Late mortality after surgery for peptic ulcer

Genetic Alterations of Periampullary and Pancreatic Ductal Adenocarcinoma: An Overview

Pancreatic Ductal AdenoCarcinoma (PDAC) is one of the most lethal malignancies of all solid cancers. Precancerous lesions for PDAC include PanIN, IPMNs and MCNs. PDAC has a poor prognosis with a 5-year survival of approximately 6%. Whereas Periampulary AdenoCarcinoma (PAC) having four anatomic subtypes, pancreatic, Common Bile Duct (CBD), ampullary and duodenum shows relative better prognosis. The highest incidence of PDAC has been reported with black with respect to white population. Similarly, incidence rate of PAC also differs with different ethnic populations. Several lifestyle, environmental and occupational exposures including long-term diabetes, obesity, and smoking, have been linked to PDAC, however, for PAC the causal risk factors were poorly described. It is now clear that PDAC and PAC are a multi-stage process resulting from the accumulation of genomic alterations in the somatic DNA of normal cells as well as inherited mutations. Approximately 10% of PDAC have a familial inheritance. Germline mutations in CDKN2A, BRCA2, STK11, PALB2, PRSS1, etc., as well as certain syndromes have been well associated with predisposition to PDAC. KRAS, CDKN2A, TP53 and SMAD4 are the 4 "mountains" (high-frequency driver genes) which have been known to earliest somatic alterations for PDAC while relatively less frequent in PAC. Our understanding of the molecular carcinogenesis has improved in the last few years due to extensive research on PDAC which was not well explored in case of PAC. The genetic alterations that have been identified in PDAC and different subgroups of PAC are important implications for the development of genetic screening test, early diagnosis, and prognostic genetic markers. The present review will provide a brief overview of the incidence and prevalence of PDAC and PAC, mainly, increased risk in India, the several kinds of risk factors associated with the diseases as well as required genetic alterations for disease initiation and progression.

Limited subtotal gastrectomy for early remnant gastric cancer

BACKGROUND

Detection of early remnant gastric cancer (ERGC) is increasing as a result of the development of endoscopic technology and a surveillance program. The aim of this study was to evaluate the results of limited subtotal gastrectomy (SG) surgery for ERGC compared to total gastrectomy (TG).

METHODS

We retrospectively reviewed a database of 72 consecutive patients with remnant gastric cancer who underwent laparotomy at the National Cancer Center Hospital East between January 1993 and December 2008. Thirty-five patients with a preoperative diagnosis of ERGC underwent curative resection: 13 SG and 22 conventional TG. Patients and tumor characteristics, operative results, and postoperative assessments 1 year after surgery were compared between the two groups.

RESULTS

Operating time, blood transfusion, and hospital stay were similar in the two groups. In the SG group, blood loss and postoperative recovery of body weight tended to be better than in the TG group. There was no dumping syndrome in the SG group, while this occurred in three patients in the TG group. The levels of hemoglobin and total protein were higher 1 year after remnant gastrectomy in the SG group than in the TG group. No recurrence of gastric cancer was detected in the SG group during median follow-up of 99.2 months.

CONCLUSION

In comparison to TG, limited SG surgery for ERGC improved the postoperative course, with no recurrence of cancer. Therefore, SG is a safe and effective treatment for ERGC.

Gastrectomy and risk of pancreatic cancer: systematic review and meta-analysis of observational studies

PURPOSE

To investigate the association between gastrectomy and risk of pancreatic cancer (PaC).

METHODS

We identified eligible studies in Medline and EMBASE up to 11 February 2012 and the reference lists of original studies and review articles on this topic. Summary relative risks with their 95 % confidence intervals were calculated with a random-effects model. Between-study heterogeneity was assessed using Cochran Q and I (2) statistics.

RESULTS

Fifteen studies (11 case-control studies and 4 cohort studies) met eligibility criteria. The current data suggest that gastrectomy is associated with a 54 % excess risk of PaC (SRRs = 1.54; 95 % CI, 1.25-1.90; test for heterogeneity Q = 17.94, p < 0.001, I (2) = 22 %). There was no publication bias in the present meta-analysis.

CONCLUSION

A significant increased risk of PaC exists in patients who have undergone gastrectomy, particularly those receiving Billroth II resection with a long postoperative interval.

Selected medical conditions and risk of pancreatic cancer

We review the current evidence for associations of several medical conditions with risk of pancreatic cancer, including allergies, pancreatitis, gall bladder disease, cholecystectomy, ulcers, gastrectomy, appendectomy, and tonsillectomy. There are consistent findings of reduced risk associated with presence of self-reported allergies, particularly hay fever but not asthma; data on other allergies are limited and inconclusive. Several studies provide evidence that patients with pancreatic cancer are more likely than comparison groups to report pancreatitis. Those studies that investigated the time between onset of pancreatitis and diagnosis of pancreatic cancer found that risk estimates declined with longer periods of time; however, increased risks were noted for long-term pancreatitis, indicating that this condition is both a risk factor and a sign of early disease. Increased risk was reported in association with cholelithiasis, but the few studies that considered time before diagnosis of cancer did not find increased risk for cholelithiasis diagnosed in the more distant past. There is weak evidence that cholecystectomy 2 or more years before cancer diagnosis is related to risk, but this is based on only a few studies. There is no consistent association between ulcers and risk, while gastrectomy may increase risk. Overall, study of these conditions, particularly those that are rare, presents methodologic challenges. Time between diagnoses is likely to be important but is not considered in most studies. Lack of adequate control in several studies for risk factors such as smoking and heavy alcohol use also makes it difficult to draw firm conclusions about these results.

Postgastrectomy syndromes

The first postgastrectomy syndrome was noted not long after the first gastrectomy was performed. The indications for gastric resection have changed dramatically over the past 4 decades, and the overall incidence of gastric resection has decreased. This article focuses on the small proportion of patients with severe, debilitating symptoms; these symptoms can challenge the acumen of the surgeon who is providing the patient's long-term follow-up and care. The article does not deal with the sequelae of bariatric surgery.

Current state of gastric stump carcinoma in Japan: based on the results of a nationwide survey

Background

Carcinoma of the gastric remnant after partial gastrectomy for benign disease or cancer is unusual but an important cancer model. The Japanese Society for the Study of Postoperative Morbidity after Gastrectomy (JSSPMG) performed a nationwide questionnaire survey to understand the current state of gastric stump carcinoma in Japan.

Methods

In the questionnaire survey of November 2008, gastric stump carcinoma was defined as an adenocarcinoma of the stomach occurring 10 years or more after Billroth I or Billroth II gastrectomy for benign condition or cancer disease. The survey was conducted at the request of reports on five or more patients with gastric stump carcinoma for each institution. Items for the survey included gender, age, methods of reconstruction in an original gastrectomy, original diseases, time interval between original gastrectomy and first detection of stump carcinomas, locations of stump carcinomas, tumor histology, tumor depth, and extent of lymph node metastasis. The questionnaire was sent to 163 surgical institutions in the JSSPMG.

Results

Ninety-five institutions (58.3%) responded to the survey, and the data of 887 patients satisfied the required conditions for the survey. A total of 887 patients were composed of 368 patients who received Billroth I distal gastrectomy and 519 who received Billroth II. The Billroth II group has a significantly higher number of original benign lesions than the Billroth I group (P < 0.001). This study confirmed the following issues: (1) The remnant stomach after gastrectomy for cancer disease had a higher prevalence to develop stump carcinomas occurring in a shorter time interval since original gastrectomy; (2) Patients with Billroth II gastrectomy had stump carcinomas most frequently in the anastomotic area, but not in the non-stump area as in Billroth I gastrectomy; (3) Tumor histology of 72.4% of 304 stump carcinomas at an early stage was intestinal type adenocarcinoma, i.e., well or moderately differentiated adenocarcinoma, whereas it decreased to 42.2% at the locally advanced stage of 521 stump carcinomas (P = 0.0015), suggesting that stump carcinoma mostly may develop from intestinal type and change to diffuse type during the evolution to advanced stage cancers.

Conclusions

This large series of surveys suggest that there are two distinct biological plausibilities in the development of gastric stump carcinoma: (1) it develops in a shorter time interval of 10 years or less since the original gastrectomy, may come from a higher risk of gastric mucosa after gastrectomy for cancer diseases that highly predisposes to cancer, and (2) it develops during a longer time interval of 20 years or more, may come from gastrectomy-relating mechanisms after gastrectomy for original benign diseases.

Increased mortality in prostate carcinoma and smoking-related disease after parietal cell vagotomy: a long-term follow-up study

OBJECTIVE

There is an increased risk of gastrointestinal carcinoma and smoking-related diseases after partial gastrectomy for peptic ulcer disease. The purpose of this study was to evaluate long-term cancer incidence and mortality after parietal cell vagotomy (PCV), a surgical method with a low rate of side effects, but creating hypochlorhydria in the stomach mimicking long-term treatment with antisecretory drugs.

MATERIAL AND METHODS

Data on 383 ulcer patients operated on with PCV during 1971-80 at Lund University Hospital were compared with the national registers for cause of death and cancer incidence for selected diagnoses. Median follow-up was 28 years and 31 years, respectively. Standardized mortality ratios (SMRs) and standardized incidence ratios (SIRs) were calculated.

RESULTS

An increased incidence of cancer in the respiratory organs (SIR 1.97, 95% CI: 1.08-3.31) and prostate carcinoma (SIR 1.85, 95% CI: 1.22-2.69) was found, and among men also an increased mortality in prostate carcinoma (SMR 3.85, 95% CI: 1.41-8.38) and chronic respiratory disease (SMR 2.76, 95% CI: 1.01-6.02). Overall mortality was similar to that of the background population and no increased risk of gastrointestinal malignancies was observed.

CONCLUSIONS

Patients with peptic ulcer operated on with PCV have a long-term increased risk of smoking-related diseases, but PCV does not seem to increase the risk of gastrointestinal carcinoma. An increased risk of, and mortality in prostate carcinoma was found, a cancer previously not found to be related to smoking. This might be the result of surgery-induced hypochlorhydria, which warrants further investigation in patients on long-term proton-pump inhibitors.

History of peptic ulcer disease and pancreatic cancer risk in men

BACKGROUND & AIMS

Peptic ulcer disease has been associated with an increased risk of pancreatic cancer, but findings on this topic are inconsistent. We investigated the association between pancreatic cancer and the occurrence of gastric or duodenal ulcer in a large US cohort.

METHODS

We analyzed data collected from 51,529 male health professionals in a prospective cohort study. History of peptic ulcer disease was assessed at baseline in 1986 and updated biennially thereafter. Relative risks (RRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models adjusting for smoking, body mass index, diabetes, and physical activity.

RESULTS

During 18 years of follow-up evaluation, we observed 274 incident pancreatic cancer cases. Compared with those with report of no peptic ulcer disease, men with gastric ulcer had an increased risk of pancreatic cancer (RR, 1.83; 95% CI, 1.13-2.97). Although the risk was highest for those with a diagnosis of gastric ulcer that was close in time to the cancer diagnosis (RR, 3.66; 95% CI, 1.45-9.24), the risk remained significantly increased 10-19 years after the gastric ulcer diagnosis (RR, 2.89; 95% CI, 1.26-6.64). In contrast, duodenal ulcer was not associated with pancreatic cancer risk (RR, 1.15; 95% CI, 0.78-1.71).

CONCLUSIONS

Gastric ulcer increases the risk of pancreatic cancer, whereas there does not appear to be an association between duodenal ulcers and pancreatic cancer.

Percutaneous transhepatic choledochoscopic lithotomy as a rescue therapy for removal of bile duct stones in Billroth II gastrectomy patients who are difficult to perform ERCP

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is more difficult and dangerous in patients with Billroth II (B II) gastrectomy than those with normal anatomy.

OBJECTIVES

To evaluate the clinical efficacy of percutaneous transhepatic choledochoscopic lithotomy (PTCSL) for removing common bile duct stones in B II gastrectomy patients who are difficult to perform ERCP.

METHODS

This study was designed as prospectively uncontrolled in a large tertiary referral center. In 20 patients, mostly men, with bile duct stones and an earlier B II gastrectomy, PTCSL was tried because of failed ERCP and high risk. The PTCSL was performed using electrohydraulic lithotripsy or papillary balloon dilation. Successful stone removal and complications were measured.

RESULTS

Stone removal was achieved in all 20 patients. The mean number of procedures and session time were 4.5 and 45 min, respectively. Minor PTCSL-related complications, such as fever, hemobilia, hyperamylasemia, and wound pain, occurred in five patients (25%). There were no major procedure-related complications, including perforation or mortality.

CONCLUSION

The PTCSL procedure is an effective and safe rescue therapy for common bile duct stones in B II gastrectomy patients with failed ERCP and high risk.

Serum pepsinogen level, atrophic gastritis and the risk of incident pancreatic cancer--a prospective cohort study

BACKGROUND

Pancreatic cancer is a highly fatal disease without screening tests. Studies have suggested possible etiologic similarities between gastric and pancreatic cancers. Atrophic gastritis, a pre-malignant condition for gastric cancer, is characterized by low serum pepsinogen I (SPGI) level. We hypothesized that low SPGI level may be associated with an increased risk of pancreatic cancer and be a useful biomarker for the disease.

METHODS

Our analytic cohort included 20,962 participants in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC) who had SPGI level measured. Of these, 1663 (7.9%) subjects had low SPGI levels (<25 microg/l) and were invited for gastroscopy which was completed in 1059 (63.7%) participants. Atrophic gastritis was histologically confirmed in 1006 (95.0%) subjects. We used Cox proportional hazards regression to calculate the hazard ratios (HR) and 95% confidence intervals (CI) for pancreatic cancer.

RESULTS

During follow-up of up to 16.3 years (mean=10.8 years; 226,325 person-years), 227 incident pancreatic cancers were diagnosed. The incidence rates were 9.9, 11.3, and 12.7 per 10,000 person-years of follow-up for participants with normal pepsinogen level (> or = 25 microg/l), low pepsinogen level and histologically confirmed atrophic gastritis, respectively. Compared to subjects with normal pepsinogen levels, there was no statistically significant increased risk of pancreatic cancer among subjects with low pepsinogen level (adjusted HR=1.01; 95% CI: 0.63-1.62) or those with histologically confirmed atrophic gastritis (adjusted HR=1.13; 95% CI: 0.66-1.95).

CONCLUSIONS

Atrophic gastritis, serological or histological, is not associated with increased risk of pancreatic cancer. These findings do not provide any evidence for potential usefulness of SPGI for pancreatic cancer screening.

Pancreatic cancer: a review of the evidence on causation

Pancreatic cancer kills more than 250,000 people each year worldwide and has a poor prognosis. The aim of this article is to critically review the epidemiologic evidence for exposures that may either increase or decrease the risk. A Medline search was performed for epidemiologic studies and reviews published up to April 2007. Consistent evidence of a positive association was found for family history and cigarette smoking. Many studies documented a positive association with diabetes mellitus and chronic pancreatitis, although the etiologic mechanisms are unclear. Other associations were detected, but the results were either inconsistent or from few studies. These included positive associations with red meat, sugar, fat, body mass index, gallstones, and Helicobacter pylori, and protective effects of increasing parity, dietary folate, aspirin, and statins. There was no evidence linking alcohol or coffee consumption with an increased risk of pancreatic cancer. The associations with many exposures need to be clarified from further epidemiologic work in which there is both precise measurement of risk factors, adjustment for potential confounders, and, for dietary studies, information recorded on the method of food preparation and pattern of consumption. Such work is important to reduce the incidence of this fatal disease.

Malignant disease in peptic ulcer surgery patients after long term follow-up: A cohort study of 1992 patients

AIMS

To assess the effect of previous peptic ulcer surgery on subsequent malignant events, in particular in relation to previous vagotomy, a historical cohort study was conducted.

METHODS

All patients undergoing surgery for peptic ulcer disease with accurate follow-up data at a large peptic ulcer clinic in the Western Infirmary, Glasgow, from 1965 to 1983 were assessed. All cancer events and specific cancer events (gastric, bronchial, laryngeal, colorectal, bladder, breast, prostate, pancreas, kidney, oesophageal cancers) were determined as outcome measures and expressed as standardised incidence ratio (SIR).

RESULTS

Vagotomy and drainage accounted for 67% of all procedures for peptic ulcer disease. Eighty-three percent were habitual smokers. For all peptic ulcer surgery patients, the SIR for all cancer events was 0.86. For specific cancers, the SIRs were bronchial cancer (SIR 1.13); laryngeal cancer (SIR 2.17), colorectal cancer (SIR 0.67). For vagotomised patients the risk of gastric cancer was significantly elevated (SIR 1.50).

CONCLUSIONS

An excess of cancers attributable to smoking have been found in peptic ulcer surgery patients. Vagotomised patients have a higher risk of gastric cancer after long term follow-up. This finding may have implications for screening and the safety of long term acid suppression with agents such as proton pump inhibitors.

The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease

Although Helicobacter pylori (H. pylori) seropositivity is linked to an excess risk of pancreatic cancer, the biologic mechanism is unknown. Gastric ulcer is primarily associated with corpus colonization of H. pylori, atrophic gastritis and formation of N-nitrosamines. Duodenal ulcer is a marker of antral colonization, hyperacidity and uninhibited secretin release. We estimated relative risks for pancreatic cancer among patients with gastric or duodenal ulcer, based on a register-based retrospective cohort study with 88,338 patients hospitalized for gastric ulcer and 70,516 patients for duodenal ulcer recorded in the Swedish Inpatient Register between 1965 and 2003. Following operation, the 14,887 patients who underwent gastric resection and 8,205 with vagotomy were analyzed separately. Multiple record-linkages allowed complete follow-up and identification of all incident cases of pancreatic cancer until December 31, 2003. Standardized incidence ratios (SIRs) estimated relative risks. During years 3-38 of follow-up, we observed a 20% excess risk (95% confidence interval [CI] 10-40%) for pancreatic cancer among unoperated gastric ulcer patients. The excess increased to 50% (95% CI 10-110%) 15 years after first hospitalization (p for trend = 0.03). SIR was 2.1 (95% CI 1.4-3.1) 20 years after gastric resection. Unoperated duodenal ulcer was not associated with pancreatic cancer risk, nor was vagotomy. Our results lend indirect support to the nitrosamine hypothesis, but not to the hyperacidity hypothesis in the etiology of pancreatic cancer.

The role of psychosocial factors in peptic ulcer disease: beyond Helicobacter pylori and NSAIDs

A variety of organic etiologies are associated with peptic ulcer disease, and the most relevant of these are infection with Helicobacter pylori and use of nonsteroidal anti-inflammatory drugs. Between 5% and 20% of patients with gastric or duodenal ulcer, however, lack an identifiable organic etiology. In these patients particularly and in all ulcer patients in general, psychosocial factors may play a significant role. At present, there is no definitive study proving a causal relationship between psychological stress and the development of ulcer disease. Studies to date suffer from significant methodological limitations and have not effectively addressed the poor correlation between ulcer craters and ulcer symptoms. A conservative application of available data would suggest that psychosocial factors play a significant role in symptom perception and reporting in patients with dyspeptic symptoms and may play a role in ulcer formation.

Epidemiology of pancreatic cancer: an overview

INTRODUCTION

The incidence of pancreatic cancer worldwide appears to correlate with increasing age, and it is slightly more common among men and Jewish people. There is evidence that the incidence rate is higher among blacks than among whites.

METHODS

The published literature was reviewed for preparation of an overview on epidemiology of pancreatic cancer.

RESULTS

A possible role of diabetes in the etiology of pancreatic cancer has been suggested by different epidemiological studies. Several investigations indicate that a history of pancreatitis may increase the risk of pancreas cancer, and it appears that people with a history of pernicious anemia or partial gastrectomy for ulcer as well as cholecystectomy may be at higher risk. Individuals with familial adenomatous polyposis (FAP) also have a high risk of developing this cancer. Pancreatic cancer is seen in some breast cancer families with BRCA1 and BRCA2 mutations. Epidemiological studies have confirmed that relatives of individuals with pancreatic cancer have an increased risk of this malignancy. Affected family members of the familial atypical multiple-mole melanoma (FAMMM) as well as those with a positive family history of ataxia-telangiectasia (AT) have much higher risk of developing pancreatic cancer, compared with the general population. A positive association has been reported between pancreatic cancer risk and dietary intake such as fat and oil, meat, and dairy products, as well as with high intake of energy, fried foods, carbohydrates, cholesterol, and salt. The risk is found to decrease with increased consumption of fresh fruits and vegetables, fiber, natural foods, and Vitamin C. Cigarette smoking has shown the strongest positive association with risk of pancreatic cancer.

CONCLUSION

Some diseases and medical conditions such as diabetes, chronic pancreatitis, AP, family aggregation of pancreatic cancer, FAMMM, AT, as well as nutrition and lifestyle factors, like smoking may play important role in the etiology of pancreatic cancer.

Etiology of pancreatic cancer, with a hypothesis concerning the role of N-nitroso compounds and excess gastric acidity

In the United States, pancreatic cancer is the fourth most frequent cause of cancer death in males as well as females, after lung, prostate or breast, and colorectal cancer. Each year, approximately 30 000 Americans are diagnosed with pancreatic cancer and about the same number die of it. Germline mutations in a few genes including p16 and BRCA2 have been implicated in a small fraction of cases, as has chronic pancreatitis. The one established risk factor for pancreatic cancer is cigarette smoking: current smokers have two to three times the risk of nonsmokers. Studies of dietary factors have not been entirely consistent but do suggest associations of higher risk with consumption of smoked or processed meats or with animal foods in general and lower risk with consumption of fruits and vegetables. Colonization by Helicobacter pylori appears to increase risk, and a history of diabetes mellitus may also increase risk. The purpose of this epidemiologic review is to consider the possibility that risk of pancreatic cancer is increased by factors associated with pancreatic N-nitrosamine or N-nitrosamide exposures and with chronic excess gastric or duodenal acidity. Host genetic variation in inflammatory cytokine mechanisms may also be involved in this process. Many features of the evidence bearing on the pathophysiology of pancreatic cancer appear to support connections with N-nitroso compounds and with gastric acidity.

Changes in food tolerance and lifestyle after eradication of Helicobacter pylori

BACKGROUND

It is known that patients with peptic ulcer disease (PUD) often have an unhealthy lifestyle that results in increased mortality because of smoking-related diseases. No thorough study has been done to see what changes, if any, the patient makes to lifestyle after eradication of Helicobacter pylori.

METHODS

One-hundred-and-eighty-three patients were enrolled in an open-endoscopy setting; 58% had PUD and 42% gastritis and/or duodenitis (G/D). They filled out a lifestyle questionnaire before the start of anti-Helicobacter therapy and again 1 year later.

RESULTS

The prevalence of food intolerance decreased from 71% to 44% among patients with PUD (P < 0.0001) and from 76% to 63% among patients with G/D (P = 0.09). Tolerance improved for coffee, orange juice, fried foods, spicy foods and fruits. There was no significant change in smoking or alcohol consumption after eradication. Coffee and tea consumption was unchanged. Milk consumption decreased from 4.2 dL/day to 3.3 (P = 0.01). The number of meals decreased from 3.5/day to 3.4 (P = 0.005) and snacking from 1.3 snacks/day to 1.1 (P = 0.02). Consumption of fruit increased from 4.0 to 4.3 times/week (P = 0.04), but the frequency of meat, fish, vegetables, spicy foods, salty foods, sweets and cakes did not change. The time spent on each meal was unchanged. There was no change in the time spent exercising. There were few significant differences between PUD and G/D patients.

CONCLUSIONS

Food was better tolerated, but there were no major changes in lifestyle after eradication of H. pylori. Patients therefore do not abuse the privilege of a more tolerant digestion by indulging in a more unhealthy lifestyle.

Pancreatic cancer after remote peptic ulcer surgery

BACKGROUND

Peptic ulcer surgery may carry an increased risk for pancreatic cancer development. Molecular analysis of K-ras codon 12, frequently mutated in conventional pancreatic cancers, might provide insight into the aetiological mechanisms.

METHODS

The relative risk of pancreatic cancer was computed by multivariate and person-year analysis in a cohort of 2633 patients who had undergone gastrectomy. Lung cancer risk was analysed as an indirect means of assessing smoking behaviour. K-ras codon 12 mutational analysis was performed on 15 postgastrectomy pancreatic cancers.

RESULTS

There was an overall increased risk of pancreatic carcinoma of 1.8 (95% confidence interval, 1.3 to 2.6) five to 59 years postoperatively, which gradually increased to 3.6 at 35 years or more after surgery (chi(2) test for trend, p < 0.05). Multivariate analysis indicated that parameters other than postoperative interval did not influence the risk. Lung cancer risk was significantly increased after surgery, but no time trend was observed. The spectrum and prevalence of K-ras codon 12 mutations were comparable to conventional pancreatic cancer.

CONCLUSIONS

Remote partial gastrectomy is associated with an increased risk of pancreatic cancer. Postgastrectomy and non-postgastrectomy pancreatic cancers may share similar aetiological factors, such as smoking. However, the neoplastic process in patients who have undergone gastrectomy appears to be accelerated by factors related to the surgery itself.

Results of local resection with regional lymphadenectomy for early gastric cancer

BACKGROUND

In 1999, the authors reported preliminary results of local resection with regional lymphadenectomy(LR) for early gastric cancer.

METHODS

Twenty-four patients underwent LR until May 2000. Laparoscopic techniques were recently applied. The dissected area for lymphadenectomy depended on the lymphatic flow from the tumor. Local gastric resection was performed with a 2 cm cancer-free margin. Among the 24 patients, 14 who had been followed up for more than 1 year were eligible for the nutritional study, and the nutritional parameters were compared with those for patients undergoing pylorus-preserving gastrectomy (PPG).

RESULTS

Twenty-two patients not receiving additional gastrectomy needed no restriction of food intake and had neither postgastrectomy symptoms nor recurrence. All nutritional parameters remained stable between the preoperative and the subsequent period. Nutritional superiority of LR over PPG was observed.

CONCLUSIONS

For selected patients with early gastric cancer, LR can be a treatment of choice to provide a good quality of life.

The role of genetic factors in the etiology of pancreatic adenocarcinoma: an update

Pancreatic cancer is a disease with a very poor prognosis and its etiology is still largely elusive. The only consistent environmental risk factor is cigarette smoking. A previous history of pancreatitis or diabetes mellitus is also considered to be a risk factor. Epidemiological studies have confirmed that relatives of those with pancreatic cancer have an increased risk of this malignancy, and it has been evaluated that 3-5% of all pancreatic cancer cases are caused by genetic predisposition to the disease. Usually this occurs in the setting of a known inherited cancer syndrome caused by mutations in genes such as BRCA1/2 and CDKN2A. Whether or not a true site-specific pancreatic adenocarcinoma syndrome exists is not known. The real challenge for the management of high risk patients is to develop new screening methods than can identify pre-neoplastic or early neoplastic lesions in a timely manner.

Risk of gastric cancer is not increased after partial gastrectomy

BACKGROUND

It has been suggested that there is an increased risk of gastric cancer following partial gastrectomy. This question has not been studied in an Australian population.

METHODS

The records of a total of 569 patients who had a partial gastrectomy for peptic ulcer disease at Repatriation General Hospital, Heidelberg, between 1957 and 1976 were reviewed. All were followed to date of death or 31 December 1996. The expected rate of gastric cancer for this population was estimated from published Australian age-and sex-specific gastric cancer mortality rates over this period, and a standardized incidence ratio was calculated.

RESULTS

The mean age at surgery was 53.5 years (range 27-83 years). There were 547 male (96.4%) and 22 female (3.6%) patients. Five hundred and seven (83.5%) had a Billroth II procedure. Thirty-eight patients (6.3%) were lost to follow up and were not included in the analysis. From the records of the Department of Veterans' Affairs, it was established that 125 (20.6%) were alive in December 1996, a mean survival after surgery of 18.8 years. The mean documented duration of follow up was 17.3 years (range 1-41 years). Nine patients developed cancer in the gastric remnant. The expected number of cancers in this population was 6.5. Assuming all survivors were free of gastric cancer, the standardized incidence ratio was 1.39 (95% confidence intervals 0.64-2.65, P=0.313).

CONCLUSION

The risk of gastric cancer was not increased after partial gastrectomy in this Australian population.

[Therapy of pancreatic adenocarcinoma]

BACKGROUND

Despite significant advances in the areas of epidemiology, risk factors, molecular genetics and diagnosis pancreatic carcinoma is characterized by a dismal prognosis and ranks 5th among malignancy-associated deaths. This article attempts to critically review the current literature and analyze therapeutic recommendations based on published evidence. Therapeutic options are based on the stage of the disease.

SURGICAL TREATMENT

Surgical resection with curative intention is feasible only in a minority of patients presenting with locally confined tumor disease. RADIO- AND CHEMOTHERAPY: Adjuvant combined radiochemotherapy might potentially improve survival and can also be considered in unresectable, locally advanced disease. The role of chemotherapy in advanced disease is exclusively palliative. Up to now, no chemotherapeutic regimen has demonstrated convincing impact on survival. Newer substances, such as gemcitabine, appear to be of some value in respect to quality of life. Best supportive care oriented at clinical symptoms remains a cornerstone in the therapeutic concept of patients with pancreatic carcinoma.

CONCLUSION

Development of innovative therapeutic strategies is therefore mandatory.

Long-term survival among patients operated upon for peptic ulcer disease

BACKGROUND

Although surgery has been used widely for treating peptic ulcer disease, there is conflicting evidence with respect to subsequent life expectancy and the determinants of mortality. Our aim was to compare long-term survival in a large, population-based cohort of operated patients with that expected in the general population.

METHODS

We followed 471 Rochester, Minnesota residents who had surgery for peptic ulcer at the Mayo Clinic during 1956-85 for a total of 6174 person-years. Patients were followed through their complete (inpatient and outpatient) medical records in the community until death or last clinical contact and death certificates were obtained for all who succumbed. We compared observed survival and cause-specific death rates in this cohort with expected values and identified the determinants of short (30 day) and long-term mortality.

RESULTS AND CONCLUSIONS

Survival was worse than expected, but excess deaths were confined to those with perforated ulcers (42 deaths observed; 18.8 expected). Independent predictors of death included age, male gender, emergency operation, gastric ulcer and cigarette smoking. Most deaths were due to heart disease and cancer, but only those due to digestive diseases (standardized mortality ratio (SMR) 3.8, 95% CI 2.4-5.7) and respiratory diseases (SMR 1.9, 95% CI 1.3-2.7) were increased compared to expected figures. Overall survival was reduced in this cohort but was normal among those whose ulcers were not perforated. However, the data suggest an adverse role for alcohol and smoking in these patients.

Pancreatic cancer: any prospects for prevention?

Primary prevention of pancreatic cancer and public health measures to reduce its incidence are dependent on data from epidemiological studies. Currently, the only definite risk factor is smoking, although a diet rich in fruit and vegetables may be protective. The K-ras mutation may have a role in diagnosis and screening.

Diabetes mellitus, other medical conditions and familial history of cancer as risk factors for pancreatic cancer

In a population-based case-control study of pancreatic cancer conducted in three areas of the USA, 484 cases and 2099 controls were interviewed to evaluate the aetiologic role of several medical conditions/interventions, including diabetes mellitus, cholecystectomy, ulcer/gastrectomy and allergic states. We also evaluated risk associated with family history of cancer. Our findings support previous studies indicating that diabetes is a risk factor for pancreatic cancer, as well as a possible complication of the tumour. A significant positive trend in risk with increasing years prior to diagnosis of pancreatic cancer was apparent (P-value for test of trend = 0.016), with diabetics diagnosed at least 10 years prior to diagnosis having a significant 50% increased risk. Those treated with insulin had risks similar to those not treated with insulin (odds ratio (OR) = 1.6 and 1.5 respectively), and no trend in risk was associated with increasing duration of insulin treatment. Cholecystectomy also appeared to be a risk factor, as well as a consequence of the malignancy. Subjects with a cholecystectomy at least 20 years prior to the diagnosis of pancreatic cancer experienced a 70% increased risk, which was marginally significant. In contrast, subjects with a history of duodenal or gastric ulcer had little or no elevated risk (OR = 1.2; confidence interval = 0.9-1.6). Those treated by gastrectomy had the same risk as those not receiving surgery, providing little support for the hypothesis that gastrectomy is a risk factor for pancreatic cancer. A significant 40% reduced risk was associated with hay fever, a non-significant 50% decreased risk with allergies to animals, and a non-significant 40% reduced risk with allergies to dust/moulds. These associations, however, may be due to chance since no risk reductions were apparent for asthma or several other types of allergies. In addition, we observed significantly increased risks for subjects reporting a first-degree relative with cancers of the pancreas (OR = 3.2), colon (OR = 1.7) or ovary (OR = 5.3) and non-significantly increased risks for cancers of the endometrium (OR = 1.5) or breast (OR = 1.3). The pattern is consistent with the familial predisposition reported for pancreatic cancer and with the array of tumours associated with hereditary non-polyposis colon cancer.

Causes of death in patients with peptic ulcer perforation: a long-term follow-up study

BACKGROUND

Survival is lower in ulcer perforation patients than in the general population. This study assesses the causes of death in patients treated for peptic ulcer perforation.

METHODS

Cause-specific mortality in a population-based cohort of 817 patients treated for ulcer perforation in western Norway during the period 1962-1990 was compared with cause-specific population death rates. Analyses were based on observed and expected mortality curves for major causes of death and on standardized mortality rates (SMRs). Cox regression models were used to analyse possible differences on the basis of sex, birth cohort, surgical procedure, and ulcer location.

RESULTS

Ulcer perforation patients experienced increased mortality from neoplasms (SMR = 1.8; 95% confidence interval (CI) = 1.4-2.1), lung cancer (SMR = 3.6; 95% CI = 2.3-4.9), circulatory diseases (SMR = 1.3; 95% CI = 1.1-1.6), ischaemic heart disease (SMR = 1.3; 95% CI = 1.03-1.6), and respiratory diseases (SMR = 1.9; 95% CI = 1.3-2.6). Postoperative deaths accounted for 38% of all excess deaths. Death from recurrent peptic ulcer was increased also in subjects who survived the 1st year after the perforation (SMR = 5.8; 95% CI = 1.2-10.4) but accounted for only a few deaths. The increase in mortality from lung cancer was higher in subjects born after 1910 than in patients of older generations. Excess mortality from lung cancer and from circulatory diseases was higher in male than in female patients.

CONCLUSIONS

Increased mortality in ulcer perforation patients could mainly be attributed to smoking-related diseases. This is indirect evidence that smoking may be an important aetiologic factor for ulcer perforation.

Expected survival compared with survival of peptic ulcer patients

In analyses of patient survival it is often desirable to compare observed survival curves with expected survival curves based on information obtained from the general population. However, current methods of calculating expected survival curves are difficult to interpret and are often poorly documented. We discuss an alternative formulation of the so-called direct method which we recommend for general use. By simulation, we show that the expected survival curve obtained from this method represents the expectation of a Kaplan-Meier curve for a set of random population controls. Thus, the term expected survival does not refer to the expectation of patient survival, but rather to the expected survival curve for a random set of controls. The alternative methods are discussed, and we illustrate the methods in an analysis of long time survival of a population-based sample of peptic ulcer patients.

Experimental models of colorectal cancer

PURPOSE

A review of in vivo and in vitro models of colorectal cancer is presented.

METHODS

A retrospective literature review was performed with reference to CD-ROM Medline and Index Medicus.

RESULTS

A comparison of the advantages and disadvantages of the models is presented in addition to a summary of individual model methodology and applications.

CONCLUSIONS

Such models are a useful adjunct for surgical research in colorectal oncology.

Pancreatic carcinoma following gastric resection. A case-control study based on 21,660 consecutive clinical necropsies at Malmö University Hospital

CONCLUSION

In this necropsy-based case-control study, there was no relationship between pancreatic carcinoma and previous gastric resection. Based on the association between lung cancer and gastric resection, it is suggested that the relationship between pancreatic carcinoma and gastric resection shown in other studies may have been confounded by smoking.

BACKGROUND

This case-control study was designed to assess whether in patients dying from pancreatic carcinoma, there is a relationship to previous gastric resection for peptic ulcer disease.

METHODS

By linking the autopsy data base in Malmö with the national Cause of Death Register, we identified 439 autopsied individuals who had died of pancreatic carcinoma between 1970 and 1982. The 21,660 individuals in the data base represent 64% of all deaths during that time period. For each of these individuals who died of pancreatic carcinoma, we randomly chose three controls who were matched for age at death, gender, and year of death. In order to assess the specificity of the assumed relationship, we also used as a control group the 1337 autopsied individuals who had died of lung cancer.

RESULTS

The prevalence of previous gastric resections was 3.4% in patients dying from pancreatic carcinoma, 7.6% in patients dying from lung cancer, and 4.4% in the age- and sex-matched control group. The odds for previous gastric resection in patients dying from pancreatic carcinoma was 0.9 [95% confidence interval (CI) 0.5-1.7] in comparison with this age- and sex-matched control group. The lower odds for previous gastric resection in patients dying of pancreatic carcinoma than in patients dying of lung cancer remained in the logistic regression analysis after controlling for age at death, gender, and year of death (odds ratio [OR] 0.5; 95% CI 0.3-0.9).

Survival after peptic ulcer perforation: a time trend analysis

The survival of 1098 patients with ulcer perforation in Norway during the period 1952-1990 was compared with expected survival. Cox regression models incorporating population mortality rates, were used to analyse effects of sex, age, year of birth, and year at risk on excess mortality. Survival was lower in patients than in the general population through a follow-up period of 38 years. Relative survival was lower in women as compared to men, due to more delayed treatment. Long-term survival was lower after praepyloric perforations than after the other perforation types. Relative survival was higher in patients treated 1952-1970 than in those treated more recently. However, adjustment for year of birth revealed a decline in short-term mortality with calendar time, which is in accordance with improved management during the study period. Relative mortality, particularly long-term mortality, was higher in younger birth cohorts, suggesting a shift towards more serious etiologies.

Pancreatic adenocarcinoma: epidemiology and genetics

Pancreatic adenocarcinoma is an important cause of death from cancer throughout the developed world. There are few established environmental risk factors, but a previous history of pancreatitis and exposure to tobacco and salted food appear to be the most important. A family history of pancreatic adenocarcinoma is not common in patients with this disease, but recent research has shown that pancreatic adenocarcinoma can be a feature of cancer susceptibility syndromes associated with germline mutations in p16, BRCA1, BRCA2, and APC. This highlights the need for a full family history in apparently sporadic cases. Somatic mutations in p16, BRCA2, and APC have also been reported in pancreatic cancer; however, K-RAS mutations appear to be the commonest oncogenic alteration. Recent advances in our understanding of the basis of hereditary cancer syndromes may be applicable to the diagnosis, treatment, and possibly prevention of pancreatic adenocarcinoma in the future.

Risk of pancreatic cancer associated with cholelithiasis, cholecystectomy, or gastrectomy

Current data regarding an association between cholelithiasis, cholecystectomy, or gastrectomy and pancreatic cancer are conflicting. We evaluated the frequency with which these factors were present in 720 patients with newly diagnosed pancreatic cancer and in 720 matched controls. All subjects were interviewed personally and in detail about their clinical history. Cholelithiasis was present in 126 patients with pancreatic cancer (17.5%) and in 95 controls (13.2%), constituting a statistically significant association (odds ratio, 1.39; 95% confidence interval, 1.04-1.86); however, considering only the patients and controls in whom the diagnosis of cholelithiasis was made more than one year before cancer diagnosis or interview, the association was no longer significant (odds ratio, 1.04; 95% confidence interval, 0.75-1.44). Cholecystectomy had been performed in 93 patients with pancreatic cancer (12.9%) and in 71 controls (9.9%). When all subjects were considered, the odds ratio was mildly, although not significantly, increased (odds ratio, 1.35; 95% confidence interval, 0.97-1.87); when only subjects who underwent cholecystectomy one year or more before the cancer diagnosis or interview were considered, the odds ratio fell to unity. Gastrectomy had been performed in 28 patients with pancreatic cancer (3.9%) and in 25 controls (3.5%); analysis revealed no significant association between these two factors (odds ratio, 1.14; 95% confidence interval, 0.64-2.05). In conclusion, our study, one of the largest on this topic, has found no evidence for an association between cholelithiasis, cholecystectomy, or gastrectomy and pancreatic cancer.

Sympathoadrenal activity and psychosocial stress. The significance of aging, long-term smoking, and stress models

Recent studies have indicated that the increase in plasma norepinephrine and sympathetic activity with aging in healthy subjects is largely due to long-term cigarette smoking. In patients who have or have had duodenal ulcer the increase in plasma norepinephrine with age was markedly increased. These patients as a group perceive their lives somewhat more stressful than the general population and they tend to die prematurely due to smoking-associated diseases. These patients may select dysfunctional coping strategies like smoking, which may result in organ pathologies and a compensatory increase in plasma norepinephrine. No close correlation has been established between plasma epinephrine and "ill health." High plasma epinephrine levels may have a deleterious effect on the cardiovascular system in elderly subjects during certain conditions. In a population study, we found, however, that low resting plasma epinephrine levels were associated with an unfavorable survival rate. We speculate that an inadequate response to psychosocial stress and the choice of dysfunctional coping strategies may be more harmful and cause more "ill health" than hypersecretion of stress hormones like epinephrine and cortisol, which has been the traditional view. We suggest that there are different stress states. Stress hormones like epinephrine and cortisol may play a major role during situations like combat, illness, and strenuous exercise. In response to psychosocial stress, dysfunctional coping strategies are, however, largely responsible for harmful effects of stress.

Synchronous double cancers of the remnant stomach and pancreas: report of a case

We present here in the case of a 75-year-old man who developed synchronous double cancers of the remnant stomach and pancreas 12 years after undergoing distal gastrectomy for gastric carcinoma. The patient was referred to our hospital in March, 1993, with a provisional diagnosis of carcinoma of the remnant stomach. Laboratory data on admission showed an abnormal level of CA19-9 (116.1 U/ml) and positive occult blood in the stools. An upper gastrointestinal series and gastroendoscopy demonstrated an ulcerative polypoid tumor in the gastric stump proximal to the gastroduo-denostomy anastomosis, and a biopsy confirmed the findings of mucinous adenocarcinoma. Abdominal computed tomography (CT) scan revealed a low-density nodule anterior to the abdominal aorta, suggestive of a nodal metastasis. A laparotomy was performed which also disclosed a low-density mass located within the head of the pancreas. The patient was subsequently diagnosed as having double carcinomas of the remnant stomach and pancreas, and total gastrectomy and pancreatoduodenectomy were carried out. The histologic sections from the remnant stomach showed mucinous adenocarcinoma, whereas those from the pancreas showed tubular adenocarcinoma. Double carcinomas in this association are extremely rare and this case may in fact be the first observation of synchronous double cancers of the remnant stomach and pancreas.

Effects of smoking on interdigestive gastrointestinal motility

The effect of smoking on interdigestive gastrointestinal motility is little studied but may play a role in gastrointestinal morbidity. We studied gastroduodenal motility in 10 volunteers (five smokers and five nonsmokers) using a water-perfused pressure catheter. A pH probe was placed in the duodenal bulb. Baseline motility was recorded until phase III of the migrating-motor complex had occurred in the stomach three times in order to record two complete cycles of MMC activity. Subjects then began smoking until phase III activity occurred again (mean duration of smoking 117 min). During the control period, all subjects had normal MMC cycles and there were no differences between smokers and nonsmokers. While smoking, no gastric phase III was observed in any subject and gastric motility was markedly reduced. In seven of 10 subjects, smoking did not prevent the occurrence of normal duodenal phase III activity. Three subjects had no duodenal phase III activity during smoking. The duodenal pH profile did not change during smoking and motilin levels continued to fluctuate in conjunction with phase III activity. In conclusion, smoking abolished phase III activity in the stomach without affecting the plasma motilin cyclic fluctuations or duodenal bulb pH. In contrast, smoking has little effect on duodenal motility.

Mortality after remote surgery for benign gastroduodenal disease

Mortality was studied after partial gastrectomy in a cohort of 1575 patients operated on because of benign gastroduodenal disease 29 to 59 years ago. The final status was confirmed in all but 8.4% of the cohort. At the close of the study 78% of the traced population were dead. Overall mortality was significantly higher than in the general population of southern Sweden (standardised mortality ratio = 1.10; 95% confidence intervals 1.03 to 1.17). Excess deaths resulted from neoplasms in the stomach, pancreas, male genital organs, and respiratory organs, as well as from respiratory diseases and suicide. Patients operated on before the age of 45 had a 60% increase in overall mortality during the first 19 years after surgery, mainly because of cardiovascular disease and suicide, whereas among those operated on after this age mortality was comparable to that in the reference population. The 75% increased death rate in cardiovascular disease during the first 19 years after surgery in patients operated on at young age, dramatically decreased during the years thereafter. An increased risk of death caused by malignancy was apparent more than 20 years postoperatively, irrespective of age at surgery. Excess deaths resulting from gastrointestinal malignancies, mainly gastric and pancreatic carcinoma, outnumbered the increased number of deaths resulting from cancer in the respiratory organs.

Pathophysiological effects of long-term acid suppression in man

A critical evaluation has been made of the available evidence in man of the effects of prolonged low acid states on the structure and function of the stomach. Various human models have been examined. 1. Ageing does not affect acid output from the normal male stomach, and there may be an increase in women. With progressive atrophy of the corpus mucosa, which is more frequent and rapid in patients with gastric ulcer, there is an associated loss of secretory function. Chronic gastritis and atrophy are the most important age-related changes, which in many cultures are hypothesized to develop via a prior Helicobacter pylori-related gastritis. However, H. pylori colonization of the mucosa decreases with increasing grades of gastric atrophy probably because intestinal metaplasia provides a hostile environment. Atrophy and intestinal metaplasia are associated with precancerous lesions and gastric cancer. Apparent hyperplasia of the gastric argyrophil endocrine cells is a common and spontaneous phenomenon in patients with atrophic gastritis, which in part may be related to the preferential loss of nonendocrine cells. 2. Pernicious anemia is associated with a complete lack of acid production, marked hypergastrinemia, and endocrine cell hyperplasia in the majority of patients. ECL-cell carcinoids and gastric cancer occur with a prevalence of 3-7%, and endoscopic surveillance in routine clinical practice is not warranted. 3. Gastric ECL-cell carcinoids are rare events that have been described in association with two diseases in man, pernicious anemia and Zollinger-Ellison syndrome as part of multiple endocrine neoplasia syndrome type I, and usually relate to marked hypergastrinemia and the presence of chronic atrophic gastritis with gastric antibodies or a genetic defect rather than the presence or absence of acid. Regression or disappearance of ECL-cell carcinoids, either spontaneously or after removal of the gastrin drive, has been recorded. Lymph node, and rarely hepatic, metastases are documented but death in these cases has been anecdotal. 4. Therapy with H2 antagonists may result in up to a twofold rise in serum gastrin levels but in man no endocrine cell hyperplasia has been recorded. However, the data for H2 antagonists on these aspects are very limited. There is no drug-related risk of gastric or esophageal cancer, although the incidence of the latter may be raised. Long-term treatment with omeprazole is associated with a two- to fourfold increase in gastrin levels over baseline values in one third of patients and apparent endocrine cell hyperplasia in 7% of cases overall.(ABSTRACT TRUNCATED AT 400 WORDS)

Late outcome of bleeding gastric ulcer. Five to eight years' follow-up

BACKGROUND

Gastric ulcer haemorrhage is associated with a high immediate mortality, but few data exist on the late prognosis of these patients. The aim of this study was to determine the long-term recurrence rate and late outcome in patients with gastric ulcer complicated with bleeding.

METHODS

In a prospective follow-up study 90 consecutive patients with a bleeding gastric ulcer discharged after non-operative treatment (bleeding controlled by endoscopic electrocoagulation or ceased spontaneously) were followed up once every year for 5-8 years (median, 6.5 years).

RESULTS

Recurrent ulcer was seen in 17 patients, repeat haemorrhage being the presenting symptom in 13 of them. The estimated cumulative recurrence rate after 2, 5, and 8 years was 10%, 19% and 33%, respectively. Recurrence rate was unaffected by sex, complicating disease, and non-steroidal anti-inflammatory drugs (NSAIDs) ingestion before and after the index bleeding episode. The recurrence rate of patients with a history of ulcer before the index bleeding episode did not differ from that of patients with no previous ulcer history. A significantly increased risk of recurrence was seen in patients with previous bleed as opposed to patients with previous non-bleeding ulcer (p < 0.05). The cumulative survival rate was significantly reduced compared with the expected survival rate of the sex- and age-matched background population (p < 0.01), primarily because of diseases not related to the ulcer disease.

CONCLUSION

Bleeding gastric ulcer is associated with a relatively low long-term recurrence rate, except in a few patients with a history of previous bleeding ulcer, who have an increased risk of recurrence. Patients with bleeding gastric ulcer have an excess mortality not related to the ulcer disease.

Risk of cancer following partial gastrectomy for benign ulcer disease

The relative risk of developing cancer after partial gastrectomy for benign ulcer disease, expressed as the standardized incidence ratio, was examined in a population-based cohort comprising 6459 patients operated on between 1950 and 1958. Follow-up to 1983 revealed 1112 patients with cancer versus 1128 expected cases (relative risk 1.0 (95 per cent confidence interval (c.i.) 0.9-1.1)). The overall risk increased over time; it was higher in younger than in older patients but was not related to sex, surgical procedure (Billroth I or II gastrectomy) or diagnosis at operation (duodenal or stomach ulcer). There was an increased risk for lung cancer (relative risk 1.5 (95 per cent c.i. 1.2-1.7)), for oesophageal cancer in patients operated on for stomach ulcer (relative risk 2.2 (95 per cent c.i. 1.0-4.2)) and for cancer of the biliary tract in men (relative risk 1.9 (95 per cent c.i. 1.2-2.9)) and in those operated on for duodenal ulcer (relative risk 1.7 (95 per cent c.i. 1.0-2.8)). The overall risk for genital cancer in women was unchanged but decreased with increasing duration of follow-up and age. Cancers of the nervous system occurred less frequently than expected (relative risk 0.5 (95 per cent c.i. 0.3-0.8)), while the risk for cancer of the buccal cavity, lymphatic and haematopoietic systems, pancreas, breast, prostate, kidney and bladder was unchanged.

Gastrectomy and subsequent risk of oesophageal cancer in Milan

STUDY OBJECTIVE

To analyse quantitatively the relationship between gastrectomy and oesophageal cancer risk.

DESIGN

This was a case-control study, based on a structured questionnaire that included a problem-oriented medical history.

SETTING

A network of hospitals in the Greater Milan area between 1984 and 1992.

SUBJECTS

Subjects were 316 incident, histologically confirmed cases of oesophageal cancer (258 males and 58 females), and 1408 controls (1031 males, 377 females), admitted to hospital for acute, non-neoplastic, non-digestive tract conditions.

MEASUREMENTS AND MAIN RESULTS

Relative risks (RR) and the corresponding 95% confidence intervals (CI) adjusted for age and sex, plus area of residence, education, tobacco, and alcohol consumption. There was an association of borderline significance of oesophageal cancer with gastric ulcer (RR = 1.6), but not with duodenal ulcer (RR = 0.9). Among cases, 25 (7.9%) reported a history of gastrectomy, versus 29 (2.1%) of the controls. The corresponding multivariate RR was 3.8 (95% CI 2.0, 7.0). The RR of oesophageal cancer was significantly raised (RR = 3.6) within 20 years after gastrectomy, and the association seemed stronger with increasing time since gastrectomy (RR = 4.2).

CONCLUSIONS

Since gastrectomy may cause gastric hypoacidity and favour oesophageal reflux, and hence oesophagitis, the results of this study, if confirmed, are of interest to a better understanding of the mechanisms of oesophageal carcinogenesis.

Death from malignant disease after surgery for duodenal ulcer

A total of 2241 patients who had an operation for duodenal ulcer between 1947 and 1968 were followed up to determine the cause of death and to compare the observed number of deaths with the expected. Death certificates were traced for 1251 of 1387 known to have died. Observed deaths from all causes were significantly greater than expected (O/E 1.13) (95% CI 1.08 to 1.20). This was because of significant increases in deaths from neoplasms (O/E 1.25) (95% CI 1.13 to 1.39) and digestive diseases (O/E 1.71) (95% CI 1.11 to 2.59). Analysis of deaths from malignant disease showed an excess of deaths from carcinoma of lung (O/E 1.37) (95% CI 1.14 to 1.62) and from smoking related cancers (O/E 1.32) (95% CI 1.13 to 1.52) but there was no significant excess mortality from any other neoplasm. An excess of deaths within one year of the operation was seen from circulatory disease (O/E 1.85) (95% CI 1.17 to 2.78), respiratory disease (O/E 3.56) (95% CI 1.78 to 6.37), and digestive disease (O/E 21.46) (95% CI 13.75 to 31.93). These deaths are concentrated in the first postoperative month and as there is no excess mortality from circulatory, respiratory or digestive disease between 1 and 20 years postoperatively, show the direct effects of the operation as a cause of death. This together with the excess mortality from all respiratory disease confirms that excess mortality after duodenal ulcer surgery is, in the short term, the result of the operation itself and in the long term largely attributable to cigarette smoking. Operations for gastric ulcer largely account for the subsequent excess mortality from gastric cancer reported after peptic ulcer surgery. The findings do not support the theory that the operation has carcinogenic effects and do not support the case for routine endoscopic screening after operations for duodenal ulcer.

Effect of omeprazole on intragastric bacterial counts, nitrates, nitrites, and N-nitroso compounds

Previous studies have suggested that profound inhibition of gastric acid secretion may increase exposure to potentially carcinogenic N-nitroso compounds. The aim of this study was to find out if the proton pump inhibitor omeprazole (20 mg daily) is associated with increased concentrations of potentially carcinogenic N-nitroso compounds in gastric juice. The volume of gastric contents, number of bacteria, and concentrations of nitrates, nitrites, and N-nitroso compounds was determined in gastric aspirates obtained after an overnight fast in 14 healthy volunteers (7M:7F) after one week of treatment with placebo, and one and two weeks' treatment with omeprazole. Median bacterial concentrations were 1.0 x 10(4) (range 5.0 x 10(3)-5.0 x 10(6)) colony forming units (CFU)/ml after one weeks' treatment with placebo and increased significantly to 4.0 x 10(5) (0-3.3 x 10(7)) CFU/ml after two weeks' treatment with omeprazole (p < 0.05). A similar increase was seen in the concentration of nitrate reducing bacteria. There was no difference in the volume of gastric aspirates after treatment with omeprazole when compared with placebo (65 (29-155) ml v 42 (19-194) ml). The concentration of N-nitroso compounds was 0.13 (0-1.0) mumol/l after two weeks of omeprazole, which was not significantly different from that seen with placebo (0.15 (0-0.61) mumol/l). There was also no increase in the concentrations of nitrates or nitrites. It is concluded that omeprazole (20 mg once daily) for two weeks in healthy volunteers is associated with gastric bacterial proliferation but does not increase concentrations of N-nitroso compounds.

Mortality among patients with partial gastrectomy for benign ulcer disease

Partial gastrectomy for benign ulcer disease may influence future risk of death, eg, through changes in life-style or metabolism. To reveal such possible long-term effects, we analyzed a population-based cohort of 6459 patients operated on from 1950 through 1958 and followed through 1985. We found a lower overall mortality than in the general Swedish population (standardized mortality ratio = 0.94; 95% confidence interval 0.91-0.97). Mortality was decreased among those with duodenal ulcers, Billroth II operations, and older age at operation but increased as time passed after operation. Mortality was significantly (P < 0.05) increased from tuberculosis, alcoholism, emphysema, stomach ulcer, intestinal obstruction, gallbladder or biliary disease, suicide, and accidental falls but decreased from ischemic heart disease and cerebrovascular disease. Preoperative selection of healthy patients and the probable increased prevalence of risk factors for ulcer disease (smoking, alcoholism, and lower socioeconomic status) in this cohort explain most of these findings. Apart from intestinal obstruction, gallbladder or biliary tract diseases, and tuberculosis, the surgical procedure did not appear to increase mortality beyond one year after operation.