Epidemiological study of oesophageal and gastric cancer in south-east England.

BACKGROUND: This epidemiological study was carried out to establish the magnitude of the changing incidence of gastric and oesophageal cancer. METHODS: Time-trend analyses of subsite-specific cancers of the oesophagus and stomach were performed using data from the Thames Cancer Registry database (1960-1996) for the South Thames Region. The changes in sex ratio and peak age of incidence are reported. RESULTS: In the upper two-thirds of the oesophagus there was no significant change in the incidence rate, but the lower third of the oesophagus showed a marked rise for both sexes (average annual change + 0.05 for men, + 0.009 for women). For the gastric cardia, the incidence in males increased (average annual change + 0.025), while in females it remained unchanged. Cancers of the oesophagogastric junction showed a clear increase for both sexes (average annual change + 0.07 for men, + 0.009 for women). There were changes in the sex ratio and peak age of incidence for all subsite cancers for both sexes. CONCLUSION: Over a 37-year period the incidence of cancer of the oesophagogastric junction increased threefold, while the incidence of cancers of the other subsites of the stomach decreased. Further studies are needed to investigate the aetiology of these changes.

Operative mortality rates among surgeons: comparison of POSSUM and p-POSSUM scoring systems in gastrointestinal surgery.

PURPOSE: The original Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity and the more recent Portsmouth predictor equation for mortality scoring systems were developed to provide risk-adjusted mortality rates in general surgery. The aim of this study was to compare crude and risk-adjusted operative mortality rates among four surgeons using the above scoring systems and assess their applicability for patients scored retrospectively. METHODS: A total of 505 consecutive patients undergoing major gastrointestinal surgery were analyzed; 65 percent underwent colorectal, 27.5 percent underwent upper gastrointestinal, and 7.5 percent underwent small-bowel surgery. The observed:predicted mortality ratios using the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity and Portsmouth predictor equation for mortality scoring systems were calculated for each surgeon. RESULTS: The actual overall operative mortality rate was 11.1 percent (elective was 3.9 percent, and emergency was 25.1 percent). The Portsmouth predictor equation for mortality equation predicted a mortality rate of 11.3 percent (P = 0.51). However, the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity scoring system was found to overpredict death by a factor of two: 21.5 percent (P < 0.001). Mortality rates among the four surgeons varied from 7.6 to 14.7 percent but depended on the proportion of elective vs. emergency surgery. The observed:predicted ratio for Portsmouth predictor equation for mortality was close to unity (0.905-1.067) for all surgeons, but it was 0.45 to 0.56 for Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. CONCLUSION: The Portsmouth predictor equation for mortality equation seems to be a more accurate predictor of mortality in gastrointestinal surgery. It would seem to provide the best choice for analyzing operative mortality rates for individual surgeons, taking into account variation in case mix and fitness of patients even when scored retrospectively. This has important implications for the future assessment of surgeons' clinical standards and the assessment of quality of surgical care.

Dieulafoy's lesion: an obscure cause of GI bleeding.

Dieulafoy's lesion is an uncommon cause of major gastrointestinal bleeding and may be difficult to recognise. It consists of an arteriole that protrudes through a tiny mucosal defect, usually within 6 cm of the gastroesophageal junction on the lesser curve of the stomach. Similar lesions have also been described in the distal oesophagus, small intestine, colon, and rectum. Awareness of the condition and experience in endoscopy are the mainstay of diagnosis. Therapeutic endoscopy is the first line of treatment. It is safe, effective and has very good long term results.

Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses.

PURPOSE: To evaluate prospectively the efficacy of plastic-covered metallic endoprostheses in patients with malignant esophageal fistulas and perforations. MATERIALS AND METHODS: Thirty-nine patients with incurable esophageal carcinoma who developed esophagorespiratory fistulas (n = 20) or perforations (n = 19) were treated with plastic-covered metallic stents. RESULTS: Covered Wallstent endoprostheses were placed in 36 patients and covered Gianturco stents in three. All 19 perforations and 18 of 20 fistulas were successfully closed (clinical success rate, 95%). Symptoms of aspiration or dysphagia improved in all successfully treated patients. Mean survival was 81.8 days (range, 1-370 days). One patient with a closed perforation developed a fistula 16 weeks later and was treated with a second, overlapping stent; three patients with recurrent fistulas were treated with additional esophageal stents (one patient) or tracheal stents (two patients). In four patients, stent migration (two Gianturco and two Wallstent endoprostheses) necessitated placement of an additional stent. CONCLUSION: Covered metallic stents offer effective treatment for perforations and fistulas in patients with esophageal malignancy. Patients with recurrent fistulas can be treated with additional stents. Fistulas close to the upper esophageal sphincter may be closed with placement of parallel covered metallic stents in the esophagus and trachea.

Mucoid breast carcinomas: histology and prognosis.

In a series of 73 patients with mucoid breast carcinomas treated at Guy's Hospital between 1973 and 1989, 24 (33%) patients had pure mucoid lesions and 49 (67%) had mixed mucoid carcinomas. The patients with pure mucoid cancers had significantly smaller tumours and, among those in whom an axillary dissection was performed, mixed mucoid cancers were more likely to be associated with axillary nodal metastases (46% vs 14%). After long-term follow-up of 64 patients, both relapse-free and overall survival were significantly better for those with pure mucoid carcinomas, for whom the 10-year actuarial overall survival was 100%. The overall proportion of the tumour that was mucoid was also positively associated with a more favourable prognosis in patients with mixed tumours. With such a good prognosis, patients with pure mucoid carcinomas may not require systemic adjuvant therapy after adequate primary treatment.

Self-expanding metal stents for the palliation of dysphagia due to inoperable oesophageal carcinoma.

Adequate palliation of dysphagia due to inoperable oesophageal carcinoma is difficult to achieve with low morbidity. Thirty-three patients (21 men and 12 women of mean(s.e.m.) age 69(2) years) with inoperable carcinoma of the oesophagus underwent insertion of self-expanding metal stents. In 22 patients the tumours were in the lower third of the oesophagus, in eight in the middle third and in three in the upper third. A stent was inserted as primary palliative therapy in 14 patients, after failed laser therapy in 13 and after oesophageal perforation following other treatments in six. Patients presented with dysphagia of grade 3 or 4. Three types of stent were used: Wallstent, Strecker and Gianturco; stents were inserted under fluoroscopic guidance after balloon dilatation of the stricture. All attempted insertions of metal stents were successful. Dysphagia reduced from grade 3 or 4 to 0 or 1. There were no perforations related to insertion. Patients who had stents inserted to seal previous perforations left hospital a median 7 days later. Dysphagia recurred in six patients, due to migration of the stent (three), blockage by food bolus (one) and tumour overgrowth (two). These problems were easily treated. Self-expanding metal stents seem to offer excellent palliation with minimal morbidity for patients with inoperable carcinoma of the oesophagus.

In vitro determination by 1H-NMR studies that bile with shorter nucleation times contain cholesterol-enriched vesicles.

Although biliary vesicles are considered to be the primary source of cholesterol found in cholesterol gallstones, difficulties in quantitatively separating the different cholesterol transport modes in bile still remain. Proton nuclear magnetic resonance spectroscopy (1H-NMR) offers an alternative approach. Investigations were carried out on both model biles and human gallbladder bile samples: (i) to follow the effect of increasing sodium glycocholate concentrations on the 1H-NMR spectra of arachidonic acid rich-phospholipid, and cholesterol-lecithin vesicles, (ii) to compare the concentrations of total phospholipids in bile determined enzymatically with those obtained by integration of the phospholipid choline head group resonance peak, and (iii) to examine the relationship between biliary cholesterol nucleation time (NT) and the areas of the biliary lipid 1H-NMR peaks. It was found that the molecular motions of vesicle phospholipid, as determined by 1H-NMR, were restricted by saturation with cholesterol. In bile from patients with cholesterol gallstones, the reduced NMR fluidity of the phospholipid choline-head group indicated that the proportion of cholesterol-phospholipid vesicles containing more than 50% cholesterol, on a molar basis, was increased. The ratios of the N+(CH3)3 and = CH proton resonance peaks showed no overlap between samples with cholesterol gallstones and shorter NT and those with either no gallstones or pigment stones and longer NT. 1H-NMR spectroscopy indicates in a non-invasive manner those biles which are prone to cholesterol crystal formation.

Percutaneous cholecystolithotomy: risks, benefits, and long-term outcome.

BACKGROUND: For symptomatic patients with gallbladder stones and a patent cystic duct who wish to retain their 'functioning' gallbladders, percutaneous cholecystolithotomy (PCCL) offers an alternative to open or laparoscopic cholecystectomy. However, there are few data on the risks and benefits of this approach or on the long-term outcome. METHODS AND RESULTS: In 21 patients with symptomatic calcified gallstones, PCCL was successful (gallstone clearance) in 17 (81%). Four to 62 (median, 35) months after clearance 9 of the 17 remained symptom-free and stone-free, whereas 4 developed biliary sludge at 7, 30, 32, and 35 months, 2 of whom subsequently developed gallstones. In four other patients gallstones recurred without evidence of preceding biliary sludge at 9, 16, 19, and 27 months, corresponding to an actuarial gallstone recurrence rate at 36 months of 53.4 +/- SEM 15.1%, and a combined stone/sludge recurrence rate of 63.4 +/- 13.5%. CONCLUSIONS: PCCL is moderately effective but, because of the frequency of complications and sludge/stone recurrence, is likely to have only a limited residual role in the era of laparoscopic cholecystectomy.

Lichen planus associated with chenodeoxycholic acid and ursodeoxycholic acid for gallstone dissolution.

A patient who developed lichen planus while receiving chenodeoxycholic acid and ursodeoxycholic acid therapy for gallstones is described. Skin biopsy was performed and histological examination suggested a drug etiology. An association between lichen planus and liver disease is recognized, but this patient exhibited no clinical or biochemical evidence of liver disease and the rash disappeared after cessation of the bile acid therapy. Bile acids may cause lichen planus. The mechanism is unknown.

Nuclear magnetic resonance spectroscopy to determine the micellar cholesterol in human bile.

The cholesterol of gallstones comes from the vesicular rather than the micellar phase of bile. Progress in this field has been limited because conventional analytical methods disturb the distribution of cholesterol between the two phases. The resonance of the cholesterol C6 proton occurs at a chemical shift of 5.4 ppm, to be shown by 2D NMR to be specific for biliary cholesterol, and arises only from the micellar mode. Thus integration of the C6 proton resonance peak area provides a direct non-invasive determination of the cholesterol distribution in human bile.

Combination therapy with oral ursodeoxycholic and chenodeoxycholic acids: pretreatment computed tomography of the gall bladder improves gall stone dissolution efficacy.

In a five year study, 55 patients with radiolucent gall stones were treated with the combination of 7.5 mg chenodeoxycholic acid (CDCA) and 5.0 mg ursodeoxycholic acid (UDCA)/kg/day--that is, half the monotherapeutic doses. Side effects were few but four patients could not tolerate the prescribed bile acids because of diarrhoea or nausea. Analysis of fasting duodenal bile confirmed that CDCA+UDCA converted supersaturated into unsaturated bile but the saturation indices did not predict the dissolution response. By actuarial analysis, the confirmed (by ultrasound x2) complete gall stone dissolution rates in all 55 patients were mean (SEM) 29 (7)% at 12 and 44 (8)% at 24 months. The advent of routine computed tomography before treatment enabled comparison of dissolution efficacy in those screened by computed tomography (n = 24), whose maximum gall stone attenuation was less than 100 Hounsfield units, with that in those not screened (n = 29). Although stone size and number were comparable, patients screened by computed tomography had significantly better dissolution rates (p less than 0.025) than those not screened in this way. At 12 months, partial or complete gall stone dissolution rates were 93 (7)% in the screened and 55 (11)% in the non-screened patients. At 18 months, complete dissolution rates were 64 (12%) and 20 (9)% respectively. Computed tomography before treatment is cost effective in selecting those patients likely to achieve gall stone dissolution on treatment with UDCA+CDCA.