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Gastric cancer has seen a considerable change in management, and outcomes for the past 30 years. Historically, the overall prognosis has been regarded as poor. However, the use of multimodal treatment, and integration of enhanced recovery pathways have improved short and long-term outcomes. The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for gastric cancers over 30 years.Data from consecutive patients undergoing gastrectomy with curative intent for gastric adenocarcinoma between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies and outcomes were reviewed. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends.Between 1989 and 2018, 1,162 patients underwent gastrectomy with curative intent for cancer. Median age was 71 years (interquartile range, 63-76 years) and 763 (66%) were male. Patient presentation changed with epigastric discomfort now the most common presentation (67%). An improvement in overall complications from 54% to 35% (P = .006) and mortality from 8% to 1% (P.001) was seen over the time period and overall survival improved from 28 months to 53 months (P.001).Both short-term and long-term outcomes have significantly improved over the 30 years studied. The reasons for this are multifactorial and include the use of perioperative chemotherapy, the introduction of an enhanced recovery pathway, and improved preoperative assessment of patients through a multidisciplinary input.

Introduction Esophagectomy is a key component in the curative treatment of esophageal cancer. Little is understood about the impact of smoking status on perioperative morbidity and mortality and the long-term outcome of patients following esophagectomy. Objective This study aimed to evaluate morbidity and mortality according to smoking status in patients undergoing esophagectomy for esophageal cancer. Methods Consecutive patients undergoing two-stage transthoracic esophagectomy (TTE) for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between January 1997 and December 2016 at the Northern Oesophagogastric Unit were included from a prospectively maintained database. The main explanatory variable was smoking status, defined as current smoker, ex-smoker, and non-smoker. The primary outcome was overall survival (OS), while secondary outcomes included perioperative complications (overall, anastomotic leaks, and pulmonary complications) and survival (cancer-specific survival [CSS], recurrence-free survival [RFS]). Results During the study period, 1168 patients underwent esophagectomy for cancer. Of these, 24% (n = 282) were current smokers and only 30% (n = 356) had never smoked. The median OS of current smokers was significantly shorter than ex-smokers and non-smokers (median 36 vs. 42 vs. 48 months; p = 0.015). However, on adjusted analysis, there was no significant difference in long-term OS between smoking status in the entire cohort. The overall complication rates were significantly higher with current smokers compared with ex-smokers or non-smokers (73% vs. 66% vs. 62%; p = 0.018), and there were no significant differences in anastomotic leaks and pulmonary complications between the groups. On subgroup analysis by receipt of neoadjuvant therapy and tumor histology, smoking status did not impact long-term survival in adjusted multivariable analyses. Conclusion Although smoking is associated with higher rates of short-term perioperative morbidity, it does not affect long-term OS, CSS, and RFS following esophagectomy for esophageal cancer. Therefore, implementation of perioperative pathways to optimize patients may help reduce the risk of complications.

Background Esophageal cancer has seen a considerable change in management and outcomes over the last 30 years. Historically, the overall prognosis has been regarded as poor; however, the use of multimodal treatment and the integration of enhanced recovery pathways have improved short- and long-term outcomes. Objective The aim of this study was to evaluate the changing trends in presentation, management, and outcomes for patients undergoing surgical treatment for esophageal cancer over 30 years from a single-center, high-volume unit in the UK. Patients and Methods Data from consecutive patients undergoing esophagectomy for cancer (adenocarcinoma or squamous cell carcinoma) between 1989 and 2018 from a single-center, high-volume unit were reviewed. Presentation method, management strategies, and outcomes were evaluated. Patients were grouped into successive 5-year cohorts for comparison and evaluation of changing trends. Results Between 1989 and 2018, 1486 patients underwent esophagectomy for cancer. Median age was 65 years (interquartile range [IQR] 59–71) and 1105 (75%) patients were male. Adenocarcinoma constituted 1105 (75%) patients, and overall median survival was 29 months (IQR 15–68). Patient presentation changed, with epigastric discomfort now the most common presentation (70%). An improvement in mortality from 5 to 2% (p p p = 0.004). Conclusions Long-term outcomes have significantly improved over the 30-year study period. In addition, mortality and length of stay have improved despite an increase in complications. The reasons for this are multifactorial and include the use of perioperative chemo(radio)therapy, the introduction of an enhanced recovery pathway, and improved patient selection.

Objective To determine the impact of downstaging on outcomes in esophageal cancer, the prognostic value of clinical and pathological stage, and the difference in survival in patients with similar pathological stages with and without neoadjuvant treatment. Background There is little data evaluating adenocarcinoma and squamous cell carcinoma (SCC) and difference in outcomes for similar pathological stage with and without neoadjuvant treatment. Patients and Methods Consecutive patients with esophageal cancer from a single center were evaluated. Patients with esophageal adenocarcinoma or SCC treated with transthoracic esophagectomy and two-field lymphadenectomy were included. Comparison of outcomes with those primarily treated with surgery was made. The cTNM and ypTNM 8th edition was used. Results This study included 992 patients, of whom 417 received surgery alone and 575 received neoadjuvant therapy and surgery. In the neoadjuvant group, 7 (1%) had cTNM stage 2 and 418 (73%) had cTNM stage 3. Downstaging rates were similar between adenocarcinoma and SCC (54% vs. 61%, p = 0.5). Downstaging was associated with longer survival than patients with no change (adenocarcinoma, median: 82 vs. 26 months, p p Conclusions Pathological stage provides a better estimate of prognosis compared with clinical stage. Downstaged patients may have an improved outcome over those with comparable pathological stage who did not receive neoadjuvant treatment.

BackgroundEsophagectomy is a technically demanding procedure associated with high levels of morbidity. Anastomotic leak (AL) is a common complication with potentially major ramifications for patients. It has also been associated with poorer long-term overall survival (OS) and disease recurrence.ObjectiveThe aim of this study was to determine whether AL contributes to poor OS and recurrence-free survival (RFS) for patients with esophageal cancer.MethodsConsecutive patients undergoing a two-stage, two-field transthoracic esophagectomy from a single high-volume unit between 1997 and 2016 were evaluated. Clinicopathologic characteristics, along with oncological and postoperative outcomes, were stratified by no AL versus non-severe leak (NSL) versus severe esophageal AL (SEAL). SEAL was defined as ALs associated with Clavien–Dindo grade III/IV complications.ResultsThis study included 1063 patients, of whom 8% (87/1063) developed AL; 45% of those who developed AL were SEALs (39/87). SEAL was associated with a prolonged critical care stay (median 8 vs. 3 vs. 2 days;p p ConclusionThese results demonstrate that AL leads to prolonged critical care and in-hospital length of stay; however, contrary to previous reports, our results do not compromise long-term outcomes and are unlikely to have a detrimental oncological impact.

Background Lymphadenectomy is essential for adequate oncological clearance and accurate staging during oesophagectomy for malignant disease. Adequate lymph node clearance has implications on patient outcomes and confers a survival benefit. Abdominal lymph node clearance may be technically challenging due to the location of nodes along key structures such as the common hepatic artery and splenic vessels. Robotic assistance during abdominal lymphadenectomy permits improved 3-D visualisation and instrument articulation in a potentially constricted space. This video demonstrates a technique for robotic abdominal lymphadenectomy during oesophagectomy. Methods This video demonstrates a technique for coeliac axis lymph node clearance during the abdominal phase of an oesophagectomy, as practiced at this institution. The intention for such a video is for ongoing appraisal and refinement of robotic techniques within the unit, as well as for teaching and training. The video was edited using iOS software, and text has been used to explain each step in conjunction with the images. Results Dissection of all relevant coeliac axis nodal stations is successfully demonstrated, with the lymph nodes resected en-bloc with the specimen. Text has also been used to explain the steps seen in the video images. Conclusions Robotic assistance permits safe and adequate lymphadenectomy during minimally invasive oesophagectomy, as demonstrated in this video.

Background 15% of the adult population are estimated to have gallstones (GS) and managing GS related disease can represent a significant challenge to surgical and endoscopic services alike. One particular challenge is the management of bile duct calculi (BDC), and treatment can vary according to the unit/institution. NICE has published guidelines (CG188) on the management of GS disease with the recommendation that bile duct clearance and cholecystectomy be offered for symptomatic and asymptomatic BDC. This retrospective audit was performed to determine compliance of a single centre with respect to offering cholecystectomy following ERCP for BDC. Methods A retrospective audit was performed for the year 2018 at a single centre utilising the trust ERCP database. The audit was analysed against NICE guideline CG188 and specifically whether patients treated with ERCP for BDC were then treated with cholecystectomy or had a documented justification as to why cholecystectomy was declined. 2018 was chosen so that at least a 2-year period of follow-up could be analysed. As well as the trust ERCP database, the trust electronic documentation record and paper notes were consulted to determine compliance with the guideline. Results 149 ERCPs were performed on 121 patients at this centre in 2018. Of these, 82 patients were included as 39 had an ERCP for malignant disease or had already had a cholecystectomy. Of those 82, 51 (62%) had an ERCP as an emergency while 31 (38%) had an elective procedure. The median age was 65, 54% being male and 46% female. 45 (55%) had a cholecystectomy following ERCP, 29 as an emergency, and 16 electively. Of those 37 who did not have a cholecystectomy, 20 (54%) had no recorded documentation to justify a decision not to proceed to cholecystectomy. Conclusions GS disease has the potential to cause significant morbidity. If an ERCP has been performed for BDC, NICE recommends that cholecystectomy should be offered to mitigate further GS related complications. Patients may of course decline an operation, or a joint decision made not to pursue operative management due to identified surgical risks. This audit demonstrated that 54% of patients at this institution who did not have a cholecystectomy following ERCP had no documented reason why cholecystectomy was declined. Robust follow-up and documentation measures have since been put in place and a follow-up audit is being performed to monitor improvement.

Background Pain control is a vital component of enhanced recovery programmes for patients undergoing an oesophagectomy. Multimodal analgesia using intrathecal diamorphine and local anaesthetic infusion catheters into the paravertebral space and rectus sheath is increasingly utilised. Multimodal analgesia can provide comparable pain relief while potentially reducing side effects associated with thoracic epidurals. This video demonstrates the placement of paravertebral catheters following thoracoscopic oesophagectomy. Methods The video demonstrates the technique for paravertebral catheter placement at the end of the thoracic phase of an oesophagectomy, as practiced at our institution. Results Once the catheter has been placed and flushed, a bolus 15-20mls of 0.25 per cent Levobupivicaine is injected. A 600mls reservoir of Levobupivicaine is attached at the end of the procedure. Conclusions Paravertebral catheters provide a safe and feasible option for pain control following oesophagectomy.

Background Covid-19 has had a devastating global impact and resulted in over 4.4 million directly attributed deaths. The UK entered lockdown in March 2020, redistributing its medical workforce and resources. Early estimations suggested at least 4700 extra cancer deaths at 5 years if there was a 3-month delay to surgery. Delays to diagnosis and treatment for osophagogastric (OG) cancers can be particularly detrimental to survival. The aim of this study is to assess the impact of Covid-19 on new cancer referrals to a centralised UK OG cancer centre, including presentation, decision making and treatment. Methods Patients with OG cancer referred to a tertiary, high-volume centre between March 2019 and March 2021 were reviewed. Patients were stratified into Pre-covid (March 2019-March 2020) and Covid (March 2020-2021) cohorts. Number of new referrals, clinical stage, treatment decision, and time to treatment were compared for gastric adenocarcinoma (GA), oesophagogastric-junction adenocarcinoma (OGJA), oesophageal adenocarcinoma (OA) and oesophageal SCC (OSCC). Results There was an 11% reduction in new cancer referrals (485 vs 431). GA, OGJA and OA did not have significant change in treatment intent, although there was a significant increase in the decision for definitive non-surgical treatment of OA (P = 0.046). GA and OA patients had a small, but significant increase in mean clinical stage at presentation (P Conclusions This high-volume centre has seen a reduction in new cancer referrals since the first UK lockdown. This was associated with a small, but significant, increase in clinical stage of GA and OA at presentation. This may represent an early indication of excess oesophagogastric cancer deaths due to the impact of Covid-19. This data also confirms initial results showing that oncological decisions were not compromised, although Covid-19 remains a dynamic challenge.

Summary Locally advanced esophageal cancer is associated with poor long-term survival. Pre- and post-treatment stages may differ because of neoadjuvant therapy and inaccuracies in staging. The aim of this study was to determine the outcomes of patients staged with clinical T3 N3 and pathological T3 N3 carcinoma of the esophagus and determine differences between the groups. Consecutive patients from a single unit between 2010 and 2018 were included with either clinical (cT3 N3) or pathological (pT3 N3) esophageal cancer. Outcomes were compared between patients that underwent esophagectomy with or without neoadjuvant treatment and those patients staged cT3 N3 treated non-surgically (NSR). Patients were staged using the TNM 8. This study included 156 patients, 63 patients were staged cT3 N3 initially and had NSR treatment, only three of these had radical treatment. Of the remaining 93 patients who underwent esophagectomy, 34 were initially staged as cT3 N3, 54 were found to be pT3 N3 having been staged earlier initially, and five were unchanged before and after treatment. Median overall survival (OS) for surgical cT3 N3 patients was significantly longer than pT3 N3 and NSR (median: NR vs 19 vs 8 months, P

Aim To evaluate the outcomes patients undergoing endoscopic mucosal resection (EMR) as a therapeutic and or diagnostic treatment for oesophageal cancer. Background Management of early oesophageal cancer usually involves major surgery (oesophagostomy) which has a reported morbidity of 50% and mortality of 3%. EMR is increasingly used as a treatment for patients with early (T1 N0) oesophageal cancer. It may also be employed as a diagnostic tool in those where previous biopsies have been insufficient in proving a cancer. Methods A retrospective review of patients who underwent EMR with a curative intent for cancer of the oesophagus or oesophago-gastric junction (OGJ) at a single centre between October 2006 and February 2019 was conducted. Patients were included in the study if the EMR sample was positive for T1a or T1b cancer. Results Overall 144 patients were identified who underwent 276 therapeutic or diagnostic procedures. 141 patients were diagnosed with adenocarcinoma and 3 patients with squamous cell cancer (SCC). T1a stage was confirmed for 120 patients with adenocarcinoma and one with SCC. 21 patients with adenocarcinoma and 2 with SCC were staged as T1b. 78 patients underwent EMR as their sole treatment for cancer- three year cancer related survival was 89% and 5 year 69%. A further 49 patients progressed to having surgery (gastrectomy (2), trans-thoracic oesophagectomy (47). Six (12%) were node positive. There was no mortality associated with EMR, however bleeding requiring intervention or readmission was observed after 29 procedures (11%) and perforation was seen after 3 procedures (1.1%). Conclusion EMR is a safe procedure in the treatment of early oesophageal or OG junctional cancer. However survival may not be as high as expected in patients similarly staged but undergoing more radical treatment.

Background Chyle leaks may result from damage of the main thoracic duct or its tributaries during radical en-bloc sub-total oesophagectomy (STO). Treatment strategies and outcomes vary and management of this problem remains controversial. This study assessed the incidence, management and outcomes of chyle leaks in a dedicated oesophago-gastric cancer unit. Methods A retrospective study was conducted among patients who underwent elective STO with 2-field nodal dissection for oesophageal cancer between January 1997 and March 2019. The thoracic duct was routinely ligated during surgery. The diagnosis of post-operative chyle leak was performed clinically by a consultant and it was based on high output (> 500 ml/24h) from chest and/or abdominal drains and on visual characteristics of the fluid. Results 1320 patients underwent surgery over the time reviewed. The study group consisted of 347 (26.3%) women and 974 (73.7%) men, with a median age of 65 (IQR 13) years. Oesophageal adenocarcinoma was diagnosed in a total of 937 (70.9%) patients, while squamous cell carcinoma in 274 (20.7%) patients. 93 (7%) patients developed a chylothorax. Univariable analysis showed that lower body weight, lower BMI, female sex and histology of a squamous cell carcinoma were significant independent predictive factors for chyle leak (p Chyle leak was associated with a higher risk of return to ITU (45.1% vs 10.1%, p Chylothorax was treated surgically in 39 (41.9%) patients and conservatively in 54 (58.1%). Between these two groups, a significant difference in terms of post-operative hospital stay and in 30-day mortality rate was seen (p< 0.002 and p=0.031, respectively). Survival rate was similar in both groups. Conclusions Chyle Leak post oesophagectomy is associated with an increased risk of return to ITU, and longer hospital stay and increased in hospital mortality. However, surgical treatment is safe and early re-operation is recommended in order to diminish hospital stay and to decrease the 30-day mortality rate.

Background Oesophagogastric cancer surgery is immunosuppressive. This may be modulated by omega-3 fatty acids (O-3FAs). The aim of this study was to assess the effect of perioperative O-3FAs on clinical outcome and immune function after oesophagogastric cancer surgery. Methods Patients undergoing subtotal oesophagectomy and total gastrectomy were recruited and allocated randomly to an O-3FA enteral immunoenhancing diet (IED) or standard enteral nutrition (SEN) for 7 days before and after surgery, or to postoperative supplementation alone (control group). Clinical outcome, fatty acid concentrations, and HLA-DR expression on monocytes and activated T lymphocytes were determined before and after operation. Results Of 221 patients recruited, 26 were excluded. Groups (IED, 66; SEN, 63; control, 66) were matched for age, malnutrition and co-morbidity. There were no differences in morbidity (P = 0·646), mortality (P = 1·000) or hospital stay (P = 0·701) between the groups. O-3FA concentrations were higher in the IED group after supplementation (P < 0·001). The ratio of omega-6 fatty acid to O-3FA was 1·9:1, 4·1:1 and 4·8:1 on the day before surgery in the IED, SEN and control groups (P < 0·001). There were no differences between the groups in HLA-DR expression in either monocytes (P = 0·538) or activated T lymphocytes (P = 0·204). Conclusion Despite a significant increase in plasma concentrations of O-3FA, immunonutrition with O-3FA did not affect overall HLA-DR expression on leucocytes or clinical outcome following oesophagogastric cancer surgery. Registration number: ISRCTN43730758 (http://www.controlled-trials.com).

Background The aim of this study was to evaluate the diagnosis, management and outcome of patients with spontaneous rupture of the oesophagus in a single centre. Methods Between October 1993 and May 2007, 51 consecutive patients with spontaneous oesophageal rupture were evaluated with contrast radiology and flexible endoscopy. Patients with limited contamination who fulfilled specific criteria were managed by a non-operative approach, whereas the remainder underwent thoracotomy. Results The median time to diagnosis was 24 (range 4–604) h. Initial diagnosis was by contrast swallow in 18 of 24 patients, computed tomography in 15 of 17 and endoscopy in 18 of 18. There were no deaths among 17 patients who were managed non-operatively with targeted drainage, intravenous antimicrobials, nasogastric decompression and enteral nutrition. Of 31 patients who underwent primary thoracotomy and oesophageal repair (over a Τ tube in 29), 11 died in hospital. Three patients could not be resuscitated adequately and did not have surgical intervention. Conclusion Spontaneous oesophageal rupture represents a spectrum of disease. Accurate radiological and endoscopic evaluation can identify those suitable for radical non-operative treatment and those who require thoracotomy.

Background About 10 per cent of patients undergoing radical oesophagectomy for transmural (T3) carcinoma with lymph node involvement (N1) develop symptomatic bone metastases within 12 months of surgery. The aim of this study was to evaluate the introduction of targeted preoperative bone scintigraphy. Methods Of 790 patients with oesophageal carcinoma staged between December 2000 and December 2004, 189 were eligible for potentially curative treatment. 99mTc-labelled hydroxymethylene diphosphonate bone scintigraphy was performed in those with stage T3 N1 disease (identified by computed tomography and endoscopic ultrasonography) who were suitable for radical treatment. Results A total of 115 patients had bone scintigraphy. The histological diagnosis was adenocarcinoma in 82 patients and squamous cell carcinoma in 33. Bone scintigraphy was normal or showed degenerative changes in 93 patients, and abnormal requiring further investigation in 22. Plain radiography, magnetic resonance imaging and biopsy confirmed the presence of bone metastases in 11 patients (9·6 per cent). Conclusion Bone is frequently the first site of identifiable distant metastatic spread, and bone scintigraphy is recommended to exclude metastatic disease before radical treatment of advanced oesophageal carcinoma.

Background Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high-volume institution that did not use stenting as a primary treatment modality. Methods All patients undergoing an oesophagectomy between January 2009 and December 2013 were included. Patients were identified from a prospectively maintained database. Results A total of 390 oesophagectomies were performed (median age 65 (range 32–81) years). In 96·7 per cent of patients this was a two-stage subtotal oesophagectomy. Overall in-hospital and 90-day mortality rates were both 2·1 per cent (8 patients). Some 31 patients (7·9 per cent) developed a leak (median age 64·5 (range 52–80) years), of whom 27 (87 per cent) were initially managed without surgery, whereas four (13 per cent) required immediate thoracotomy. The median length of stay for patients with a leak was 41·5 (range 15–159) days; none of these patients died. Conclusion Leaks can be managed with excellent outcomes without using oesophageal stents. The results do not support the widespread adoption of endoscopic stenting.

Background The aim of this study was to determine the feasibility and accuracy of sentinel lymph node (SLN) biopsy for oesophageal adenocarcinoma. Methods Fifty-seven patients with adenocarcinoma of the lower oesophagus (n = 40) or gastric cardia (n = 17) underwent endoscopic peritumoral injection of 99mTc-radiolabelled nanocolloid before en bloc resection with extended lymphadenectomy. SLNs were identified during surgery using a handheld γ probe and the pattern of radioactive uptake was quantified after operation. All 1667 resected lymph nodes were examined immunohistochemically for micrometastases. Results SLNs were identified in all 57 patients. They contained metastases (n = 32) or micrometastases (n = 3) in 35 of 37 node-positive patients and there were two false-negative studies. The overall accuracy of SLN biopsy was 96 per cent and SLNs were more likely to contain tumour than other lymph nodes (P < 0·001). Tumour-infiltrated nodal stations had a higher proportion of radioactive uptake (P < 0·001). Lower oesophageal tumours had a greater proportion of SLNs (P = 0·018), radioactive uptake (P < 0·001) and malignant nodes (P = 0·004) in the mediastinum than gastric cardia tumours. Conclusion The sentinel node concept is applicable to oesophageal adenocarcinoma and could be used to tailor the extent of lymphadenectomy. There is a close relationship between patterns of radioactive uptake and lymphatic tumour dissemination, which differ for lower oesophageal and gastric cardia tumours.

Background The practice of routine contrast radiology before recommencing oral nutrition after total gastrectomy is not evidence based. The aim of this prospective study was to evaluate the clinical role and timing of this investigation. Methods Seventy-six consecutive patients underwent total gastrectomy with a stapled oesophagojejunal anastomosis. A contrast swallow using non-ionic contrast and barium was performed routinely 5 and 9 days after surgery. The surgeon was blinded to the result of the first of these examinations. Patients with clinical evidence of a leak underwent contrast radiology and upper gastrointestinal videoendoscopy. Results Eight patients (11 per cent) developed a clinical leak from the oesophagojejunal anastomosis, seven before the first scheduled contrast swallow. Contrast radiology identified a leak in four of six patients. Endoscopy detected a leak in both patients with a false-negative swallow and in two patients who were not fit to undergo contrast radiology. Routine contrast radiology identified a subclinical leak in a further five patients (7 per cent), none of whom developed clinical signs. Four of seven in-hospital deaths were associated with an anastomotic leak. Conclusion There is no role for routine contrast swallow after total gastrectomy with a stapled oesophagojejunal anastomosis, but patients with clinical suspicion of leakage should undergo urgent contrast radiology, plus endoscopy if the contrast examination is normal.

Background The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a stapled intrathoracic anastomosis. Methods Some 291 consecutive patients underwent two-phase subtotal oesophagectomy with gastric interposition for malignancy. Patients with clinical suspicion of a leak were investigated with contrast radiology and flexible upper gastrointestinal endoscopy. Results Nineteen patients (6·5 per cent) developed a proven mediastinal leak at a median of 8 (range 3–30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had widespread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology was normal. In six patients the diagnosis of leakage followed an apparently normal routine contrast examination on day 5–8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intravenous antibiotics and antifungal therapy, nasogastric decompression and enteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical picture; they were managed with repeat thoracotomy and either revision of the conduit or resection and exclusion. Despite early intervention four of the six patients died. Conclusion Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology and endoscopic evaluation. Isolated anastomotic leaks can be managed successfully with non-operative treatment, whereas more extensive leaks from the gastric conduit require revisional surgery which carries a high mortality rate.

Introduction: Peri-operative allogeneic blood transfusion may exert an immunomodulatory effect and has been associated with early recurrence and decreased survival following resection for several gastro-intestinal malignancies. The aim of this study was to evaluate the prognostic influence of transfusion requirements following radical oesophagectomy for cancer. Methods: A consecutive series of 235 patients undergoing subtotal oesophagectomy with two-field lymphadenectomy in a single centre from April 1990 to June 1999 were studied. Results: The median age was 64 years (30–79) with a male to female ratio of 3:1. The predominant histological subtype was adenocarcinoma (n=154) compared to squamous carcinoma (n=81). To avoid the influence of surgical complications data were excluded from the 5.5% of patients suffering in-hospital mortality. In the remaining patients, median blood loss was 900 ml (200–5500) with 46% (103/222) requiring transfusion (median 3 units, range 2–21). Median survival of non-transfused patients was 36 months compared to only 19 months for those receiving transfusion (log-rank=4.44; 1 df, P=0.0352). Non-transfused patients had significantly higher 2 and 5-year survival rates of 62% and 41% respectively in contrast to only 40% and 25% in those receiving blood transfusion. Even after stratification of results according to disease stage or the presence of major complications, survival was significantly worse in those receiving transfusion. Multivariate analysis demonstrated that in addition to nodal status, >4 units transfusion was an independent prognostic indicator.Conclusion: Post-operative transfusion is associated with a significantly worse prognosis following radical oesophagectomy. Meticulous haemostasis and avoidance of unnecessary transfusion may prove oncologically beneficial.

Many patients undergoing surgery for gastric carcinoma will develop peritoneal metastases. A method to identify those patients at risk of peritoneal recurrence would help in the selection of patients for adjuvant therapy. Peritoneal cytology has received little attention in the West, but may prove a useful additional means of evaluating patients with gastric cancer. The aims of this study were to evaluate sampling techniques for peritoneal cytology in patients with gastric cancer, to assess the prognostic significance of free peritoneal malignant cells and to discover the effect of the operative procedure on dissemination of malignant cells. The study is based on 85 consecutive patients undergoing surgical treatment of gastric cancer and followed up for 2 years or until death. Peritoneal cytology samples were collected at laparoscopy, and at operation prior to resection by intraperitoneal lavage and serosal brushings. After resection, samples were taken by peritoneal lavage, imprint cytology of the resected specimen and post-operatively by peritoneal irrigation via a percutaneous catheter. Malignant cells were diagnosed by two independent microscopists. Preoperative peritoneal lavage yielded malignant cells in 16 out of 85 cases (19%). The yield of free malignant cells was increased by using serosal brushings (by four cases) and imprint cytology (by two cases); all of the cases had evidence of serosal penetration. One serosa-negative case exhibited positive cytology in the post-resection peritoneal specimen in which the preresection cytology specimen was negative. Survival was worse in the cytology-positive group (χ2 = 25.1; P < 0.0001). Among serosa-positive patients, survival was significantly reduced if cytology was positive, if cases yielded by brushings and imprint cytology were included (log-rank test = 8.44; 1 df, P = 0.004). In conclusion, free peritoneal malignant cells can be identified in patients with gastric cancer who have a poor prognosis; the yield can be increased with brushings and imprint cytology in addition to conventional peritoneal lavage. Evaluation of peritoneal cytology by these methods may have a role in the selection of patients with the poorest prognosis who may benefit most from adjuvant therapy. © 1999 Cancer Research Campaign

Gastrectomy with extended lymphadenectomy is the advocated treatment in Japan for patients with "curable" stomach cancer. Attempts in units elsewhere adopting this approach failed to show any survival advantage, and the high operative mortality has prevented global acceptance of the operation. This study examines the safety and efficacy of radical gastrectomy in a Far East center outside Japan.A consecutive series of 121 patients with gastric cancer who fulfilled criteria for radical surgery had total gastrectomy with extended lymphadenectomy equivalent to D3 dissection over a 6-year period in a single unit.The operation carried a morbidity of 50%, with a perioperative mortality of 5%. Survival was best predicted by tumor stage: 5-year survival for patients with intact gastric serosa was 64%, versus 10% for those with serosal penetration (p0.001). The majority of documented metastases occurred by transperitoneal route in serosa-positive patients, but via the hematogenous mechanisms in those who were serosa-negative.Radical gastrectomy with extended lymphadenectomy carries high operative morbidity. Increased mortality occurred because of loco-regional recurrence in patients with T3/T4 diseases. Novel approaches including neoadjuvant treatment or regional therapy should be explored.

A plea not to dilate

Pathological appearance of the stomach after endoscopic mucosal resection for early gastric cancer S. Kundu, D. Karat, J. Wayman, N. Hayes, S. M. Griffin, Oesophago-Gastric Cancer Unit, Newcastle General Hospital, Westgate Road, Newcastle upon Tyne NE4 6BE, UK Authors' reply: D. Korenaga, Department of Surgery, Fukuoka Dental College Hospital, 2-15-1 Tamura, Sawara-ku, Fukuoka 814-01, Japan Hereditary breast cancer Reply to letter published in previous issue (Br J Surg 1998; 85: 570–1): A. Hill, E. McDermott, N. O'Higgins, Department of Surgery, University College Dublin, St Vincent's Hospital, Elm Park, Dublin 4, Ireland Effect of a no-conversion policy on patient outcome following laparoscopic cholecystectomy M. D. Barber, P. C. Bornman, O. J. Garden, University Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK Authors' reply: P. J. O'Dwyer, Department of Surgery, Western Infirmary, Glasgow G11 6NT, UK Correlation between blood loss and inferior vena caval pressure during liver resection P. B. S. Lai, C. K. Leow, W. Y. Lau, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong and P. T. Chui, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Dynamic graciloplasty for severe anal incontinence A. J. P. Eccersley, N. S. Williams, Academic Department of Surgery, The Royal London Hospital, Whitechapel, London E1 1BB, UK Authors' reply: J. Christiansen, O. Rasmussen, Department of Surgery, Herlev Hospital, University of Copenhagen, 75 Herlev Ringvej, DK 2730 Herlev, Denmark ‘Routine’ pathological examination of the gallbladder is a futile exercise Letter 1: K. S. Zayyan, D. P. Sellu, Surgical Sciences Unit, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK Letter 2: R. Y. Ball, Department of Histopathology/Cytopathology, Norfolk and Norwich Hospital, Brunswick Road, Norwich NR1 3SR, UK Letter 3 D. J. Bowrey, G. J. Morris-Stiff, B. I. Rees, University Department of Surgery, University Hospital of Wales, Heath Park, Cardiff CF4 4XN, UK Authors' reply: J. K. C. Huang, University Department of Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK and H. W. Taylor, Department of Surgery, Basildon Hospital, Nethermayne, Basildon SS16 5NL, UK Activated protein C resistance: the commonest hereditary hypercoagulation disorder Letter 1: I. Khogali, G. P. Summerfield, A. Mudawi, Departments of Haematology and Surgery, Queen Elizabeth Hospital, Sheriff Hill, Gateshead NE9 6SX, UK Letter 2: S. Sulaiman-Shoab, Department of Surgery, University College London Medical School, First Floor Jules Thorne Building, Middlesex Hospital, London W1N 8AA, UK Authors' reply: K. Schuster, D. Jentschura, Department of Surgery, Klinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Strasse 1–3, 68135 Mannheim, Germany Laparoscopic stoma formation for faecal diversion R. E. K. Marshall, J. F. McPartlin, Department of Colorectal Surgery, William Harvey Hospital, Ashford TN24 0LZ, UK Authors' reply: J. W. Lumley, R. W. Stitz, Wesley Medical Centre, 24/40 Chasely Street, Auchenflower 4066, Brisbane, Australia Lateral rectal ligaments contain important nerves J.-T. Liang, K.-J. Chang, S.-M. Wang, Department of Colorectal Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan Authors' reply J. Rutegård for the authors, Department of Surgery, Örnsköldsvik Hospital, S891 89 Örnsköldsvik, Sweden Perioperative allogeneic blood transfusion does not cause adverse sequelae in patients with cancer: a meta-analysis of unconfounded studies Letter 1: L. S. Jensen, Department of Surgical Gastroenterology, Aarhus University Hospital, 8000 Aarhus C, Denmark Letter 2: N. Blumberg, Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Box 608, Rochester, New York 14642, USA Authors' reply: F. A. McAlister, Divisions of General Internal Medicine and Clinical Epidemiology, Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, Canada

In a prospective study of 69 patients being treated for oesophageal carcinoma, quality of life was assessed with the Rotterdam Symptom Checklist, a dysphagia score and an activities of daily living questionnaire. Significant correlations were found between the results of the Rotterdam Symptom Checklist, the dysphagia score and most aspects of the activities of daily living questionnaire. Eighteen patients underwent surgery, 43 radiotherapy or intubation, and eight a combination of surgery and other therapy. Patients undergoing surgery were significantly younger and had better scores in all parameters examined before operation, including significantly better scores in ‘knowledge and communication’ and ‘mobility and fatigue’. The dysphagia score fell significantly after intervention both in patients undergoing surgery alone and in those receiving palliative therapy. The activities of daily living questionnaire showed significant improvements in two parameters in the surgical group (‘self-care’ and ‘eating and drinking’) and in none of the parameters assessed in the palliation group in 16 weeks. Quality-of-life assessment is useful in assessing quality of care and patient well-being after the diagnosis and treatment of oesophageal carcinoma.

Surgery has been the mainstay of treatment for spontaneous full-thickness rupture of the esophagus for the last 50 years. In an acute presentation with contamination of the mediastinal or pleural cavities, this remains the definitive course of action. However, the management when diagnosis has been delayed is more contentious. This is a description of a novel approach with a combined percutaneousendoscopic technique that was used in 2 such cases.

Nausea and vomiting in patients with advanced gastric malignancy and mechanical obstruction are distressing and difficult to manage. We describe a patient with linitis plastica and gastric stasis who was treated with a percutaneous endoscopic duodenostomy as the stomach could not be used for percutaneous endoscopic gastrostomy (PEG) formation. A ConfloTM PEG tube was inserted into the second part of the duodenum using the Ponsky–Gauderer technique without complication. The patient experienced excellent symptomatic relief and tolerated enteral nutrition extremely well, regaining some weight. This manoeuvre can produce effective symptom palliation allowing the patient to be managed at home during the terminal phase of their illness.

Background Endoscopic ultrasonography (EUS) can detect low-volume ascites (LVA) not apparent on computed tomography. The aim of this study was to assess the importance of LVA for management of patients with oesophagogastric (OG) cancer. Methods Patients with LVA were identified from a prospective OG cancer unit database between January 2002 and January 2006. Results Of 1118 patients staged with OG cancer, 802 had EUS. The incidence of LVA was 8·4 per cent overall but fell to 6·5 per cent when those with metastases on computed tomography were excluded. Only patients with gastric and OG junction carcinoma had LVA. Staging laparoscopy in the 21 patients with LVA revealed that 11 (52 per cent) were inoperable. The remainder had laparotomy and complete (R0) resection was possible in only five (50 per cent). In 106 patients who had staging laparoscopy after EUS without LVA, 37 (34·9 per cent) were inoperable and 56 of the remaining 69 (81 per cent) had R0 resection. Conclusion The presence of LVA on EUS is uncommon in patients with OG cancer but very important, being indicative of incurable disease in 76 per cent. This information will be helpful in counselling patients regarding management options and the low likelihood of potentially curative treatment.

Introduction The presence of lymphatic dissemination in oesophageal cancer affects prognosis. The relevance of location of an involved solitary lymph node is unclear. The concept of sentinel node guided lymphadenectomy to reduce surgical stress of a transthoracic operation has some advocates. However, the site of solitary lymph node metastasis, is unpredictable. Similarly, metastases to anatomically distant lymph nodes, known as skip lesions, could develop in the early phase of lymphatic invasion. The aim of this study was to examine the pattern of a single named lymph node metastasis in patients with oesophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) who underwent resection with curative intent. No study to date has investigated this concept. Method Results of consecutive patients from a prospectively maintained database were analysed. All patients with potentially curable AC or SCC who underwent a radical two-field, two-stage, transthoracic oesophagectomy were included. Ex-vivo surgical dissection of the specimen was carried out post-operatively by the surgeon, with harvested lymph node stations labelled. This permitted accurate ‘lymph node mapping’. All harvested lymph nodes were examined by a consultant histopathologist. Results Between 1995 and 2014 a total of 120 patients with one positive lymph node who had undergone a radical two-field, two-stage oesophagectomy were identified. A median age of 65 (45–80) was observed. Seventy three ACs and 47 SCCs were noted. Twenty three middle oesophageal (19.2%), 54 lower oesophageal (45%) and 43 (35.8%) junctional tumours were resected. There was no difference between patterns of solitary lymphatic metastases between AC and SCC. The pattern and number of solitary lymph node metastasis is as follows: paracardial 34 (28.3%); paraoesophageal 31 (25.8%); left gastric 28 (23.3%); subcarinal/bronchial 10 (8.3%) and truncal/coeliac/splenic 9 (7.5%). Tumour location and corresponding single node metastasis are summarised in Table 1. Median survival for patients with AD and SCC were similar at 45 months and 52 months respectively (p = 0.84). Conclusion This study provides further support to the concept that metastasis to anatomically distant lymph nodes (skip metastasis), could develop even in the early phase of lymphatic invasion in oesophageal carcinoma. This unpredictability necessitates a radical resection. This can only be achieved with an extended transthoracic operation to allow a complete two-field lymphadenectomy in order to provide locoregional clearance and a potentially curative resection. Disclosure of interest None Declared.

In August 2004, the United Kingdom Department of Health advisory body published dyspepsia referral guidelines for primary care practitioners. These guidelines advised empiric treatment with antisecretory medications and referral for endoscopy only in the presence of alarm symptoms. The current study aimed to evaluate the effect of these guidelines on the detection of esophagogastric cancer.The study reviewed a prospectively compiled database of 4,018 subjects who underwent open access gastroscopy during the years 1990 to 1998. The main outcome measures for the study were cancer detection rates, International Union Against Cancer (UICC) stage, and survival.Gastroscopy identified esophagogastric carcinoma in 123 (3%) of the 4,018 subjects. Of these 123 patients, 104 (85%) with esophagogastric cancer had "alarm" symptoms (anemia, mass, dysphagia, weight loss, vomiting) and would have satisfied the referral criteria. The remaining 15% would not have been referred for initial endoscopic assessment because their symptoms were those of uncomplicated "benign" dyspepsia. The patients with "alarm" symptoms had a significantly more advanced tumor stage (metastatic disease in 47% vs 11%; p0.001), were less likely to undergo surgical resection (50% vs 95%; p0.001), and had a poorer survival (median, 11 vs 39 months; p = 0.01) than their counterparts without such symptoms.The use of alarm symptoms to select dyspeptics for endoscopy identifies patients with advanced and usually incurable esophagogastric cancer. Patients with early curable cancers often have only dyspeptic symptoms, and their diagnosis will be delayed until the symptoms of advanced cancer develop.

Lymph node metastasis in patients with early gastric cancer was evaluated prospectively to determine whether radical (D2) lymphadenectomy is appropriate in such cases. Twenty-eight (18 per cent) of 156 patients having surgery for gastric cancer had early disease. Lymph node metastasis was found in 12 of the 28 patients. Metastasis was more likely in submucosal than mucosal early gastric cancer (nine of 14 versus three of 14; P = 0·024, Fisher's exact test). In two of three patients with metastasis at the N2 level, the N1 nodes were entirely clear. This study shows a higher incidence of lymph node metastasis than has been reported previously in both the UK and Japan. The high incidence of lymph node metastasis in early gastric cancer supports the continuing use of radical lymphadenectomy in patients who are fit for such major surgery.

Background Patients with an intrathoracic oesophagogastrostomy after subtotal oesophagectomy experience profound duodenogastro-oesophageal reflux (DGOR). This study investigated the degree of mucosal injury and histopathological changes in oesophageal squamous epithelium after subtotal oesophagectomy with gastric interposition in relation to the extent of postoperative DGOR. Methods Serial endoscopic assessment and systematic biopsy at the oesophagogastric anastomosis was undertaken in 40 patients following curative radical subtotal oesophagectomy and reconstruction with a gastric conduit subjected to a pyloroplasty. Thirty patients subsequently underwent combined 24-h ambulatory pH and bilirubin monitoring. Results Grade I–III oesophagitis was identified in 14 patients and oesophageal columnar epithelium in 19 patients. Biopsies from columnar regeneration revealed cardiac-type epithelium in ten patients and intestinal metaplasia in nine. Seven patients followed serially showed progression from cardiac-type epithelium to intestinal metaplasia. The incidence of Barrett's metaplasia was similar irrespective of the histological subtype of the resected tumour. Patients with oesophageal columnar epithelium had significantly higher acid (P = 0·015) and bilirubin (P = 0·011) reflux. Conclusion Severe DGOR occurs following subtotal oesophagectomy and provides an environment for the acquisition of Barrett's metaplasia via a sequence of cardiac epithelium and eventual intestinal metaplasia.

Acute lung injury after oesophagectomy is well recognized but the risk factors associated with its development are poorly defined. We analysed retrospectively the effect of a number of pre-, peri- and post-operative risk factors on the development of lung injury in 168 patients after elective oesophagectomy performed at a single centre. The acute respiratory distress syndrome (ARDS) developed in 14.5% of patients and acute lung injury in 23.8%. Mortality in patients developing ARDS was 50% compared with 3.5% in the remainder. Features associated with the development of ARDS included a low pre-operative body mass index, a history of cigarette smoking, the experience of the surgeon, the duration of both the operation and of one-lung ventilation, and the occurrence of a post-operative anastomotic leak. Peri-operative cardiorespiratory instability (measured by peri-operative hypoxaemia, hypotension, fluid and blood requirements and the need for inotropic support) was also associated with ARDS. Acute lung injury after elective oesophagectomy is associated with intraoperative cardiorespiratory instability.

Background. The incidence of adenocarcinoma of the esophagogastric junction is rapidly increasing, and the extent of lymphadenectomy for such tumors remains controversial. The aim of this study was to identify the pattern of dissemination by examination of all lymph nodes retrieved from resected tumors of the esophagogastric junction. Methods. The endoscopic and pathologic reports of patients who underwent RO resection for adenocarcinoma of the esophagogastric junction between January 1996 and November 1999 were examined. Patients with type 1 tumors (distal esophagus) underwent subtotal esophagectomy with 2-field lymphadenectomy. Patients with type 2 (gastric cardia) tumors underwent transhiatal D2 total gastro-esophagectomy. Lymph node groups were dissected from the main specimens and examined separately. Results. One hundred and four type 1 and 48 type 2 tumors were studied. Median nodal recovery was 23 lymph nodes (type 1, 22 lymph nodes; type 2, 23 lymph nodes). Seventy-eight percent of the type 1 tumors with nodal metastases had dissemination in both the abdomen and mediastinum. The common abdominal sites were the paracardiac and the left gastric stations. Within the mediastinum, paraesophageal, paraaortic and tracheobronchial metastases were more often encountered. Type 2 tumors had positive lymph nodes most frequently in the left and right paracardiac, lesser curve (N1 group), and left gastric (N2 group) territories. Nodal status correlated with increasing depth of tumor invasion ( P = .002). Conclusions. The pattern of nodal dissemination for cardia tumors concurs with that described by other studies. The current definition of nodal fields in the abdomen and mediastinum for esophageal tumors relates to experience with squamous carcinomas. Our results demonstrate a different pattern of dissemination for junctional esophageal adenocarcinomas. The nodal stations to be resected in radical lymphadenectomies for such tumors should be redefined. (Surgery 2001;129:103-9.)

Twenty-seven patients with oesophageal carcinoma had subtotal oesophagectomy by the Lewis-Tanner operation (group 1, n=14) or a synchronous modification (group 2, n=13). Synchronous operations were completed more quickly (230 versus 305 min, P < 0·01), but with more time spent under single-lung anaesthesia (160 versus 120 min, P < 0·01) and a greater fall in systolic blood pressure during hiatal manipulation (60 versus 30mmHg, P < 0·01). Operative blood loss was not significantly greater in group 2, but the total volume of blood transfused in the perioperative period was greater in this group (5 versus 3 units, P < 0·01). Four patients in group 1 suffered significant postoperative complications, compared with seven in group 2; three postoperative deaths occurred in group 2. This study suggests that the synchronous two-team oesophagectomy produces a higher incidence of complications than the conventional operation. Continued use of the Lewis-Tanner two-stage oesophagectomy is recommended for patients with carcinoma of the oesophagus.

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Aims Benign anastomotic stricture (BAS) is a common cause of dysphagia following oesophagectomy. The aim of this study was to assess the incidence of BAS, identify risk factors for its development and evaluate the results of postoperative endoscopic dilatation. Methods A consecutive series of 234 patients undergoing oesophagectomy with a stapled intrathoracic oesophagogastric anastomosis (Autosuture CEEA gun) between April 1990 and April 1999 were studied. BAS was defined as dysphagia with anastomotic narrowing (XQ200 endoscope) and no suspicion of recurrence. Statistical analysis was by the χ2 and Mann–Whitney U tests. Results The postoperative mortality rate was 5 per cent (12 of 234) and the anastomotic leak rate 3 per cent (six of 234). One-third of patients (70 of 222) who survived surgery re-presented with dysphagia; 5 per cent (11 of 222) were found to have proven local recurrence and 27 per cent (59 of 222) BAS. The median time to development of BAS was 92 (range 24–210) days. BAS formation was significantly related to the size of the staple gun employed: 21 mm, 80 per cent (eight of ten); 25 mm, 32 per cent (25 of 78); 28 mm, 23 per cent (19 of 81); 31 mm, 19 per cent (seven of 37) and 34 mm, 0 per cent (none of five) (χ2 = 18·3, 4 d.f., P < 0·01). All patients underwent radiographically controlled endoscopic dilatation with no complications. Recurrent BAS occurred in over half of these patients (32 of 59), who had a median of 2 (range 2–17) recurrences all resolving within 532 (mean interval 68) days. Recurrent BAS formation was also significantly related to the size of the staple gun employed (χ2 = 11·6, 4 d.f., P < 0·05). Following the introduction of the Autosuture ‘tilt-top’ device in July 1995 the median size of gun used rose from 25 to 28 mm with an overall decrease in the incidence of BAS from 33 to 21 per cent (χ2 = 4·0, 1 d.f., P < 0·05). All patients with anastomotic leaks survived and none subsequently developed BAS. Similarly, no association was found between the development of BAS and the anastomotic site (measured from incisors), tumour subtype, resection margin length, sex, age or preoperative cardiorespiratory status. Conclusions Staple gun size is an important risk factor for BAS formation and ‘tilt-top’ devices enable the use of a larger head with a subsequently lower incidence of BAS. Endoscopic dilatation is an effective treatment for BAS which rarely recurs and always resolves within 18 months.

Background Subjects over 75 years old constitute an increasing proportion of the general population and hitherto the management of most malignant diseases in this elderly group has been predominantly palliative. The aim of this study was to assess the mode of presentation, management and outcome of treatment in patients aged over 75 years presenting with oesophageal malignancy. Methods Data were collected prospectively from all patients aged over 75 years at presentation who were diagnosed at or referred to a single centre between October 1989 and May 1998. All patients underwent a full protocol of staging investigations and assessment of co-morbid disease. The main modality of therapy and its outcome were analysed, as was the overall survival. Statistical analysis was with the χ2, Mann–Whitney and log rank tests. Results Eighty patients were studied (41 men). The median age at presentation was 82 (range 75–97) years. Adenocarcinoma was the predominant histological subtype (46, 58 per cent) compared with squamous cell carcinoma (SCC; 34, 42 per cent). Most patients were referred by a gastroenterologist (34 patients) or general practitioner (25). Dysphagia and weight loss were the commonest presenting symptoms (67 patients), with dyspepsia a significantly more frequent symptom for adenocarcinoma (22 of 46 versus six of 34; P < 0·05). Patients with adenocarcinoma had more often received acid suppressing medication (20 of 46 versus seven of 34; P < 0·05). The median duration of symptoms was 5 months and was significantly longer for adenocarcinoma than SCC (7 versus 4 months; P < 0·05). Twenty-nine (26 per cent) of 80 patients were unfit for surgery mainly because of co-morbid cardiorespiratory disease, despite being staged as suitable for resection. A further 37 (46 per cent) were staged as having irresectable local disease or distant metastases and could not be offered surgery. Three patients declined surgery and two with high-grade dysplasia in Barrett's oesophagus remain under surveillance. Thirty-nine patients (49 per cent) were palliated with external beam and endoluminal radiotherapy, twenty-eight (35 per cent) had oesophageal dilatation and endoprosthesis insertion, two patients had no intervention and a further two had laser therapy. Nine (11 per cent) underwent Ivor–Lewis subtotal oesophagectomy with two-tier lymphadenectomy. The overall median survival for all modalities of therapy was 183 (95 per cent confidence interval 143–223) days. There was a significant survival benefit for those undergoing surgery compared with other options (402 versus 171 days; P = 0·0204). Survival following palliative measures was significantly better for radiotherapy than for dilatation and endoprosthesis insertion (214 versus 80 days; P = 0·0006). Conclusion While surgical resection in selected patients offers the only chance of long-term survival, the advanced nature of oesophageal malignancy at presentation coupled with the high incidence of significant co-morbid disease precludes its use in most elderly patients. Thorough staging and careful assessment of overall fitness are crucial in identifying those suitable for surgery as well as establishing which palliative measures are most appropriate.

A case is presented describing a new, potentially life threatening complication of vomiting after a 21 year old man presented in shock with a haemoperitoneum caused by violent, self induced emesis.

Aims: Gastrointestinal stromal tumours (GIST) represent a rare group of heterogenous mesenchymal tumours. The aim of this study was to analyse the clinical presentation and outcome for patients with oesophago-gastric stromal tumours managed in a single institution. Methods: Of 1312 patients undergoing assessment for oesophago-gastric tumours from 1994 to 2001, 25 (2 per cent) patients (median age 60 years, M:F ratio 1:1.1) had stromal tumours. The clinical features, management and long-term outcome was evaluated for these patients. Results: A total of 19 (76 per cent) gastric and 6 (24 per cent) oesophageal stromal tumours were seen during this period. The commonest symptoms were acute (n = 2) or chronic (n = 10) gastrointestinal haemorrhage (48 per cent), indigestion (20 per cent) and anorexia (32 per cent). Twenty underwent surgical resection (15 gastrectomy, 5 subtotal oesophagectomy). There were no in-hospital deaths. Three patients were unfit for surgery and one patient had an unresectable tumour at laparotomy. Tumours were classified as leiomyoma (80 per cent) and leiomyosarcoma (20 per cent) according to cellular atypia and mitotic rate. Leiomyosarcomas (mean diameter = 8 cm) were larger than leiomyomas (mean diameter = 4.1 cm, P = 0.03). 10 (45.5 per cent) tumours were epithelioid in origin including all sarcomas and 12 (54.5 per cent) were spindle cell. At a median follow up of 32 months all patients with a benign diagnosis were alive with no recurrent disease. Three of four sarcomas died of local recurrence at 6, 52 and 66 months. Conclusion: GISTs of the upper gastrointestinal tract are rare and most commonly present with gastrointestinal haemorrhage. Surgical resection has excellent outcome but tumour size and epithelioid cell origin are associated with an increased risk of malignancy.

Aims: From 1990 to 1999, 9 per cent (11/125) of patients undergoing radical oesophagectomy for node positive carcinoma re-presented with symptomatic bone metastases within 12 months of surgery. The aim of this study was to prospectively evaluate the introduction of preoperative bone scintigraphy. Methods: From 01 December 2000 to 30 November 2001, 159 patients with oesophageal carcinoma were assessed. Tc99-HDP bone scintigraphy was performed for patients identified as having transmural (T3) disease and lymph node involvement (N1) by conventional investigations (CT and endoscopic ultrasound), and who were otherwise suitable for radical treatment. Results: A total of 69 patients (43 per cent) were suitable for radical treatment and of these 45 patients (median age 62 years, M:F ratio 3:1) staged with T3N1 disease underwent bone scintigraphy. The histological diagnosis was adenocarcinoma in 76 per cent and squamous carcinoma in 24 per cent. Bone scintigraphy was normal or showed degenerative change in 33 patients (73 per cent), and demonstrated areas of abnormal radioisotope uptake requiring further investigation in 12 patients (27 per cent). In six patients (13 per cent) plain radiographs, MRI, and biopsy confirmed the presence of bone metastases; a single metastasis in five patients (iliac-2, humerus-2, femur-1) and multiple vertebral metastases in one patient. These six patients received palliative treatment. No patient undergoing bone scintigraphy has developed bone metastases following surgery (n = 35) or chemoradiotherapy (n = 4), after initial median follow-up of 5 months. Conclusions: Bone scintigraphy is essential to exclude metastatic disease prior to the radical treatment of advanced oesophageal carcinoma. Bone is frequently the first site of distant metastatic spread and these patients are most appropriately managed by nonsurgical palliation.

Respiratory complications are a major cause of morbidity and mortality following oesophagectomy.1 We hypothesized that patients who develop postoperative respiratory failure would have an unstable intraoperative course. Two stage oesophagectomy requires a period of one lung ventilation (OLV) and one measure of intraoperative instability is desaturation during OLV. We therefore studied the relationship betweenSaO2 during OLV and postoperative course. Previous work has focused on preoperative factors associated with postoperative complications.2 There is little information on intraoperative factors that may influence outcome. We performed a retrospective analysis of all elective oesophagectomies performed between January 1998 and August 1999. Seventy-seven patients had a 2-stage sub-total oesophagectomy requiring OLV. Oxygen saturation recorded on the anaesthetic chart during OLV was plotted on a fixed linear scale of 0–100% against time for each patient. The area above the curve was calculated, as a measure of intraoperative oxygenation during OLV. This was standardized by dividing the area by the OLV duration, thus obtaining the Area Per Unit Time (APUT). The postoperative course of each patient was recorded including outcome, total duration of ITU stay and the worstPaO2/FIO2 ratio attained. ARDS was defined using the American-European Consensus Conference on ARDS criteria. Twenty-one patients had a prolonged ITU stay (>48 h) and all had a persistentPaO2/FIO2 Total OLV time was not significantly different between the groups but patients who developed ARDS had significantly greater intraoperative hypoxaemia as measured by the APUT (Table 17). We conclude that intraoperative hypoxaemia is associated with respiratory failure following oesophagectomy.

Aims Spontaneous rupture of the oesophagus (SRO) is a rare and often fatal event. The aim of this study was to evaluate the presentation, management and outcome of SRO in a single unit. Methods Data were collected on all patients presenting with SRO over a 5-year period with respect to presenting features, diagnostic investigations and subsequent management. Statistical analysis was by Student's t test, χ2 and Fisher's exact tests. Results Fourteen patients were identified, 12 men and two women with a median age of 64 (range 18–78) years; eight were tertiary referrals. Thirteen of 14 patients presented with chest or upper abdominal pain following vomiting or retching and 13 had an abnormal initial chest radiograph; only one presented with Mackler's triad of pain, vomiting and surgical emphysema. The median delay to diagnosis was 21 (range 1–84) h; this delay did not significantly affect outcome (P = 0·16). An endoscopic assessment and contrast swallow were performed in all patients. Nine of ten patients with a demonstrable leak and full-thickness tear were managed surgically and the four patients with no leak were managed conservatively (P = 0·005); surgical management consisted of thoracotomy, lavage, repair of the perforation and a feeding jejunostomy. Seven patients had a repair over a T tube and two had a primary repair. All conservatively managed patients had contained, controlled or intramural perforations and two also required a feeding jejunostomy. Patients requiring surgery had a longer hospital stay (mean(s.d.) 57·9(34·8) versus 22·2(30·7) days; P = 0·081) and a significantly longer intensive care unit stay (P = 0·044). The overall mortality rate from SRO was 14 per cent (two patients); no deaths occurred in the conservatively managed group. Conclusions SRO continues to be diagnosed late despite a classical history and/or abnormal chest radiograph. Endoscopic assessment of perforations is safe and in combination with a contrast swallow can confidently predict patients with contained or controlled rupture in whom non-operative management is successful.