The significance of ulcer disease on late mortality after partial gastric resection.

OBJECTIVE: To study the causes of long-term mortality after peptic ulcer surgery with special attention to the impact of underlying ulcer disease. DESIGN: Retrospective cohort investigation. PATIENTS: A cohort of 1305 patients who had surgery for gastric and duodenal ulcer disease 29 to 59 years ago. At the end of follow-up 80% of gastric ulcer patients, and 64% of duodenal ulcer patients were dead. RESULTS: Overall mortality was significantly higher among gastric ulcer patients: standardized mortality ratio (SMR) 1.17 (95% confidence interval (CI) 1.05-1.29); duodenal ulcer patients had an overall mortality comparable to the reference population: SMR 1.06 (CI 0.97-1.15). Excess mortality among gastric ulcer patients was found to be due to neoplasms in gastrointestinal organs (SMR 1.54 (CI 1.11-2.11) which developed more than 20 years postoperatively, and to respiratory diseases and suicide unrelated to time since surgery. An increased mortality due to malignant tumours, respiratory diseases and suicide was also found among duodenal ulcer patients but this increased mortality was offset due to a significantly decreased mortality in diseases of the heart and vascular system (SMR 0.86 (CI 0.75-0.97)), evident mainly after 20 years postoperatively. Excess mortality due to gastrointestinal cancers outnumbered excess mortality from carcinomas in the respiratory organs, and was due to cancers in the stomach, colon and pancreas. CONCLUSION: An increased mortality due to gastrointestinal carcinoma, especially gastric and pancreatic carcinoma, is apparent regardless of underlying ulcer disease. As preventive measures against these tumours have yielded little benefit in prospective trials, and as smoking-related diseases and tumours together with suicide constitute 75% of the excess mortality, measures to combat smoking and suicide might be more worthwhile to reduce mortality in this cohort.

Mortality after remote surgery for benign gastroduodenal disease.

Mortality was studied after partial gastrectomy in a cohort of 1575 patients operated on because of benign gastroduodenal disease 29 to 59 years ago. The final status was confirmed in all but 8.4% of the cohort. At the close of the study 78% of the traced population were dead. Overall mortality was significantly higher than in the general population of southern Sweden (standardised mortality ratio = 1.10; 95% confidence intervals 1.03 to 1.17). Excess deaths resulted from neoplasms in the stomach, pancreas, male genital organs, and respiratory organs, as well as from respiratory diseases and suicide. Patients operated on before the age of 45 had a 60% increase in overall mortality during the first 19 years after surgery, mainly because of cardiovascular disease and suicide, whereas among those operated on after this age mortality was comparable to that in the reference population. The 75% increased death rate in cardiovascular disease during the first 19 years after surgery in patients operated on at young age, dramatically decreased during the years thereafter. An increased risk of death caused by malignancy was apparent more than 20 years postoperatively, irrespective of age at surgery. Excess deaths resulting from gastrointestinal malignancies, mainly gastric and pancreatic carcinoma, outnumbered the increased number of deaths resulting from cancer in the respiratory organs.

Clinical significance of dysplasia in gastric remnant biopsy specimens.

BACKGROUND: Dysplasia often is found in biopsy specimens from the gastric stump some 20 years after ulcer surgery. A high frequency of patients with severe dysplasia in the nonoperated stomach develop carcinoma but the clinical significance of dysplasia in the gastric stump is still confounding. METHODS: In the current study, two groups of patients were evaluated. One group of 22 patients, found at the first investigation in an endoscopic screening study with moderate dysplasia in the gastric stump, were regularly followed up to 18 years with endoscopy and biopsies. In the second part of the investigation, the authors evaluated 17 patients from the same endoscopic screening study, who at any instance during the 18 years were found to have severe dysplasia in biopsy specimens from the gastric remnant. RESULTS: In three of the 22 patients with moderate dysplasia, stump carcinoma was diagnosed 2, 2, and 6 years, respectively, after the first endoscopic examination. Severe dysplasia was found in two other patients at one occasion but later investigations only revealed moderate dysplasia. The remainder of the patients in this group had either persisting moderate dysplasia or mild dysplasia at follow-up. Seven (41%) of the 17 patients with severe dysplasia had stump carcinoma within a median time of 2 years (range, 1-11). Two other patients had surgery based on suspicion of carcinoma, but had only severe dysplasia in the surgical specimen. Finally, three men died (after 1, 2, and 17 years, respectively) of unrelated disease without suspicion of stump carcinoma and five patients were followed between 6 and 18 years without signs of malignant development. CONCLUSIONS: Patients with moderate and, especially, severe dysplasia in the gastric remnant are at high risk for gastric carcinoma. Severe dysplasia calls for endoscopic surveillance at short intervals. For patients with moderate dysplasia a close surveillance for 2 years followed by biannual evaluation appears sufficient.

Endoscopic screening during 17 years for gastric stump carcinoma. A prospective clinical trial.

In an attempt to reduce mortality in gastric stump carcinoma a defined cohort of operated peptic ulcer patients was followed up with an endoscopic screening programme. From 1930 and through 1960, 1575 patients were operated on for peptic ulcer disease at the Dept. of Surgery in Lund, Sweden. Of 838 still alive in January 1973, 682 were selected for geographical reasons and were offered endoscopic screening with biopsy at regular intervals. Three hundred and fifty-four patients came to the first examination. The follow-up programme was individualized thereafter with screening at 1- to 3-year intervals, depending on endoscopic and histologic findings. The remaining patients have, since then, constituted a control group, followed up only through death certificates and the Swedish Cancer Registry. By December 1989, 202 patients in the screening group had died and 320 in the control group. During the 17 years of follow-up 12 patients in the screening group died of gastric cancer, compared with 14 in the control group, even though 17 cases of early gastric cancer were diagnosed and operated on in the first group, compared with only 2 in the latter. We conclude that regular endoscopic screening does not reduce gastric cancer mortality and can thus not be recommended in asymptomatic patients previously subjected to partial gastric resection due to peptic ulcer disease.

The effect of cytostatic drugs on the synthesis of DNA in adenocarcinomas of the stomach. An in vitro study.

The sensitivity of adenocarcinomas of the stomach to various cytostatic drugs has been tested in short-term incubations. A suspension of single cells and small tissue fragments was prepared. It was used for incubation with the following drugs: melphalan, vinblastine sulphate, amethopterin, and 5-fluoro-uracil. The effect of the cytostatic drugs was measured as the difference in incorporation of labelled precursors in treated tubes and untreated control tubes. The different tumours were found to vary significantly in the their sensitivity. Moreover, a correlation of the effects between melphalan and vinblastine sulphate, and between amethopterin and vinblastine sulphate was observed.