Outcome of index upper gastrointestinal endoscopy in patients presenting with dysphagia in a tertiary care hospital-A 10 years review.

BACKGROUND: Patients with malignant tumours of the upper gastrointestinal tract tumours exhibit important alarm symptoms such as dysphagia that warrant clinical investigations. An endoscopic examination of the upper gastrointestinal tract will be required in most cases. This study evaluates the diagnostic potential of index endoscopy in a random population of patients with dysphagia. METHODS: This is a retrospective analysis of prospectively collected data over 10 years. Patients with previous endoscopic evaluation or upper gastrointestinal pathology were excluded from the study. Data was analysed to see the number and frequency of abnormal findings in upper gastrointestinal tract, and their significance in relation to the presenting symptoms. RESULTS: Total number of index endoscopies was 13, 881. 913 patients were included in the study including 465 males (age range: 17-92 years, median: 55 years) and 448 females (age range: 18-100, median: 59 years), with male to female ratio of 1.04: 1. Oesophagus was abnormal in 678 cases (74%) and biopsies were taken in 428 patients (47%). Superficial oesophagitis, Barrett's oesophagus, oesophageal cancer, and oesophageal ulcer were main histological findings. Age more than 50 years and weight loss were significant predictors of oesophageal cancer (p < 0.0001). Male gender, heartburn, epigastric pain, weight loss and vomiting were significantly related to Barrett's oesophagus. A total of 486 gastric and 56 duodenal biopsies were also taken. There were 20 cases of gastric adenocarcinoma. CONCLUSION: OGD is an effective initial investigation to assess patients with dysphagia, especially males above the age of 50 years. Patients may be started on treatment or referred for further investigations, for example, a barium meal in the absence of any anatomical abnormality.

Early diagnosis of early gastric cancer.

The prognosis of gastric cancer is closely related to the stage of disease at diagnosis. Early gastric cancer, whereby disease is limited to mucosa and submucosa, confers a survival rate of greater than 90% in 5 years in many centres. Gastric cancer is still a major cause of cancer mortality worldwide. In high incidence areas such as Japan, screening of asymptomatic population has been advocated. However, in Western countries, mass screening is not cost-effective. Hence, strategy has been directed to screen symptomatic individuals who are at higher risk of gastric cancer. Most patients with early gastric cancer present with symptoms indistinguishable from benign peptic ulcer disease. Screening for this group of patients improves detection rate of early gastric cancer and therefore its prognosis. Endoscopy for surveillance of premalignant lesions has been explored with this objective in mind. Serology testing for biomarkers such as pepsinogen, anti-Helicobacter pylori antibody and gastrin has been studied as an alternative to endoscopy. There is compelling evidence for the role of H. pylori in the initiation of Correa's cascade (stepwise progression from chronic active gastritis, atrophic gastritis, intestinal metaplasia, dysplasia and finally adenocarcinoma). Regression of premalignant lesions has been demonstrated with H. pylori eradication. However, it is not known whether this might effectively prevent gastric cancer in either low or high-risk population.

Improving outcomes in gastric cancer over 20 years.

BACKGROUND: Gastric cancer has in the past proven to be a difficult disease to cure. Surgery is the most effective treatment, although the extent of lymphadenectomy undertaken is controversial. This paper examines trends in the detection and treatment of gastric cancer, the move toward targeted surgery, and their impact on survival. METHODS: From 1982 to 2001, 430 patients with gastric cancer were under the care of a single surgeon at the same institution. Copies of the operation records, discharge summaries, and histology reports were retained and subsequently reviewed. RESULTS: Thirty-six patients were excluded from the analysis. Two hundred and five patients (52%) had potentially curative surgery for adenocarcinoma and 189 had incurable disease. During the 20-year period, overall 5-year survival increased significantly, from 15% to 41% (P < 0.01). The number of curative procedures also increased significantly, from 33% to 73% (P1 < 0.001) as disease was detected earlier, and 5-year survival in these patients increased from 26% to 46%. Eighty-seven D1, 92 D2, and 26 targeted procedures were performed, with 30-day mortalities of 5%, 9%, and 5%, respectively. The 5-year survival was 47% for D1, 42% for D2, and 66% for targeted surgery. CONCLUSION: This paper demonstrates an improvement in the stage at which disease was detected and improvement in long-term survival for patients with gastric cancer. The development of targeted surgery has shown promising early results.