AIM: To compare the diagnostic performances of transnasal and standard transoral esophagogastroduodenoscopy (EGD) in gastric cancer screening of asymptomatic healthy subjects.
METHODS: Between January 2006 and March 2010, a total of 3324 subjects underwent examination of the upper gastrointestinal tract by EGD for cancer screening, with 1382 subjects (41.6%) screened by transnasal EGD and the remaining 1942 subjects (58.4%) by standard transoral EGD. Clinical profiles of the screened subjects, detection rates of gastric neoplasia and histopathology of the detected neoplasias were compared between groups according to the stage of Helicobacter pylori
(H. pylori)-related chronic gastritis.
RESULTS: Clinical profiles of subjects did not differ significantly between the two EGD groups, except that there were significantly more men in the transnasal EGD group. During the study period, 55 cases of gastric mucosal neoplasias were detected. Of these, 23 cases were detected by transnasal EGD and 32 cases by standard transoral EGD. The detection rate for gastric mucosal neoplasia in the transnasal EGD group was thus 1.66%, compared to 1.65% in the standard transoral EGD group, with no significant difference between the two groups. Detection rates using the two endoscopies were likewise comparable, regardless of H. pylori infection. However, detection rates when screening subjects without extensive chronic atrophic gastritis (CAG) were significantly higher with standard transoral EGD (0.70%) than with transnasal EGD (0.12%, P < 0.05). In particular, standard transoral EGD was far better for detecting neoplasia in subjects with H. pylori-related non-atrophic gastritis, with a detection rate of 3.11% compared to 0.53% using transnasal EGD (P < 0.05). In the screening of subjects with extensive CAG, no significant differences in detection of neoplasia were evident between the two endoscopies, although the mean size of detected cancers was significantly smaller and the percentage of early cancers was significantly higher with standard transoral EGD.
CONCLUSION: These results strongly suggest that the diagnostic performance of transnasal endoscopy is suboptimal for cancer screening, particularly in subjects with H. pylori-related non-atrophic gastritis.
Transnasal endoscopy; Gastric cancer; Gastric adenoma; Atrophic gastritis; Helicobacter pylori; Cancer screening
Asymptomatic subjects volunteering for research studies are generally stratified as healthy based on a questionnaire, medical interviewing, and physical examination. The aim of this study was to evaluate the prevalence of upper GI abnormalities in healthy asymptomatic volunteers using unsedated transnasal esophago-gastro-duodenoscopy (T-EGD) with an ultrathin endoscope as an additional screening tool.
This is a prospective study from one academic medical center with extensive experience in T-EGD. Consecutive 150 subjects volunteering for research studies were initially screened by using a gastroesophageal reflux disease (GERD) questionnaire, interviewing, and examination. Based on these, they were stratified as healthy asymptomatic volunteers or with GERD. Unsedated T-EGD was then performed by a faculty who was blinded to the results of the initial assessment.
On initial assessment using GERD questionnaire, medical interviewing, and physical examination, of the total 150 consecutive research volunteers, 83 (33±16, 46 females, 37 males) subjects were healthy asymptomatic volunteers and 67 (36±15, 35 females, 32 males) had symptoms of GERD. On T-EGD, gastrointestinal pathology was found in 15 of 83 (18%) healthy asymptomatic volunteers as compared to 24 of 67 (36%) stratified as having GERD (p <0.01). The esophageal abnormalities found in healthy asymptomatic volunteers were esophagitis (13.3%), Barrett’s esophagus (2.4%), hiatus hernia (2.4%) and gastritis (2.4%).
A small but significant number of asymptomatic subjects have abnormal upper GI findings. Hence, transnasal unsedated endoscopy can be considered as a screening tool to stratify subjects as healthy especially when considering them for research studies.
Transnasal endoscopy; unsedated endoscopy; ultrathin endoscope; gastroesophageal reflux disease; Barretts esophagus
A gastro-tracheal fistula following esophagectomy for cancer is a rare but potentially lethal complication. We report the successful surgical closure after failed endoscopic treatment, of a gastro-tracheal fistula following esophago-gastrectomy for cancer after induction chemo-radiotherapy.
A 58 year-old male patient presented with a distal third uT3N1 carcinoma of the esophagus. After induction chemo-radiotherapy, he underwent an esophago-gastrectomy with radical lymphadenectomy and reconstruction by gastric pull-up. Immediate postoperative outcome was uneventful. On the 15th postoperative day however, our patient was readmitted in the Intensive Care Unit with severe bilateral basal pneumonia. Three days later a gastro-tracheal fistula was diagnosed upon gastroscopy and bronchoscopy. His good general condition allowed for an endoscopic primary approach which consisted in the insertion of a covered stent in the trachea along with clipping and glueing of the gastric fistular orifice. Two attempts proved unsuccessful.
After several weeks of conservative measures, surgical re-intervention through a right thoracotomy with transection of the fistula and closure by primary interrupted sutures of both fistular orifices along with intercostal muscle flap interposition led to excellent patient outcome. Oral feeding was started and our patient was discharged.
We report a case of gastric choriocarcinoma admixed with an α-fetoprotein (AFP)-producing adenocarcinoma. A 70-year-old man was hospitalized for gastric cancer that was detected during screening by esophagogastroduodenoscopy (EGD). Initial laboratory data showed the increased serum level of AFP and EGD revealed a 5-cm ulcerofungating mass in the greater curvature of the gastric antrum. The patient underwent radical subtotal gastrectomy with D2 lymph node dissection and Billroth II gastrojejunostomy. Histopathological evaluation confirmed double primary gastric cancer: gastric choriocarcinoma admixed with an AFP-producing adenocarcinoma and separated adenocarcinoma. At 2 wk postoperatively, his human chorionic gonadotropin and AFP levels had reduced and six cycles of adjuvant chemotherapy were initiated. No recurrence or distant metastasis was observed at 4 years postoperatively.
α-fetoproteins; Adenocarcinoma; Choriocarcinoma; Stomach neoplasms
AIM: To investigate the utility of esophageal capsule endoscopy in the diagnosis and grading of esophageal varices.
METHODS: Cirrhotic patients who were undergoing esophagogastroduodenoscopy (EGD) for variceal screening or surveillance underwent capsule endoscopy. Two separate blinded investigators read each capsule endoscopy for the following results: variceal grade, need for treatment with variceal banding or prophylaxis with beta-blocker therapy, degree of portal hypertensive gastropathy, and gastric varices.
RESULTS: Fifty patients underwent both capsule and EGD. Forty-eight patients had both procedures on the same day, and 2 patients had capsule endoscopy within 72 h of EGD. The accuracy of capsule endoscopy to decide on the need for prophylaxis was 74%, with sensitivity of 63% and specificity of 82%. Inter-rater agreement was moderate (kappa = 0.56). Agreement between EGD and capsule endoscopy on grade of varices was 0.53 (moderate). Inter-rater reliability was good (kappa = 0.77). In diagnosis of portal hypertensive gastropathy, accuracy was 57%, with sensitivity of 96% and specificity of 17%. Two patients had gastric varices seen on EGD, one of which was seen on capsule endoscopy. There were no complications from capsule endoscopy.
CONCLUSION: We conclude that capsule endoscopy has a limited role in deciding which patients would benefit from EGD with banding or beta-blocker therapy. More data is needed to assess accuracy for staging esophageal varices, PHG, and the detection of gastric varices.
Esophageal varices; Capsule endoscopy; Portal hypertension
AIM: To investigate the proportion of patients with moderate-severe erosive esophagitis (EE) who will have Barrett’s esophagus (BE) after healing of inflammation.
METHODS: Patients with EE of Los Angeles (LA) class B, C and D who underwent follow-up endoscopy documenting complete mucosal healing.
RESULTS: A total of 86/169 patients were suspected of having BE (38 before healing and 48 after healing of EE) and, 46/86 eventually had the histological confirmation. At index esophago-gastro-duodenoscopy (EGD), BE was suspected in 38/169 (22%), and ultimately, histologically confirmed in 20 of these. In 11 patients where biopsies were performed in the presence of inflammation, BE was detected in 2 and missed in 5 (including 2 dysplasias). In 131/169 patients (77.5%), BE was not suspected at index EGD. After healing of EE though, 48 patients had suspicion of BE who underwent biopsies, and in 26 of these histology was positive for BE. The length of inflammation had a linear correlation with the length of BE (P = 0.01). Out of multiple variables to predict BE, only the suspicion at index endoscopy was statistically significant (P = 0.01).
CONCLUSION: BE was seen in 46/169 (27%) patients with EE of LA class B, C and D. The length of EE can predict the length of underlying BE segment. Even when suspected, BE and associated dysplasia can be missed in the presence of inflammation; therefore, repeat evaluation should be considered after complete healing of esophagitis.
Erosive esophagitis; Barrett’s; Prevalence of Barrett’s; Gastroesophageal reflux
Objective To evaluate the effect of comorbidity and other risk factors on postoperative mortality and morbidity in patients undergoing major oesophageal and gastric surgery.
Design Multicentre cohort study with data on postoperative mortality and morbidity in hospital.
Data source and methods The ASCOT prospective database, comprising 2087 patients with newly diagnosed oesophageal and gastric cancer in 24 hospitals in England and Wales between 1 January 1999 and 31 December 2002. Multivariate logistic regression analysis was used to model the risk of death and postoperative complications.
Results 955 patients underwent oesophagectomy or gastrectomy. Of these, 253 (27%) were graded ASA III or IV, and 187 (20%) had a high physiological POSSUM score (≥ 20). Operative mortality was 12% (111/955). Physiological POSSUM score, surgeon's assessment, type of operation, hospital case volume, and tumour stage independently predicted operative mortality. Medical complications were associated with higher physiological POSSUM scores and ASA grade, oesophagectomy or total gastrectomy, thoracotomy, and radical nodal dissection. Stage and additional organ resection predicted surgical (technical) complications.
Conclusions Many patients undergoing surgery for gastro-oesophageal cancer have major comorbid disease, which strongly influences their risk of postoperative death. Technical complications do not seem to be influenced by preoperative factors but reflect the extent of surgery and perhaps surgical judgment. Detailed prospective multicentre cooperative audit, with appropriate risk adjustment, is fundamental in the evaluation of cancer care and must be properly resourced.
It was recently shown that the tonic pressure contribution to the high-pressure zone (HPZ) of the esophagogastric segment (EGS) contains contributions from three distinct components, two of which are smooth muscle intrinsic sphincter components, a proximal and a distal component (1).
To compare the pressure contributions from the three sphincteric components in normal subjects with those in GERD patients.
A simultaneous endoluminal ultrasound (EUS) and manometry catheter was pulled through the esophago-gastric segment in 15 healthy volunteers and 7 patients with symptomatic GERD, before and after administration of atropine. Pre-atropine (complete muscle tone), postatropine (non-muscarinic muscle tone plus residual muscarinic tone), and subtracted (pure muscarinic muscle tone) pressure contributions to the sphincter were averaged after referencing spatially to the right crural diaphragm (RCd) and the pull-through start position.
In the normal group the atropine-resistant and atropine-attenuated pressures identified the crural and two smooth muscle sphincteric components respectively. The subtraction pressure curve contained proximal and distal peaks. The proximal component moved with the crural sling between FI and FE and the distal component coincided with the gastric sling-clasp fiber muscle complex. The subtraction curve in the GERD patients contained only a single pressure peak that moved with the crural sphincter, while the distal pressure peak of the intrinsic muscle component, which was previously recognized in the normal subjects, was absent.
We hypothesize that the distal muscarinic smooth muscle pressure component (gastric sling/clasp muscle fiber component) is defective in GERD patients.
There is a lack of agreement on which gastric cancer screening method is the most effective in the general population. The present study compared the relative performance of upper-gastrointestinal series (UGIS) and endoscopy screening for gastric cancer.
A population-based study was conducted using the National Cancer Screening Program (NCSP) database. We analyzed data on 2,690,731 men and women in Korea who underwent either UGIS or endoscopy screening for gastric cancer between January 1, 2002 and December 31, 2005. Final gastric cancer diagnosis was ascertained through linkage with the Korean Central Cancer Registry. We calculated positivity rate, gastric cancer detection rate, interval cancer rate, sensitivity, specificity, and positive predictive value of UGIS and endoscopy screening.
The positivity rates for UGIS and endoscopy screening were 39.7 and 42.1 per 1,000 screenings, respectively. Gastric cancer detection rates were 0.68 and 2.61 per 1,000 screenings, respectively. In total, 2,067 interval cancers occurred within 1 year of a negative UGIS screening result (rate, 1.17/1,000) and 1,083 after a negative endoscopy screening result (rate, 1.17/1,000). The sensitivity of UGIS and endoscopy screening to detect gastric cancer was 36.7 and 69.0%, respectively, and specificity was 96.1 and 96.0%. The sensitivity of endoscopy screening to detect localized gastric cancer was 65.7%, which was statistically significantly higher than that of UGIS screening.
Overall, endoscopy performed better than UGIS in the NCSP for gastric cancer. Further evaluation of the impact of these screening methods should take into account the corresponding costs and reduction in mortality.
AIM: To re-evaluate the recent clinicopathological features of remnant gastric cancer (RGC) and to develop desirable surveillance programs.
METHODS: Between 1997 and 2008, 1149 patients underwent gastrectomy for gastric cancer at the Department of Digestive Surgery, Kyoto Prefectural University of Medicine, Japan. Of these, 33 patients underwent gastrectomy with lymphadenectomy for RGC. Regarding the initial gastric disease, there were 19 patients with benign disease and 14 patients with gastric cancer. The hospital records of these patients were reviewed retrospectively.
RESULTS: Concerning the initial gastric disease, the RGC group following gastric cancer had a shorter interval [P < 0.05; gastric cancer vs benign disease: 12 (2-22) vs 30 (4-51) years] and were more frequently reconstructed by Billroth-I procedure than those following benign lesions (P < 0.001). Regarding reconstruction, RGC following Billroth-II reconstruction showed a longer interval between surgical procedures [P < 0.001; Billroth-II vs Billroth-I: 32 (5-51) vs 12 (2-36) years] and tumors were more frequently associated with benign disease (P < 0.001) than those following Billroth-I reconstruction. In tumor location of RGC, after Billroth-I reconstruction, RGC occurred more frequently near the suture line and remnant gastric wall. After Billroth-II reconstruction, RGC occurred more frequently at the anastomotic site. The duration of follow-up was significantly associated with the stage of RGC (P < 0.05). Patients diagnosed with early stage RGC such as stage I-II tended to have been followed up almost every second year.
CONCLUSION: Meticulous follow-up examination and early detection of RGC might lead to a better prognosis. Based on the initial gastric disease and the procedure of reconstruction, an appropriate follow-up interval and programs might enable early detection of RGC.
Remnant gastric cancer; Surveillance; Follow-up; Reconstruction; Distal gastrectomy
A 67-year-old man, presenting with anemia and suspected gastric cancer, was referred to our hospital, where he underwent esophagogastroduodenoscopy (EGD). Biopsy revealed densely populated semi-circular cells with abundant cytoplasm that were positive for S-100 protein, melanoma antigen, and HMB-45, resulting in a diagnosis of malignant melanoma. A gastrointestinal barium study for further exploration demonstrated a filling defect 6 cm in size at the ligament of Treitz. Follow-up EGD of this finding revealed an ulcerated, half-circumferential lesion with a distinct ulcer mound extending from the ascending part of the duodenum to the jejunum, and additional biopsy also indicated malignant melanoma. Computed tomography scans showed wall thickening from the ascending part of duodenum to the proximal jejunum, whereas positron emission tomography revealed accumulation at the upper gastric body, the duodenum to the jejunum, and the left adrenal gland. Systemic exploration of the patient, including the skin, anus, and eyeballs, revealed no other lesions, and primary small intestinal malignant melanoma with metastasis to the stomach and adrenal gland was diagnosed. Partial duodenojejunectomy, partial gastrectomy, and left adrenalectomy were performed, and adjuvant chemotherapy with dacarbazine, nimustine hydrochloride, and vincristine sulfate was administered. No postoperative recurrence has been observed in the past 3 years.
AMM; Melanoma; DAV; Small intestine
AIM: To determine the rate and yield of repeat esophagogastroduodenoscopy (EGD) for dyspepsia in clinical practice, whether second opinions drive its use, and whether it is performed at the expense of colorectal cancer screening.
METHODS: We performed a retrospective cohort study of all patients who underwent repeat EGD for dyspepsia from 1996 to 2006 at the University of California, San Francisco endoscopy service.
RESULTS: Of 24 780 EGDs, 5460 (22%) were performed for dyspepsia in 4873 patients. Of these, 451 patients (9.3%) underwent repeat EGD for dyspepsia at a median 1.7 (interquartile range, 0.8-3.1) years after initial EGD. Significant findings possibly related to dyspepsia were more likely at initial (29%) vs repeat EGD (18%) [odds ratio (OR), 1.45; 95% confidence interval (CI): 1.20-1.75, P < 0.0001], and at repeat EGD if the initial EGD had reported such findings (26%) than if it had not (14%) (OR, 1.32; 95% CI: 1.08-1.62, P = 0.0015). The same endoscopist performed the repeat and initial EGD in 77% of cases. Of patients aged 50 years or older, 286/311 (92%) underwent lower endoscopy.
CONCLUSION: Repeat EGD for dyspepsia occurred at a low but substantial rate, with lower yield than initial EGD. Optimizing endoscopy use remains a public health priority.
Dyspepsia; Esophagogastroduodenoscopy; Health resources; Diagnostic techniques and procedures; Repeat; Treatment outcome
Background and aims
The relationship between Helicobacter pylori infection and gastro‐oesophageal reflux disease (GORD) is controversial but it is accepted that GORD is associated with increased exposure to gastric acidity. The proinflammatory interleukin (IL)‐1B polymorphisms increase the risk of hypochlorhydria and gastric atrophy. We examined the association between proinflammatory cytokine gene polymorphisms, presence of gastric atrophy, and risk of GORD in H pylori positive and negative subjects in Japan.
We studied 320 consecutive dyspeptic patients without peptic ulcers or cancers. GORD symptoms were scored using the Carlsson‐Dent questionnaire and erosive oesophagitis was assessed endoscopically. H pylori infection was diagnosed by urea breath test, histological examination, and serology. Gastric atrophy was assessed histologically, and polymorphisms in the IL‐1B, IL‐10, and tumour necrosis factor α (TNF‐A) genes were genotyped.
Two hundred and eight patients were H pylori positive and 112 were negative. One hundred and eight (34%) were found to have erosive oesophagitis by endoscopic criteria (grade A: 78; grade B: 23; grade C: 6; grade D: 1). Erosive oesophagitis and GORD symptoms were significantly more common in H pylori negative compared with H pylori positive subjects (p<0.05). H pylori positive subjects were more likely to have corpus gastric atrophy than H pylori negative subjects (p<0.001). Among H pylori positive patients, those without erosive oesophagitis or GORD symptoms were significantly more likely to have corpus atrophy than subjects with erosive oesophagitis or GORD symptoms (p<0.05). Among H pylori positive patients, subjects homozygous for the proinflammatory allele IL‐1B−511T had a significantly lower risk of erosive oesophagitis (odds ratio (OR) 0.06 (95% confidence interval (CI) 0.006–0.51); p = 0.01) and GORD symptoms (OR 0.10 (95% CI 0.01–0.85); p = 0.04) compared with those homozygous for the −511C allele, while none of the two other proinflammatory cytokine gene polymorphisms had significant correlations with erosive oesophagitis or GORD symptoms.
A proinflammatory IL‐1B genotype is associated with increased risk of atrophy and decreased risk of GORD in H pylori infected subjects in Japan. These data indicate that in some genetically predisposed subjects, H pylori infection may protect against GORD through induction of gastric atrophy.
gastro‐oesophageal reflux disease; Helicobacter pylori ; gastric atrophy; genetic polymorphisms; interleukin 1β
The National Cancer Screening Program (NCSP) began in 1999. The objective of this report is to evaluate the results of the NCSP in 2008 and provide essential evidence associated with the gastric cancer screening program in Korea.
Materials and Methods
Data was obtained from the National Cancer Screening Information System; participation rates in gastric cancer screening were calculated. According to screening modalities, recall rates were estimated with 95% confidence intervals (CIs).
The target population of the gastric cancer screening program in 2008 was 7,132,820 Korean men and women aged 40 and over, 2,076,544 of whom underwent upper endoscopy or upper gastrointestinal (UGI) series as screening tools (participation rate, 29.1%). Disparities in participation rates were observed relating to gender and health insurance type. Overall, recall rates of upper endoscopy and UGI series were 3.1% (95% CI, 3.0 to 3.1) and 33.3% (95% CI, 33.3 to 33.4), respectively.
According to our research, efforts to facilitate participation and to reduce disparities in gastric cancer screening among Korean men and women are needed. These results will provide essential data for evidence-based strategies in gastric cancer control in Korea.
Korea; Mass screening; Stomach neoplasms
There are no prospective data regarding the risk of prosthetic joint infection following routine gastrointestinal endoscopic procedures. We wanted to determine the risk of prosthetic hip or knee infection following gastrointestinal endoscopic procedures in patients with joint arthroplasty.
We conducted a prospective, single-center, case-control study at a single, tertiary-care referral center. Cases were defined as adult patients hospitalized for prosthetic joint infection of the hip or knee between December 1, 2001 and May 31, 2006. Controls were adult patients with hip or knee arthroplasties but without a diagnosis of joint infection, hospitalized during the same time period at the same orthopedic hospital. The main outcome measure was the odds ratio (OR) of prosthetic joint infection after gastrointestinal endoscopic procedures performed within 2 years before admission.
339 cases and 339 controls were included in the study. Of these, 70 cases (21%) cases and 82 controls (24%) had undergone a gastrointestinal endoscopic procedure in the preceding 2 years. Among gastrointestinal procedures that were assessed, esophago-gastro-duodenoscopy (EGD) with biopsy was associated with an increased risk of prosthetic joint infection (OR = 3, 95% CI: 1.1–7). In a multivariable analysis adjusting for sex, age, joint age, immunosuppression, BMI, presence of wound drain, prior arthroplasty, malignancy, ASA score, and prothrombin time, the OR for infection after EGD with biopsy was 4 (95% CI: 1.5–10).
EGD with biopsy was associated with an increased risk of prosthetic joint infection in patients with hip or knee arthroplasties. This association will need to be confirmed in other epidemiological studies and adequately powered prospective clinical trials prior to recommending antibiotic prophylaxis in these patients.
Aim. To clarify the endoscopic mucosal change of the stomach caused by Lugol's iodine solution spray on screening esophagogastroduodenoscopy (EGD).
Methods. Sixty-four consecutive patients who underwent EGD for esophageal squamous cell
carcinoma screening were included in this study. The records for these patients included gastric
mucosa findings before and after Lugol's iodine solution was sprayed. The endoscopic findings of
the greater curvature of the gastric body were retrospectively analyzed based on the following
findings: fold thickening, exudates, ulcers, and hemorrhage. Results. Mucosal changes occurred after Lugol's solution spray totally in 51 patients (80%). Fold thickening was observed in all 51 patients (80%), and a reticular pattern of white lines was found on the surface of the thickened gastric folds found in 28 of the patients (44%). Exudates were observed in 6 patients (9%). Conclusion. The gastric mucosa could be affected by Lugol's iodine; the most frequent endoscopic finding of this effect is gastric fold thickening, which should not be misdiagnosed as a severe gastric disease.
AIM: To analyze the diagnostic utility of a small-caliber endoscope (SC-E) and clinicopathological features of false-negative gastric cancers (FN-GCs).
METHODS: A total of 21638 esophagogastroduodenoscopy (EGD) gastric cancer (GC) screening examinations were analyzed. Secondary endoscopic examinations (n = 3352) were excluded because most secondary examinations tended to be included in the conventional endoscopy (C-E) group. Detection rates of GCs and FN-GCs were compared between SC-E and C-E groups. FN-GC was defined as GC performed with EGD within the past 3 years without GC detection. Macroscopic types, histopathological characteristics and locations of FN-GCs were compared with firstly found-gastric cancers (FF-GCs) in detail.
RESULTS: SC-E cases (n = 6657) and C-E cases (n = 11644), a total of 18301 cases, were analyzed. GCs were detected in 16 (0.24%) SC-E cases and 40 C-E (0.34%) cases (P = 0.23) and there were 4 FN-GCs (0.06%) in SC-E and 13 (0.11%) in C-E (P = 0.27), with no significant difference. FN-GCs/GCs ratio between SC-E and C-E groups was not significantly different (P = 0.75). The comparison of endoscopic macroscopic types of FN-GCs tended to be a less advanced type (P = 0.02). Histopathologically, 70.6% of FN-GCs were differentiated and 29.4% undifferentiated type. On the other hand, 43.0% of FF-GCs were differentiated and 53.8% undifferentiated type, so FN-GCs tended to be more differentiated type (P = 0.048).
CONCLUSION: The diagnostic utility of SC-E for the detection of GCs and FN-GCs was not inferior to that of C-E. Careful observation for superficially depressed type lesions in the upper lesser curvature region is needed to decrease FN-GCs.
Gastric cancer; Small-caliber endoscope; False-negative gastric cancer
The utility of esophagogastroduodenoscopy (EGD) performed at the time of percutaneous endoscopic gastrostomy (PEG) is unclear. We examined whether EGD at time of PEG yielded clinically useful information important in patient care. We also reviewed the outcome and complication rates of EGD-PEG performed by trauma surgeons.
Retrospective review of all trauma patients undergoing EGD with PEG at a level I trauma center from 1/01–6/03.
210 patients underwent combined EGD with PEG by the trauma team. A total of 37% of patients had unsuspected upper gastrointestinal lesions seen on EGD. Of these, 35% had traumatic brain injury, 10% suffered multisystem injury, and 47% had spinal cord injury. These included 15 esophageal, 61 gastric, and six duodenal lesions, mucosal or hemorrhagic findings on EGD. This finding led to a change in therapy in 90% of patients; either resumption/continuation of H2 -blockers or conversion to proton-pump inhibitors. One patient suffered an upper gastrointestinal bleed while on H2-blocker. It was treated endoscopically. Complication rates were low. There were no iatrogenic visceral perforations seen. Three PEGs were inadvertently removed by the patient (1.5%); one was replaced with a Foley, one replaced endoscopically, and one patient underwent gastric repair and open jejunostomy tube. One PEG leak was repaired during exploration for unrelated hemorrhage. Six patients had significant site infections (3%); four treated with local drainage and antibiotics, one requiring operative debridement and later closure, and one with antibiotics alone.
EGD at the time of PEG may add clinically useful data in the management of trauma patients. Only one patient treated with acid suppression therapy for EGD diagnosed lesions suffered delayed gastrointestinal bleeding. Trauma surgeons can perform EGD and PEG with acceptable outcomes and complication rates.
AIM: To investigate the trend in gastric cancer surgery in the context of rapid therapeutic advancement in Japan and East Asia.
METHODS: A retrospective analysis was performed on 4163 patients who underwent gastric resection for gastric cancer with histological confirmation between 1971 and 2007 at the surgical unit in Kitasato University Hospital, to determine the trend in gastric cancer requiring surgery.
RESULTS: Gastric cancer requiring surgical resection increased in our hospital, but the incidence adjusted for population was constant during the observed period. Interestingly, the ratio of diffuse type/intestinal type gastric cancer was unexpectedly unchanged, and that of advanced/early gastric cancer (EGC) was, however, markedly reduced, while the actual incidence of potentially curative advanced gastric cancer tended to decrease. The incidence of EGC requiring surgery tended to increase as a whole, which is consistent with increased prevalence of endoscopic surveillance. As a result, overall survival and mortality of gastric cancer requiring gastric resection has recently markedly improved.
CONCLUSION: In Japan, planned interventions may improve surgical gastric cancer mortality, but an unexpected trend of persistent existence of intestinal type cancer suggests the need for more robust medical intervention.
Histology; Age factors; Clinical classification; Prognosis; Disease progression; Gastric cancer
Gastro-oesophageal cancer is associated with a high incidence of cachexia. Proteolysis-inducing factor (PIF) has been identified as a possible cachectic factor and studies suggest that PIF is produced exclusively by tumour cells. We investigated PIF core peptide (PIF-CP) mRNA expression in tumour and benign tissue from patients with gastro-oesophageal cancer and in gastro-oesophageal biopsies for healthy volunteers. Tumour tissue and adjacent benign tissue were collected from patients with gastric and oesophageal cancer (n=46) and from benign tissue only in healthy controls (n=11). Expression of PIF-CP mRNA was quantified by real-time PCR. Clinical and pathological information along with nutritional status was collected prospectively. In the cancer patients, PIF-CP mRNA was detected in 27 (59%) tumour samples and 31 (67%) adjacent benign tissue samples. Four (36%) gastro-oesophageal biopsies from healthy controls also expressed PIF-CP mRNA. Expression was higher in tumour tissue (P=0.031) and benign tissue (P=0.022) from cancer patients compared with healthy controls. In the cancer patients, tumour and adjacent benign tissue PIF-CP mRNA concentrations were correlated with each other (P<0.0001, r=0.73) but did not correlate with weight loss or prognosis. Although PIF-CP mRNA expression is upregulated in both tumour and adjacent normal tissue in gastro-oesophageal malignancy, expression does not relate to prognosis or cachexia. Post-translational modification of PIF may be a key step in determining the biological role of PIF in the patient with advanced cancer and cachexia.
real-time PCR; cachexia; inflammation; prognosis
X-ray screening of gastric cancer is broadly used in Japan, although no controlled trial has proved its effectiveness. This study evaluates the impact of an X-ray screening demonstrative intervention to reduce gastric cancer mortality in a Costa Rican region. The evaluation follows a quasi-experimental, community-controlled design, with measures before and after. About 7000 individuals participated by invitation in the two-wave screening programme. X-ray screening was followed by videoendoscopy and gastric biopsies. Treatment included resection with or without lymph node dissection. Comparisons with two control groups estimate that gastric cancer mortality was halved in the period from 2 to 7 years after the first screening visit. Validity of X-rays as used in this intervention had 88% sensitivity, 80% specificity, and 3% predictive value for individuals with two screening visits. Incidence in the screened group increased up to four times. Case survival was 85% in the intervention group after 5 years, compared to 12% among the controls before the intervention and 35% among the controls in the same region after the intervention. Although X-ray mass screening seems able to reduce stomach cancer mortality, its high cost may be an obstacle for scaling up this intervention in a non-rich country like Costa Rica.
gastric cancer; gastric cancer screening; impact evaluation; Costa Rica
Although an annual screening programme for lung cancer has been carried out widely in Japan since 1987, there is insufficient evidence to confirm its efficacy in terms of reducing mortality. In order to evaluate the efficacy of the lung cancer screening which has been widely carried out in Japan since 1987, a case–control study was conducted in Niigata Prefecture, Japan. In the study area, chest X-ray examinations for all participants and sputum cytology for high-risk participants were offered annually. Case subjects, who had died from lung cancer (174), and control subjects matched by sex, year of birth, residence and smoking status (801), who had been alive at the time of diagnosis of the corresponding case, were selected from the National Health Insurance holders. Screening histories of the subjects were compared between cases and matched controls for the identical calendar period before the time of diagnosis of the cases. The odds ratio of death from lung cancer for those screened within 12 months vs those not screened was 0.401 (95% CI: 0.272–0.591) with adjustment by smoking index. Our results suggest that annual lung cancer screening might reduce mortality from lung cancer by approximately 60%. © 2001 Cancer Research Campaign
lung cancer; screening; case–control study; efficacy
It remains unclear whether any aspect of quality of life has a role in predicting survival in an unselected cohort of patients with gastro-oesophageal cancer. Therefore the aim of the present study was to examine the relationship between quality of life (EORTC QLQ-C30), clinico-pathological characteristics and survival in patients with gastro-oesophageal cancer. Patients presenting with gastric or oesophageal cancer, staged using the UICC tumour node metastasis (TNM) classification and who received either potentially curative surgery or palliative treatment between November 1997 and December 2002 (n=152) participated in a quality of life study, using the EORTC QLQ-C30 core questionnaire. On univariate analysis, age (P<0.01), tumour length (P<0.0001), TNM stage (P<0.0001), weight loss (P<0.0001), dysphagia score (P<0.001), performance status (P<0.1) and treatment (P<0.0001) were significantly associated with cancer-specific survival. EORTC QLQ-C30, physical functioning (P<0.0001), role functioning (P<0.001), cognitive functioning (P<0.01), social functioning (P<0.0001), global quality of life (P<0.0001), fatigue (P<0.0001), nausea/vomiting (P<0.01), pain (P<0.001), dyspnoea (P<0.0001), appetite loss (P<0.0001) and constipation (P<0.05) were also significantly associated with cancer-specific survival. On multivariate survival analysis, tumour stage (P<0.0001), treatment (P<0.001) and appetite loss (P<0.0001) were significant independent predictors of cancer-specific survival. The present study highlights the importance of quality of life (EORTC QLQ-C30) measures, in particular appetite loss, as a prognostic factor in these patients.
gastro-oesophageal cancer; stage; treatment; quality of life
AIM: To investigate the prevalence of celiac disease (CD) in adult patients referred to an open access gastroenterology clinic in the south of Italy and submitted to esophago-gastro-duodenoscopy (EGD) for evaluation of refractory functional dyspepsia.
METHODS: Seven hundred and twenty six consecutive dyspeptic patients (282 male, 444 female; mean age 39.6 years, range 18-75 years) with unexplained prolonged dyspepsia were prospectively enrolled. Duodenal biopsies were taken and processed by standard staining. Histological evaluation was carried out according to the Marsh-Oberhuber criteria.
RESULTS: The endoscopic findings were: normal in 61.2%, peptic lesions in 20.5%, malignancies in 0.5%, miscellaneous in 16.7%. CD was endoscopically diagnosed in 8 patients (1.1%), histologically in 15 patients (2%). The endoscopic features alone showed a sensitivity of 34.8% and specificity of 100%, with a positive predictive value (PPV) of 100% and a negative predictive value (NPP) of 97.9%.
CONCLUSION: This prospective study showed that CD has a high prevalence (1:48) in adult dyspeptic patients and suggests the routine use of duodenal biopsy in this type of patient undergoing EGD.
Celiac disease; Endoscopy; Biopsy; Functional; Dyspepsia
Noncardiac chest pain (NCCP) is a very common disorder world-wide and gastroesophageal reflux disease (GERD) is known to be the most common cause. The prevalence of NCCP may tend to decrease with increasing age. However, there is little report about young aged NCCP. The aim of this study was to examine the prevalence of GERD and to evaluate the efficacy of proton pump inhibitor (PPI) test in the young NCCP patients.
Thirty patients with at least weekly NCCP less than 40 years were enrolled. The baseline symptoms were assessed using a daily symptom diary for 14 days. Esophago-gastro-duodenoscopy (EGD) and 24 hr esophageal pH monitoring were performed for the diagnosis of GERD and esophageal manometry was done. Then, patients were tried with lansoprazole 30 mg twice daily for 14 days, considering positive if a symptom score improved ≥ 50% compared to the baseline.
Nine (30%) of the patients were diagnosed with GERD at EGD and/or 24 hr esophageal pH monitoring, also, 3 (10%) were diagnosed with GERD-associated esophageal motility disorder and 3 (10%) were non GERD-associated. Concerning PPI test, GERD-related NCCP had a higher positive PPI test (n = 8, 89%) than non GERD-related NCCP (n = 5, 24%) (p = 0.002).
In young patients with NCCP, a prevalence of GERD diagnosed using EGD and/or 24 hr esophageal pH monitoring was 30%. PPI test was very predictable on diagnosis of GERD-related NCCP, thus, PPI test in young NCCP patients may assist to the physician's clinical judgment of NCCP.
Gastroesophageal reflux disease; Noncardiac chest pain; Proton pump inhibitor; Young adult