Does endoscopy diagnose early gastrointestinal cancer in patients with uncomplicated dyspepsia?

BACKGROUND: Recent guidelines from NICE have proposed that open access gastroscopy is largely limited to patients with "alarm" symptoms. AIMS AND METHODS: This study reviewed the outcome of all our patients with verified oesophageal or gastric carcinoma who presented with uncomplicated dyspepsia to see if endoscopic investigation is warranted in this group. All patients with histologically verified upper gastrointestinal (GI) cancers who presented over a period from 1998 to 2002 were identified. Their presenting symptoms, treatment, and outcome were analysed. RESULTS: 228 upper GI cancers (119 oesophageal, 109 gastric; mean age 72 years (29-99 years); 130 male, 82 female) were identified in 11 145 endoscopies performed. Only 14 patients (6.2%) presented without alarm symptoms; three patients were under 55 years of age and all had gastric carcinoma-one of these had chronic diarrhoea only. Eleven had dyspepsia or reflux symptoms only, and two were under surveillance for Barrett's oesophagus. Only five patients had a curative surgical resection and are still alive two-six years from diagnosis. A sixth patient had a curative operation but died of a cerebrovascular accident one year later. The remaining eight patients unfortunately had either metastatic disease or comorbidity, which precluded surgery. All of these died within two years of diagnosis, mean survival 10 months. CONCLUSION: Only five patients with dyspepsia and no alarm symptoms had resectable upper GI malignancies over a four year period. Limiting open access gastroscopy to those with alarm features only would "miss" a small number of patients who have curable upper GI malignancy.

Atkinson tubes are a good cost-effective means of palliating inoperable oesophageal malignant strictures: an eight-year experience.

OBJECTIVE: To determine how many oesophageal and oesophago-gastric malignancies could be successfully intubated endoscopically with an Atkinson tube, and how often a metal mesh tube would be required instead. DESIGN: A consecutive series of 125 patients underwent endoscopy and intubation. METHODS: A total of 142 Atkinson tubes were inserted into 122 patients, and four metal mesh stents were put into three patients. The median hospital stay was 3 days, and 28 patients were treated as day cases. RESULTS: Atkinson tube insertion failed in only one patient. There were eight oesophageal perforations (5.6%); the procedure-related mortality was 4%. Three patients required a metal mesh stent, as dilatation proved difficult because of prior radiotherapy in two and prior surgery in one. CONCLUSION: Atkinson tubes are the stents of choice for inoperable oesophageal tumours because of low complication rates and cost efficiency. In 20% of patients, day case insertion was successful. Metal mesh stents should be reserved for those patients with tight post-radiotherapy or post-surgical strictures when dilatation is difficult.

Outcome in unipolar affective disorder after stereotactic tractotomy.

An evaluation of 15 patients treated by subcaudate stereotactic tractotomy (SST) for treatment-resistant unipolar affective disorder was made for frequency and severity of recurrence of illness. One-third had died by the time of assessment, but none by suicide. Two-thirds of the sample experienced a reduction in the severity of depressive episodes after the operation; only one-third reported a reduction in frequency of episodes.

A comparison of the antidepressant action of citalopram and amitriptyline.

The response of patients with major depressive illness to citalopram of amitriptyline was compared in a double-blind multi-centre trial. No differences in efficacy were observed, but citalopram had less hypnotic effect, and a remarkably lower profile of side-effects.