable long-term prognosis.