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ABSTRACT: Surgery for oesophageal cancer remains the only means of cure for invasive tumours. It is claimed that the surgical approach for these cancers impacts on morbidity and may influence the ability to achieve tumour clearance and therefore survival, however there is no conclusive evidence to support one approach over another. This study aims to determine the impact of operative approach on tumour margin involvement and survival.
Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of five-year follow up. Analysis focused on the three commonest approaches (Ivor Lewis n = 140, transhiatal n = 68, left thoraco-laparotomy n = 142) for oesophageal cancer.
Operative approach had no significant impact on post-operative morbidity, mortality, overall margin involvement and survival. Transhiatal approach resulted in significantly more circumferential margin involvement (p = 0.019), and the presence of circumferential margin involvement significantly reduced five-year survival (median survival 13 months) compared to no margin involvement (median survival 25 months, p = 0.001).
Surgical approach for oesophageal cancer had no significant effect on morbidity, post-operative mortality and five-year survival. Non-selective use of the transhiatal approach is associated with a significantly greater circumferential margin involvement, with positive circumferential margin impacting adversely on 5-year survival.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 12/2011; 38(2):157-65. · 2.56 Impact Factor
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ABSTRACT: The aim of this review is to consolidate our knowledge on an important and rapidly expanding area of expertise. Numerous methods for predicting response (in terms of pathological response and survival) to neoadjuvant therapy (chemotherapy/chemo-radiotherapy) in oesophageal and junctional cancers have been proposed. This review concerns itself only with the use of positron emission tomography for such a purpose. At present there are no standardised criteria amongst PET trials as to what determines a response according to PET, what is the optimal time to perform PET in relation to the timing of neoadjuvant therapy, and what is the ideal method of quantifying PET tracer uptake.
An electronic search was performed of PubMed, Ovid and Embase websites to identify studies, in the English language, using the search terms: PET; oesophageal; oesophago-gastric; survival; cancer; response; chemotherapy and chemo-radiotherapy. The reference lists were searched manually to identify further relevant studies.
Twenty-two studies were identified, all using (18)FDG as the tracer, using PET to predict response in terms of pathological response and survival following neoadjuvant therapy (chemotherapy/chemo-radiotherapy). PET had a varying degree of success in predicting both pathological response and survival outcomes, with only one study using PET to influence management decisions.
PET seems a promising technique, but large-scale conclusions are hindered by small study numbers, lack of criteria as to what constitutes a response and markedly differing PET imaging times. A large randomised trial concerning a homogeneous group of patients and tumours is required before PET might be used to influence management.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 03/2009; 35(10):1019-29. · 2.56 Impact Factor
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ABSTRACT: Aim: To elicit factors associated with survival in unselected patients undergoing oesophageal or gastric cancer resection.Methods: The population based Scottish Audit of Gastric and Oesophageal Cancer (SAGOC) collected data from every patient diagnosed with oesophageal, junctional or gastric cancer in Scotland over 2 years to September 1999 with 1 year minimum follow-up. Data were analysed by univariate, case-mix-adjusted then multivariate analysis.Results: For the 3293 patients (1302 of whom underwent surgery) overall survival was 32 per cent at 1 year and 17 per cent at 2 years. For the 1302 (39.5 per cent) surgical patients, survival was significantly better (P < 0.001): 54 per cent at 1 year and 33 per cent at 2 years. Factors adversely affecting survival by multivariate analysis in the surgical group (Table) were comorbid disease (ASA 4 or 5) and margin involvement in the resected specimen. A better outcome was associated with a history of peptic ulcer or H. pylori infection, nonsmokers or junctional cancer.Neither the size of hospital of diagnosis nor the caseload for hospital of surgery had any impact on survival by univariate, case-mix-adjusted or multivariate analysis.Conclusion: For patients undergoing oesophagogastric surgery, patient fitness, the site of the cancer and the completeness of resection are significantly related to survival.
British Journal of Surgery 01/2009; 89(S1):26 - 27. · 4.61 Impact Factor
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British Journal of Surgery 06/2008; 95(5):665; author reply 665-6. · 4.61 Impact Factor
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ABSTRACT: Decreased tumour [(18)F]2-fluoro-2-deoxy-D-glucose ((18)FDG) incorporation is related to response however its significance at the cell level in gastro-oesophageal cancer and how it relates to cell death is unknown. Here human gastric adenocarcinoma (AGS) cells were treated with lethal dose 10 and 50 (LD(10) and LD(50)), determined by using the MTT assay, of the three drugs, epirubicin, 5-fluorouracil and cisplatin, commonly used in the treatment of patients with gastro-oesophageal cancer. (18)FDG incorporation was determined after 48 and 72 h of treatment with each drug and related to drug-induced changes in glucose transport, hexokinase activity, cell cycle distribution and annexin V-PE binding (a measure of apoptosis). Treatment of cells for 48 and 72 h with LD(50) doses of cisplatin resulted in reductions in (18)FDG incorporation of 27 and 25% respectively and of 5-fluorouracil reduced (18)FDG incorporation by 34 and 33% respectively: epirubicin treatment reduced incorporation by 30 and 69% respectively. Cells that had been treated for 72 h with each drug were incubated in drug-free media for a further 6 days to determine their ability to recover. Comparison of the ability to recover from the chemotherapy agent, with (18)FDG incorporation before the recovery period allowed an assessment of the predictive ability of (18)FDG incorporation. Cells treated with either 5-fluorouracil or cisplatin demonstrated recovery on removal of the drug. In contrast, cells treated with epirubicin did not recover corresponding with the greatest 72 h treatment decrease in (18)FDG incorporation. In contrast to adherent cells treated with cisplatin or 5-fluorouracil, adherent epirubicin-treated cells also exhibited very high levels of apoptosis. Glucose transport was decreased after each treatment whilst hexokinase activity was only decreased after 72 h of treatment with each drug. There was no consistent relationship observed between (18)FDG incorporation and cell cycle distribution. Our results show that at the tumour cell level in gastric tumour cells, decreased (18)FDG incorporation and glucose transport, accompanies therapeutic growth inhibition. (18)FDG incorporation is particularly diminished in cells exhibiting apoptosis.
British Journal of Cancer 11/2007; 97(7):902-9. · 5.04 Impact Factor
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ABSTRACT: Guidelines suggest that surgery for oesophageal and gastric cancer should be conducted in large cancer centres. This national study examined the relationship between hospital volume and outcome in Scotland.
This was a prospective, population-based study of 3293 consecutive patients with oesophageal or gastric cancer diagnosed between 1997 and 1999. Some 1302 patients underwent surgery and were followed for 5 years after operation.
The 5-year adjusted overall survival rate for the 3293 patients was 18.7 (95 per cent confidence interval (c.i.) 17.2 to 20.2) per cent and that after surgical resection was 39.6 (95 per cent c.i. 36.3 to 43.0) per cent. Death within 1 year after surgical resection was associated with a postoperative complication (odds ratio (OR) 2.5 (95 per cent c.i. 1.6 to 3.8); P < 0.001) or resection margin involvement by tumour (OR 7.2 (95 per cent c.i. 1.1 to 47.5); P = 0.042) after adjustment for age, sex and tumour location. There was no relationship between hospital volume and postoperative morbidity or mortality, nor between survival and volume of patients either for hospital of diagnosis or hospital of surgery.
This population-based study of oesophageal and gastric cancer suggests that the link between hospital volume and long-term survival for patients undergoing surgery requires re-evaluation.
British Journal of Surgery 05/2007; 94(5):578-84. · 4.61 Impact Factor
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ABSTRACT: Following transhiatal oesophagectomy, delivery of the conduit into the posterior mediastinum and neck can potentially result in its devascularisation. A simple technique is described to protect the conduit during this phase of the operation. This procedure has now been performed in 56 consecutive cases (54 gastric and two colonic conduits). In one case (1.8%) the colonic conduit had to be removed due to venous engorgement. The anastomotic leak rate was 8/56 (14%), and 12 (21%) patients required oesophageal dilatation for a stricture. There were no cases of ischaemia of the conduit. This technique provides a means of safe delivery of the oesophageal replacement into the neck following transhiatal oesophagectomy.
The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 03/2007; 5(1):51-3. · 1.41 Impact Factor
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ABSTRACT: Urgent endoscopy is indicated for suspected upper gastrointestinal malignancy. However, there is limited evidence on the age threshold for performing urgent endoscopy in uncomplicated dyspepsia (that is, without alarm features).
To quantify the risk of missing upper gastrointestinal malignancy within Scotland, if the age threshold for urgent endoscopy in uncomplicated dyspepsia was increased from 45 to 55 years.
Analysis of data collected prospectively by the Scottish Audit of Gastric and Oesophageal Cancer. 'Alarm' features at presentation were defined as dysphagia, weight loss, gastrointestinal bleeding, anaemia, vomiting, history of gastric surgery and history of peptic ulcer disease.
Of the 3293 patients diagnosed with upper gastrointestinal malignancy, 290 (8.8%) patients were <55 years of age. Twenty-one of the patients aged <55 years had no alarm features (0.64% of all patients); 12 were aged 45-55 years and nine were aged <45 years. Only two patients (one aged <45 years) underwent potentially curative surgery.
Upper gastrointestinal malignancy is uncommon under 55 years of age and most of the patients present with alarm features. Raising the age threshold for endoscopy for new-onset uncomplicated dyspepsia from 45 to 55 years would not impact adversely on the diagnosis or outcome of upper gastrointestinal malignancy.
Alimentary Pharmacology & Therapeutics 01/2006; 23(2):229-33. · 3.77 Impact Factor
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ABSTRACT: Complete surgical (R0) resection remains the only potentially curative intervention for patients with localised gastric cancer. To achieve a curative resection, patients may require complex operations with resection of contiguous organs. The aim of this study was to assess how the extent of surgical resection influenced morbidity, mortality and survival in an aged non-selected population with significant comorbid disease.
Data were extracted from the Scottish Audit of Gastric and Oesophageal Cancer (SAGOC), a prospective population-based audit of all oesophageal and gastric cancers in Scotland between 1997 and 1999 with a minimum of 1-year follow-up.
A total of 646 patients underwent surgical exploration for gastric cancer. A significantly higher incidence of chest infections (18.5 vs 11%, p< 0.05) and anastomotic leaks (14.3 vs 2.2%, p< 0.05) were associated with total gastrectomy (n=168) when compared to distal gastrectomy (n=272) resections. A 9.2% mortality rate and a 60% 1-year survival were associated with gastric resection alone. Removal of the spleen (n=131), pancreas (n=30) or liver resection (n=5) was associated with a significantly higher mortality rates, 18.3, 23.3 and 40%, respectively (p< 0.05), and significantly lower 1-year survival rates, 50.9, 39.1 and 20%, respectively (p< 0.05).
The risk of more extensive resection is not balanced by improved survival in this population based series. Extending gastric resection to involve contiguous organs should be confined to highly selected cases.
European Journal of Surgical Oncology 12/2005; 31(10):1141-4. · 2.50 Impact Factor
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ABSTRACT: Under the auspices of the Scottish Audit of Gastric and Esophageal Cancer, we investigated treatment techniques, complications, and survival in a population-based cohort of patients undergoing endoscopic palliative therapy for esophageal or gastric cancer.
A total of 948 patients undergoing endoscopic palliative therapy were identified prospectively and followed for a minimum of 1 year.
Expandable metal stent placement (506 patients) and LASER (117 patients) were the most frequently used treatment options. Stent placement was more common for grade 3 or 4 dysphagia. Delivery of endoscopic palliative therapy varied by region of residence (from 18% to 38% of patients, p < 0.001) but not by deprivation category. Complications were recorded in 16% of patients (155 of 948). Overall survival was 40% (95% confidence interval [CI], 36-43) at 6 months, 17% (95% CI, 14-19) at 12 months, and 10% (95% CI, 8-12%) at 18 months.
These data define the reality of endoscopic palliative therapy for patients with advanced esophageal or gastric cancer and provide a baseline against which future improvements in care can be measured.
Surgical Endoscopy 08/2004; 18(8):1257-62. · 4.01 Impact Factor
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ABSTRACT: Elective surgical procedures are often delayed for up to six months in patients who have suffered a myocardial infarction (MI) because of the substantial risk of re-infarction and high peri-operative mortality. The optimal management of patients who have sustained a recent myocardial infarction and who require an emergency abdominal operation, however, has yet to be defined. The use of an intraaortic balloon pump (IABP) may play a role in such patients by improving the function of the injured heart. Three cases are presented in which IABP was used in patients who had recently sustained a myocardial infarction and who required emergency abdominal surgery. A review of the literature is presented and the application of IABP in such circumstances is discussed. Although clinical experience is limited, the use of the IABP may be useful in selected patients who have sustained a recent MI and who require emergency surgery.
The surgeon: journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 11/2003; 1(5):279-82. · 1.41 Impact Factor
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Annals of Surgery 03/2003; 237(2):289; author reply 289-90. · 7.49 Impact Factor
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K G M Park
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ABSTRACT: The prognosis of patients with gastric and oesophageal cancers remains poor but increased knowledge of the factors involved in carcinogenesis and a better understanding of the disease process has led to strategies to improve outcomes. These are discussed under the following headings: (1) Prevention of the disease, (2) early detection of tumours, (3) treatment selection and (4) treatment. The likely impact of developments in each of these areas is considered in relation to population-based data from the Scottish Audit of Gastro-Oesophageal Cancer (SAGOC). Although there are a number of novel developments in the management of gastric and oesophageal cancer it is only by the conduct of controlled trials that the value of these will be determined. More immediate improvements in patient care may be derived from rationalisation of existing resources to ensure that all patients benefit from early diagnosis, the appropriate selection and delivery of treatment. One model of care, which may ensure this is the development of managed clinical networks, would maintain the involvement of all units in the management and treatment of upper GI cancers to a level that is possible with the facilities available. At the same time the patients requiring more specialised treatment would benefit from established referral networks
Journal of the Royal College of Surgeons of Edinburgh 01/2003; 47(6):716-30.
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British Journal of Surgery 07/2002; 89(6):810-1; discussion 811. · 4.61 Impact Factor
