Carcinoma Of Cardia Research Articles

Association between tooth loss and upper gastrointestinal cancer: A 30-year follow-up of the Linxian Dysplasia Nutrition Intervention Trial Cohort.

BackgroundThis prospective study investigated the association between tooth loss and upper gastrointestinal (UGI) cancer mortality in the Linxian Dysplasia Nutrition Intervention Trial Cohort.MethodsSubjects were categorized into three groups according to age at baseline. No missing teeth and less or greater than median tooth loss in each group was defined as none, moderate, and severe, respectively. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were estimated using the Cox proportional hazard model.ResultsThrough 30 September 2015, 541 esophageal squamous cell carcinoma (ESCC), 284 gastric cardia carcinoma (GCC), and 77 gastric non‐cardia carcinoma (GNCC) deaths occurred. In the six‐year follow‐up, severe tooth loss was associated with an increased risk of GCC mortality (HR 1.55, 95% CI 1.06–2.18). In the 15‐year follow‐up, moderate tooth loss increased the ESCC mortality risk by 58% (HR 1.58, 95% CI 1.06–2.35), while severe loss increased the GCC mortality risk by 30% (HR 1.30, 95% CI 1.03–1.64). In the 30‐year follow‐up, moderate tooth loss increased the risk of ESCC mortality (HR 1.34, 95% CI 1.01–1.76). In subjects aged < 55 at baseline and men, moderate tooth loss had 53% and 52% higher risks of ESCC mortality (HR<55 years 1.53, 95% CI 1.06–2.05; HRmen 1.52, 95% CI 1.01–2.28). No significant association was observed for GNCC in any subjects or subgroups.ConclusionModerate tooth loss increased the risk of ESCC mortality, particularly in younger subjects and men. Severe tooth loss increased the risk of GCC mortality. Future studies are needed to confirm these findings.

Influence of the surgical technique on survival in the treatment of carcinomas of the true cardia (Siewert Type II) - Right thoracoabdominal vs. transhiatal-abdominal approach

IntroductionIt is still a matter of debate whether subtotal esophagectomy via a right thoracoabdominal approach (RTA) or extended gastrectomy using a transhiatal-abdominal approach (TH) is the favorable technique in the treatment of Siewert type II esophago-gastric junction adenocarcinoma (EJA). Materials and methodsPatients undergoing RTA or TH for EJA at our institution between 2000 and 2013 were extracted from a prospective database. Of 270 patients 91 (33.7%) underwent RTA and 179 (66.3%) were treated by TH.Differences in baseline characteristics, 30d mortality and complications were investigated using the χ2-test or exact testing. Survival analysis was performed using the Kaplan-Meier method and log rank testing. Median survival and hazard ratios were calculated and multivariable analysis of predictors was performed using a Cox model. Confounders were balanced using propensity score matching (PSM). ResultsNo significant difference between the two procedures was detected regarding overall-survival (OS) and disease-free survival (DFS). 30d mortality rates were 1.1% in the RTA group and 4.5% in the TH group (p = 0.134). Morbidity was 34.1% in the RTA and 24.6% in the TH group (p = 0.006). Cox regression analysis identified age, ASA class and UICC stage as independent prognostic factors for OS. After PSM survival curves (OS + PFS) showed no significant difference. ConclusionThe present study could not detect a difference between RTA and TH from the oncologic point of view; RTA was not associated with higher 30d mortality. RTA for Siewert Type II EJA is justified whenever the oral tumor margin cannot be safely reached via a transhiatal approach.

PS02.142: CONVERSION SURGERY: A FEASIBLE GOAL FOR AFTERWARDS IN CARDIA CANCER TREATMENT

Abstract Background Conversion surgery is a surgical treatment aiming R0 resection after chemotherapy of tumors that were originally regarded as technically or oncologically unresectable or only marginally resectable. Performing surgery in such patients may result in a long-term survival. The current experience concerns stage IV gastric cancer patients with marginally resectable metastasis, while the evidence concerning cardia tumors are poor. We report a case of primary cardia cancer with potentially unresectable metastasis, successfully treated by a multidisplinary approach including chemotherapy and surgery. Methods We report a case about a 65-year-old man affected by EGJ adenocarcinoma (Siewert II) with multiple hepatic metastases and para-aortic adenopathy (cT3N + M1 according to UICC 7th edition). He received intensive chemotherapy with Taxotere, Cisplatin and 5 FU. After therapy, primary tumor and liver lesions had markedly regressed according to CT, using RECIST guidelines. The endoscopy confirmed the reduction in the cardia lesion with negative biopsies. For that reason, the patient was addressed to follow up. Results After 6 years of follow up, endoscopy indicated a local relapse with a pathological diagnosis of adenocarcinoma. CT scan showed a clinical stage was cT3N + M0. The patient was treated with neoadjuvant concurrent chemoradiotherapy. After treatment the exams showed a partial response. The patient was eligible for conversion surgery and we proceeded to laparotomy total gastrectomy with D2 lymphadenectomy. We performed also exeresis of a liver nodule, which resulted fibrous. The surgical procedure was radical (R0). According to histological examination, the postoperative stage was ypT0N0. Treatment-induced response at the primary tumor site, evaluated according to SPR classification and TRG classification, was SPR 1 and TRG 1. Conclusion Despite limited evidence in literature about conversion surgery in cardia carcinoma, this case shows that intensive chemotherapy allows for conversion of unresectable cardia cancer to resectable cancer, resulting in long-term survival. The following surgical resection provided a R0 resection, leaving no macroscopic residual tumor. This result indicates a potential strategy for patients affected by unresectable cardia cancer. Clearly this strategy requires further analysis to be confirmed. However, based on our case report, the conversion surgery seems safe and feasible, associated with R0 resection. Disclosure All authors have declared no conflicts of interest.

Society for Translational Medicine Expert Consensus on the prevention and treatment of postoperative pulmonary infection in esophageal cancer patients

Esophageal cancer is ranked as the malignant tumor with the 6th highest morbidity and mortality rate worldwide. Chinese people are prone to develop esophageal cancer, and the number of new cases that occur every year account for more than half of the esophageal cancer patients worldwide (1,2). Although reports have confirmed the effectiveness of chemoradiotherapy for esophageal cancer, esophageal resection remains the primary means of treatment. Anastomotic leaks and pulmonary complications are the most common postoperative complications of esophageal cancer and carcinoma of the gastric cardia. Pulmonary complications have become more noticeable (3) as the incidence of postoperative anastomotic fistula (8–15%) has decreased due to the improvement of surgical techniques, the use of disposable staplers, and the continuous improvement of postoperative nutritional support Cervical and upper thoracic esophageal cancer are associated with a higher risk for postoperative pulmonary infection.

Neuroendocrine carcinoma of esophageal and gastric cardia: clinicopathologic and immunohistochemistry study of 80 cases.

Neuroendocrine carcinoma (NEC) of the esophagus and gastric cardia is a rare tumor, and the Chaoshan region has one of the highest incidences of esophageal and gastric cardia cancer (GCC) worldwide. The aim of this study was to characterize the clinicopathologic features of esophageal NEC (n = 67) and gastric cardia NEC (n = 13) cases identified over a 9-year period in the Chaoshan region. Esophageal NECs were either purely NEC (n = 47) or mixed with squamous cell carcinoma or adenocarcinoma (n = 20). For GCC; pure NEC was found in 5 cases, whereas 8 cases were mixed with adenocarcinomas. The majority of esophageal and gastric cardia NECs was of the small cell type, and 24/67 esophageal and 5/13 gastric cardia patients were found with lymph node metastasis. Immunohistochemistry was performed in all cases, and positive staining for synaptophysin (Syn) was found for all cases, with half the esophageal NEC cases being also chromogranin A (CgA)-positive. In the multivariate Cox regression model, lymph node and further metastasis were independent prognostic factors for esophageal NEC. Our study revealed the clinicopathological features of esophageal and gastric cardia NECs in the Chaoshan region and found mixed NECs patients may have a better prognosis than pure NECs patients, which may provide therapeutic clue for treating this rare tumor.

Association between oral leukoplakia and risk of upper gastrointestinal cancer death: A follow-up study of the Linxian General Population Trial.

BackgroundThis study was conducted to explore the association between oral leukoplakia (OL) and the risk of upper gastrointestinal cancer death in the Linxian General Population Trial Cohort.MethodsA prospective cohort study of the Linxian General Population Trial Cohort was performed. Participants with OL were treated as an exposed group, and the remainder was selected as a control group. All subjects were followed monthly by village health workers and reviewed quarterly by the Linxian Cancer Registry. Hazard ratios (HRs) and 95% confidence interval (CIs) were evaluated using proportional hazard and proportional subdistribution hazard models, respectively.ResultsOver a median of 27 years of observation, 29 476 subjects were followed‐up. A total of 17 473 deaths occurred, including 2345 esophageal squamous cell carcinoma (ESCC), 1139 gastric cardia carcinoma, and 506 gastric non‐cardia carcinoma deaths. Significant increased ESCC mortality was observed in subjects with OL (exposed 9.66% vs. unexposed 7.39%; P < 0.0001). Furthermore, subjects with OL had a 22% higher risk of death from ESCC (HR 1.22, 95% CI 1.10–1.34; P = 0.0001) after adjusted covariates. In subjects aged ≤52 at the baseline, OL was significantly associated with an elevated risk of ESCC mortality (HR 1.32, 95% CI 1.13–1.54; P = 0.0005). No significant associations were observed for gastric cardia carcinoma and non‐cardia carcinoma mortality.ConclusionsOL may increase the risk of ESCC mortality, especially in the younger population. These associations should be investigated in further studies.

Abstract 264: Time trending for the ratio of rural and urban patients with esophageal squamous cell carcinoma in a single institute in northern China over the past 30 years

Abstract Esophageal squamous cell carcinoma (ESCC) has been well characterized as a major histological type in China and occurred predominantly in the mountain rural region with poor economics. Nutritional deficiencies have been recognized as major risk for esophageal carcinogenesis in these rural regions. In the past decades, the rural economic status in China has improved apparently. However, the time trending for ESCC in rural regions has not been characterized. The present study was thus undertaken to determine the time trending for the ratio of rural and urban patients with ESCC in a single institute in northern China over the past 30 years (1985-2014). All the 66,515 ESCC patients in this study were derived from the esophageal and gastric cardia carcinoma databases of 500 thousands patients (1973-2015) established by Henan Key Laboratory for Esophageal Cancer Research of the First Affiliated Hospital of Zhengzhou University in Henan, China. Of the ESCC patients, 50,313 patients had been recorded with detailed address. Based on the diagnosed time, these patients were divided into three groups with periods of 1985-1994, 1995-2004 and 2005-2014. The rural and urban regions were recognized based on the government administrative division of China. The rural region in China refers to the farmer village with hundreds to thousands population. Chi-Square test was used to analyze the different distributions of ESCC patients with a p-value of less than 0.05 as significant. The results demonstrated that more than 84% of the ESCC patients occurred in rural regions with an overall ratio of 5:1 for rural and urban regions (p &amp;lt; 0.0001). Moreover, over the past 30 years with three periods, the ratios for rural and urban regions were 5.4:1, 5.5:1 and 5.4:1, respectively. The present results also demonstrated that over the past 30 years with three periods, ESCC occurred predominantly in males with ratios for male and female as 1.5:1, 1.4:1 and 1.5:1, respectively in rural regions and 1.6:1, 1.6:1 and 1.8:1, respectively in urban regions. Interestingly, the mean age both in male and female in urban regions was slightly older than that in rural regions (urban vs. rural: 60.7±9.86 vs. 59.8±9.38 in male and 62.2±9.57 vs. 60.6±9.47 in female, respectively). The present study demonstrated that ESCC remains the major healthy burden in rural regions in China. Considering the relative low socioeconomic status in China, the prevention and control of ESCC should be enhanced in rural regions in terms of more control programs, medical and education resources. [Supported by National High-Tech Research and Development Program of China (SQ2015AA0202183), Project for Characteristic and Advantage Discipline of Henan Province (20151208)] Note: This abstract was not presented at the meeting. Citation Format: Shou Jia Hu, Hai Jun Yang, Neng Chao Wang, Xiu Min Li, Shuang Lv, Qi De Bao, Wen Bin Yue, Hui Meng, Dan Feng Du, Xue Min Li, Fu You Zhou, Jian Li, Li Dong Wang. Time trending for the ratio of rural and urban patients with esophageal squamous cell carcinoma in a single institute in northern China over the past 30 years [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 264. doi:10.1158/1538-7445.AM2017-264

Prognostic factors influencing the survival of patients with carcinoma of the gastric cardia receiving preoperative interventional embolization chemotherapy.

The purpose of this study was to analyze the characteristics of patients with gastric cardia cancer (GCC) to identify the main factors the influence the survival rate after interventional embolization chemotherapy (IEC). One hundred and fifty-six patients with advanced GCC were treated with IEC via the left gastric artery. Survival time was defined as from the date of diagnosis until death or the end of this study in June 2015. The median survival time was 15 months (range 3 to 29 months). The Cox proportional hazard model found that patients’ age (p < 0.001), sex (p = 0.039), weight loss more than 10% in the prior 3 months (p = 0.014), body mass index (BMI) (p = 0.047), and hematocrit value less than 37% (p < 0.001) were correlated with mortality after removal of cases of poorly differentiated carcinoma and undifferentiated carcinoma from the analysis. Kaplan-Meier curves of survival according to patients’ age showed significant differences by the log-rank test (p = 0.0015). The median survival time was 17 months among patients of aged < 50 years. In conclusion, BMI, weight loss > 10% in the prior 3 months, albumin, and hematocrit were prognostic indicators for patients with advanced GCC, and patients younger than 50 years have a higher survival rate after IEC.

Proportion of cancer in a Middle eastern country attributable to established risk factors

BackgroundProviding an estimate of the percentage of cancer in Lebanon by 2018 that is due to the exposure to risk factors in 2008. Factors include: smoking, body mass index (BMI), physical inactivity, dietary factors, alcohol consumption, infections, and air pollution in adults.MethodPopulation Attributable Fraction (PAF) was calculated using the proportion of the population exposed and relative risks for each risk factor from meta-analyses. The PAF estimates the proportion of cases in which exposure may have played a causal role.ResultsSmoking caused most cancer cases, and it will further add a total of 1800 new cases by 2018. Among many other cancers, lung cancer had the largest proportion attributable of around 75%. BMI is expected to increase colorectal, liver and gastric cardia carcinoma specifically in males. High physical activity has a an average of 15% protection rate on cancer on colorectal cancer. Minimal adherence to Mediterranean diet will affect gastric cancer incidence by 7%. Cases of oropharyngeal and esophageal cancer will be the result of alcohol consumption mainly in males. H.Pylori infection is expected to result in half of the gastric cases by 2018. The high exposure to air pollution is expected to contribute by 13% to lung cancer cases in 2018.ConclusionThe highest benefits can be achieved by controlling tobacco smoking. Interrelated and small changes in weight, physical activity and healthy diet with limited alcohol consumption can protect against several GI cancers in the long run. These results can be used to determine public health interventions that target important risk factors in the general population.

Tissue inhibitor of metalloproteinases 3 promoter methylation and mRNA expression in cardia carcinoma and its relationship with prognosis

Objective To explore the relationship of the methylation levels of tissue inhibitor of metalloproteinases 3(TIMP-3) gene promoter CpG islands with the invasiveness and prognosis in cardia carcinoma. Methods The tumors tissues were collected from 65 patients with cardia carcinoma. The methylation levels of the promoter of TIMP-3 gene were detected by methylation-specific PCR(MSP), the mRNA expression levels of TIMP-3 gene were detected by RT-PCR. The relationship of TIMP-3 gene ectopic methylation with invasiveness and prognosis of the cardia carcinoma patients was analyzed. Results The positive expression rates of TIMP-3 mRNA in gastric cancer and normal gastric tissues were 53.8 % (35/65) and 96.9 % (63/65), respectively. The difference was not statistically significant(Fisher exact test, P=0.912). The positive rate of TIMP-3 mRNA was negatively correlated with the depth of tumor invasion and lymph node metastasis [mucosa and muscular vs. serosa and mucosa outside of the serosa and muscula: 83.3 % (10/12) vs. 45.3 % (24/53); with lymph node metastasis vs. without lymph node metastasis: 73.9 % (17/23) vs. 40.5 % (17/42)] (both P<0.05). There was a negative correlation between TIMP-3 gene promoter methylation and TIMP-3 mRNA expression (r=-0.276, P=0.026). The size of tumor and TIMP-3 gene promoter methylation were both the independent influencial factors of prognosis in cardia carcinoma(both P<0.05). Conclusion The methylation of promoter region in CpG islands plays an important role in the invasion and metastasis of cardia carcinoma, and it can be used as an independent predictor of biological behavior and prognosis. Key words: Stomach neoplasms; Tissue inhibitor of metalloproteinase 3; Methylation; RNA, messenger; Prognosis

B32 - HER-2 in gastric cancer: a single institution experience

Gastric cancer is the fourth most common cancer disease worldwide and it's the second leading cause of cancer-related death. The study of HER-2 expression and the use of targeted agent trastuzumab have improved the prognosis of many patients. This abstract aims to show a casuistry of patients with gastric cancer related with their HER-2 expression. From May 2010 to November 2015 we observed 157 cases of patients with gastric cancer. Median age was 69,2 years (range 26,7-88 years), 116 were male and 41 were female. At diagnosis 19 patients had I stage disease, 15 patients II stage, 69 patients III stage and 54 patients were metastatic (IV stage). Globally we treated 84 metastatic patients. Among these HER-2 status was not assessable in 34,5% (n 29) because of Performance Status, comorbidities and age of patients. We tested 55 patients (65,5%): of these 72,7% were negative (n 40), 27,3% were positive (n 15). This percentage is higher than literature, maybe for the small number of patients of our casuistry. HER-2 expression was higher in intestinal-type cancer (8 of 23 patients, 34,8%). In relation of gastric site the highest percentage is in cardia (5 of 11 patients, 45,5%), the lowest in antrum (4 of 21, 19%). We treated with chemotherapy 30 of 40 patients HER-2 negative and with chemotherapy and trastuzumab 15 of 15 patients HER-2 positive. The chemotherapy regimen used for HER-2 positive patient were: cisplatin + 5-fluorouracil + trastuzumab (6 patients), weekly PFL (cisplatin, 5-fluorouracil, leucovorin) + trastuzumab (4 patients) and cisplatin + capecitabine + trastuzumab (5 patients). Among all treated patients, the Progression Free Survival was 3,4 months for HER-2 negative subgroup and 9,11 months for HER-2 positive. The Overall Survival was 7,7 months for HER-2 negative group and 13,7 months for HER-2 positives ones. It's interesting to notice that we are treating a young man 36 years old since 2011 with trastuzumab, without any signs of progression. This man has cardia carcinoma, intestinal-type, metastatic at adrenal gland and liver. These data, despite the little sample, confirm how the prognosis of HER-2 positive patients treated with trastuzumab is globally better than HER-2 negative, in agreement with literature.

Clinical value of gastric bare area for the prognosis of gastric fundus and cardia carcinoma

Objective To explore the clinical value of gastric bare area (GBA) for the prognosis of gastric fundus and cardia carcinoma. Methods The data of 82 patients with gastric fundus and cardia carcinoma from January 2010 to December 2011 were retrospectively analyzed. The patients were divided into group A (49 cases) with cancer cell invasion in GBA and group B (33 cases) without invasion in GBA. All the patients underwent D2 gastrectomy plus surgical resection of GBA and were treated by 6 cycles of postoperative FOLFOX-4 chemotherapy scheme. Postoperative follow-up and survival analysis were carried out for patients in both groups. Results According to survival analysis (Kaplan-Meier method), the postoperative 1-, 2- and 3-year cumulative survival rates of the patients in group A were 91.8 %, 57.3 % and 29.0 %, respectively, while those of the patients in group B were 93.9 %, 75.0 % and 48.2 %, respectively. The median survival times of the patients in group A and group B were 27.0 months and 36.0 months, respectively, which was demonstrated existing statistical significance(χ2 = 4.972, P= 0.026). Conclusions The prognosis of gastric fundus and cardia carcinoma patients with invasion in GBA by cancer cells is poor. Surgical resection of GBA may help to improve the prognosis of the patients with gastric fundus and cardia carcinoma. Key words: Stomach neoplasms; Gastric bare area; Survival analysis

Résultats à long terme de la chimioradiothérapie néoadjuvante des cancers de l’œsophage : étude rétrospective monocentrique sur 102 patients

Purpose and objectivesTo report survival and morbidity of a large homogeneous cohort of patients with a locally advanced esophageal or cardia carcinoma and put in evidence predictive factors of locoregional control and survival. Patients and methodsHundred and two patients were treated at the university hospital of Tours between 1990 and 2010 and received neo-adjuvant chemoradiation therapy with external irradiation (40Gy–44Gy) and two courses of chemotherapy (5-fluoro-uracile and cisplatine). Esophagectomy associated with lymph node dissection was performed about ten weeks after the end of chemoradiation therapy. ResultsThe median follow-up was 22.4 months [6–185 months]. The overall survival rates at 2 and 5years were 53% and 27%, respectively. The median overall survival was estimated at 27months. The overall 2-year survival between patients “responders” and patients “non-responders” was 67% vs 26%, respectively (P<0.0001). In case of histological response, there was a benefit in terms of overall survival (P<0.0001), locoregional control (P<0.0036) and disease-free survival (P<0.001). Overall survival at 2years was 64% for ypN0 group vs 32% for ypN1 group (P<0.0001). The median survival was estimated at 37months against 15months in the absence of lymph node involvement (P<0.0001). ConclusionOur results in terms of survival, tolerance and morbidity and mortality were comparable to those in the literature. Complete histological response of lymph node was associated with an improvement of local control, disease-free survival and overall survival.

Trends in gastric cancer incidence: a period and birth cohort analysis in a well-defined French population.

The incidence of gastric cancer has declined over the past decades. Little is known about trends by site and histological subtype. The aim of this study was to analyze changes in gastric cancer incidence patterns in a French well-defined population. Data on patients with an epithelial gastric cancer diagnosed between 1982 and 2011 were collected by the population-based digestive cancer registry of Burgundy (n = 4694). Time trends in gastric cancer incidence by period of diagnosis and birth cohort were analyzed by sex, subsite, and histological type. There was a decrease in incidence rates for antral carcinomas (-2.6 % per year in males, -2.5 % per year in females; p < 0.001) and corpus carcinomas (-3.3 % and -3.2 %, respectively; p < 0.001). Annual percentage changes were not significant for fundus carcinomas in both sexes and cardia carcinoma in females, although they increased in males (+1.0 % per year; p < 0.02).When comparing the 1900 cohort and the 1950 cohort, there was a five- to sevenfold decrease in the cumulative risk at 0-79 years for corpus and antral carcinomas in both sexes and a threefold decrease for fundus carcinomas. There were minor variations for cardia carcinomas. There was a decrease of incidence both by period of diagnosis and by birth cohort for adenocarcinoma and colloid carcinoma. It was more marked for undifferentiated carcinoma. The variation for signet-ring carcinoma was minor. Temporal variations in incidence rates of gastric cancer differed according to subsite and histology, suggesting different etiological factors. Available analytical studies provide an explanation for the reported trends by subsite.

Clinical research of dezocine combined butorphanol for postoperative analgesia in elderly patients

Objective To observe the effect of combined dezocine with butorphanol for postoperative analgesia in elderly patients. Methods Totally 40 patients older than 65 years under general anesthesia for abdominal radical resection of gastric cancer or thoracic esophageal cancer or cardia carcinoma radical resection were randomly divided into combined dezocine with butorphanol group (group I) and butorphanol group (group II), 20 cases of each group. Before operation, phenobarbita 0.1 g and atropine 0.5 mg im. The operations were under total intravenous anesthesia with endotracheal intubation and mechanical ventilation. Propofol, remifentanil and cisatracurium maintain anesthesia. Thirty minutes before the end of operation, analgesic load dose was given and opened the analgesia pump. Group I: dezocine 25 mg, butorphanol 8 mg and granisetron hydrochloride 3 mg.group Ⅱ: butorphanol 13 mg and granisetron hydrochloride 3 mg.The volume was diluted with saline to 150 ml. Continuous intravenous infusion velocity was 3 ml/h.Bolus dose was 3 ml/time, lock time was 15 min and maximum dose was 9 ml/h. The time of recovery and extubation were recorded. VAS score was used to assess pain, nausea and vomiting; Ramsay score was used to evaluate the degree of sedation; Cognitive functions were evaluated with MMSE scale. Results 48 h postoperatively, VAS score of group I (1.75±0.44) was lower than that of group Ⅱ(2.25±0.79) (P<0.05). 6 h postoperatively, sedation score of group Ⅱ(3.75±0.79)was higher than that of group I(2.15±0.75) (P<0.05). 48 h postoperatively, nausea and vomiting scores of group I (0) was lower than that of group Ⅱ(0.70 ±1.30)(P<0.05). Compared with the MMSE score at 1 d postoperatively, the MMSE scores of two groups decreased at 6 h postoperatively, and the MMSE score of group Ⅱ(15.00±2.00) was lower than that of group I(20.95±1.54)(P<0.05). Conclusion Intravenous dezocine combined butorphanol for postoperative analgesia in elderly patients is safe, and the side effects are less than that of the pure butorphanol analgesia. Key words: Dezocine; Butorphanol; The elderly; Postoperative analgesia

Comparative analysis of three kinds of digestive tract reconstruction after radical gastrectomy in the treat-ment of gastric cardia carcinoma

Objective To compare the effects of three kinds digestive tract reconstruction after radical gas-trectomy for gastric cardia carcinoma.Methods The data of 150 patients underwent radical gastrectomy for gastric cardia cancer patients were analyzed.According to the reconstruction of digestive tract,they were divided into group A （55 cases）,group B （46 cases）,group C（49 cases）.Patients in group A underwent jejunal anastomosis.Patients in group B underwent esophageal empty intestine Roux-en-Y anastomosis.Patients in group C underwent esophageal gas-tric wall anastomosis.All were follow-up for 12 months.Results During the follow-up period,the rate of reflux esoph-agitis in group A were significantly lower than that in B group （1.82%vs 19.57%,χ^2=6.966,P=0.008）,the rate of reflux esophagitis in B group were significantly lower than that in C group （19.57%vs 38.78%,χ^2=4.212,P=0.042） .12 months after operation,overall health,constipation,diarrhea,nausea and vomiting index score of group A was significantly lower than those of group B and group C （all P〈0.05）.Conclusion The esophagus jejunum Roux-en-Y anastomosis is suitable for radical total gastrectomy in the treatment of gastric cardia carcinoma.The jeju-nal interposition anastomosis after proximal radical gastrectomy in the treatment of gastric cardia carcinoma shows low incidence of reflux esophagitis and high quality of life. Key words: Stomach neoplasms; Digestive system surgical procedures

The study of general anesthesia combined with paravertebral block for radical resection of cardia carcinoma

Objective To investigate the effect of general anesthesia combined with paravertebral block for thoracic surgery.Methods Retrospectively analyzed 30 patients (group P) under general anesthesia combined with paravertebral block for accepting radical resection of cardia carcinoma and 30 patients (group G) undergoing same surgery with only general anesthesia in the same period.Before general anesthesia,patients in group P received paravertebral nerve block in operating side with 20 ml 0.375％ ropivacaine injected into paravertebral space and catheters were left after injection.The consumption of anesthetic drugs,anesthetic management,anesthetic recovering,postoperative visual analog scale(VAS) at rest and when coughing in both groups were recorded.Satisfaction of anesthesia was recorded 24 h postoperatively.Results The process of anesthesia and operation went well in all groups.The mean consumption of sulfentanyl and sevoflurane in group P was less than that in group G [(5±4) μg vs (26±4) μg](P＜0.01).Recovery time in group P was shorter than that in group G [(45±18) min vs (100±20) min] (P＜0.01).Mean V AS scores when coughing were significantly decreased in group P (P＜0.01).The postoperative fentanyl consumption of patients in group P was significantly less than that in group G [(0.11±0.12) mg vs (0.42±0.11) mg](P＜0.01).Conclusions Using landmark technique in paravertebral block combined with general anesthesia for thoracic surgeries may simplify the anesthesia management and decrease anesthetics consumption in favor of anesthesia recovery and postoperative analgesia. Key words: Balanced anesthesia; Paravertebral block; Thoracic surgery

Different roles for p16(INK) (4a) -Rb pathway and INK4a/ARF methylation between adenocarcinomas of gastric cardia and distal stomach.

The incidence of distal gastric adenocarcinoma has significantly decreased, but gastric cardia adenocarcinoma has been on the rise. Cardia adenocarcinoma might be a specific entity distinct from the carcinoma of the rest stomach. The aim was to explore putative differences in p16(INK) (4a) -retinoblastoma (Rb) pathway and INK4a/ARF methylation between gastric cardia and distal adenocarcinomas. Ninety-six cardia adenocarcinomas and 79 distal samples were analyzed for comparing p16(INK) (4a) -Rb expressions, INK4a/ARF deletion, and methylation using immunohistochemistry, polymerase chain reaction, and methylation-specific polymerase chain reaction. The expression of p16(INK) (4a) in cardia adenocarcinoma (43.2%) was significantly lower than in distal cases (75.0%, P < 0.05). As well, cardia adenocarcinoma showed lower expression of p14(ARF) compared with distal cases (34.1% vs 57.5%, P < 0.05). The incidence of p16(INK) (4a) deletion was 20.5% and 15.0%, while p14(ARF) deletion was 18.2% and 10.0% in cardia and distal adenocarcinomas, respectively, showing no significant differences between two entities. However, the incidences of p14(ARF) and p16(INK) (4a) methylation in cardia adenocarcinoma were significantly higher than in distal samples (p14(ARF) : 61.5% vs 43.6%; p16(INK) (4a) : 73.1% vs 51.3%, P < 0.05). INK4a/ARF methylations were more prevalent in poorly differentiated cardia carcinoma compared with poorly differentiated distal cases. There were differences in p16(INK) (4a) -Rb immunotypes and INK4a/ARF methylation between two entities, indicating that cardia adenocarcinoma may be different in cell proliferation, differentiation, and gene biomarkers compared with distal gastric adenocarcinoma.

Delayed gastric emptying after esophagectomy for malignancy.

Controversy still exists about the need for pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. Although pyloric drainage may prevent postoperative delayed gastric emptying (DGE), it may also promote dumping syndrome and bile reflux. The aims of this study were to audit the incidence and management of DGE in patients without routine pyloric drainage after esophagectomy in a university medical center. From July 2006 to June 2012, data from 356 consecutive patients who underwent esophagectomy with a gastric conduit without pyloric drainage for esophageal or gastric cardia carcinoma were reviewed. Major observation parameters were the incidence, management, and outcomes of DGE. Overall incidence of DGE was 15.7% (56 of 356). Early DGE developed in 26 patients, and late DGE developed in 30 patients. There were no differences in demographic and intraoperative data between the two groups with or without DGE. More DGE was documented in patients with an intra-right thoracic gastric conduit (P=.031). A higher incidence of postoperative pneumonia was observed in patients exhibiting early DGE, but without significance (P=.254). There were also no significant impacts on respiratory failure (P=.848) and anastomotic leakage (P=.257). There was an increased postoperative hospital stay with DGE, but without significance (P=.089). Endoscopic balloon dilatation of the pylorus was used to manage 33.9% of patients with DGE, yielding a 78.9% (15 of 19) success rate without complications. In 3 patients endoscopy showed the pylorus was open, and their symptoms improved over time. One patient with tumor-related DGE was treated by pyloric stent. The remaining patients were adequately treated with conservative management. Omitting the operative drainage procedure does not lead to an increased frequency of DGE after esophagectomy with a gastric conduit. Many patients responded to conservative management, and endoscopic balloon pyloric dilatation can be effective in managing the DGE postoperatively.

The evil lies below the surface: Subsquamous tumor extension in Barrett's adenocarcinoma.

The presence of intestinal metaplasia underneath the surrounding squamous epithelium is a well known phenomenon in Barrett’s esophagus (BE) 1. Mostly caused by re-epithelialization with neosquamous epithelium in the context of mucosal healing (due to acid suppressive therapy or after biopsy sampling, for example), this issue has recently attracted new attention in the context of an increasing application of ablative therapies for Barrett’s esophagus, above all radiofrequency ablation (RFA). Although follow-up studies after RFA treatment have shown that the frequency of so called “buried glands” after re-epithelialization with neosquamous epithelium is much lower than previously feared, the limited diagnostic accessibility of these structures below the surface is still worrisome due to their potential risk of malignant transformation 2 Retrospective studies on resection specimens of Barrett’s adenocarcinoma have revealed subsquamous extension of intestinal metaplasia and even neoplasia in a huge number of cases 3. Although the clinical impact of this “subsquamous tumor extension” (SSTE) is still controversial, it needs consideration in the context of assessing the lateral borders of neoplastic lesions prior to endoscopic resection, especially for carcinomas arising near the squamocolumnar junction. As for buried glands, the prediction of SSTE relying on superficial features is very difficult. Slight elevation and irregular vascular architecture might be some of the subtle changes that can be seen in areas of the squamous epithelium that have been undermined by an adjacent adenocarcinoma. Attempts to improve visualization of SSTE included the use of chromoendoscopy with acetic acid, magnifying endoscopy with narrow band imaging, and optical coherence tomography 4 5 6. However, controlled studies on the additional diagnostic yield of these techniques for the detection of SSTE are still lacking. Given that SSTE is mostly limited to a few millimeters, this raises the question whether it is really necessary to assess its precise extent in order to achieve complete resection of neoplasia. In the present study of Nagamy et al. which represents a retrospective analysis of prospectively gained clinical data, the authors investigated the efficacy of endoscopic submucosal dissection (ESD) on tumors of the esophagogastric junction (EGJ). Applying a proximal safety margin of 1 cm outside of the squamocolumnar junction or the slight elevation interpreted as SSTE, they were able to achieve an en bloc resection rate of 100 % for both gastric cardia carcinoma and Barrett’s adenocarcinoma. For the latter, the histological evaluation revealed SSTE in 12/14 cases, half of them undetected prior to endoscopic resection, but at worst 7 mm at maximum extent, wherefore the authors concluded quite rightly that a safety margin of 1 cm may be acceptable for ESD in these tumors. Although exact delineation of SSTE by advanced endoscopic imaging techniques may be fancy, the study by Nagamy et al. nicely demonstrates that a simple and clear algorithm for resection margins based on former clinical experience may lead to excellent results for endoscopic resection. Even if SSTE might be frequent and sometimes indiscernible, it seems to be a soluble problem in the endoscopic management of Barrett’s adenocarcinoma.