Oesophagogastric Surgery - Print and E-Book

A Companion to Specialist Surgical Practice
 
 
Saunders Ltd. (Verlag)
  • 5. Auflage
  • |
  • erschienen am 22. Juni 2013
  • |
  • 418 Seiten
 
E-Book | ePUB mit Adobe DRM | Systemvoraussetzungen
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978-0-7020-4970-5 (ISBN)
 

Oesophagogastric Surgery meets the needs of surgeons in higher training and practising consultants for a contemporary and evidence-based account of this sub-specialty that is relevant to their general surgical practice. It is a practical reference source incorporating the most current information on recent developments, management issues and operative procedures. The text is thoroughly referenced and supported by evidence-based recommendations wherever possible, distinguishing between strong evidence to support a conclusion, and evidence suggesting that a recommendation can be reached on the balance of probabilities.

This is a title in the Companion to Specialist Surgical Practice series whose eight volumes are an established and highly regarded source of information for the specialist general surgeon.

  • The Companion to Specialist Surgical Practice series provides a current and concise summary of the key topics within each major surgical sub-specialty.

  • Each volume highlights evidence-based practice both in the text and within the extensive list of references at the end of every chapter.

  • An expanded authorship team across the series includes additional European and World experts with an increased emphasis on global practice.

  • The contents of the series have been extensively revised in line with recently published evidence.
  • This revised edition takes full account of the advances in the roles of endoscopic and laparoscopic investigation, management and the treatment of benign and malignant oesophagogastric disease.

  • Key areas of evolving oesophagogastric practice are reflected in state of the art chapters from authors in the United States, Japan and Australia.
  • Over half of the chapters have been updated to reflect the latest opinions on complicated and rapidly changing disciplines in endoscopic and open surgery
  • Englisch
  • London
  • |
  • Großbritannien
Elsevier Health Sciences
  • 24,58 MB
978-0-7020-4970-5 (9780702049705)
0702049700 (0702049700)
weitere Ausgaben werden ermittelt
1 - Front Cover [Seite 1]
2 - Oesophagogastric Surgery: A Companion to Specialist Surgical Practice [Seite 4]
3 - Copyright [Seite 5]
4 - Contents [Seite 6]
5 - Contributors [Seite 8]
6 - Series Editors' preface [Seite 10]
7 - Editor's preface [Seite 12]
7.1 - Acknowledgements [Seite 12]
8 - Evidence-based practice in surgery [Seite 14]
9 - Chapter 1: Pathology of oesophageal and gastric tumours [Seite 16]
9.1 - Oesophagus [Seite 16]
9.1.1 - Introduction [Seite 16]
9.1.2 - Epithelial tumours of the oesophagus and the gastro-oesophageal junction [Seite 16]
9.1.2.1 - Benign tumours and tumour-like lesions [Seite 16]
9.1.2.2 - Malignant tumours [Seite 16]
9.1.2.2.1 - Squamous cell carcinoma [Seite 16]
9.1.2.2.1.1 - Precursor lesions of squamous cell carcinoma [Seite 18]
9.1.2.2.1.2 - Molecular pathology of squamous cell carcinoma [Seite 19]
9.1.2.2.2 - Adenocarcinoma [Seite 19]
9.1.2.2.3 - Adenocarcinoma associated with Barrett's oesophagus [Seite 20]
9.1.2.2.4 - Variants of oesophageal adenocarcinoma [Seite 20]
9.1.2.2.5 - Neuroendocrine tumours of the oesophagus [Seite 21]
9.1.2.2.6 - Mesenchymal tumours of the oesophagus [Seite 21]
9.1.2.2.6.1 - Leiomyoma [Seite 21]
9.1.2.2.6.2 - Granular cell tumour [Seite 21]
9.2 - Stomach [Seite 21]
9.2.1 - Gastric polyps [Seite 21]
9.2.1.1 - Fundic gland polyps [Seite 21]
9.2.2 - Polyposis syndromes [Seite 22]
9.2.3 - Gastric carcinoma [Seite 22]
9.2.3.1 - Epidemiology of gastric carcinoma [Seite 22]
9.2.3.2 - Aetiology and risk factors of gastric carcinoma [Seite 22]
9.2.3.3 - Lesions predisposing to gastric carcinoma [Seite 24]
9.2.3.3.1 - Chronic atrophic gastritis and intestinal metaplasia [Seite 24]
9.2.3.3.2 - Chronic gastric ulcer [Seite 24]
9.2.3.3.3 - Gastric dysplasia [Seite 25]
9.2.3.4 - Early and advanced gastric carcinoma [Seite 25]
9.2.3.5 - Morphological subtypes of gastric carcinoma [Seite 27]
9.2.3.6 - Molecular pathology of gastric carcinoma [Seite 28]
9.2.4 - Neuroendocrine tumours of the stomach [Seite 28]
9.2.5 - Mesenchymal tumours of the stomach [Seite 30]
9.2.6 - Lymphoma of the stomach [Seite 31]
9.2.6.1 - MALT lymphoma [Seite 31]
9.2.6.2 - Diffuse large B cell lymphoma [Seite 32]
9.3 - References [Seite 33]
10 - Chapter 2: Epidemiology, genetics and screening for oesophageal and gastric cancer [Seite 37]
10.1 - Introduction [Seite 37]
10.2 - Definitions [Seite 37]
10.3 - Epidemiology [Seite 38]
10.3.1 - Incidence [Seite 38]
10.3.2 - Oesophageal cancer [Seite 38]
10.3.3 - Oesophageal and oesophagogastric junctional adenocarcinoma [Seite 38]
10.3.4 - Gastric cancer [Seite 38]
10.4 - Aetiology [Seite 38]
10.4.1 - Squamous cell carcinoma of the oesophagus [Seite 38]
10.4.1.1 - Smoking and alcohol [Seite 38]
10.4.1.2 - Socio-economic and dietary influences [Seite 39]
10.4.1.3 - Associated conditions [Seite 39]
10.4.2 - Adenocarcinoma of the oesophagus and junctional cancers [Seite 39]
10.4.2.1 - Gastro-oesophageal reflux disease (GORD) [Seite 39]
10.4.2.2 - Obesity and dietary factors [Seite 40]
10.4.2.3 - Helicobacter pylori [Seite 40]
10.4.2.4 - Socio-economic factors [Seite 40]
10.4.3 - Gastric cancer [Seite 41]
10.4.3.1 - Socio-economic influences [Seite 41]
10.4.3.2 - Diet [Seite 41]
10.4.3.3 - Helicobacter pylori [Seite 42]
10.4.3.4 - Precancerous conditions [Seite 42]
10.4.3.5 - Prevention of oesophageal and gastric cancer [Seite 42]
10.5 - Genetics of oesophageal and gastric cancer [Seite 43]
10.5.1 - Oesophageal cancer [Seite 43]
10.5.2 - Gastric cancer [Seite 43]
10.5.2.1 - Hereditary diffuse gastric carcinoma (HDGC) [Seite 43]
10.5.2.2 - Hereditary cancer syndromes [Seite 44]
10.5.2.3 - Moderate cancer risk [Seite 44]
10.5.3 - Molecular genetics of oesophageal and gastric cancer [Seite 45]
10.6 - Screening for oesophageal and gastric cancer [Seite 46]
10.6.1 - Asymptomatic screening [Seite 46]
10.6.1.1 - Oesophageal cancer [Seite 46]
10.6.1.2 - Gastric cancer [Seite 47]
10.6.2 - Symptomatic screening and early detection [Seite 47]
10.6.2.1 - High-risk groups [Seite 48]
10.6.2.1.1 - GORD and Barrett's oesophagus [Seite 48]
10.6.2.1.2 - Helicobacter pylori [Seite 49]
10.6.2.1.3 - Gastric atrophy and intestinal metaplasia [Seite 49]
10.7 - Summary and future [Seite 49]
10.8 - References [Seite 50]
11 - Chapter 3: Staging of oesophageal and gastric cancer [Seite 53]
11.1 - Introduction [Seite 53]
11.2 - Staging classifications [Seite 53]
11.2.1 - Gastric cancer staging [Seite 54]
11.2.2 - Oesophageal cancer staging [Seite 55]
11.3 - Multidisciplinary team [Seite 57]
11.4 - Staging investigations [Seite 57]
11.4.1 - Clinical assessment [Seite 57]
11.4.2 - Contrast radiography [Seite 57]
11.4.3 - Endoscopy [Seite 57]
11.4.4 - Computed tomography (CT) [Seite 58]
11.4.4.1 - Gastric cancer [Seite 58]
11.4.4.2 - Oesophageal cancer [Seite 60]
11.4.5 - Positron emission tomography (PET) [Seite 61]
11.4.5.1 - Gastric cancer [Seite 61]
11.4.5.2 - Oesophageal cancer [Seite 61]
11.4.6 - Endoscopic ultrasonography (EUS) [Seite 63]
11.4.6.1 - Gastric cancer [Seite 63]
11.4.6.2 - Oesophageal cancer [Seite 64]
11.4.7 - Ultrasonography (US) [Seite 65]
11.4.8 - Laparoscopy [Seite 66]
11.4.9 - Peritoneal cytology [Seite 66]
11.4.10 - Laparoscopic ultrasonography (lapUS) [Seite 67]
11.4.11 - Magnetic resonance imaging (MRI) [Seite 67]
11.4.12 - Endobronchial ultrasonography (EBUS) [Seite 68]
11.5 - Restaging following neoadjuvant or radical therapy [Seite 68]
11.6 - Sentinel lymph nodes [Seite 69]
11.7 - Future developments [Seite 69]
11.8 - Acknowledgements [Seite 70]
11.9 - References [Seite 70]
12 - Chapter 4: Preoperative assessment and perioperative management in oesophageal and gastric surgery [Seite 77]
12.1 - Introduction [Seite 77]
12.2 - Physiological stress during the treatment of oesophagogastric malignancy [Seite 77]
12.3 - Diagnosis [Seite 78]
12.4 - Multidisciplinary team evaluation [Seite 78]
12.5 - Neoadjuvant therapy [Seite 79]
12.5.1 - Radiotherapy [Seite 79]
12.5.2 - Chemotherapy [Seite 79]
12.5.3 - Nutrition [Seite 79]
12.6 - Preoperative assessment [Seite 80]
12.6.1 - Cardiac assessment (Box 4.4) [Seite 80]
12.6.1.1 - History [Seite 81]
12.6.1.2 - Functional capacity [Seite 81]
12.6.1.3 - Investigations (Box 4.4) [Seite 81]
12.6.1.3.1 - Electrocardiogram (ECG) [Seite 81]
12.6.1.3.2 - Cardiopulmonary exercise testing (CPX) [Seite 81]
12.6.1.3.3 - Stress testing [Seite 81]
12.6.1.4 - Optimisation [Seite 82]
12.6.1.4.1 - Preoperative physical cardiopulmonary rehabilitation [Seite 82]
12.6.1.4.2 - Beta-blockade [Seite 82]
12.6.1.4.3 - Other relevant cardiac medication [Seite 83]
12.6.1.4.3.1 - Statins [Seite 83]
12.6.1.4.3.2 - Anticoagulants [Seite 83]
12.6.1.4.3.3 - Aspirin/clopidogrel [Seite 83]
12.6.1.4.3.4 - Warfarin [Seite 83]
12.6.2 - Pulmonary assessment [Seite 83]
12.6.2.1 - History [Seite 83]
12.6.2.2 - Investigations (Box 4.5) [Seite 84]
12.6.2.2.1 - Arterial blood gas (ABG) [Seite 84]
12.6.2.2.2 - Chest X-ray (CXR) [Seite 84]
12.6.2.2.3 - Pulmonary function testing (PFT) [Seite 84]
12.6.2.3 - Optimisation [Seite 84]
12.6.3 - Neurological assessment [Seite 84]
12.6.3.1 - History [Seite 84]
12.6.3.2 - Investigations [Seite 85]
12.6.3.3 - Optimisation [Seite 85]
12.6.4 - Renal assessment [Seite 85]
12.6.4.1 - History [Seite 85]
12.6.4.2 - Investigations [Seite 85]
12.6.4.3 - Optimisation [Seite 86]
12.7 - Anaesthetic technique [Seite 86]
12.7.1 - Intraoperative monitoring [Seite 86]
12.7.1.1 - Cardiovascular system [Seite 86]
12.7.1.2 - Renal system [Seite 86]
12.7.2 - Anaesthetic agents [Seite 86]
12.7.3 - Airway management [Seite 87]
12.7.3.1 - Lung isolation techniques [Seite 87]
12.7.3.1.1 - Endobronchial blockers (Fig. 4.2) [Seite 87]
12.7.3.2 - Timing of extubation [Seite 87]
12.7.4 - Fluid management [Seite 88]
12.7.5 - Postoperative analgesia [Seite 88]
12.8 - Oesophagogastric clinical pathways [Seite 89]
12.8.1 - Preoperative [Seite 89]
12.8.2 - Intraoperative [Seite 89]
12.8.3 - Postoperative [Seite 90]
12.9 - References [Seite 91]
13 - Chapter 5: Surgery for cancer of the oesophagus [Seite 96]
13.1 - Introduction [Seite 96]
13.2 - Surgical pathology [Seite 96]
13.3 - Surgical anatomy [Seite 97]
13.3.1 - Hypopharynx and cervical oesophagus [Seite 97]
13.3.2 - Upper oesophagus [Seite 97]
13.3.3 - Middle oesophagus [Seite 97]
13.3.4 - Lower oesophagus [Seite 97]
13.3.5 - Blood supply and lymphatic drainage [Seite 98]
13.4 - Preoperative surgical preparation [Seite 98]
13.4.1 - Nutritional support [Seite 98]
13.4.2 - Preoperative nutritional support [Seite 98]
13.4.3 - Respiratory care [Seite 99]
13.4.4 - Mental preparation/communication [Seite 99]
13.5 - Surgical objectives [Seite 99]
13.6 - Principles of oesophagectomy [Seite 100]
13.6.1 - Resection of primary tumour [Seite 100]
13.6.2 - Rules on resection margins [Seite 100]
13.6.3 - Resection of lymph nodes [Seite 101]
13.6.3.1 - Nodal tiers [Seite 101]
13.6.3.2 - The rationale for lymphadenectomy [Seite 101]
13.6.3.2.1 - Optimal staging [Seite 101]
13.6.3.2.2 - Locoregional tumour control [Seite 101]
13.6.3.2.3 - Improved cure rate [Seite 101]
13.6.3.3 - Summary [Seite 104]
13.6.4 - Method of reconstruction of the oesophagus [Seite 104]
13.6.4.1 - Route of reconstruction [Seite 104]
13.6.4.1.1 - Presternal route [Seite 104]
13.6.4.1.2 - Retrosternal route (anterior mediastinal) [Seite 104]
13.6.4.1.3 - Posterior mediastinal route [Seite 104]
13.6.4.2 - Organ of reconstruction [Seite 104]
13.6.4.2.1 - Reconstruction with stomach [Seite 104]
13.6.4.2.2 - Reconstruction with colon [Seite 106]
13.6.4.2.2.1 - Indications for colonic reconstruction (Box 5.3) [Seite 106]
13.6.4.2.2.2 - Surgical technique [Seite 106]
13.6.4.2.3 - Reconstruction with jejunum [Seite 107]
13.6.5 - Open surgical approaches to oesophagectomy [Seite 107]
13.6.5.1 - Pharyngolaryngo-oesophagectomy for carcinoma of the hypopharynx and cervical oesophagus [Seite 107]
13.6.5.2 - Two-phase subtotal oesophagectomy via a right thoracotomy for carcinomas of the middle and lower thirds of the oesophagus [Seite 108]
13.6.5.2.1 - Combined synchronous two-team oesophagectomy [Seite 109]
13.6.5.3 - Three-phase subtotal oesophagectomy for tumours of the upper middle third of the oesophagus [Seite 109]
13.6.5.4 - Left-sided subtotal oesophagectomy for lower-third oesophageal cancers [Seite 109]
13.6.5.5 - Transhiatal oesophagectomy for upper- and lower-third tumours of the oesophagus [Seite 109]
13.6.6 - Minimally invasive surgical approaches to oesophagectomy [Seite 110]
13.6.6.1 - Minimally invasive three-stage procedures [Seite 110]
13.6.6.2 - Minimally invasive two-stage procedures [Seite 111]
13.6.6.3 - Minimally invasive hybrid procedures [Seite 111]
13.6.6.4 - Overview of minimally invasive approaches [Seite 111]
13.6.6.5 - Current practice [Seite 111]
13.7 - Technique of anastomosis [Seite 112]
13.8 - Postoperative management [Seite 112]
13.9 - Postoperative complications [Seite 113]
13.9.1 - General complications [Seite 113]
13.9.2 - Specific complications [Seite 113]
13.9.2.1 - Anastomotic leakage and leakage from the gastric conduit [Seite 113]
13.9.2.2 - Chylothorax [Seite 114]
13.9.2.3 - Recurrent laryngeal palsy [Seite 114]
13.9.2.4 - Gastric outlet obstruction [Seite 114]
13.9.2.5 - Duodeno-gastro-oesophageal reflux [Seite 115]
13.9.2.6 - Benign anastomotic stricture [Seite 115]
13.10 - Overall results of single-modality resectional therapy [Seite 115]
13.10.1 - Hospital mortality [Seite 115]
13.10.2 - Survival figures [Seite 115]
13.11 - Summary and future research [Seite 116]
13.12 - References [Seite 117]
14 - Chapter 6: Treatment of early oesophageal cancer [Seite 122]
14.1 - Introduction [Seite 122]
14.2 - Definition of early oesophageal cancer and relevant pathology [Seite 122]
14.3 - Investigations [Seite 123]
14.3.1 - Endoscopic assessment [Seite 123]
14.3.1.1 - Barrett's neoplasia [Seite 123]
14.3.1.2 - Squamous neoplasia [Seite 123]
14.3.1.3 - Endoscopic mucosal resection (EMR) [Seite 123]
14.3.1.4 - Endoscopic submucosal dissection (ESD) [Seite 124]
14.3.2 - Imaging [Seite 124]
14.4 - Management of early oesophageal cancer [Seite 124]
14.4.1 - Oesophageal resection [Seite 125]
14.4.2 - Endoscopic therapy [Seite 126]
14.4.2.1 - Endoscopic mucosal resection [Seite 126]
14.4.2.2 - Endoscopic submucosal dissection (ESD) [Seite 126]
14.4.2.3 - Mucosal ablation [Seite 126]
14.4.3 - Results from endoscopic therapy for early oesophageal cancer [Seite 127]
14.4.3.1 - Adenocarcinoma [Seite 127]
14.4.3.2 - Squamous cell carcinoma [Seite 127]
14.4.4 - Definitive radiotherapy with or without chemotherapy [Seite 128]
14.4.5 - Role of a multidisciplinary team [Seite 128]
14.5 - Conclusion [Seite 129]
14.6 - References [Seite 129]
15 - Chapter 7: Surgery for cancer of the stomach [Seite 133]
15.1 - Introduction [Seite 133]
15.2 - Modes of spread and areas of potential failure after gastric cancer surgery [Seite 133]
15.2.1 - Metastatic pathway [Seite 133]
15.2.1.1 - Lymphatic spread [Seite 133]
15.2.1.2 - Peritoneal spread [Seite 134]
15.2.1.3 - Haematogenous spread [Seite 135]
15.2.1.4 - Metastasis by uncertain pathway [Seite 135]
15.2.1.5 - Direct extension [Seite 135]
15.2.2 - Intraoperative spillage [Seite 135]
15.2.3 - Summary [Seite 135]
15.3 - The concept of radical gastric cancer surgery [Seite 135]
15.3.1 - Gastric cancer surgery in Japan [Seite 136]
15.3.2 - Development of gastric cancer surgery in the West [Seite 136]
15.3.2.1 - Different staging systems [Seite 136]
15.3.2.2 - Different disease hypotheses [Seite 136]
15.3.2.2.1 - Proximal location [Seite 136]
15.3.2.2.2 - Patient factor [Seite 137]
15.3.3 - Role of radical surgery in Western practice [Seite 137]
15.3.4 - Summary [Seite 137]
15.4 - Principles of radical gastric cancer surgery [Seite 137]
15.4.1 - Extent of gastric resection [Seite 137]
15.4.1.1 - Resection margins [Seite 137]
15.4.1.2 - Type of gastrectomy [Seite 138]
15.4.1.2.1 - Total gastrectomy [Seite 138]
15.4.1.2.2 - Distal (subtotal) gastrectomy [Seite 138]
15.4.1.2.3 - Proximal gastrectomy [Seite 138]
15.4.1.2.4 - Other resections for T1 tumours [Seite 138]
15.4.1.2.5 - Total gastrectomy 'de principe' for distal cancers [Seite 138]
15.4.2 - Lymphadenectomy [Seite 138]
15.4.2.1 - Lymph node groups in the former Japanese classifications [Seite 139]
15.4.2.2 - New definition of lymphadenectomy [Seite 141]
15.4.2.3 - D2 lymphadenectomy - evidence [Seite 142]
15.4.2.4 - Number of lymph nodes and extent of lymphadenectomy [Seite 142]
15.4.3 - Bursectomy [Seite 142]
15.4.4 - Splenectomy [Seite 143]
15.4.5 - Distal pancreatectomy [Seite 143]
15.4.6 - Extended resections [Seite 143]
15.4.6.1 - En bloc resection of involved adjacent organs [Seite 144]
15.4.6.2 - Extended lymphadenectomy [Seite 144]
15.4.6.3 - Resection of liver metastases [Seite 144]
15.4.7 - Summary [Seite 144]
15.5 - Technique of gastric resection with D2 lymphadenectomy [Seite 144]
15.5.1 - Incision [Seite 144]
15.5.2 - Intraoperative staging [Seite 144]
15.5.3 - Procedure of D2 lymphadenectomy [Seite 145]
15.5.3.1 - Distal gastrectomy [Seite 145]
15.5.3.1.1 - Kocherisation [Seite 145]
15.5.3.1.2 - Omentectomy [Seite 145]
15.5.3.1.3 - Division of left gastroepiploic vessels [Seite 145]
15.5.3.1.4 - Infrapyloric node dissection (no. 6) [Seite 145]
15.5.3.1.5 - Suprapyloric nodes dissection (no. 5) and transection of the duodenum [Seite 146]
15.5.3.1.6 - Exposure of the oesophageal hiatus [Seite 146]
15.5.3.1.7 - Dissection of the upper border of the pancreas (nos. 8a, 9, 11p and 12a) [Seite 146]
15.5.3.1.8 - Dissection of the upper lesser curvature nodes (nos. 1 and 3a) [Seite 147]
15.5.3.2 - Total gastrectomy [Seite 147]
15.5.3.2.1 - Dissection of the upper greater curvature nodes (nos. 2 and 4sa) [Seite 147]
15.5.3.2.2 - Dissection along the distal splenic artery (no. 11d) and splenic hilum (no. 10) [Seite 148]
15.5.3.2.3 - Splenectomy [Seite 148]
15.5.3.3 - Summary [Seite 148]
15.5.4 - Modified surgery for early gastric cancer [Seite 148]
15.5.4.1 - Lymph node metastasis from early gastric cancer [Seite 148]
15.5.4.2 - Limited lymphadenectomy [Seite 149]
15.5.4.3 - Pylorus-preserving gastrectomy (PPG) (Fig. 7.8) [Seite 149]
15.5.4.4 - Local tumour resection based on sentinel lymph node diagnosis [Seite 149]
15.5.4.5 - Summary [Seite 150]
15.6 - Reconstruction after gastric resection [Seite 150]
15.6.1 - Reconstruction after distal gastrectomy (Fig. 7.9) [Seite 150]
15.6.1.1 - Roux-en-Y [Seite 151]
15.6.1.1.1 - Indication [Seite 151]
15.6.1.1.2 - Procedure [Seite 151]
15.6.1.2 - Billroth I [Seite 151]
15.6.1.2.1 - Indication and procedure [Seite 151]
15.6.2 - Reconstruction after total gastrectomy (Fig. 7.10) [Seite 151]
15.6.2.1 - Roux-en-Y [Seite 151]
15.6.2.1.1 - Indication [Seite 151]
15.6.2.1.2 - Procedure [Seite 151]
15.6.2.2 - Jejunal interposition [Seite 152]
15.6.2.3 - Pouch formation [Seite 152]
15.6.3 - Reconstruction after proximal gastrectomy (Fig. 7.11) [Seite 152]
15.6.3.1 - Jejunal interposition [Seite 152]
15.6.3.1.1 - Indication [Seite 152]
15.6.3.1.2 - Procedure [Seite 152]
15.6.3.2 - Oesophagogastrostomy [Seite 153]
15.6.3.2.1 - Indication [Seite 153]
15.6.3.2.2 - Procedure [Seite 153]
15.6.3.3 - Summary [Seite 153]
15.7 - Early postoperative complications [Seite 153]
15.7.1 - Anastomotic leak [Seite 154]
15.7.2 - Duodenal stump leak [Seite 154]
15.7.3 - Pancreatic fistula [Seite 154]
15.7.4 - Haemorrhage [Seite 155]
15.7.5 - Postsplenectomy infections [Seite 155]
15.8 - Late sequelae and complications [Seite 155]
15.8.1 - Side-effects and postprandial sequelae [Seite 155]
15.8.1.1 - Early dumping syndrome [Seite 155]
15.8.1.2 - Late dumping syndrome or reactive hypoglycaemic attacks [Seite 155]
15.8.2 - Nutritional problems [Seite 156]
15.8.2.1 - Vitamin B12 [Seite 156]
15.8.2.2 - Vitamin D [Seite 156]
15.8.2.3 - Iron [Seite 156]
15.9 - References [Seite 157]
16 - Chapter 8: Endoscopic and surgical treatment of early gastric cancer [Seite 161]
16.1 - Introduction [Seite 161]
16.1.1 - Definition of early gastric cancer [Seite 161]
16.1.2 - Risk and development of early gastric cancer [Seite 161]
16.2 - Classification of early gastric cancer [Seite 161]
16.2.1 - Endoscopic appearance [Seite 162]
16.2.2 - Lymph node metastasis [Seite 163]
16.2.3 - Endosonography [Seite 163]
16.2.4 - Revised Vienna classification [Seite 164]
16.3 - Endoscopic treatment [Seite 164]
16.3.1 - Endoscopic mucosal resection [Seite 164]
16.3.2 - Endoscopic submucosal dissection [Seite 165]
16.3.3 - Complete resections [Seite 165]
16.3.4 - Complications of endoscopic resections [Seite 166]
16.4 - Surgical resection [Seite 166]
16.4.1 - Proximal gastrectomy [Seite 167]
16.4.2 - Pylorus-preserving gastrectomy [Seite 167]
16.4.3 - Local (or wedge) segmental resection [Seite 168]
16.4.4 - Minimally invasive surgery [Seite 169]
16.4.5 - Lymphadenectomy [Seite 169]
16.4.6 - Sentinel node biopsy [Seite 170]
16.5 - References [Seite 172]
17 - Chapter 9: Radiotherapy and chemotherapy in treatment of oesophageal and gastric cancer [Seite 175]
17.1 - Introduction [Seite 175]
17.2 - Oesophageal cancer [Seite 176]
17.2.1 - Potentially curative treatment [Seite 176]
17.2.1.1 - Preoperative radiotherapy alone [Seite 176]
17.2.1.2 - Postoperative radiotherapy [Seite 176]
17.2.1.3 - Preoperative chemotherapy [Seite 177]
17.2.1.4 - Randomised trials of preoperative chemotherapy [Seite 177]
17.2.1.5 - Postoperative chemotherapy [Seite 178]
17.2.1.6 - Preoperative chemoradiotherapy [Seite 179]
17.2.1.7 - Neoadjuvant chemoradiotherapy or chemotherapy? [Seite 182]
17.2.2 - Definitive radiotherapy and chemoradiotherapy [Seite 182]
17.2.2.1 - Definitive radiotherapy [Seite 183]
17.2.2.2 - Definitive chemoradiotherapy [Seite 183]
17.2.2.3 - Future directions in definitive chemoradiation [Seite 184]
17.2.2.4 - Definitive CRT versus surgery [Seite 185]
17.2.3 - Small-cell oesophageal cancer [Seite 186]
17.3 - Gastric cancer [Seite 187]
17.3.1 - Potentially curative treatment [Seite 187]
17.3.1.1 - Perioperative adjuvant chemotherapy [Seite 187]
17.3.1.2 - Intraperitoneal chemotherapy [Seite 188]
17.3.1.3 - Postoperative chemoradiotherapy [Seite 188]
17.4 - Palliative chemotherapy [Seite 188]
17.4.1 - Squamous carcinoma of the oesophagus [Seite 188]
17.4.2 - Adenocarcinoma of the oesophagus and stomach [Seite 189]
17.5 - Palliative radiotherapy [Seite 190]
17.5.1 - External beam radiotherapy [Seite 190]
17.5.2 - Brachytherapy [Seite 191]
17.6 - Future strategies [Seite 191]
17.7 - References [Seite 193]
18 - Chapter 10: Palliative treatments of carcinoma of the oesophagus and stomach [Seite 198]
18.1 - Epidemiology and survival [Seite 198]
18.2 - Patient selection and multidisciplinary teams [Seite 199]
18.2.1 - Fitness for treatment [Seite 199]
18.2.2 - Staging investigations [Seite 200]
18.2.3 - Patient preferences and information provision [Seite 200]
18.3 - Symptoms and signs of advanced oesophageal and gastric cancer [Seite 201]
18.3.1 - Tumours of the oesophagus and gastric cardia [Seite 201]
18.3.2 - Tumours of the gastric body and antrum [Seite 201]
18.4 - Palliative treatments for cancer of the oesophagus and gastric cardia [Seite 201]
18.4.1 - The endoscopic relief of luminal obstruction [Seite 202]
18.4.1.1 - Intubation [Seite 202]
18.4.1.1.1 - Self-expanding metal stents (SEMS) [Seite 204]
18.4.1.1.2 - Method of insertion [Seite 205]
18.4.1.1.3 - Preparation [Seite 205]
18.4.1.1.4 - Endoscopic insertion with fluoroscopy [Seite 205]
18.4.1.1.5 - Radiological insertion [Seite 205]
18.4.1.1.6 - Postoperative management [Seite 205]
18.4.1.1.7 - Complications [Seite 205]
18.4.1.1.7.1 - Early complications [Seite 206]
18.4.1.1.7.2 - Late complications [Seite 206]
18.4.1.2 - Laser treatment [Seite 207]
18.4.1.2.1 - Endoscopic technique [Seite 207]
18.4.1.2.2 - Early complications [Seite 207]
18.4.1.2.3 - Late complications [Seite 208]
18.4.1.2.4 - Combination laser treatment [Seite 208]
18.4.1.3 - Thermal recanalisation or stenting? [Seite 208]
18.4.1.4 - Argon-beam plasma coagulation [Seite 208]
18.4.1.5 - Photodynamic therapy [Seite 209]
18.4.1.5.1 - Clinical indications [Seite 209]
18.4.1.5.2 - Complications [Seite 209]
18.4.1.6 - Bipolar electrocoagulation [Seite 209]
18.4.1.7 - Chemically induced tumour necrosis [Seite 209]
18.4.1.7.1 - Endoscopic technique [Seite 209]
18.4.1.7.2 - Outcome [Seite 209]
18.4.2 - External beam and intracavity radiotherapy [Seite 210]
18.4.2.1 - External beam radiotherapy [Seite 210]
18.4.2.1.1 - Complications [Seite 210]
18.4.2.1.2 - Brachytherapy (intracavitary irradiation) [Seite 210]
18.4.2.1.3 - Relief of dysphagia and patient-reported outcomes [Seite 210]
18.4.2.2 - Palliative chemotherapy or combination chemoradiotherapy for oesophageal cancer [Seite 211]
18.4.3 - Epidermal growth factor receptor inhibitors in the palliation of oesophageal cancer [Seite 211]
18.4.4 - Aero-digestive fistulas [Seite 211]
18.4.5 - Recurrent laryngeal nerve palsy [Seite 212]
18.4.6 - Bleeding [Seite 212]
18.5 - Palliative treatments of tumours of the gastric body and antrum [Seite 212]
18.5.1 - Chemotherapy for advanced gastric and oesophagogastric cancer [Seite 212]
18.5.2 - Gastric outlet obstruction [Seite 213]
18.5.3 - Chronic bleeding [Seite 214]
18.6 - Summary [Seite 214]
18.7 - References [Seite 215]
19 - Chapter 11: Other oesophageal and gastric neoplasms [Seite 219]
19.1 - Introduction [Seite 219]
19.2 - Gastrointestinal stromal tumours (GISTs) [Seite 219]
19.2.1 - Pathophysiology [Seite 219]
19.2.2 - Incidence and malignant potential [Seite 220]
19.2.3 - Patient demographics and anatomical distribution [Seite 220]
19.2.4 - Presentation [Seite 221]
19.2.5 - Investigation [Seite 221]
19.2.5.1 - Endoscopic ultrasound (EUS) [Seite 221]
19.2.5.2 - CT scanning [Seite 222]
19.2.5.3 - Magnetic resonance imaging (MRI) [Seite 222]
19.2.5.4 - Positron emission tomography (PET) [Seite 222]
19.2.6 - GIST syndromes [Seite 222]
19.2.7 - Treatment and prognosis (Box 11.1) [Seite 222]
19.2.7.1 - Imatinib [Seite 224]
19.2.8 - Unresectable or metastatic disease [Seite 225]
19.2.9 - Adjuvant therapy post-resection [Seite 225]
19.3 - Gastric lymphoma [Seite 225]
19.3.1 - Staging [Seite 225]
19.3.2 - Classification [Seite 226]
19.4 - Neuroendocrine gastroenteropancreatic tumours (GEP-NETs) [Seite 226]
19.4.1 - Presentation, classification and treatment [Seite 227]
19.5 - Rarities [Seite 228]
19.6 - References [Seite 228]
20 - Chapter 12: Pathophysiology and investigation of gastro-oesophageal reflux disease [Seite 233]
20.1 - Introduction [Seite 233]
20.2 - Epidemiology [Seite 233]
20.3 - Symptoms [Seite 234]
20.4 - Normal oesophageal anatomy [Seite 234]
20.5 - Normal oesophageal physiology [Seite 234]
20.6 - Antireflux mechanisms [Seite 235]
20.6.1 - Lower oesophageal sphincter [Seite 236]
20.6.2 - Diaphragmatic sphincter [Seite 237]
20.6.3 - Distal oesophageal compression [Seite 237]
20.6.4 - Other mechanical barriers [Seite 238]
20.7 - Oesophageal mucosal acid defence mechanisms [Seite 238]
20.8 - Risk factors for reflux [Seite 238]
20.8.1 - Inherited factors [Seite 238]
20.8.2 - Demographic factors [Seite 239]
20.8.3 - Lifestyle factors [Seite 239]
20.8.4 - Medical factors [Seite 239]
20.9 - Hiatus hernia [Seite 239]
20.10 - Oesophageal dysmotility and GORD: cause or effect? [Seite 240]
20.11 - Role of duodenogastric reflux [Seite 241]
20.12 - Investigation and diagnosis [Seite 241]
20.12.1 - Symptomatic diagnosis [Seite 241]
20.12.2 - Endoscopy [Seite 242]
20.12.3 - Contrast radiology [Seite 242]
20.12.4 - pH studies [Seite 242]
20.12.4.1 - Wireless pH monitoring [Seite 244]
20.12.5 - Oesophageal impedance monitoring [Seite 245]
20.12.6 - Manometry [Seite 246]
20.12.6.1 - Standard static manometry [Seite 246]
20.12.6.2 - High-resolution manometry (HRM) [Seite 247]
20.13 - References [Seite 250]
21 - Chapter 13: Treatment of gastro-oesophageal reflux disease [Seite 256]
21.1 - Introduction [Seite 256]
21.2 - Medical treatment [Seite 256]
21.2.1 - Simple measures [Seite 256]
21.2.2 - H2-receptor antagonists [Seite 257]
21.2.3 - Proton-pump inhibitors [Seite 257]
21.2.4 - Prokinetic agents [Seite 257]
21.3 - Surgical treatment [Seite 257]
21.3.1 - Selection criteria for surgery [Seite 257]
21.3.1.1 - Patients with complicated reflux disease [Seite 258]
21.3.1.1.1 - Reflux with stricture formation [Seite 258]
21.3.1.1.2 - Reflux with respiratory complications [Seite 258]
21.3.1.1.3 - Reflux with throat symptoms [Seite 258]
21.3.1.1.4 - Columnar-lined (Barrett's) oesophagus [Seite 258]
21.3.1.2 - Patients with uncomplicated reflux disease [Seite 258]
21.3.2 - Medical versus surgical therapy [Seite 259]
21.3.3 - Pros and cons of antireflux surgery [Seite 260]
21.3.3.1 - Advantages [Seite 260]
21.3.3.2 - Disadvantages [Seite 260]
21.3.4 - Preoperative investigations [Seite 260]
21.3.4.1 - Endoscopy [Seite 260]
21.3.4.2 - Manometry [Seite 260]
21.3.4.3 - Oesophageal pH monitoring [Seite 260]
21.3.4.4 - Other investigations [Seite 260]
21.3.5 - Antireflux surgery [Seite 261]
21.3.5.1 - Mechanisms of action of antireflux surgery [Seite 261]
21.3.5.2 - Techniques of antireflux surgery [Seite 261]
21.3.5.2.1 - Nissen fundoplication (Figs 13.1 and 13.2) [Seite 261]
21.3.5.2.2 - Posterior partial fundoplication (Fig. 13.3) [Seite 262]
21.3.5.2.3 - Anterior partial fundoplication [Seite 263]
21.3.5.3 - Other antireflux procedures [Seite 263]
21.3.5.3.1 - Hill procedure [Seite 263]
21.3.5.3.2 - Collis procedure (Fig. 13.7) [Seite 264]
21.3.5.3.3 - Augmentation of the lower oesophageal sphincter [Seite 264]
21.3.5.3.3.1 - LINX® [Seite 264]
21.3.5.3.3.2 - EndoStim® [Seite 265]
21.4 - Controversies and comparisons [Seite 265]
21.4.1 - Complete or partial fundoplication? [Seite 265]
21.4.1.1 - Nissen versus posterior fundoplication [Seite 265]
21.4.1.2 - Nissen versus anterior fundoplication [Seite 266]
21.4.1.3 - Anterior versus posterior partial fundoplication [Seite 266]
21.4.2 - Division/no division of short gastric vessels [Seite 267]
21.5 - Laparoscopic antireflux surgery [Seite 268]
21.5.1 - Laparoscopic versus open antireflux surgery [Seite 268]
21.5.2 - Complications of laparoscopic antireflux surgery [Seite 269]
21.5.2.1 - Complications that are more common following laparoscopic antireflux surgery [Seite 270]
21.5.2.1.1 - Paraoesophageal hiatus hernia [Seite 270]
21.5.2.1.2 - Dysphagia [Seite 270]
21.5.2.1.3 - Pulmonary embolism [Seite 271]
21.5.2.2 - Complications unique to laparoscopic antireflux surgery [Seite 271]
21.5.2.2.1 - Bilobed stomach [Seite 271]
21.5.2.2.2 - Pneumothorax [Seite 271]
21.5.2.2.3 - Vascular injury [Seite 272]
21.5.2.2.4 - Perforation of the upper gastrointestinal tract [Seite 272]
21.5.2.3 - Mortality [Seite 272]
21.5.2.4 - Avoiding complications following laparoscopic antireflux surgery and minimising their impact [Seite 272]
21.6 - Synthesis of the results from prospective randomised trials [Seite 273]
21.7 - Endoscopic therapies for reflux [Seite 273]
21.7.1 - Radiofrequency [Seite 274]
21.7.2 - Polymer injection [Seite 274]
21.7.3 - Endoscopic suturing [Seite 274]
21.7.3.1 - EndoCinch [Seite 274]
21.7.3.2 - NDO Plicator [Seite 274]
21.7.4 - Endoscopic fundoplication [Seite 275]
21.7.5 - Overview of endoscopic antireflux surgery [Seite 275]
21.8 - References [Seite 277]
22 - Chapter 14: Treatment of the complications of gastro-oesophageal reflux disease and failed gastro-oesophageal surgery [Seite 284]
22.1 - Introduction [Seite 284]
22.2 - Complications of GORD [Seite 284]
22.2.1 - Short oesophagus [Seite 285]
22.2.2 - Gastrointestinal haemorrhage [Seite 285]
22.2.3 - Peptic oesophageal stricture [Seite 285]
22.3 - Failed antireflux surgery [Seite 286]
22.3.1 - Investigation of the failed antireflux operation [Seite 286]
22.3.1.1 - Endoscopy [Seite 286]
22.3.1.2 - Barium studies [Seite 286]
22.3.1.3 - Computerised tomography [Seite 287]
22.3.1.4 - Oesophageal physiology tests [Seite 287]
22.3.2 - Management of failure after antireflux surgery [Seite 288]
22.3.2.1 - Recurrence of reflux symptoms [Seite 288]
22.3.2.2 - Persistence of preoperative symptoms [Seite 288]
22.3.2.3 - Dysphagia [Seite 288]
22.3.2.4 - Other symptoms [Seite 289]
22.3.3 - Revisional surgery following failed antireflux surgery [Seite 289]
22.4 - Complex revisional surgery [Seite 291]
22.5 - Summary [Seite 292]
22.6 - References [Seite 293]
23 - Chapter 15: Barrett's oesophagus [Seite 295]
23.1 - Definition [Seite 295]
23.2 - Epidemiology [Seite 295]
23.3 - Endoscopic assessment [Seite 296]
23.4 - Pathophysiology of Barrett's oesophagus and progression to adenocarcinoma [Seite 296]
23.5 - Risk of cancer and mortality in Barrett's oesophagus [Seite 298]
23.6 - Natural history of dysplasia in Barrett's oesophagus [Seite 299]
23.6.1 - Low-grade dysplasia [Seite 300]
23.6.2 - High-grade dysplasia [Seite 300]
23.7 - Risk factors for progression to cancer [Seite 301]
23.8 - Screening for Barrett's oesophagus and adenocarcinoma using molecular markers [Seite 302]
23.9 - Surveillance of non-dysplastic disease [Seite 303]
23.10 - Effect of medical therapy and antireflux surgery [Seite 303]
23.11 - Endotherapy [Seite 304]
23.11.1 - Endoscopic resection [Seite 304]
23.11.2 - Endoscopic ablation [Seite 304]
23.12 - Management of LGD [Seite 305]
23.13 - Management of HGD [Seite 305]
23.14 - Conclusion [Seite 306]
23.15 - References [Seite 307]
24 - Chapter 16: The management of achalasia and other motility disorders of the oesophagus [Seite 313]
24.1 - Introduction [Seite 313]
24.2 - Achalasia [Seite 313]
24.2.1 - Background [Seite 313]
24.2.2 - Primary achalasia [Seite 313]
24.2.3 - Clinical features [Seite 314]
24.2.4 - Investigations [Seite 314]
24.2.5 - Treatment [Seite 315]
24.2.5.1 - Botulinum toxin injection [Seite 315]
24.2.5.2 - Pneumatic dilatation [Seite 315]
24.2.5.3 - Cardiomyotomy [Seite 316]
24.2.5.4 - Revisional procedures and oesophagectomy [Seite 316]
24.2.6 - Secondary achalasia [Seite 317]
24.3 - Diffuse oesophageal spasm [Seite 317]
24.4 - Oesophagogastric junction outflow obstruction and non-specific oesophageal motor disorders [Seite 318]
24.5 - Oesophageal motor disturbances and autoimmune disease [Seite 319]
24.5.1 - Systemic sclerosis [Seite 319]
24.5.2 - Polymyositis and dermatomyositis [Seite 319]
24.5.3 - Systemic lupus erythematosus [Seite 319]
24.5.4 - Polyarteritis nodosa and rheumatoid disease [Seite 319]
24.6 - Oesophageal diverticula [Seite 319]
24.6.1 - Clinical features [Seite 319]
24.6.2 - Diagnosis [Seite 319]
24.6.3 - Treatment [Seite 320]
24.6.3.1 - Acknowledgements [Seite 320]
24.7 - References [Seite 320]
25 - Chapter 17: Paraoesophageal hernia and gastric volvulus [Seite 323]
25.1 - Introduction [Seite 323]
25.2 - Epidemiology [Seite 323]
25.3 - Anatomy and natural history [Seite 323]
25.4 - Presentation and diagnosis [Seite 324]
25.5 - Operative indications [Seite 325]
25.6 - Operative approaches [Seite 325]
25.6.1 - Principles of paraoesophageal hernia repair [Seite 325]
25.6.2 - Transthoracic repair [Seite 325]
25.6.3 - Transabdominal repair [Seite 325]
25.6.4 - Laparoscopic repair [Seite 325]
25.6.4.1 - Set-up and port placement [Seite 326]
25.6.4.2 - Reduction of hernia sac and fundic mobilisation [Seite 326]
25.6.4.3 - Assessment of oesophageal length [Seite 326]
25.6.4.4 - Crural dissection and repair [Seite 327]
25.6.4.5 - Fundoplication [Seite 327]
25.7 - Current controversies in paraoesophageal hernia management [Seite 327]
25.7.1 - Recurrence rate [Seite 327]
25.7.2 - Oesophageal lengthening procedures [Seite 327]
25.7.3 - Prosthetic crural reinforcement [Seite 328]
25.8 - Acute gastric volvulus [Seite 328]
25.8.1 - Frequency and mechanism [Seite 328]
25.8.2 - Presentation and diagnosis [Seite 329]
25.8.3 - Management [Seite 329]
25.9 - References [Seite 330]
26 - Chapter 18: Benign ulceration of the stomach and duodenum and the complications of previous ulcer surgery [Seite 332]
26.1 - Introduction [Seite 332]
26.2 - Management of refractory peptic ulceration [Seite 332]
26.2.1 - Endoscopic confirmation [Seite 332]
26.2.2 - Confirmation of persistent Helicobacter infection [Seite 332]
26.2.3 - Non-HP-related refractory ulceration [Seite 333]
26.2.3.1 - Elective surgery for peptic ulceration [Seite 333]
26.2.3.1.1 - Operations for refractory duodenal ulcers [Seite 333]
26.2.3.1.2 - Operations for refractory gastric ulcers [Seite 334]
26.2.4 - Laparoscopic peptic ulcer surgery [Seite 334]
26.3 - Zollinger-Ellison syndrome (ZES) [Seite 334]
26.3.1 - Pathology [Seite 334]
26.3.2 - Diagnosis [Seite 335]
26.3.3 - Tumour localisation [Seite 335]
26.3.4 - Surgery for ZES [Seite 335]
26.4 - Emergency management of complicated peptic ulcer disease [Seite 336]
26.4.1 - Perforation [Seite 336]
26.4.1.1 - Conservative management [Seite 336]
26.4.1.2 - Surgery [Seite 336]
26.4.2 - Bleeding [Seite 337]
26.4.2.1 - Medical therapy [Seite 337]
26.4.2.2 - Endoscopic therapy [Seite 337]
26.4.2.3 - Surgery [Seite 338]
26.4.2.3.1 - Bleeding duodenal ulcer [Seite 338]
26.4.2.3.2 - Bleeding gastric ulcer [Seite 340]
26.4.3 - Interventional radiology [Seite 340]
26.4.4 - Pyloric stenosis [Seite 341]
26.4.4.1 - Resuscitation and medical therapy [Seite 341]
26.4.4.2 - Endoscopic treatment [Seite 341]
26.4.4.3 - Surgery [Seite 341]
26.5 - Complications of previous ulcer surgery [Seite 341]
26.5.1 - Preoperative evaluation [Seite 342]
26.5.1.1 - Endoscopy [Seite 342]
26.5.1.2 - Radiology [Seite 342]
26.5.1.3 - Gastric-emptying studies [Seite 342]
26.5.1.4 - Other tests [Seite 342]
26.5.2 - Enterogastric reflux [Seite 342]
26.5.2.1 - Medical treatment [Seite 342]
26.5.2.2 - Surgical treatment [Seite 342]
26.5.3 - Chronic afferent loop syndrome [Seite 344]
26.5.4 - Dumping [Seite 344]
26.5.4.1 - Medical treatment [Seite 345]
26.5.4.2 - Surgical treatment [Seite 345]
26.5.5 - Diarrhoea [Seite 346]
26.5.5.1 - Medical treatment [Seite 346]
26.5.5.2 - Surgical treatment [Seite 346]
26.5.6 - Small stomach syndrome [Seite 346]
26.6 - References [Seite 347]
27 - Chapter 19: Oesophageal emergencies [Seite 351]
27.1 - Introduction [Seite 351]
27.2 - Perforation of the oesophagus [Seite 351]
27.2.1 - Aetiology and pathophysiology [Seite 351]
27.2.1.1 - Iatrogenic perforation of the oesophagus [Seite 351]
27.2.1.2 - Spontaneous perforation of the oesophagus [Seite 352]
27.2.1.3 - Penetrating injuries [Seite 352]
27.2.1.4 - Blunt trauma [Seite 352]
27.2.2 - Clinical presentation [Seite 353]
27.2.3 - Investigations [Seite 353]
27.2.3.1 - Plain radiography [Seite 353]
27.2.3.2 - Contrast radiography [Seite 353]
27.2.3.3 - Upper gastrointestinal endoscopy [Seite 354]
27.2.3.4 - Computed tomography (CT) [Seite 354]
27.2.3.5 - Other investigations [Seite 356]
27.2.4 - Management [Seite 356]
27.2.4.1 - Non-operative management [Seite 356]
27.2.4.2 - Adjuncts to non-operative management [Seite 357]
27.2.4.2.1 - Closure: clips and sealants [Seite 357]
27.2.4.2.2 - Diversion: stents [Seite 357]
27.2.4.2.3 - Drainage: repeated endoscopy [Seite 357]
27.2.4.3 - Operative management [Seite 358]
27.2.4.3.1 - Open surgery [Seite 358]
27.2.4.3.2 - Primary repair with or without reinforcement [Seite 358]
27.2.4.3.3 - T-tube repair [Seite 358]
27.2.4.3.4 - Resection [Seite 359]
27.2.4.3.5 - Other approaches [Seite 359]
27.2.4.3.5.1 - Minimally invasive surgery: laparoscopic/thoracoscopic [Seite 359]
27.2.4.3.5.2 - Surgical repair over a stent [Seite 359]
27.2.5 - Management of penetrating injuries [Seite 359]
27.2.5.1 - Cervical [Seite 359]
27.2.5.2 - Thoracic [Seite 359]
27.2.6 - Management of underlying pathology [Seite 360]
27.2.7 - Paraoesophageal surgery and procedural injuries [Seite 361]
27.2.8 - Management algorithm [Seite 361]
27.2.9 - Non-perforated spontaneous injuries of the oesophagus [Seite 361]
27.3 - Caustic injuries [Seite 361]
27.3.1 - Clinical presentation [Seite 363]
27.3.2 - Investigation and management [Seite 363]
27.3.3 - Long-term complications and outcomes [Seite 365]
27.3.4 - Cancer risk [Seite 366]
27.3.5 - Management algorithm [Seite 366]
27.4 - Ingestion of foreign bodies [Seite 367]
27.4.1 - Clinical presentation [Seite 367]
27.4.2 - Diagnosis [Seite 367]
27.4.3 - Management [Seite 368]
27.5 - Summary [Seite 369]
27.6 - References [Seite 370]
28 - Chapter 20: Bariatric surgery [Seite 373]
28.1 - Introduction [Seite 373]
28.2 - Obesity as a public health problem [Seite 373]
28.2.1 - Diabetes risk with obesity [Seite 374]
28.2.2 - Cancer risk with obesity [Seite 374]
28.2.3 - Psychosocial morbidity and prejudice [Seite 375]
28.2.4 - Baseline obesity-related disease [Seite 375]
28.2.4.1 - Data from the NBSR [Seite 375]
28.3 - Multidisciplinary work-up [Seite 375]
28.3.1 - Optimisation of patients [Seite 376]
28.3.2 - Obesity Surgery-Mortality Risk score (OS-MRS) [Seite 376]
28.4 - Current bariatric operations and surgical techniques [Seite 376]
28.4.1 - Gastric bypass [Seite 376]
28.4.2 - Gastric banding [Seite 377]
28.4.3 - Sleeve gastrectomy [Seite 378]
28.4.4 - Biliopancreatic diversion/duodenal switch [Seite 378]
28.5 - Mechanisms of bypass and banding [Seite 379]
28.6 - Weight loss outcomes [Seite 379]
28.6.1 - Band versus bypass RCTs [Seite 379]
28.6.2 - Band versus sleeve gastrectomy RCT [Seite 381]
28.6.3 - Banded versus non-banded gastric bypass RCT [Seite 381]
28.6.4 - Sleeve versus bypass RCTs [Seite 381]
28.6.5 - Bypass versus duodenal switch RCT [Seite 381]
28.7 - Complications of surgery [Seite 382]
28.7.1 - Operative mortality [Seite 382]
28.7.2 - Gastric bypass [Seite 382]
28.7.2.1 - Early [Seite 382]
28.7.2.2 - Late [Seite 383]
28.7.3 - Gastric Band [Seite 383]
28.7.3.1 - Early [Seite 383]
28.7.3.2 - Late [Seite 383]
28.7.3.2.1 - Slippage [Seite 383]
28.7.3.2.2 - Erosion [Seite 384]
28.7.4 - Sleeve gastrectomy [Seite 384]
28.8 - High-volume specialisation [Seite 384]
28.9 - Comorbidity outcomes [Seite 384]
28.9.1 - Swedish Obese Subjects study [Seite 384]
28.9.2 - Data from the NBSR [Seite 385]
28.9.3 - Quality of life (QoL) after bariatric surgery [Seite 385]
28.9.4 - Patient-reported outcomes [Seite 385]
28.10 - Diabetes outcomes [Seite 385]
28.11 - Nutritional support in follow-up [Seite 386]
28.12 - Long-term survival benefit after surgery [Seite 387]
28.13 - Cancer incidence after bariatric surgery [Seite 387]
28.14 - Cost-effectiveness of bariatric surgery [Seite 388]
28.15 - Wider economic benefit of bariatric surgery [Seite 388]
28.16 - Who should have surgery? [Seite 389]
28.17 - Summary [Seite 389]
28.18 - References [Seite 390]
29 - Index [Seite 396]
1

Pathology of oesophageal and gastric tumours


Heike I. Grabsch

Oesophagus


Introduction


Patients with neoplastic processes of the oesophagus most commonly present clinically at an advanced disease stage with strictures, plaque-like or polypoid masses protruding into the lumen, diffuse thickening of the mucosa and wall or deeply penetrating ulcers. Oesophageal neoplasms can be broadly divided into epithelial and mesenchymal subtypes according to the cell of origin. Whilst epithelial neoplasms are more common and can be recognised endoscopically due to mucosal irregularities, mesenchymal neoplasms are usually located subepithelially with an intact overlying mucosa. Precursor lesions have been recognised for malignant epithelial tumours and will be discussed in this chapter together with the histopathological features and molecular pathology of oesophageal tumours.

Epithelial tumours of the oesophagus and the gastro-oesophageal junction


Benign tumours and tumour-like lesions

Squamous cell papillomas are the most frequent benign epithelial tumours of the oesophagus, with a distinctive endoscopic appearance. They are most commonly located in the middle or lower third of the oesophagus, are exophytic, sessile or partly pedunculated, well demarcated and measure usually less than 5 mm in diameter. Only patients with very large lesions become clinically symptomatic. True adenomas of the oesophagus are benign tumours that develop from the submucosal oesophageal glands and are exceedingly rare.

Developmental cysts and congenital oesophageal duplications are benign lesions that may clinically mimic a tumour because of their mass effect, causing compression of the neighbouring respiratory tract. Similarly, patients with giant fibrovascular polyps, an entirely benign neoplasm, may present with severe dysphagia and respiratory symptoms and a large pedunculated mass obliterating the oesophageal lumen.

Malignant tumours

Squamous cell carcinoma

Squamous cell carcinoma is the most common malignant tumour of the oesophagus worldwide and affects men two to ten times more often than females, with an average age between 50 and 60 years at time of diagnosis. There is a marked geographic and ethnic variation in incidence. Incidence rates are highest in Iran, China, South America and Eastern Africa and are higher in African-Americans than Caucasian-Americans regardless of gender.

The aetiology and predisposing factors for oesophageal squamous cell carcinoma vary significantly in different regions of the world.1 Tobacco smoking and alcohol consumption are major risk factors for oesophageal squamous cell carcinoma.2,3

The intake of hot beverages has been shown to increase the risk of squamous cell carcinoma. Furthermore, dietary factors such as a lack of fresh fruit and vegetables and high intake of barbecued meat or pickled vegetables most likely play a role in the aetiology of squamous cell carcinoma. Human papilloma virus infection has been implicated in the pathogenesis of oesophageal squamous cell carcinoma, but its precise role is still controversial at present. Patients with achalasia have an increased risk of developing cancer compared to the normal population.4 The risk of developing oesophageal carcinoma is also increased in patients with coeliac disease,5 Plummer–Vinson syndrome (also called Paterson–Kelly syndrome),6 tylosis (also called focal non-epidermolytic palmoplantar keratoderma),7,8 previous ingestion of corrosive substances,9 Zenker's diverticulum10 or after ionising radiation.11 In the Asian population, polymorphisms in ALDH1B1 and ALDH2, both genes encoding aldehyde dehydrogenases, are associated with squamous cell carcinoma.12

Oesophageal squamous cell carcinomas are found in the upper, middle and lower third of the oesophagus in a ratio of approximately 1:5:2. The macroscopic appearance depends on the depth of tumour invasion and is classified into four different types according to the Japanese classification for oesophageal cancer,13 which is similar to the macroscopic classification of gastric cancer (see Fig. 1.8 below). Approximately 60% of squamous cell carcinomas show an exophytic or fungating growth pattern, 25% are ulcerative and 15% are infiltrative (Fig. 1.1). However, the macroscopic appearance of all cancers can significantly change as a result of neoadjuvant chemotherapy or chemoradiation, with tumour shrinkage, extensive necrosis and fibrosis.

Figure 1.1 Oesophageal squamous cell carcinoma located in the middle oesophagus. (a) Fresh oesophagectomy specimen with a polypoid exophytic tumour growth and a smaller flat (red coloured) mucosal abnormality. (b) Lack of (dark) iodine staining in the abnormal areas. (c) Same specimen after fixation. Courtesy of Dr Tomio Arai, Tokyo.

Figure 1.8 (a) Borrmann classification for advanced cancers. Type I: polypoid with a broad base, may be superficially ulcerated. Type II: excavated ulcerated lesion with elevated borders, sharp margin with no definitive infiltration into adjacent mucosa. Type III: ulcerative, diffusely infiltrating base. Type IV: diffusely infiltrative thickening of the wall (linitis plastica). (b) Murakami classification for early cancers. Modified from Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma, 3rd English edn. Gastric Cancer 2011; 14(2):101–12.

Squamous cell carcinomas invade both horizontally and vertically. In the West, 60% of patients have carcinomas that have invaded beyond the muscularis propria and have regional lymph node metastases at the time of diagnosis, whereas in Japan up to 40% of all resected carcinomas are superficial or early carcinomas involving mucosa and submucosa only.14 The frequency of lymph node metastases is related to the depth of tumour invasion and has been reported as less than 5% for intramucosal carcinomas and up to 45% for submucosal carcinomas. Although tumours located in the upper third of the oesophagus are more likely to spread to cervical and upper mediastinal nodes, a significant proportion will also spread to perigastric nodes.

Tumours located in the middle and lower oesophagus can spread to upper mediastinal and perigastric nodes, and patients with lymph node metastases on both sides of the diaphragm have been shown to have a poorer prognosis.1517

Distant metastases due to haematogenous spread are most commonly found in liver, lung, adrenal gland and kidney.18

Histologically, squamous cell carcinomas are characterised by keratinocyte-like cells that may or may not have intercellular bridges and show a variable degree of keratinisation (Fig. 1.2). Depending on the extent of mitotic activity, nuclear atypia and degree of squamous differentiation including degree of keratinisation, squamous cell carcinomas are graded as well, moderately or poorly differentiated.12 The histology of squamous cell carcinoma can change dramatically after neoadjuvant chemo(radio)therapy and then typically shows extensive necrosis, inflammation, fibrosis and foreign body-type granulomas around keratin pearls. There is currently no consensus on how to grade tumour regression. The regression grading according to Mandard et al.19 considers the relative proportion of residual viable tumour cells and fibrosis in the primary cancer and is probably currently the one most commonly used in the UK. Very recently, a grading system to assess tumour regression in lymph nodes has been proposed and showed prognostic significance in a small series of patients.20

Figure 1.2 Histological images from specimen in Fig. 1.1. (a) Histology of the nodule shows poorly differentiated squamous cell carcinoma with no evidence of keratin formation and necrosis (pink material) between strands of neoplastic cells. (b) Histology of the flat lesion shows early infiltrative squamous cell carcinoma. Courtesy of Dr Tomio Arai, Tokyo.

Three main variants of squamous cell carcinoma have been described:12

1. Verrucous carcinoma of the oesophagus is a rare, locally aggressive tumour that is more common in males. Macroscopically, the tumour has an exophytic papillary appearance and tumours are usually very large before they become clinically apparent. Microscopically, the tumour is very well differentiated with minimal atypia. Superficial biopsies are often insufficient to distinguish between a squamous papilloma, pseudoepitheliomatous hyperplasia and verrucous carcinoma.21

2. Spindle cell carcinoma (also known as carcinosarcoma, sarcomatoid carcinoma and polypoid carcinoma) is a polypoid tumour located in the middle or lower third of the oesophagus. Histologically, the tumour is a mixture of a well-differentiated squamous cell carcinoma and a high-grade spindle cell component that can show osseous, cartilaginous or skeletal muscle...

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