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Background Early gastric cancer is frequently seen with nonspecific dyspeptic symptoms and subtle endoscopic features. Treatment at this stage of the disease produces a high chance of cure. If the diagnosis is missed at this early stage, then the prognosis may be much poorer depending on the subsequent delay in reaching a diagnosis. Objectives To report the healing effect of proton pump inhibitors on early gastric cancer. Methods This article reports a case series of 7 patients with ulcerated early gastric cancers indistinguishable as malignant gastric ulcers at endoscopy who were inadvertently prescribed a short course of a proton pump inhibitor prior to a second confirmatory endoscopy. The cases studied were patients with dyspeptic symptoms referred from primary care physicians for upper gastrointestinal endoscopy. Results In each case the patient became asymptomatic, the endoscopic signs seen at the first endoscopy had resolved, and the lesions could not be recognized even by an experienced endoscopist. If the proton pump inhibitors had been prescribed by the referring physician before the first endoscopy, the diagnosis probably would have been missed. These cases demonstrate the potentially serious masking effect of prescribing a short course of these drugs before making an endoscopic diagnosis. Even though the patient has been referred for endoscopy, the endoscopist may fail to identify the lesion and thus miss the diagnosis. Conclusions Primary care physicians must resist the pressures to prescribe proton pump inhibitors before endoscopy, particularly in patients older than 45 years, if the diagnostic yield of gastric cancer in the early curable stages is to be maximized.

This collection of essays brings together the latest historical research on cultural production and reception during the Second World War. Its starting point is how this war was presented to, and understood by, contemporaries and how they differentiated it from earlier conflicts. Although this was particularly noticeable in the construction of ideas of inclusiveness and commonality where the people' pulled together to secure victory and a socially equitable peace, the essays also seek to explore the diversity of institutional and personal experiences. Essays look at major national institutions and industries such as the recently formed BBC, the culturally diverse and rapidly expanding commercial press, and the British film industry. The collection explores the role of the individual agent, with studies on established writers and composers, and how each related to the collective rationales of wartime.

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.

EDITOR, - We welcome the attention brought by David Coggon and Hazel Inskip to the large increase in death rates from oesophageal cancer over the past 30 years.1 However, their conclusion on aetiological factors is flawed by relying on Office of Population Censuses and Surveys data, which fail to differentiate between the different histological types of oesophageal malignancy.2 It is widely accepted that smoking, and perhaps to a lesser extent, alcohol consumption, are important aetiological …

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.

Background Adenocarcinoma of the oesophagogastric junction (OGJ) is rapidly increasing in incidence and the role of radical lymphadenectomy for such tumours remains controversial. The aim of this study was to identify the pattern of metastatic nodal spread by histopathological assessment of all lymph node groups retrieved from resected specimens. Methods Data were collected prospectively from patients undergoing potentially curative (R0) resection with lymphadenectomy for adenocarcinoma of the OGJ between January 1996 and May 1998. Patients with type 1 tumours (lower third of the oesophagus) underwent two-stage subtotal oesophagogastrectomy with two-tier lymphadenectomy. Patients with type 2 (gastric cardia) tumours underwent D2 total gastrectomy. At the time of surgery all lymph node groups were dissected out from the specimens, labelled and assessed by a single consultant histopathologist. Results A total of 103 patients were studied. Eleven patients were understaged before operation and were inoperable or had palliative resections. Of the remaining 92 patients, 68 had type 1 tumours and 24 had type 2 tumours. Some 2301 nodes were analysed representing a median of 27 nodes per patient (26 from the oesophagectomy group and 30 from the gastrectomy group). Over 70 per cent of all patients had lymph node metastases at the time of surgery. Some 6 per cent of type 1 tumours with lymph node metastases had dissemination in both the abdominal and mediastinal nodal tiers. The common abdominal sites were the paracardial (right, 23 of 41; left, 23 of 41) and left gastric nodes (29 of 41) whereas within the mediastinum paraoesophageal (25 of 41) and bronchial (right, seven of 41; left, six of 41) metastases were more often encountered. Type 2 tumours had positive lymph nodes most frequently in the left paracardial (nine of 16), lesser curve (11 of 16) (N1 group) and left gastric (eight of 16) (N2 group) territories. The extent of lymph node positivity correlated with the T stage and differentiation of the primary tumour, as well as the presence of perineural, lymphatic and vascular invasion (P < 0·05). Conclusion The high incidence and widespread dissemination of nodal metastases at the time of surgery seen with these tumours may justify the approach of systematic lymphadenectomy in the hope of performing a curative resection. The current definition of the lymph node sites in the abdominal and mediastinal tiers for type 1 tumours is based on experience with lower-third squamous carcinomas. These results demonstrate a different pattern of dissemination for junctional␣oesophageal adenocarcinomas requiring redefinition of the nodal stations to be resected in radical lymphadenectomies for such tumours.