The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Prognostic significance of the endoscopic ultrasound defined lymph node metastasis count in esophageal cancer

The key prognostic factor which predicts outcome after esophagectomy for cancer is the number of malignant lymph node metastases, but data regarding the accuracy of endoscopic ultrasound (EUS) in determining and predicting the metastatic lymph node count preoperatively are limited. The aim of this study was to assess the prognostic significance of EUS defined lymph node metastasis count (eLNMC) in patients diagnosed with esophageal cancer. Two hundred and sixty-seven consecutive patients (median age 63 years, 187 months) underwent specialist EUS followed by stage directed multidisciplinary treatment (183 esophagectomy [64 neoadjuvant chemotherapy, 19 neoadjuvant chemoradiotherapy], 79 definitive chemoradiotherapy, and 5 palliative therapy). The eLNMC was subdivided into four groups (0, 1, 2 to 4, >4) and the primary measure of outcome was survival. Survival was related to EUS tumor (T) stage (P < 0.0001), EUS node (N) stage (P < 0.0001), EUS tumor length (p < 0.0001), and eLNMC (P < 0.0001). Multivariable analysis revealed EUS tumor length (hazard ratio [HR] 1.071, 95% CI 1.008-1.138, P= 0.027) and eLNMC (HR 1.302, 95% CI 1.133-1.496, P= 0.0001) to be significantly and independently associated with survival. Median and 2-year survival for patients with 0, 1, 2-4, and >4 lymph node metastases were: 44 months and 71%, 36 months and 59%, 24 months and 50%, and 17 months and 32%, respectively. The total number of EUS defined lymph node metastases was an important and significant prognostic indicator.

Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network

The aim of this study was to determine the contemporary prevalence, outcome, and survival after esophagogastric anastomotic leakage (EGAL) following esophagectomy by a regional upper gastrointestinal cancer network and to investigate etiological factors. Two hundred forty consecutive patients underwent esophagectomy over a 10-year period (median age 61 [31-79] years, 147 transthoracic and 93 transhiatal esophagectomy, 105 neoadjuvant chemotherapy, 49 chemoradiotherapy). The primary outcome measures were the development of EGAL and survival. Twenty patients developed EGAL (8.3%, 15 managed conservatively, 5 reoperation). Overall operative mortality was 2% (5 patients in total, 1 after EGAL). Median, 1 and 2-year survival was 22 months, 73% and 50%, in patients after EGAL, compared with 31 months, 80% and 56%, in patients who did not suffer EGAL (P= 0.314). On multivariate analysis, low body mass indices (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.11-0.79, P= 0.016), individual surgeon (HR 1.21, 95% CI 1.02-1.43, P= 0.02), and neoadjuvant chemotherapy (HR 3.28, 95% CI 1.16-9.22, P= 0.024) were significantly associated with the development of EGAL. EGAL following esophagectomy remained common, but associated mortality was less common than reported in earlier Western series and long-term survival was unaffected.

Influence of age on outcome after radical treatment of esophageal cancer with surgery or chemoradiotherapy (dCRT)

4569

Background: To compare the outcomes of stage directed surgical therapy and dCRT, related to age, to determine if there is an age threshold or Age x Treatment Interaction, above which the risks of serious treatment related complications outweigh any potential survival benefit. Methods: Prospective study of 504 consecutive patients managed by a single regional upper GI cancer network with curative intent based on CT, EUS and performance status; 270 underwent surgical based therapy [104 neoadjuvant chemotherapy, 49 neoadjuvant chemoradiotherapy, median age 61 (31–79) yr], and 234 dCRT [68 (41–83) yr]. One hundred and forty- one patients (28%) were aged over 70 years, of whom 40 (28%) underwent surgery, and 101 (72%) dCRT. Analysis was based on intention to treat and the primary measure of outcome was survival. Results: Deaths within 30 days of surgery, median and 5 yr survival were 1%, 30 months and 37% in patients <70 years, compared with 8.1%, 20 months and 18% in patients >70 years. Deaths within 30 days of dCRT, median and 5 yr survival were 0%, 21 months and 20% in patients <70 years, compared with 0%, 21 months and 33% in patients >70 years. On multivariable analysis, EUS T stage (HR 1.33, 95% CI 1.021 to 1.747, p=0.035), EUS defined lymph node metastasis count (HR 1.169, 95% CI 1.044 to 1.308, p=0.007), and age (HR 1.556, 95% 1.095 to 2.211, p=0.014) were independently and significantly associated with survival. There was an age related stepwise incremental increase in the ratio of hazard of death following surgery and dCRT, with a hazard cross-over observed at 69 years of age (Age x Treatment Interaction, 95% CI 62 to 86 yr, p=0.047). Conclusions: Age was an important and significant prognostic indicator and the estimated tipping point at which dCRT conveyed better outcomes than surgery was in the region of 70 years. Elderly patients diagnosed with esophageal cancer are arguably better treated with dCRT than multimodal surgical therapy.

No significant financial relationships to disclose.

Prognostic significance of endoluminal ultrasound defined tumor volume (EDTV) in patients diagnosed with esophageal cancer

e15519

Background: The aim of this study was to assess the prognostic significance of endoluminal ultrasound defined tumour volume (EDTV) in patients diagnosed with esophageal cancer. The hypothesis was that tumour volume is a better predictor of outcome than tumour length. Methods: One hundred and seventy-four consecutive patients (median age 64y, 128 m) underwent both CT and specialist EUS, and the maximum potential tumour cylinder volume (EDTV) was calculated using the formula πr2L (cylinder volume), where r = tumour thickness (cm) and L = total length of disease, including the position and level of both the primary tumour and proximal and distal lymph nodes (cm). All patients received stage directed multidisciplinary treatment [surgery 104 patients (80 neoadjuvant chemotherapy), definitive chemoradiotherapy 54 patients, and palliative therapy alone 16 patients]. The primary measure of outcome was survival. Results: Survival was related to EUS T (p=0.013), EUS N (p=0.001), EUS M1a stage (p=0.004), EUS disease length (p=0.001), and EDTV (all patients <25cm3, p=0.001, surgical patients <40cm3, p=0.036). Forward conditional multivariate analysis revealed 3 factors to be associated with survival; EUS N stage (HR= 1.646, 95% CI 1.041 to 2.602, p=0.033), EUS M1a stage (HR= 2.702, 95% CI 1.069 to 6.830, p=0.036), and EDTV (HR= 2.702, 95% CI 1.069 to 6.830, p=0.025). Conclusions: EDTV emerged as a new and important prognostic indicator for patients diagnosed with esophageal cancer.

No significant financial relationships to disclose.

Prognostic significance of the endoluminal ultrasound defined lymph node metastasis count in esophageal cancer

4558

Background: TNM histopathological staging system for esophageal cancer is controversial, and will soon be revised to account for the relative burden of the number of lymph node metastases. The aim of this study was to assess the prognostic significance of endoluminal ultrasound (EUS) defined lymph node metastasis count (eLNMC) in patients with esophageal cancer. Methods: Two hundred and sixty-seven consecutive patients (median age 63 yr, 187 m) underwent EUS followed by stage directed multidisciplinary treatment [183 esophagectomy (92 neoadjuvant chemotherapy), 79 definitive chemoradiotherapy, and 5 palliative therapy]. The eLMNC was subdivided into four groups (0, 1, 2 to 4, >4) and the primary measure of outcome was survival. Results: Survival was related to EUS T stage (p<0.0001), EUS N stage (p<0.0001), EUS tumour length (p<0.0001), and the eLNMC (p<0.0001). Multivariable analysis revealed EUS tumour length (HR 1.071, 95% CI 1.008 to 1.138, p=0.027) and eLNMC (HR 1.302, 95% CI 1.133 to 1.496, p<0.0001) to be significantly and independently associated with survival. Median and 2 year survival for patients with 0, 1, 2 to 4, and >4 lymph node metastases were: 44 months and 71%; 36 months and 59%; 24 months and 50%; and 17 months and 32% respectively. Conclusions: The eLNMC was an important and significant prognostic indicator in patients with esophageal cancer, which should in future be reported and used to revise the perceived radiological stage, in order to inform stage directed multimodal therapy.

No significant financial relationships to disclose.

Workload and resource implications of upper gastrointestinal cancer surgical centralisation in South East Wales

INTRODUCTION

The aim of this study was to determine whether one specialist unit could manage all patients diagnosed with oesophagogastric cancer in Gwent and Cardiff and Vale NHS Trusts over a 6-month period with regard to workload, resource and training opportunities.

PATIENTS AND METHODS

All patients diagnosed with oesophagogastric (OG) cancer in Gwent and Cardiff and Vale NHS Trusts and referred to the regional South East Wales Upper GI multidisciplinary team over the 6-month period from 1 July to 31 December 2005 were studied prospectively and compared with the previous 6-month caseload at Cardiff and Vale.

RESULTS

Out-patient workload increased from 160 new (33 OG cancers) and 533 follow-up patients (161 OG cancers) between 1 January and 30 June 2005, to 290 new (68 OG cancers, 106% increase) and 865 follow-up patients (230 OG cancers, 43% increase) between 1 July, and 31 December 2005. The number of patients undergoing radical surgery increased from 14 to 23 (D2 gastrectomy 8 versus 13; oesophagectomy 6 versus 10). Cancer-related workload in the latter period generated 118 intermediate equivalents (IEs) of operative work for two specialist surgeons and one SpR occupying 38% of the total time available on 104 scheduled operating lists, compared with 64 IEs in the previous 6 months, representing an 84% increase in cancer-related operative training opportunities.

CONCLUSIONS

Centralisation of oesophagogastric cancer surgery is feasible and desirable if national guidelines are to be satisfied, and this strategy has significant positive implications for surgical training and audit.

Prospective cohort comparison of neoadjuvant chemoradiotherapy versus chemotherapy in patients with oesophageal cancer

Background

Chemotherapy and chemoradiotherapy are common neoadjuvant treatments for resectable T3 N0–1 M0 oesophageal carcinoma. The aim of this study was to compare the outcomes of these therapies in consecutive cohorts of patients.

Methods

Between January 1998 and December 2001, 88 patients received neoadjuvant chemoradiotherapy (two cycles of cisplatin and 5-fluorouracil (5-FU), prior to 45 Gy in 25 F concurrent radiotherapy with cisplatin and 5-FU). From 2002, 117 patients received neoadjuvant chemotherapy (76 patients had two cycles of cisplatin and 41 had four cycles of epirubicin, cisplatin and 5-FU). The primary outcome measure was survival, and analysis was by intention to treat.

Results

Postoperative morbidity and mortality rates were 56 per cent (40 patients) and 10 per cent (seven patients) respectively in the chemoradiotherapy group, compared with 47 per cent (46 patients) and 1 per cent (one patient) in the chemotherapy group (P = 0·008). The cumulative 5-year survival rate by intention to treat was 35 per cent after chemoradiotherapy versus 21 per cent after chemotherapy (P = 0·188). The cumulative corrected 5-year survival rate after completed treatment was 44 per cent for chemoradiotherapy compared with 25 per cent for chemotherapy (P = 0·032).

Conclusion

Neoadjuvant chemoradiotherapy should remain an option for patients with satisfactory performance status.

Prospective comparison of transthoracic versus transhiatal esophagectomy following neoadjuvant therapy for esophageal cancer

Transthoracic esophagectomy (TT) has been championed as a better cancer operation than transhiatal esophagectomy (TH) because the approach facilitates meticulous wide tumor excision and lymphadenectomy. However, neoadjuvant chemoradiotherapy (CRTS) and chemotherapy (CS) have been reported to improve outcomes, and we aimed to compare outcomes after multimodal therapy related to the operative approach. One hundred and fifty-one consecutive patients were studied prospectively. All patients were staged with computed tomography and endoluminal ultrasound, and treatment decisions were related to stage and performance status. One hundred and nineteen TT (median age 58 years, 92 male, 54 CRTS, 65 CS) were performed compared to 32 TH (median age 57 year, 27 male, 14 CRTS, 18 CS). Primary outcome measure was survival. Post-operative morbidity and mortality were 54% and 4%, respectively, after TT compared with 59% and 6% after TH (chi2 0.239 df 1, P=0.625). Recurrent cancer was no less frequent after TT (52%) than after TH (37.5%, chi2 2.151 df=1, P=0.142). Cumulative uncorrected 5-year survival was 34% after TT compared with 53% after TH (log rank 1.44, df=1, P=0.2298). Median survival was also similar in lymph node positive patients (TT vs. TH, 23 months vs. 22 months, respectively, log rank 0.25, df=1, P=0.6199). Despite the fact that patients receiving multimodal therapy and a TH esophagectomy were less fit, operative morbidity, mortality and recurrence were similar, and survival did not differ significantly when compared with multimodal TT esophagectomy.

Lessons to be learned: a case study approach. Lateral aberrant thyroid tissue: is it always malignant?

Traditionally 'lateral aberrant thyroid' tissue present in cervical lymph nodes in the face of a clinically normal thyroid gland is held to be a metastasis from an occult primary thyroid carcinoma. A patient in whom follicular thyroid tissue was found in a lymph node lateral to the carotid sheath in the presence of a thyroid gland which was histologically free of cancer is herewith presented.

Prognostic significance of body mass indices for patients undergoing esophagectomy for cancer

The aim of this study was to determine the role of body mass index (BMI) in a Western population on outcomes after esophagectomy for cancer. Two hundred and fifteen consecutive patients undergoing esophagectomy for esophageal cancer of any cell type were studied prospectively. Patients with BMIs > 25 kg/m were classified as overweight and compared with control patients with BMIs below these reference values. Ninety-seven patients (45%) had low or normal BMIs, 86 patients (40%) were overweight, and a further 32 (15%) were obese. High BMIs were associated with a higher incidence of adenocarcinoma versus squamous cell carcinoma (83%vs. 14%, P = 0.041). Operative morbidity and mortality were 53% and 3% in overweight patients compared with 49% (P = 0.489) and 8% (P = 0.123) in control patients. Cumulative survival at 5 years was 27% for overweight patients compared with 38% for control patients (P = 0.6896). In a multivariate analysis, age (hazard ratio [HR] 1.492, 95% CI 1.143-1.948, P = 0.003), T-stage (HR 1.459, 95% CI 1.028-2.071, P = 0.034), N-stage (HR 1.815, 95% CI 1.039-3.172, P = 0.036) and the number of lymph node metastases (HR 1.008, 95% CI 1.023-1.158, P = 0.008), were significantly and independently associated with durations of survival. High BMIs were not associated with increased operative risk, and long-term outcomes were similar after R0 esophagectomy.

Spontaneous splenic rupture--a rare complication of amyloidosis

We present a case of spontaneous rupture of the spleen, an uncommon complication of systemic amyloidosis. Amyloid deposition leading to capsular distension and increased vascular fragility is thought to predispose the spleen to rupture spontaneously.

Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts

BACKGROUND

End Stage Renal Failure (ESRF) patients often require either the formation of an arteriovenous (A-V) fistula or an A-V interposition prosthetic shunt for haemodialysis.

OBJECTIVES

To determine the effects of adjuvant drug treatment on the patency of fistulae and shunts in patients with ESRF undergoing haemodialysis by assessing the number of thrombotic episodes.

SEARCH STRATEGY

Publications describing (or potentially describing), randomised controlled trials of medical adjuvant treatment of patients with ESRF on haemodialysis via A-V fistula or interposition prosthetic A-V shunt, were sought through electronic searches of the Cochrane Peripheral Vascular Diseases Specialised Trials Register (last searched October 2002), and the Cochrane Central Register of Controlled Trials (CENTRAL) database (last searched Issue 3, 2002).

SELECTION CRITERIA

Randomised controlled trials of active drug versus placebo in patients with ESRF undergoing haemodialysis via an A-V fistula or prosthetic interposition A-V shunt.

DATA COLLECTION AND ANALYSIS

Two reviewers (ADS, PAR), independently assessed trial quality and three (ADS, XE, PAR) extracted data. Information on adverse events was collected from the trials. The outcome measure analysed was the long term fistula, or shunt patency rate.

MAIN RESULTS

The overall search identified three randomised controlled trials of aspirin versus placebo with a total number of 173 participants followed up to a maximum of 18 months. The aspirin dosage given was different in each of the trials (325 mg/once daily; 500 mg/once daily; and 160 mg/once daily). The overall result of the meta-analysis favoured treatment with aspirin (Odds Ratio (OR) 0.42, 95% Confidence Interval (CI) 0.20 to 0.86). The overall p-value for the three studies was 0.02. Three ticlopidine (a platelet aggregation inhibitor) versus placebo trials were also identified with a total number of 312 participants. All patients were followed up for one month, and the dose of ticlopidine given was the same for all three studies (250 mg/twice daily). The overall result of the meta-analysis also favoured treatment. (OR = 0.47, 95% CI 0.26 to 0.85). P-value for overall effect was 0.01. One trial in a parallel group design examined the effect of dipyridamole versus placebo, and dipyridamole plus aspirin versus placebo, and followed up patients for eighteen months. The overall result favoured treatment (OR 0.29, 95% CI 0.06 to 1.40) and (OR 0.77, CI 0.19 to 3.19) respectively.

REVIEWER'S CONCLUSIONS

The meta-analysis confirmed the beneficial effect of antiplatelet treatment as an adjuvant to increase the patency of A-V fistulae and shunts in the short term.

The Bouveret syndrome: an unusual complication of gallstone disease

We present a case of Bouveret's syndrome which is gastric outlet obstruction due to gallstone impaction in the duodenum. The paper also discusses the aetiology, presentation, methods of diagnosis and options for management of Bouveret's syndrome.

Validation of a modified GTNM classification in peri-junctional oesophago-gastric carcinoma and its use as a prognostic indicator

AIM

A modified GTNM classification (with additional T and N subdivisions) has been used for many years. The aim of this paper was to validate this classification in a group of patients with oesophago-gastric carcinoma and to see if the more detailed information may be useful.

METHOD

The 3-year survival of 139 consecutive patients who survived resection has been related to the individual values of the modified and international classifications.

RESULTS

A step-wise reduction in the survival was found with increasing values of G, T, N and M. The international T3 value yielded a 17.7% survival rate, when subdivided, rates of 37.5%, 17.3% and 3.2% were found. The international N1 value yielded a rate of 12.9% which subdivided into rates of 25.0%, 18.7% and 7.5%.

CONCLUSION

If these results are repeated in a larger and more detailed study, this modified classification may provide added information when discussing prognosis and management.