The survival difference between gastric cancer patients from the UK and Japan remains after weighted propensity score analysis considering all background factors.

BACKGROUND: Previous studies comparing survival between gastric cancer (GC) patients from the West and the East were based on the assumption that background factors and prognostic factors were identical. The aim of the current study was to compare the survival of GC patients from the UK and Japan using weighted propensity score analysis after identifying all different background factors. METHODS: Data from 464 patients from the Leeds Teaching Hospital NHS Trust, Leeds, UK (LTHT), and 465 patients from the Kanagawa Cancer Center Hospital, Yokohama, Japan (KCCH), who had surgery for GC were analyzed. Prognostic factors for overall survival (OS) and cancer-specific survival (CSS) were identified by univariate and multivariate analyses. Survival was compared by propensity score weighting after adjusting for all significantly different background factors. RESULTS: Most background factors were different between LTHT and KCCH patients. Unadjusted stage-specific OS and CSS were significantly better in KCCH. Independent prognostic factors for unadjusted OS and CSS were pT and pN in KCCH and in addition tumor location, pancreatectomy, resection margin status and number of examined lymph nodes in LTHT. Even after adjusting for all background characteristics, survival remained better in KCCH. CONCLUSIONS: These results suggest that differences in background factors are unable to fully explain the survival difference of GC patients between UK and Japan. Comprehensive studies into the biology of GC and/or host factors are needed to fully understand the survival difference.

The superiority of the seventh edition of the TNM classification depends on the overall survival of the patient cohort: comparative analysis of the sixth and seventh TNM editions in patients with gastric cancer from Japan and the United Kingdom.

BACKGROUND: The objective of this study was to investigate whether the seventh edition of the American Joint Committee on Cancer/International Union Against Cancer TNM classification (TNM7) had superior discriminatory ability over the sixth edition of the TNM classification (TNM6) in patients with gastric cancer regardless of their country of origin. METHODS: In total, 538 patients from the Kanagawa Cancer Center Hospital (Yokohama, Japan) (KCCH) and 519 patients from the Leeds Teaching Hospitals National Health Service Trust (Leeds, United Kingdom) (LTHT) who underwent surgery for gastric cancer were selected. Overall survival was used for statistical analysis. Hazard ratios (HRs) were estimated with disease stage as a continuous variable to evaluate the discriminatory ability of the TNM stage groups. The estimates of log HRs (logHRs) for the TNM6 and the TNM7 stage groups were compared. RESULTS: In the KCCH cohort, 82 patients (15%) were upstaged, and 26 patients (5%) were downstaged between TNM6 and TNM7 compared with 253 patients (49%) and 53 patients (10%), respectively, in the LTHT cohort. The logHRs for a 1-stage increase within TNM6 and TNM7 were 1.06 and 1.16, respectively, in the KCCH cohort and 0.57 and 0.79, respectively, in the LTHT cohort. The differences in logHRs between TNM6 and TNM7 were significant in each cohort (KCCH: logHR, 0.11; P = .024; LTHT: logHR, 0.21; P = .0002) and between the 2 cohorts. CONCLUSIONS: TNM7 had superior discriminatory ability compared with TNM6 in both cohorts. The improved ability to discriminate patients with different survival probability when using TNM7 was greater in the LTHT cohort. The current findings indicated that the discriminatory ability of the TNM stage groups may depend on the baseline survival characteristics of the patient cohort.

Anastomotic leakage after esophagectomy for cancer: a mortality-free experience.

BACKGROUND: Leakage is a serious complication of esophagectomy and is historically associated with high mortality. This study aimed to describe the morphology and strategies for clinical management of leakage after esophagectomy. STUDY DESIGN: A database prospectively maintained from July 2002 to July 2005 at a referral unit for foregut cancer was used to identify patients with leakage of saliva or gastrointestinal contents after esophagectomy and reconstruction with stomach. Contrast swallow was routinely performed on postoperative day 7. Leakage was diagnosed and classified by well-defined criteria. RESULTS: There were 99 men and 27 women, yielding an institutional volume of 42 esophagectomies per year. There was no in-hospital mortality from any cause. Actual 1-year survival was 87%. An Ivor Lewis operation was performed on 103 patients (82%); 4 patients had leakage within 5 days of operation and all had immediate rethoracotomy. An additional 8 patients with Ivor Lewis operation had leakage after day 5, and this was detected by contrast swallow in only 3 patients; 2 patients had no intervention, 4 patients had radiology-guided drainage, 1 had thoracoscopy, and 1 had rethoracotomy. Leakage was from the actual esophagogastric anastomosis in eight patients, from the linear gastric staple line in three patients, or from gastric necrosis in one patient. Twenty-three patients had a transhiatal or three-stage operation; leakage was from the actual anastomosis in five patients or gastric necrosis in one patient. CONCLUSIONS: After Ivor Lewis esophagectomy, leakage was from the actual anastomosis in two-thirds of patients or from the gastric conduit in the remaining one-third. Prompt reoperation is recommended for early postoperative leakage. Most patients with leakage after day 5 can be treated nonoperatively.

Diagnostic variation and outcome for high-grade gastric epithelial dysplasia.

HYPOTHESIS: High-grade dysplasia (HGD) of the gastric epithelium is associated with high prevalence of invasive carcinoma, and distinction by endoscopic biopsy is difficult. DESIGN: Cohort study, 1996 to 2003. SETTING: Tertiary care center. PATIENTS: Consecutive sample of 22 patients with initial diagnosis of gastric HGD by endoscopic biopsy. Biopsy specimens were separately reviewed by 3 experienced pathologists. Clinical management was individually decided. MAIN OUTCOME MEASURES: Strength of interpathologist agreement (kappa) and final pathological diagnosis. RESULTS: The diagnosis was revised to intramucosal carcinoma in 14% to 32% of patients or suspicious for invasive carcinoma in 23% to 41%. The strength of agreement between any 2 pathologists for distinguishing between dysplasia and invasive carcinoma was fair (kappa = 0.35-0.36). A diagnosis of intramucosal carcinoma or suspicious for invasive carcinoma by 2 pathologists correlated strongly with subsequent detection of invasive carcinoma. Three patients underwent gastrectomy for HGD, and invasive carcinoma was detected in all (2 patients, T1 N0; 1 patient, T2 N0). Six patients had invasive carcinoma on endoscopic surveillance at a median of 15 months (range, 3-34 months) after diagnosis of HGD and underwent endoscopic mucosal resection (2 patients, T1 NX), gastrectomy (2 patients, T1 N0), or no resection (2 patients). Another patient had metastatic gastric adenocarcinoma despite having a diagnosis of only HGD by endoscopy. Seven patients (32%) died of unrelated causes, without invasive carcinoma, at a median of 19 months (range, 1-38 months). Three patients were alive with persistent HGD at 26 to 61 months. Two patients had no dysplasia on follow-up. CONCLUSIONS: Experienced pathologists often disagreed in distinguishing invasive carcinoma from HGD in gastric biopsy specimens. One third of patients with gastric HGD died of causes unrelated to cancer. Invasive carcinoma was detected in 67% of the remainder.

The Magenstrasse and Mill operation for morbid obesity.

BACKGROUND: Our aim was to evolve a simpler, more physiological type of gastroplasty that would dispense with implanted foreign material such as bands and reservoirs. The Magenstrasse, or "street of the stomach", is a long narrow tube fashioned from the lesser curvature, which conveys food from the esophagus to the antral Mill. Normal antral grinding of solid food and antro-pyloro-duodenal regulation of gastric emptying and secretion are preserved. METHODS: 100 patients with morbid obesity (83M, 17F, mean age 40 years) were treated by the Magenstrasse and Mill procedure and followed-up for 1-5 years. Mean preoperative BMI was 46.3 kg/m2, and mean excess weight was 106%. RESULTS: Operative mortality was 0. Major complications occurred in 4% of patients. There were few side-effects, although mild heartburn was fairly common. Mean weight loss was 38 kg (+/- 14 kg), equivalent to 60% of excess weight, achieved within 1 year of operation, after which no further significant gain or loss of weight occurred. CONCLUSIONS: The Magenstrasse and Mill procedure is the simplest and most physiological gastroplasty yet described. Many of the drawbacks of vertical banded gastroplasty, adjustable banding and gastric bypass are avoided. It is safe, has few side-effects and leads to major and durable weight losses, similar to those produced by other types of gastroplasty.