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Oesophageal cancer staging using endoscopic ultrasound. Vickers J, Alderson D.  Br J Surg 1998; 85: 994-998.

Endoscopic ultrasound is being increasingly used for high resolution imaging of gastrointestinal pathology. Its role in both the local and nodal staging of cancers has attracted recent interest. There have been no reported UK studies of its value in the staging of oesophageal cancer. The aim of this study was to determine the accuracy of endoscopic ultrasound for the local tumour and lymph node staging in patients with oesophageal cancer compared with surgical and histological assessment. Fifty consecutive patients underwent pre-operative endoscopic ultrasound. The extent of the disease was staged both by the surgeon at operation and on the final histological specimen. Endoscopic ultrasound was 92% accurate at T staging and 86% accurate at N staging. Ultrasound was superior to surgical operative assessment. Endoscopic ultrasound appeared to be reliable for both local tumour and lymph node staging of oesophageal cancer. It was able to identify patients in whom a cure may be possible and also those who may benefit from adjuvant therapy. It also identified those with invasion into adjacent organs and thus prevented unnecessary surgery.

Symptomatic benefit from eradicating Helicobacter pylori infection in patients with nonulcer dyspepsia.  McColl K, Murray L, El-Omar E et alN Eng J Med 1998; 339: 1869-1874.

Dyspepsia affects 20-40% of the population. In those in whom upper GI endoscopy is normal they are regarded as having nonulcer or functional dyspepsia. Eradication of H. pylori has been shown to be beneficial in those with a proven duodenal or gastric ulcer. The role of H. pylori eradication in those with nonulcer dyspepsia is unclear. In this study 914 patients with dyspepsia were assessed. Almost two-thirds were excluded due mainly to the presence of a peptic ulcer or being H. pylori negative. 330 patients who were H. pylori positive and had a normal endoscopy were randomised to either triple therapy (omeprazole 20 mg bd, amoxycillin 500 mgs tds, metronidazole 400 mg tds) for 2 weeks or omeprazole alone. At one month, 88% of triple therapy patients and 5% of omeprazole patients were H. pylori negative. At one year 21% of the triple therapy groups and 7% of the omeprazole group had complete resolution of their symptoms. It was concluded that in patients with nonulcer dyspepsia who are H. pylori positive triple therapy treatment is more likely to resolve symptoms than omeprazole alone. This study has implication for the provision of endoscopy services in that it could be argued that in young patients with dyspeptic symptoms who are H. pylori positive on non-invasive testing, upper GI endoscopy is not required as the treatment would be the same whether an ulcer was identified or not.

Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation. Ng E K W,  Lam Y H, Sung J J Y et al.   Ann Surg 2000; 231:  153-158.

The optimal surgical treatment for perforated duodenal ulcer remains controversial.  Simple oversewing is associated with a significant risk of long-term recurrence.  Up to one-third of patients develop further ulceration and on-third of these patients will require further surgery.  As a result acid-reduction procedure have been advocated and surgically this has often been achieved by a truncal vagotomy.  This increases both the operation time and risk of post-operative complications.  Alternatively acid suppression can be achieved post-operatively by pharmacological treatments.  H. pylori eradication is of proven benefit in patients with uncomplicated or bleeding duodenal ulceration.  It role following surgery for ulcer perforation is unclear.  A significant proportion of patients with perforated duodenal ulcers are H. pylori positive.  The aim of this study was to evaluate whether H. pylori eradication reduces the risk of ulcer recurrence following simple oversew of a perforated duodenal ulcer.  In a prospective, randomised study of 129 patients with perforated duodenal ulceration 104 (81%) were shown to be H. pylori positive during intraoperative gastroscopy and CLO test.  The 91 patients that underwent simple oversewing of the ulcer were randomised to receive either quadruple therapy (bismuth, tetracycline, metronidazole and omeprazole) or post-operative omeprazole alone.  Endoscopy was repeated at 8 weeks, 16 weeks and one year.  The primary endpoint was ulcer healing or relapse at one year.  In total 51 patients received eradication therapy and 48 patients received omeprazole alone.  Ninety patients underwent follow up endoscopy at the prescribed times.  From these patients, 43/44 (98%) who underwent eradication therapy and 8/46 (17%) taking omeprazole alone were H. pylori negative.  The initial ulcer healing (82% vs. 87%) was similar in the two groups.  At one year ulcer relapse was significantly reduced (5% vs 38%) in the eradication group.  It was concluded that H. pylori eradication reduces ulcer recurrence in patients with H. pylori associated perforated duodenal ulceration.  Immediate acid-reduction surgery is unnecessary.

Effects of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. Lau J Y W,  Sung J J Y,  Lee K K C et al.  N Eng J Med 2000;  343:  310-316.

Endoscopic treatment is often effective for controlling bleeding from peptic ulcers but recurrent haemorrhage occurs in 15-20% of patients.  Rebleeding is associated with a high mortality rate.  The role of acid suppression following endoscopic treatment of upper gastrointestinal haemorrhage is unclear with no convincing evidence that that H2 antagonists reduce the risk of further haemorrhage or mortality.  Several studies have evaluated the effect of proton pump inhibitors on the risk of recurrent haemorrhage but most have had methodological deficiencies.  The aim of this study was to conduct a randomised double-blind placebo controlled trial to assess whether the adjuvant use of a high-dose proton pump inhibitor after endoscopic treatment of bleeding peptic ulcers would reduce the rate of recurrent bleeding.  Patients with actively bleeding ulcers or ulcers with non-bleeding visible vessels were treated with adrenaline injection and thermocoagulation. After haemostasis had been achieved patients were randomised to either an omeprazole infusion or placebo for 72 hours.  After the infusion all patients received oral omeprazole for eight weeks.  The primary end point was rebleeding within 30 days of endoscopy.  In total 120 patients were randomised in to each group.  Rebleeding occurred in 8 (6.7%) patients in the omeprazole group and in 27 (22.5%) patients in the placebo group (Hazard ratio 3.9; 95% CI 1.7-9.0).  Most rebleeding occurred within the first three days - i.e. during the infusion period.  There was no difference in the need for surgery or mortality between the two groups.  It was concluded that following endoscopic treatment of bleeding peptic ulcers a high-dose of a proton pump inhibitor significantly reduced the risk of recurrent haemorrhage.  

Oesophageal resection for high-grade dysplasia in Barrett's oesophagus.  Zaninotto G,  Parenti A R,  Ruol A,  Costantini M,  Mergliano S,  Ancona E.  Br J Surg 2000;  87:  1102-1105.

Although endoscopic surveillance programmes for Barrett's oesophagus have been widely established, the diagnosis of high-grade dysplasia in biopsies is relatively rare.  As the natural history of high-grade dysplasia is unclear the optimal management of this problem is at present unknown.  The available options include continued endoscopic surveillance, treatment limited to the Barrett's mucosa (e.g. endoscopic mucosectomy) or a more aggressive therapy such as oesophagectomy.  All of these options have particular advantages and disadvantages.  The aim of this study was to determine the prevalence of associated cancer undetected by endoscopy in patients with Barrett's high-grade dysplasia  and to assess whether an endoscopic protocol with multiple biopsies could improve the diagnostic accuracy.  In addition the morbidity and mortality associated with oesophageal resection for high-grade dysplasia were studied.  Between 1982 and 1998, 15 patients were identified who had high-grade dysplasia within an area of Barrett's oesophagus.  Seven patients underwent primary resection soon after diagnosis.  The other eight patients underwent a second endoscopy during which a  median of 12 biopsies were taken.  All later underwent oesophageal resection.  Invasive adenocarcinoma was identified in 5 (33%) patients with no difference between the two groups.  There were no perioperative deaths.  Early morbidity was seen in eight patients and late morbidity in in four patients.  The actuarial survival rate was 80% at five years.  It was concluded that patients with high-grade dysplasia had a 33% probability of harbouring invasive oesophageal carcinoma.  A second endoscopy failed to identify the invasive cancer.  Oesophagectomy can be performed with no mortality and remains the rational treatment in patients considered fit for surgery.  

Prognostic significance of peri-operative blood transfusion following radical resection for oesophageal carcinoma.  Dresner S M, Lamb P J, Shenfine J, Hayes N, Griffin S M.  Eur J Surg Oncol 2000;  26:  492-497.

It has recently become apparent that peri-operative allogeneic blood transfusion is associated with a clinically relevant immunosuppressive effect.  In some situations, such as after organ transplantation, this may be clinically advantageous but it may also have a deleterious effect on patients undergoing surgery for malignant disease.  Several reports have highlighted an association between between peri-operative blood transfusion and an increase in recurrence rates and reduced survival following surgery for several gastrointestinal malignancies.  The aim of this study was to clarify the prognostic significance of perioperative blood transfusion following oesophagectomy in a specialist centre.  A consecutive series of 235 patients undergoing subtotal oesophagectomy with a two-field lymphadenectomy between April 1990 and June 1999 were studied.  The median age was 64 years (30-79) with a male to female ratio of 3:1.  The predominant histological type was adenocarcinoma (n=154).  To avoid the influence of surgical complications the 5.5% of patients suffering in-hospital mortality were excluded.  In the remaining patients the median blood loss was 900 ml (200-5500) with 46% (n=103) of patients requiring a blood transfusion (median 3 units, range 2-21).  Median surgical of non-transfused patients was 36 months compared to 19 months for those receiving a blood transfusion (log-rank=4.44; 1df, p=0.03).  Non-transfused patients had a significantly higher 2 and 5-year survival rate.  Even after stratification of results according to disease stage or the development of complications, survival was significantly worse in those requiring a blood transfusion.  Multivariate analysis demonstrated that in addition to nodal status, transfusion of more than 4 units of blood was an independent prognostic factor.  It was concluded that peri-operative transfusion is associated with a significantly worse prognosis following radical oesophagectomy and that meticulous haemostasis and avoidance of unnecessary transfusion may prove oncologically beneficial. 

Gastrointestinal carcinoids:  characterization by site of origin and hormone production.  Onaitis M W,  Kirshbom P M,  Hayward T Z et al.  Ann Surg 2000;  232:  549-556.

Carcinoid tumours are relatively uncommon neuroendocrine lesions arising from amine precursor uptake and decarboxylation (APUD) cells.  Those arising from the gastrointestinal tract are usually classified according to their site of origin as foregut, midgut or hindgut tumours.  One of the unique features of these tumours is their ability to produce protein and peptide hormones, the most characteristic of which is serotonin. Hormonal measurements show that foregut and midgut tumours produce the highest levels.  Systemic serotonin release is believed to produce many of the symptoms of the carcinoid syndrome including diarrhoea, flushing, wheezing and right-sided heart disease.  Published data has described prognostic features of carcinoid tumours as site of origin, age, sex, disease stage and presence of high hormonal levels at presentation.  The aim of this study was to define the relationship between presenting variables and prognosis among carcinoid tumours arising at different gastrointestinal sites.  A prospective database of carcinoid patients maintained in a university teaching hospital for 30 years was interrogated to identify presenting symptoms, hormonal data, pathological features and survival.  Carcinoid tumours arising in different locations had different presentations.  Rectal carcinoids presented significantly more often with gastrointestinal bleeding.  Midgut carcinoids presented more often with carcinoid syndrome.  Patients with midgut tumours had significantly higher hormonal levels.  Although age, stage, site of origin and urinary 5-HIAA levels all predicted survival on univariate analysis only the later three were independent prognostic factors on multivariate analysis.  Of patients with metastatic disease at diagnosis, those with midgut tumours had improved survival.  It was concluded that although region of origin is an important prognostic factor, stage at presentation is more predictive of survival.  Pancreatic and midgut carcinoids are metastatic at origin more often than those arising at other sites.

Laparoscopic Heller myotomy for achalasia.  Hunt D R,  Wills V L.  Aust NZ J Surg 2000;  70: 582-586.

Achalasia is a rare condition with an incidence of approximately one per 100,000 per year.  It is characterised by incomplete relaxation of the lower oesophageal sphincter and disordered oesophageal body peristalsis.  Both endoscopic and surgical treatments are aimed at disrupting the lower oesophageal sphincter.  This is most commonly achieved by endoscopic balloon dilatation with surgical myotomy reserved for endoscopic failures.  Surgical treatments may also be combined with an anti-reflux procedure.   Minimally invasive surgical procedures have potential advantages over traditional open operations.  The aim of this study was to examine the evolution of the operative technique, postoperative outcome and the effect of the 'learning curve' in 70 patients undergoing laparoscopic Heller's myotomy between 1992 and 1999.  Pre and perioperative data regarding all patients was prospectively entered into a database.  Patients were followed up clinically or by a biennial postal questionnaire obtaining information regarding dysphagia, heartburn, regurgitation and chest pain.  Surgery was performed as a primary procedure in 20 patients, after failed endoscopic treatment in 48 cases and after failed fundoplication in 2 patients.  The myotomy was combined with a 360 degree fundoplication in 57 patients and with an anterior fundoplication in 13 patients.  Mucosal perforation occurred in 11 cases.  Conversion to an open procedure was required in 7 cases.  At a mean follow-up of 3 years, symptom scores were significantly improved for dysphagia, regurgitation and chest pain.  The 'learning curve' contributed significantly to the length of the procedure and the need for re-operation.  It was concluded that laparoscopic Heller myotomy is a technically challenging procedure but one that provided good palliation of the symptoms associated with achalasia.

Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease.  Spechler S J,  Lee E,  Ahnen D et al.  JAMA 2001;  285:  2331-2338.

Gastroesophageal reflux disease (GORD) is one of the commonest disorders of the alimentary tract with approximately 20% of adults experiencing symptoms of GORD each week.  Modern medical and surgical anti-reflux therapies are highly effective in controlling symptoms of GORD but little is know of the efficacy of these measures in preventing long-term complications such as peptic stricture, Barrett's oesophagus and oesophageal carcinoma. Whilst good short-term results have been reported following both open and laparoscopic fundoplication, the long-term outcome of surgery is unknown.  In the 1980s the Department of Veteran Affairs Cooperative Studies Program conducted a randomised trial of medical and surgical anti-reflux therapies in 247 patients with complicated GORD.  For the two-year duration of the study surgery (open fundoplication) was found to be better then medical therapy (antacids, H2 blockers and sucralfate).  To determine the long-term outcome of GORD therapies a follow-up study of this well-define cohort was of patients was performed.   Mean follow up was 10.6 years for medical patients and 9.1 years for surgical patients.  Overall, 239 (97%) of the original cohort were found with 79 patients having died.  Of the 160 survivors (157 men, 3 women), 129 participated in the follow-up study.  The main outcome measures were use of anti-reflux medication, GORD activity index (GRACI) score, grade of oesophagitis, frequency of treatment of stricture, frequency of subsequent anti-reflux operation, 36-item Short Form health survey (SF-36) score, survival and incidence of adenocarcinoma.  Overall, 92% of medical patients and 62% of surgical patients reported the regular use of anti-reflux medication (p<0.001).  After discontinuation of anti-reflux medication, mean GRACI scores were significantly lower in the surgical group (p=0.003).  There was, however, no significant difference in the frequency of oesophagitis or rate of stricture formation.  Patients with Barrett's oesophagus at baseline developed oesophageal adenocarcinoma at a rate of 0.4% whereas these cancers developed in patients without Barrett's oesophagus at an annual rate of 0.07%.  There was no difference between the two groups in the incidence of oesophageal carcinoma.  It was concluded that anti-reflux surgery should not be advised with the expectation that patients with GORD will no longer need to take anti-secretory medication or that the procedure will prevent cancer amongst those with GORD and Barrett's oesophagus.

Laparoscopic peritoneal lavage in staging gastric and oesophageal cancer.  Bryan R T,  Cruickshank N R,  Needham S J et al.  Eur J Surg Oncol 2001;  27:  291-297.

Accurate staging of gastric, oesophageal and gastro-oesophageal cancer is essential to avoid unnecessary extensive surgery in patients in whom only palliation is appropriate.  This requires a multimodal approach utilizing endoscopy, CT and diagnostic laparoscopy.  Upper GI endoscopy is usually the initial investigation leading to the diagnosis with confirmation achieved by a biopsy specimen.  CT is commonly used to further assess local invasion, nodal status and the presence of either liver metastases or gross peritoneal disease.  Staging laparoscopy is often used to complement the CT scan to further increase the accuracy of disease staging.  It allows assessment of the primary tumour, local invasion and the detection of liver and nodal metastases which may not be apparent on CT.  It is most useful in detecting small peritoneal metastases.  Peritoneal dissemination is the most frequently observed type of recurrence following gastric and oesophageal cancer surgery and arises from transcoelomic spread from the primary tumour.  The presence of free peritoneal tumours cells (FPTCs) detected at the time of laparoscopy or laparotomy carries a poor prognosis.  Various methods of peritoneal lavage for the detection of FPTCs have been described.  The aim of this study was to evaluate the prognostic value of a technique for peritoneal lavage used in Birmingham.  Between March 1997 and February 1999, 88 staging laparoscopies were performed in patients eligible for an attempted curative resection of a gastric, oesophageal or gastro-oesophageal cancer.  During laparoscopy the pelvis was irrigated with 200 ml normal saline with 100 ml aspirated and examined cytologically.  Patients were followed up until September 1999.  Overall, 11 patients had FPTC-positive cytology with a median survival from laparoscopy of 122 days (95% CI 82-161) with only a single patient surviving for more than one year.  In the FPTC-negative group, median survival was 378 days (95% CI 256,-).  Log-rank chi-squared = 16.7 p<0.001.  It was concluded that the presence of FPTCs detected by this technique is a contraindication to attempted curative resection and that in this group of patients palliation by either medical or surgical methods is appropriate. 

Effectiveness of laparoscopic fundoplication for gastro-oesophageal reflux. Khoursheed M A,  Al-Asfoor M,  Al-Shamali et al. Ann R Coll Surg Eng 2001;  83:  229-234.

Gastro-oesophageal reflux (GORD) is a common condition, symptoms of which can be effectively controlled in most patients with either life-style modification and medical therapy.  However, a small percentage of patients remain symptomatic despite optimal medical therapy.  These patients may benefit from antireflux surgery.  Since the first report of laparoscopic fundoplication in 1991, several centres have reported their experiences and with up to 95% being symptom-free and satisfied with the outcome of their surgery.  These results are similar to those seen following open surgery. The aim of this study was evaluate the effectiveness of laparoscopic fundoplication in a middle eastern population.  Between 1995 and 1998, 74 patients who failed medical treatment for GORD were treated by laparoscopic fundoplication.  The Toupet procedure (270 degree wrap) was used in 66 patients and a Nissen fundoplication (360 degree wrap) was used in 8 patients.  The patients were followed up for a mean of 15 (range 3-33) months.  Most of the patients were male (n=65).  The mean age of the patients was 36 (range 17-60) years.  Overall, 94% were symptom-free following antireflux surgery.  Five patients considered the procedure a failure.  Of these, 3 patients developed symptoms of recurrent reflux.  Two patients developed complications (gas bloat and dysphagia) which warranted taking down of the fundoplication laparoscopically.  Two patients developed small incisional hernias at the site of a 10 mm port.  It was concluded that laparoscopic fundoplication is safe and effectively relieves reflux symptoms in patients who have failed medical treatment.

Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomised controlled studies.  Kate V,  Ananthakrishnan N,  Badrinath S.  Br J Surg 2001;  88:  1054-1058.

Primary treatment of a perforated duodenal ulcer involves patch closure which can be combined with definitive ulcer surgery.  Simple closure is associated with unacceptably high recurrence rates where as definitive surgery may have long-term side-effects in patients who might otherwise have been cured by simple closure.  Trials of the use of either H2 blocking drugs or proton pump inhibitors to reduce ulcer recurrence after simple patch closure has produced conflicting results.  Attention has recently focused on the role of H. pylori and the effect of eradication on the natural history of perforated duodenal ulcer.  The aim of this study was to determine the prevalence of H. pylori in patients with perforated duodenal ulcer and to correlate the H. pylori status with the short, medium and long-term ulcer recurrence rates following simple closure.  Some 202 patients were followed prospectively for 2 years after simple closure of a perforated duodenal ulcer (prospective group).  A second group of 60 patients were reviewed 5 years or more after simple closure (retrospective group).  The prevalence of H. pylori in patients with perforated duodenal ulcer was compared with that in controls.  Patients in the prospective group were randomised to receive either ranitidine alone or quadruple therapy (ranitidine, colloidal bismuth, metronidazole, tetracycline) after operation.  The incidence of H. pylori infection after the two treatments and the association with residual or recurrent ulceration was studied.  The prevalence of H. pylori infection in patients with perforated duodenal ulcer was not significantly different to that in controls.  However, at every time interval of follow-up in both the prospective and retrospective groups the H. pylori infection rate was higher in patients with recurrent or residual ulceration.  It was concluded that eradication of H. pylori after simple closure of a perforated duodenal ulcer should reduce the incidence of residual and recurrent duodenal ulceration.

Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction.  MacDonald J S,  Smalley S R,  Benedetti J et al.  N Eng J Med 2001;  345:  725-730.

Any potentially curative treatment for stomach cancer requires gastric resection.  However, most patients are not cured by surgery alone.  The high rate of relapse (up to 70%) after resection makes it important to consider adjuvant treatment for patients with stomach cancer.  Adjuvant chemotherapy (without radiotherapy) has not resulted in improved survival compared with surgery alone.  The aim of this study was to investigate the effect of surgery plus postoperative adjuvant chemoradiotherapy on the survival of patients with resectable adenocarcinoma of the stomach and gastroesophageal junction.  Overall, 556 patients with resected adenocarcinoma were randomly assigned to surgery plus postoperative chemoradiotherapy or surgery alone.  Adjuvant therapy consisted of fluorouracil plus leucovorin for 5 days, followed by 45Gy radiotherapy for 5 weeks with further fluorouracil and leucovorin at the beginning and end of the chemotherapy.  One month after completion of radiotherapy two further cycles of chemotherapy were given.  The median survival in the surgery-only group was 27 months compared with 36 months in the chemoradiotherapy group.  The hazard ratio for death was 1.35 (95% CI; 1.09-1.66. p=0.005).  The hazard ratio for relapse was 1.52 (95% CI; 1.23-1.86.  p<0.001).  Three patients (1%) died form the toxic effects of the chemoradiotherapy.  It was concluded that postoperative chemoradiotherapy should be considered for all patients at high risk for recurrence of adenocarcinoma of the stomach and gastroesophageal junction who have undergone curative resection.

Surgical resection with or without preoperative chemotherapy in oesophageal cancer: a randomised controlled trial.  MRC Oesophageal Cancer Working Party.  Lancet 2002;  359:  1727-1733.

The outlook for patients with oesophageal cancer who undergo surgical resection with curative intent is still poor with only 20-30% surviving to two years.  Factors contributing to this poor outlook include the presence of locally advanced disease and undiagnosed metastases at presentation.  As a result there has been recent interest in the use of systemic chemotherapy in addition to local surgical treatment and radiotherapy. The aim of this study was to assess whether preoperative chemotherapy could improve survival, dysphagia and performance status in patients undergoing surgical resection for oesophageal cancer.  Overall, 802 previously untreated patients with resectable oesophageal cancer of any cell type were randomly allocated to either two cycles of cisplatin with a fluorouracil infusion over three weeks followed by surgical resection (CS group. n=400) or surgical resection alone (S group. n=402).  Patients could be give preoperative radiotherapy irrespective of their randomisation.  The primary outcome measure was survival and analysis was on an intention to treat basis. Resection was complete in 233 (60%) of 390 assessable patients in the CS group and 215 (54%) of 397 assessable patients in the S group (p<0.0001). Postoperative complications were reported in 146 (41%) of patients in the CS group and 161 (42%) patients in the S group.  Overall survival was better in the CS group (HR=0.79; 95% CI 0.67-0.93. p=0.004). Median survival was 512 days in the CS group and 405 in the S group (difference 107 days. 95% CI 30-196) and 2-year survival rates were 43% and 34% (difference 9%; CI 3-14).  It was concluded that two cycles of preoperative cisplatin and fluorouracil improves survival without additional serious adverse events in the treatment of patients with resectable oesophageal cancer.

Hepatitis B e antigen and the risk of hepatocellular carcinoma.  Yang H-I, Lu S-N, Liaw Y-F et al.  N Eng J Med 2002;  347:  168-174.

Chronic hepatitis B virus infection is a serious clinical problem because of its world wide distribution and potential for adverse sequelae, including hepatitis, cirrhosis and hepatocellular carcinoma.  It is particularly prevalent in the Asian-Pacific region, where patients usually acquire the infection at the time of birth or in early childhood.  The presence of the hepatitis B e antigen (HBeAg) in serum indicates active viral replication in hepatocytes.  HBeAg is thus a surrogate marker for the presence of hepatitis B virus DNA.  The aim of this study was to determine the relationship between positivity for hepatitis B surface antigen (HBsAg) and HBeAg and the development of hepatocellular carcinoma.  In 1991 and 1992, 11,893 men in Taiwan, aged 30-65 years and without evdience of hepatocellular carcinoma, were enrolled in the study.  Serum samples were obtained and tested for HBsAg and HBeAg by radioimmunoassay.  The diagnosis of hepatocellular carcinoma was ascertained through data linkage with the computerised National Cancer Registry in Taiwan and with death certificates.  A multiple regression analysis was performed to determine the relative risks of hepatocellular carcinoma among men who were positive for HBsAg alone or HBsAg and HBeAg, as compared with those who were negative for both. Overall, there were 111 cases of newly diagnosed hepatocellular carcinoma during 92,359 person-years of follow-up.  The incidence rate of hepatocellular carcinoma was 1169 cases per 100,000 person-years amongst men who were positive for both HBsAg and HBeAg, 324 per 100,000 person-years for those who were positive for HBsAg only and 39 per 100,000 person-years for those who were negative for both.  After adjustment for age, sex, the presence or absence of antibodies to hepatitis C virus, cigarette smoking, and use or nonuse of alcohol, the relative risk of hepatocellular carcinoma was 9.6 (95% CI 6.0-15.2) among men who were positive for HBsAg alone and 60.2 (CI 95% 35.5-102.1) amongst those who were positive for both HbsAg and HBeAg, as compared with men who were negative for both.  It was concluded that positivity for HBeAg is associated with an increased risk of hepatocellular carcinoma.

Inoperable adenocarcinoma of the oesophagogastric junction:  a comparative study of laser coagulation versus self-expanding metallic stents with special reference to cost analysis.  Sihvo E I T,  Pentikainen T,  Luostarinen M E,  Ramo O J,  Salo J A.  Eur J Surg Oncol 2002;  28:  711-715. 

The incidence of adenocarcinoma near the gastro-oesophageal junction is increasing.  Over 60% of these patients have incurable disease at presentation either because of advanced stage of disease or poor general physical condition.  Altogether, 10% or fewer of these patients will be cured of their disease so for the majority, the main aims of treatment are palliation of dysphagia, prevention of aspiration and improvement of the quality of life.  The role of palliative surgery is limited but no one method of endoscopic palliation has proved to be superior.  These include oesophageal stents - either rigid plastic or self-expanding metallic stents (SEMS) and local tumour ablative techniques such as laser therapy.  Neither clinical nor financial comparisons yet exist between SEMS and laser therapy.  The aim of this study was to compare the relative lifetime costs and clinical results of Nd-YAG laser to those of SEMS as alternative forms of primary palliation of dysphagia for adenocarcinoma near the oesophagogastric junction.  A retrospective review was undertaken of  52 patients with distal oesophageal or oesophagogastric adenocarcinoma who underwent palliative treatment for dysphagia; 32 treated with laser therapy and 20 with SEMS.  The clinical outcome and cumulative costs were analysed.  Although patients palliated with SEMS underwent fewer procedures (1.9 vs. 3.4.  p=0.0048), they spent as many days in hospital (12.9 vs. 15.1 p=0.370) and required as high overall coats of therapy as those treated with laser therapy.  In addition patients treated with SEMS had higher morbidity rates (30% vs.  6%.  p=0.043), hospital mortality (20% vs. 3%.  p=0.0066) and 30-day mortality (40% vs. 3.1%. p=0.0011) than did patients with laser therapy, with no evidence of SEMS being the more effective treatment modality.  It was concluded that in patients with adenocarcinoma in the distal oesophagus or at the oesophagogastric junction, compared with SEMS laser therapy palliates dysphagia effectively with lower morbidity and mortality and without increased costs or hospital stay.

Routine use of laparoscopic repair for perforated peptic ulcer.  Siu W T,  Chau C H,  Law  K B et al.  Br J Surg 2004;  91:  481-484

Despite reports on the feasibility of laparoscopic repair of perforated peptic ulcer in 1990,  it has not been widely adopted.  Three randomised clinical trials of laparoscopic versus open repair have demonstrated comparable to better outcomes in the laparoscopic group, revealing benefits in terms of reduced wound pain, analgesic requirement, decreased hospital stay and earlier resumption of daily activities.  The aim of this study was to evaluate the safety and efficacy of laparoscopic repair for perforated peptic ulcer in routine clinical practice.  A prospective analysis of 172 patients who underwent laparoscopic repair of perforated peptic ulcer between 1997 and 2003 was performed.  The mean age was 54 years (range 14-93 years).  Overall, 165 patients underwent omental patch closure of the perforation.  There were 6 Polya gastrectomies and one excision of the ulcer.  37 patients (22%) required conversion to an open operation.  The mean operating time was 65 (14-180) minutes.  The median stay was 6 days.  Complications occurred in 28 patients (16%) resulting in three operations.  Six patients with intra-abdominal collections were managed by percutaneous drainage.  Two patients who underwent conversion developed wound infections.  Overall, 14 patients (8%) died, 11 of whom were ASA grade III or IV.  It was concluded that laparoscopic repair of perforated peptic ulcer is a safe emergency procedure in routine clinical practice for patients with perforated peptic ulcer.

Randomised clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux.  Nilsson G,  Wenner J,  Larsson S et al.  Br J Surg 2004;  91:  552-559.

Laparoscopic surgery for gastro-oesophageal reflux disease (GORD) was introduced to reduce postoperative pain and increase patients' acceptance of surgery.  Recently, its long-term acceptance has been questioned.  A recent study has suggested that failure and dissatisfaction were significantly more common after laparoscopic than open surgery.  The aim of this study was to compare the long-term results of laparoscopic and open antireflux surgery in a randomised trial by investigating subjective and objective outcomes.  Overall, 60 patients were randomised to either laparoscopic or open 360 degree fundoplication.  Subjective evaluation was by disease-specific and generic questionnaires and structure interviews.  Objective evaluation was by endoscopy, oesophageal manometry and 24-hour pH monitoring.  These were performed before operation and one month, 6 months and 5 years after surgery.  Two patients in the laparoscopic group  had reoperations for hiatal stricture and one patient in the open group had repair of an incisional hernia.  One patient in each group underwent surgery for intestinal obstruction.  There were no differences in the subjective outcomes of diet, sleep, medication, patients satisfaction and symptoms of GORD at 5 years.  There no differences in objective outcomes determined by endoscopy, manometry or 24-hour pH monitoring.  Well-being was decreased in all patients prior to surgery but was restored to normal or above-normal values after fundoplication, regardless of the type of surgery.  Seven of 28 patients in the open group had complaints regarding the scar.  It was concluded that elimination of GORD symptoms improved well-being and eliminated the need for daily acid suppression in most patients no matter which procedure was employed.  These results were apparent one month after operation and were still valid 5 years later.

Randomised clinical trial of morbidity after D1 and D3 surgery for gastric cancer.  Wu  C W,  Hsiung C A,  Lo S S et al.   Br J Surg 2004;  91:  283-287.

Cancer of the stomach is the second commonest cancer in the world.  Currently surgery if the only curative primary treatment, but survival rates are dismal.  Recent studies from Japan and several Western centres have noted an improved survival in patients who have undergone extensive lymph node dissection with curative resection.  Two large randomised surgical trials in Holland and the UK, however, reported no survival benefit and higher morbidity and mortality rates after D2 gastric resection.  Better survival in Japan may reflect great staging accuracy and improved stage-specific survival rates owing to stage migration.  The aim of this study was to examine the difference in morbidity between D1 and D3 dissections and the impact on mortality rates.  A randomised comparison was undertake of 221 patients undergoing gastric cancer surgery.  Overall, 110 patients underwent D1 surgery and 111 underwent D3 surgery.  The morbidity was higher after D3 than after D1 surgery  (17% vs. 7%. p = 0.012).  The difference was largely related to abdominal abscess (8% after D1 versus none after D1).  The D3 group had an anastomotic leak rate of 4.5% whereas these was no leakage in the D1 group (p=0.060).  All anastomotic leaks were minor and were managed non-operatively with nutritional support.  Patients who had a D3 resection had longer operating times, greater blood loss and postoperative drain outputs and more patients needed blood transfusion. There were no deaths in either group.  The hospital stay was longer after D3 than after D1 surgery.  It was concluded that extended lymphadenectomy for gastric cancer is associated with more complications than limited lymphadenectomy but does not lead to significant mortality.

Role of endoscopic ultrasonography in the preoperative staging of gastric carcinoma.  Javaid G,  Shah O J,  Dar M A et al.  ANZ J Surg 2004;  74:  108-111. 

Preoperative staging of tumour extent in upper gastrointestinal malignancy greatly facilitates the planning of therapy.  The advent of endoscopic ultrasonography (EUS) has significantly improved the diagnosis and staging of upper gastrointestinal cancer.  The aim of this study was to evaluate whether preoperative EUS accurately predicts the tumour stage in gastric carcinoma.  EUS was performed preoperatively on 112 patients with gastric cancer.  All 112 patients underwent surgery.  The results of the EUS was compared with the postoperative histological stage.  EUS was correct in determining the primary tumour (T) and regional lymph node (N) staging in 83% and 64% of patients respectively.  EUS was correct in determining the absence of lymph node metastasis in 88% but was not reliable in determining metastasis in one to six regional nodes (N1) and metastasis in 7 to 15 regional nodes (N2) stages;  (62% and 33% respectively).  Of 26 patients with N1 stage, 10 had false negative results, whereas 11 patients in stage N2 were diagnosed endoscopically as stage N1.  The sensitivity and specificity were 67% and 89% respectively.  It was concluded that EUS staging is the most accurate method for discriminating between potentially resectable (T1 to T3) and potentially non-resectable (T4) cases of gastric cancer.

Randomised clinical trial of laparoscopic versus open fundoplication for gastro-oesophageal reflux disease.  Ackroyd R,  Watson D I,  Majeed A W et al.  Br J Surg 2004;  91:  975-982. 

Antireflux surgery is the treatment of choice for moderate to sever gastro-oesophageal reflux disease, particularly in patients with reflux symptoms that have not responded to medical therapy or who do not wish to continue medical treatment indefinitely. The most commonly performed procedure is the Nissen 360 degree fundoplication, with long-term success achieved in around 90% of patients.  Over the past decade, the development of laparoscopic techniques has changed the way in which antireflux surgery is performed.  The aim of this study was to compare laparoscopic and open fundoplication for gastro-oesophageal reflux in the setting of a randomised controlled trial.  Overall, 99 patients were randomised to either laparoscopic (n=52) or open (n=47) Nissen fundoplication.  Patients with oesophageal dysmotility, those requiring a concurrent abdominal procedure and those who had undergone previous antireflux surgery were excluded.  Independent assessment of dysphagia, heartburn and patient satisfaction was performed 1,3, 6 and 12 months after surgery using multiple standardised clinical grading systems.  Objective measurement of oesophageal acid exposure and lower oesophageal sphincter pressure before and after surgery, and endoscopic assessment of postoperative anatomy was performed.  Operating time was longer on the laparoscopic group (median 82 vs. 46 min).  Postoperative pain, analgesia requirement, time to solid food intake, hospital stay and recovery time were reduced in the laparoscopic group.  Perioperative outcomes, postoperative dysphagia, relief of heartburn and overall satisfaction were equally good at all follow-up intervals.  Reduction in oesophageal acid exposure, increase in lower oesophageal sphincter tone and improvement in endoscopic appearance were the same for the two groups.  It was concluded that the laparoscopic approach to Nissen fundoplication improved early postoperative recovery with an equally good outcome up to 12 months.

An 11-year experience of enterocutaneous fistula.  Hollington P,  Mawdsley J,  Lim W et al.  Br J Surg 2004;  91:  1646-1651.

Enterocutaneous fistula is a feared complication of abdominal surgery.  Such fistulae usually occur soon after surgery, although inflammatory bowel disease, diverticulitis, radiotherapy, trauma, ischaemic bowel and malignancy commonly contribute. Favourable outcome relies on early control of sepsis, adequate nutritional support and skin protection.  Enterocutaneous fistulae have traditionally been associated with a high risk of morbidity and death, related to sepsis, malnutrition, fluid, electrolytes or metabolic disturbances.  This study was a retrospective review of enterocutaneous fistula management over an 11-year period in major tertiary referral centre.  Most fistulas occurred secondary to abdominal surgery and a high proportion (53%) occurred in association with inflammatory bowel disease.  A low rate of spontaneous healing was observed (20%).  The healing rate after definitive fistula surgery was 82%, although more than one attempt was required to achieve surgical closure in some patients.  Definitive fistula resection resulted in a mortality rate of 3%.  In addition, one patient died after laparotomy for intra-abdominal sepsis and an additional 24% died from complications of fistulation, giving and overall fistula-related mortality rate of 11%.  It was concluded that early recognition and control of sepsis, management of fluid and electrolyte imbalances, meticulous wound care and nutritional support appear to reduce the mortality rate and allow spontaneous fistula closure in some patients.  Definitive surgical management is performed only after restitution of normal physiology, usually after at least 6 months.

Predictors of operative death after oesophagectomy.  Abunasra H,  Lewis S,  Beggs L et al.  Br J Surg 2005;  92:  1029-1033.

Oesophagectomy remains the mainstay of treatment in patients with potentially resectable oesophageal cancer.  The post operative death rate has decreased significantly over the past two decreased in experienced centres.  This has been attributed to improvements in anaesthesia, standardisation and refinement of surgical technique, better management of postoperative complications and strict preoperative selection of patients with adequate physiological reserve for surgical resection.  The aim of this study was to define risk factors for death after oesophageal resection for malignant disease.  Between 1990 and 2003, 773 oesophagectomies for oesophageal cancer were performed.  Continuous variables were categorised into quartiles for analysis.  Predictors of operative mortality were identified by univariate and multiple logistic regression analysis.  The operative mortality was 4.8%.  In univariate analysis, advanced age, reduced FEV1, reduced FVC, presence of diabetes and tumour located in the upper third of the oesophagus were associated with higher mortality rate.  Multivariate analysis identified age, tumour position and FEV1 as independent predictors of death.  It was concluded that advanced age, impaired preoperative respiratory function and a tumour high in the oesophagus are associated with a significant increased risk of death after oesophagectomy for carcinoma.

Is there a role for palliative gastrectomy in patients with Stage IV gastric cancer.  Saidi R F,  ReMine S G,  Dudrick et al.  World J Surg 2006;  30:  21-27.

Surgical resection is the only curative treatment for gastric cancer.  Although the role of palliative gastrectomy in patients with advanced gastric cancer is unclear, several studies have suggested that resection may provide some survival benefit.  However, the extended survival after palliative gastrectomy in other studies has been associated with significant postoperative morbidity, prolonged hospital stay and poor quality of life.  The aims of palliative gastrectomy are often to enable oral food intake, stop bleeding or relieve pain.  The aim of this study was to evaluate patient outcome after palliative gastric resection for metastatic gastric cancer.  Over a 10 year period, a total of 105 patients with Stage IV gastric cancer were identified of which 81 (77%) had no resection and 24 (23%) underwent palliative gastric resection.  Mean survival in those without resection who underwent chemotherapy (with or without radiation) treatment was 5.9 months (95% CI 4.2 - 7.6 months).  For those with resection and adjuvant treatment, mean survival was 16.3 months (95% CI 4.3-28.8 months).  Kaplan-Meier survival analysis showed significantly better survival in those with resection and adjuvant therapy (log-rank test. p=0.01).  Mortality and morbidity rates of those undergoing resection was 9% and 33% respectively, which did not differ statistically from those undergoing curative resection during the same time period.  However, the duration of hospital stay was significantly higher in those with Stage IV disease.  It was concluded that palliative resection combined with adjuvant treatment may improve survival in a selected group of patients with Stage IV gastric cancer.  Palliative gastrectomy plus systemic therapy should be compared with systemic treatment alone in a randomised trial.

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