Upper Gastrointestinal Surgery - part 10 pptx

Abdomen, effect of diaphragmatic contraction of 51–52Abdominal muscles, contraction of, relationship with trunk stability and respiration 56Abdominal oesophagus, anatomy of 4–5 Abdominal

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40%) However, there were more deaths within

3 months of commencing CRT in the surgery

arm (9% vs 1%; p = 0.002) Therefore, there is

good evidence to support the use of definitive

CRT in resectable squamous carcinoma of

the oesophagus as an alternative to surgery

[23, 27–29]

The majority of available data on CRT

in oesophageal cancer used synchronous 5FU

with either cisplatin or mitomycin-C Since

then, many more chemotherapy drugs have

been incorporated into routine use for cancer

therapy The assessment of these as potentially

useful radiosensitisers has produced interesting

results Paclitaxel appears safe in oesophageal

cancer and high pCR rates can be achieved with

CRT given preoperatively Other promising

agents include irinotecan and oxaliplatin

Radiotherapy Technique

Precise identification of the site and local extent

of the primary tumour and the involved lymph

nodes is essential The gross tumour volume

(GTV) can be defined by a combination of

cross-sectional imaging (CT and/or MRI),

endoscopic ultrasound and barium swallow

Radiotherapy planning is usually performed by

CT localisation of the tumour and oesophagus

The clinical target volume (CTV) is the volume

defined to encompass the GTV, the likely

micro-scopic extension beyond the GTV and the

immediate draining lymph nodes The planning

target volume (PTV) includes a final margin

which is added to compensate for daily

varia-tions in patient positioning and organ

move-ment with respiration (Figures 27.1 and 27.2)

The treatment is planned to encompass the

entire PTV At the same time, the dose received

by the surrounding organs such as the spinal

cord, lungs and heart will need to be limited to

within their normal tissue tolerance The use of

conformal and intensity modulated

radiother-apy (IMRT) should enable improved sparing of

normal organs, by better conformation of the

high dose volume around the tumour These

techniques require three-dimensional computer

planning and linear accelerators fitted with

mul-tileaf collimators (MLC) These may allow

radi-ation dose escalradi-ation to the tumour without

unacceptable toxicity to the surrounding

organs There may also be a future role for

non-conventional radiotherapy scheduling such as

acceleration (over a shorter treatment duration)

or hyperfractionation (treatment more thanonce a day)

Toxicity of Radiotherapy and Chemoradiotherapy

Acute side effects of radiotherapy include radiation-induced mucositis of the oesophagus.This can become secondarily infected bycandida and will require antifungal therapy.Symptoms of odynophagia, altered taste andanorexia are common and usually commence

10 to 14 days after starting radiotherapy.Maintenance of nutritional status is essential

to support patients through their treatment

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Figure 27.1 A simulator film during barium swallow todelineate the target volume for radiotherapy in cancer of theoesophagus

Figure 27.2 CT planning for cancer of the oesophagus.Computer-generated isodose distribution of the radiationbeams is also shown on this CT slice

Nasogastric or parenteral feeding may need to

be commenced if significant weight loss

con-tinues after commencement of radiotherapy

Patients are encouraged to cease smoking and

alcohol during radiotherapy as these may

exac-erbate acute and long-term toxicity

Radiation-induced tracheitis can cause a persistent cough

associated with thick mucus production Acute

pneumonitis can occur within the first 3 months

and may cause a dry cough, dyspnoea and low

grade pyrexia Acute radiation mediastinitis is a

rare complication causing chest pain, pyrexia

and dyspnoea In severe cases, hospital

admis-sion is necessary to exclude an oesophageal

perforation

The commonest long-term toxicity of

radio-therapy is oesophageal stricture formation The

most likely contributing cause is the extensive

tumour destruction and subsequent

treatment-related fibrosis A tracheo-oesophageal fistula

can occasionally develop but again, this is more

commonly due to direct tumour invasion

Radiotherapy is as safe and effective in

suffi-ciently fit elderly patients as it is in a younger

population

Palliative Treatment

For patients deemed incurable, short courses of

palliative radiotherapy may be effective in

improving symptoms of dysphagia and/or pain

Radiation doses of 20 Gy in 5 fractions or 30 Gy

in 10 fractions are usually tolerated well and are

associated with a low risk of serious toxicity

This can be given in combination with other

interventions including oesophageal dilation,

laser ablation and stenting In addition,

chemotherapy may be useful in delaying further

disease progression and in prolonging survival

This is discussed in Chapter 26

The insertion of radioactive sources (usually

iridium-192) into the oesophagus, known as

brachytherapy, can be an effective means of

delivering high doses of radiation to the

intra-luminal component of the tumour with

rela-tively low doses to surrounding structures

Using a high dose rate (HDR) selectron

machine, 16 Gy in two fractions or 18 Gy in three

fractions given weekly have been shown to offer

excellent palliation Brachytherapy in

combina-tion with laser ablacombina-tion may reduce the

fre-quency of required endoscopic dilatations in

selected patients

The selection of the treatment modality used

to palliate a particular patient should take intoaccount the site of disease, related symptoms,general physical condition and social circum-stances An additional factor is the level ofexpertise and technology available locally foreach of these interventions

Other Histological Types

Small cell carcinoma is occasionally seen in the

oesophagus Its clinical behaviour of early temic spread is similar to small cell carcinoma

sys-of the lung Multidrug combination apy with or without radiotherapy is probablythe optimum treatment Surgery may be con-sidered for selected patients The role of CRT isyet to be defined

chemother-Carcinoma of the oesophagus with adenoid cystic differentiation has been reported to be

clinically and morphologically distinct fromadenoid cystic carcinoma arising from salivaryglands Surgical resection is the mainstay oftreatment

Primary oesophageal T-cell non-Hodgkin’s lymphoma is rare Most cases present with evi-

dence of widespread disease and chemotherapywould be the appropriate treatment When trulylocalised, radiotherapy alone can be successful

Summary and Future

Although surgery remains the standard againstwhich new treatments must be compared, there

is emerging evidence that stage for stage, thesurvival from CRT alone is equivalent to surgeryalone [30] Salvage oesophagectomy followingCRT failure is feasible in some cases and theresults are encouraging [27] Although com-monly given, the role of preoperative CRTremains unproven and therefore can only berecommended in the context of a clinical trial.There is no proven role for postoperative radio-therapy

It is clear that different treatment modalitiesare appropriate for different patients, but themeans of selecting the appropriate treatment forthe individual patient is lacking The standard

of care for surgery has also progressed Twocycles of preoperative cisplatin and 5FUchemotherapy (without radiation) have beenshown to increase curative resection rates (60%

vs 54%) and overall survival at 2 years (43% vs

RADIOTHERAPY IN UPPER GI TRACT NEOPLASMS

34%) in an MRC randomised trial of 802

patients [31] In the future, the management of

adenocarcinoma and squamous carcinoma is

likely to diverge Patients who achieve pCR

fol-lowing CRT for squamous carcinoma are

unlikely to benefit from resection, but at the

present time there is no reliable test to predict

for this Further research is needed to develop

these tests However, a non-surgical approach

will enable organ preservation [30] and may

lead to lower treatment-related mortality [28]

and improved quality of life [32] This can only

be justified if there is no survival penalty

Improving pretreatment loco-regional

staging by the routine use of endoscopic

ultra-sound and multislice CT scanning in regional

gastro-oesophageal cancer units should be the

standard The use of 18-fluorodeoyxglucose

(FDG) positron emission tomography (PET) to

detect distant metastases not identified by CT

scan will help spare approximately 20% of

patients from a non-curative resection or an

“open and shut” procedure Serial FDG-PET

scanning may also be useful in detecting early

response to radiotherapy

In order to improve loco-regional control

of this cancer, the optimum combination of

chemotherapy and radiotherapy needs to be

defined by refining existing regimens, assessing

new agents and improving radiation dose

delivery Prevention of systemic recurrence

remains an elusive target but new chemotherapy

drugs and combinations are being explored for

the future In the next decade, there will be an

expansion of research into the molecular

biol-ogy of malignant tumours and their response to

chemotherapy and radiotherapy The

develop-ment of in vitro predictive testing may help to

tailor treatment strategies to achieve the best

responses Cyclin D1 immunoreactivity and

metallothionein expression both appear to

cor-relate with sensitivity to CRT in oesophageal

cancer

Stomach

Although there has been a decrease in the

inci-dence of gastric adenocarcinoma involving

the body and pylorus in the Western world, that

of cardia and gastro-oesophageal junction

tumours has increased markedly The overall

5-year survival of all patients with gastric

carci-noma remains poor (between 5% and 15%).Although the mainstay of treatment remainssurgical resection, the ultimate risk of recur-rence is high Adjuvant treatments are anattempt to improve outcome

Radiotherapy

Radiotherapy to the stomach is limited by themobility and variation in size of this organ Inaddition, the radiation dose that can be safelydelivered is also limited by the presence of sur-rounding radiosensitive organs including thesmall bowel, liver, kidneys and spinal cord(Figure 27.3)

In a Chinese trial, 370 patients with carcinoma of the gastric cardia were ran-domised to receive radiotherapy (40 Gy) prior

adeno-to surgery or surgery alone [33] Patients in theradiotherapy arm had higher resection rates

(89% vs 79%; p < 0.01) and an improved 5-year survival (30.1% vs 19.7%; p = 0.009).

The British Stomach Cancer Group Trial domised 436 patients who had undergone resec-tion for adenocarcinoma of the stomach toreceive postoperative radiotherapy (45–50 Gy),chemotherapy (mitomycin-C, doxorubicin and5FU) or no further treatment [34] There was nodifference in survival between the three arms(median 12.9 months vs 17.3 months vs 14.7

ran-months; 5 years 12% vs 19% vs 20%; p = 0.14).

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Figure 27.3 A schematic diagram of the cross-section of theabdomen at the level of the L1 vertebral body showing stomachand other anatomic organs in its vicinity that may be at risk ofradiation damage during radiotherapy to the stomach 1, spleen;

2, small bowel; 3, stomach; 4, transverse colon; 5, descendingcolon; 6, left kidney; 7, pancreas; 8, left lobe of liver; 9, abdominalaorta; 10, L1 vertebral body; 11, spinal cord/cauda equina; 12,spinal process of L1; 13, inferior vena cava; 14, right lobe of liver;

15, right kidney

The role of postoperative combined

chemother-apy and radiotherchemother-apy has been assessed by the

US Intergroup in a randomised trial (INT 0116)

which compared CRT with no further treatment

in 556 patients who had undergone curative

resection for locally advanced adenocarcinoma

of the stomach and gastro-oesophageal junction

[11] In the treatment arm, the patients received

one cycle of 5FU and folinic acid, followed by

CRT (45 Gy with synchronous 5FU and folinic

acid), followed by a further cycle of 5FU and

folinic acid Most patients had tumours

involv-ing the distal stomach and 85% had lymph node

involvement on histological examination of the

resection specimen Of note, 54% of the patients

had undergone a D0 dissection, meaning a less

than complete dissection of the N1 lymph

nodes The median survival was 36 months for

the CRT arm compared with 27 months for the

surgery alone arm (p = 0.005), with a 3-year

sur-vival of 50% versus 41% respectively

The Gastric Surgical Adjuvant Radiotherapy

Consensus Report [35] has outlined the factors

to be considered for planning postoperative

CRT These include anatomy, pathways of

tumour spread, patterns of failure and surgical

techniques Nevertheless, the implementation

of such complex and resource consuming

indi-vidual planning can be justified by improved

results in selected patients who are motivated

and are of sufficiently good physical condition

Mucosa Associated Lymphoid Tissue

(MALT) Lymphoma

The stomach is the commonest site of

gastroin-testinal non-Hodgkin’s lymphoma The

com-monest subtype is the MALT lymphoma This is

commonly associated with Helicobacter pylori

infection Antibiotic therapy has resulted in

complete remissions in many patients with early

disease [36] A combination of chemotherapy

and involved field radiotherapy in the

manage-ment of Ann Arbor stage I and II MALT

lym-phomas is associated with good response rates

and survival

Small Bowel

Although a wide variety of benign and

malig-nant neoplasms can arise from the small

intes-tine, the numbers are exceedingly small and therole of radiotherapy negligible Primary malig-nant tumours range from adenocarcinomathrough varieties of sarcomas and lymphomas

to carcinoid tumour Radiotherapy is unlikely to

be useful not only because small bowel is cult to target due to its mobile nature but alsobecause of its radiosensitivity Palliative radio-therapy may be considered to control acute orchronic haemorrhage

diffi-Questions

1 Outline the arguments for either surgery

or radiotherapy for squamous noma of the oesophagus

carci-2 Criticise the trial suggesting possiblebenefit of chemoradiotherapy for cancer

of the stomach

References

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2 Muller HM, Erasmi H, Stelzner M et al Surgical therapy

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4 Earlam R, Cunha-Melo JR Oesophageal squamous cell carcinoma: I A critical review of radiotherapy Br J Surg 1980;67:457–61.

5 Fok M, McShane J, Law SYK, Wong J Prospective domized study on radiotherapy and surgery in the treat- ment of oesophageal carcinoma Asian J Surg 1994;17:223–9.

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7 Fok M, Sharm JST, Choy D, Cheng SWK, Wong JW Postoperative radiotherapy for carcinoma of the oesophagus: a prospective randomized controlled trial Surgery 1993;113:138–47.

8 Teniere P Hay JM, Fingerhurt A, Fagniez P-L Postoperative radiation therapy does not increase sur- vival after curative resection of squamous cell carci- noma of the middle and lower oesophagus as shown by

a multi-centre controlled trial Surg Gynecol Obstet 1991;173:123.

9 Herskovic A Martz K, al-Sarraf M et al Combined chemotherapy and radiotherapy compared with radio-

RADIOTHERAPY IN UPPER GI TRACT NEOPLASMS

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N Eng J Med 1992;326:1593–8.

10 Moertel CG, Frytak S, Hahn RG et al Therapy of locally

unresectable pancreatic carcinoma: a randomized

com-parison of high dose radiation (6000 rads) alone.

11 Macdonald JS, Smalley SR, Benedetti J et al

Chemora-diotherapy after surgery compared with surgery alone

for adenocarcinoma of the stomach or gastroesophgeal

junction N Engl J Med 2001;345:725–30.

12 Geh JI, Crellin AM, Glynne-Jones R Preoperative

(neoadjuvant) chemoradiotherapy in oesophageal

can-cer Br J Surg 2001;88:338–56.

13 Nygaard K, Hagen S, Hansen HS et al Preoperative

radiotherapy prolongs survival in operable oesophageal

carcinoma: a randomized, multicentre study of

preop-erative radiotherapy and chemotherapy The second

Scandinavian Trial in esophageal cancer World J Surg

1992;16:1104–10.

14 Le Prise E Etienne PL, Meunier B et al A randomized

study of chemotherapy, radiation therapy and surgery

versus surgery for localized squamous cell carcinoma of

the esophagus Cancer 1994;73:1779–84.

15 Apinop C, Puttisak P, Preecha N A prospective study of

combined therapy in esophageal cancer

Hepatogas-troenterology 1994;41:391–3.

16 Walsh TN, Noonan N, Hollywood D et al A comparison

of multimodal therapy and surgery of esophageal

ade-nocarcinoma N Engl J Med 1996;335:462–7.

17 Bosset JF Gignoux M, Triboulet JP et al

Chemoradio-therapy followed by surgery compared with surgery

alone in squamous cell cancer of the esophagus N Engl

J Med 1997;337:161–7.

18 Urba SG, Orringer MB, Turrisi A et al Randomized trial

of preoperative chemoradiation versus surgery alone in

patients with locoregional esophageal carcinoma J Clin

Oncol 2001;19(2):305–13.

19 Burmeister BH, Smithers BM, Fitzgerald L et al A

ran-domized phase III trial of preoperative chemoradiation

followed by surgery (CR-S) versus surgery alone (S) for

localized resectable cancer of the esophagus

Proceed-ings of 38th Annual Meeting of American Society of

Clinical Oncology 2002;21:A518.

20 Keane TJ, Harwood AE, Elhakim T et al Radical

radia-tion therapy with 5-flourouracil infusion and

mito-mycin C for oesophageal squamous carcinoma.

Radiother Oncol 1985;4:205–10.

21 Geh JI The use of chemoradiotherapy in oesophageal

cancer Eur J Cancer 2001;38:300–13.

22 Al-Sarraf M, Martz K, Herskovic MA, et al Progress

report of combined chemoradiotherapy versus

radio-therapy alone in patients with esophageal cancer: An

intergroup study J Clin Oncol 1997;15:277–84.

23 Smith TJ, Ryan LM, Douglass HO et al Combined

chemoradiotherapy vs radiotherapy alone for early

stage squamous cel carcinoma of the esophagus: a study

of the Eastern Cooperative Oncology Group Int J Radiat

Oncol Biol Phys 1998;42:269–76.

24 Araujo CMM, Souhami L, Gil RA et al A randomized trial comparing radiation therapy versus concomitant radiation therapy and chemotherapy in carcinoma of the thorac esophagus Cancer 1991;67:2258–61.

25 Roussel A, Haegele P, Paillot B et al Results of the EORTC-GTCCG phase III trial of irradiation versus irradiation and CDDP in inoperable esophageal cancer Proc Am Soc Clin Oncol 1994;13:583 (abst).

26 Minsky BD, Pajak TF, Ginsberg RJ et al INT 0123 (Radiation Therapy Oncology Group 94–05) phase III trial of combined modality therapy for esophageal can- cerr: high-dose versus standard-dose radiation therapy.

J Clin Oncol 2002;20(5):1167–74.

27 Murakami M, Kuroda Y, Okamoto Y et al Neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy or surgery for operable thoracic esophageal carcinoma Int J Radiat Oncol Biol Phys 1998;40:1049–59.

28 Wilson KS, Lim JT Primary chemo-radiotherapy and selective oesophagectomy for oesophageal cancer: goal

of cure with organ preservation Radiother Oncol 2000;54:129–34.

29 Bedenne L, Michel P, Bouche O et al Randomized phase III trial in locally advanced esophageal cancer: radio- chemotherapy followed by surgery versus radiochemo- therapy alone (FFCD 9102) Proceedings of 38th Annual Meeting of American Society of Clinical Oncology 2002;21:A519.

30 Murakami M, Kuroda Y, Nakajima T et al Comparison between chemoradiation protocol intended for organ preservation and conventional surgery for clinical T1–T2 esophageal carcinoma Int J Radiat Oncol Biol Phys 1999;45(2):277–84.

31 Medical Research Council Oesophageal Cancer Working Party Surgical resection with or without pre- operative chemotherapy in oesophageal cancer: a ran- domised controlled trial Lancet 2002;359:1727–33.

32 Blazeby JM, Farndon JR, Donovan J, Alderson D A prospective longitudinal study examining the quality of life of patients with esophageal carcinoma Cancer 2000;88:1781–7.

33 Zhang Z-X Gu X-Z, Yin W-B et al Randomised clinical trial on the combination of preoperative irradiation and surgery in the treatment of adenocarcinoma of gastric cardia (AGC) Report on 370 patients Int J Radiat Oncol Biol Phys 1998;42(5):929–34.

34 Hallissey MT, Dunn JA, Ward LC, Allum WH The ond British Stomach Cancer Group trial of adjuvant radiotherapy or chemotherapy in resectable gastric can- cer: five year follow-up Lancet 1994;343:1309–12.

sec-35 Smalley SR, Gunderson L, Tepper J et al Gastric cal adjuvant radiotherapy consensus report: rationale and treatment implementation Int J Radiat Oncol Biol Phys 2002;52:283–93.

surgi-36 Wotherspoon AC, Doglioni C, Diss TC et al Regression

of primary low-grade gastric lymphoma of associated lymphoid tissue type after eradication of

mucosa-Helicobacter pylori Lancet 1993;342:575–7.

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Abdomen, effect of diaphragmatic contraction of

51–52Abdominal muscles, contraction of, relationship

with trunk stability and respiration 56Abdominal oesophagus, anatomy of 4–5

Abdominal plexus, of the diaphragm 49

Abnormalities

lower oesophageal, evaluating with oesophageal

transit scintigraphy 313–314oesophageal, association with defects in other

organ systems 2

of the small intestine 43–44

upper oesophageal, evaluating with oesophageal

Accuracy, of upper gastrointestinal endoscopy 280

Acetylcholine, binding to G cells, effect on gastric

secretion 33–34Achalasia 242

of the cardia, failure of the oesophageal sphincter

to relax in 8diagnosis of, with contrast radiography 294

with plain radiology 289

as a failure of oesophageal motility 79–83

oesophageal transit scintigraphy for identifying

307, 309Achlorhydria, effect of, on fasting levels of gastrin

32Acid reflux, measurement of 13–14

Acid sphingomyelinase (ASM), deficiency of, in

Niemann-Pick disease 145Acquired immunodeficiency syndrome (AIDS), risk

of small bowel malignancy associated with196

Adaptation, of the small bowel, after surgery 113

Barrett’s oesophagus as a premalignantcondition for 259–264

glandular dysplasia as an indicator of 251increasing incidence of, in men and women188–192

outcomes of lymphadenectomy for 328–329surgical approach to 330–331

surgical management of 164

of the small bowel, comparison withadenocarcinoma of the duodenum 193management of 201–202

of the stomach 250–251risk factors for 190–191Adenoid cystic carcinoma 253Adenomas

of Brunner’s gland 201endoscopic removal of 283

of the oesophagus 251Adenomatous polyps (adenomas), of the smallbowel, management of 201

Adenosquamous carcinoma, of the oesophagus 247

Adjuvant therapyfor gastric cancer, chemoradiotherapy 352for oesophageal cancer, postoperativeradiotherapy 360

for oesophagogastric cancer 352Adriamycin, as part of a combination regimen for treating gastric cancer 350

of oesophageal squamous papilloma 267–268

of peptic ulcer disease 91

of small bowel neoplasms 194–195

Aetiology (cont.)

of splenic artery aneurysms 146

of splenic rupture 147–148

Age/aging

changes within muscle fibres with 54

and incidence of achalasia 79–83

and incidence of atrophic gastritis 271

and mortality rate after total gastrectomy and D2

dissection 340

Alcohol

association of atrophic gastritis type B with 272

effect of, on gastric cancer development 170

as a risk factor in squamous cell carcinoma of the

American Association for the Surgery of Trauma,

Organ Injury Scaling of 65

American Joint Committee on Cancer (AJCC), TNM

staging system of, for determining prognosis

in small bowel adenocarcinoma 202

American National Cancer Database, data on small

bowel cancer 194

American Society of Gastrointestinal Endoscopy,

surveillance guidelines for squamous cell

carcinoma 266

Amine precursor uptake and decarboxylation

(APUD) cells, of the stomach 27

iron-deficiency, web associated with 84

pernicious, association with autoimmune

atrophic gastritis 271

risk of gastric cancer in 98

See also Haemolytic anaemia

of the stomach 25–26Anterosuperior surface, of the stomach 20Antibiotics, in Crohn’s disease 106Antibodies

IgA, proliferative disorder of, in the smallintestine 203

IgG, directed towards platelet-associated antigen61–62

IgM, synthesis in the spleen 60, 131–132production by the spleen 134–135Antidiarrhoeal agents, for medical treatment ofCrohn’s disease 105

Antioxidants, role in the aetiology of intestinalmetaplasia 273–274

Antiplatelet factor, immune thrombocytopenicpurpura caused by 61–62

Antireflux mechanism, physiology of 13–14Antireflux surgery, for gastro-oesophageal refluxdisease 73–76

Antral cancer, association of, with Helicobacter

pylori infection 92

Aortic opening, in the diaphragm 48, 118APC gene, loss of heterozygosity in oesophagealadenocarcinoma 262

Aphthoid ulceration, in Crohn’s disease 102–103Apoptosis

of metaplastic stem cells in Barrett’s oesophagus261–262

mutation of genes involved in, Bcl10 234Appleby’s operation, defined 340

Arcuate ligaments, and structure of the diaphragm45–46

Argentaffin cells

of the pyloric zone of the stomach 30Argyrophilic cells, of the pyloric zone of thestomach 30

Armed Forces Institute of Pathology, data onmetastatic neoplasms of the small bowel 205Arteries

carrying blood supply to the diaphragm 49carrying blood supply to the stomach 21–23

of the foregut 2gastroepiploic 22, 60mesenteric, blood supply to the midgut through43–44

musculophrenic 48nutrient, of the oesophagus 7pancreatic 23, 128

dorsal 128

of the small intestine 40

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damage to the stomach by 30

reduction of oesophageal COX-2 by 262–263

Asplenia 134–135

Atelectasis, pulmonary, after splenectomy 227

ATPase, H+-K+, for transport of protons onto the

luminal surface of the stomach 31Atresia

developmental, in the small intestine 44

diaphragmatic 45–46

of the oesophagus 5

Auerbach’s plexus 8

oesophageal motility disorder in 82–83

Autoimmune disorders, gastritis 244

atrophic 271

Autoimmune haemolytic anaemia (AIHA),

diagnosis and treatment of 63–64Autosplenectomy, in sickle cell disease 140

Autotransfusion, due to contraction of the spleen

131Autotransplantation, splenic 147–148

to manage post-splenectomy infections 66

Azygos vein, anatomy of 4

passage through the diaphragm 48

B

Babesiosis, as a complication of splenectomy,

66Bacteria, 66

polysaccharide-encapsulated, elimination by the

spleen 131–132

in the small intestine and large intestine 41

See also Helicobacter pylori

Balloon dilatation, oesophageal 282

Balloon testing, of oesophageal reaction 71

Barium enema, double contrast, for evaluating

large bowel Crohn’s disease 105Barium radiology

for diagnosing small bowel tumours 200

meal for contrast radiography evaluation 294

of the small bowel 295–296

Barium swallow

for diagnosing oesophageal cancer 157

for gastrointestinal evaluation 292–294

Barrett’s cancer, early, sentinel lymphadenectomy

for 333

Barrett’s metaplasia, defined 243Barrett’s oesophagus 156adenocarcinomas associated with 318columnar metaplasia of the lower oesophagus

in 6gastro-oesophageal reflux disease associated with 72–73

identifying on endoscopy 70incidence of, and scleroderma 83location of the squamocolumnar junction in 5premalignant potential of 187–188, 259B-cell lymphoma, transformation of mucosaassociated lymphoid tissue 254Benign tumours, oesophageal 86–87Benzodiazepines, for sedation in endoscopy281–282

Bezoars, gastric, managing 98Bicarbonate-chloride exchange, in the interstitium

of the stomach 31Bile reflux

aetiology of Barrett’s oesophagus in 261

as an atrophic gastritis risk factor 272after Billroth II reconstruction 177intestinal metaplasia promotion by 273reactive gastritis due to 244

Bile salt, malabsorption of, after resection of thesmall bowel 113

Biliary ducts, embryonic development of 19Biliary imaging, with radiopharmaceuticals 303

Biliary tree, gas seen within, plain abdominal film 290–291

Billroth II gastrectomyfor bleeding gastric ulcers 94for gastric cancer 177Biological therapies, for oesophagogastric cancer351

Biopsybleeding from the site of, in diagnostic endoscopy 281

value of, in gastric cancer diagnosis 172Bleeding

from gastrointestinal stromal tumours 211–212

from peptic ulcers 93–94from schwannomas 209from small bowel tumours 198

See also Haemorrhage

Blind loop syndrome 112Blood flow

altered splenic, splenomegaly due to 61diaphragmatic, during inspiration 56Blood supply

Blood tests

for evaluating Crohn’s disease 104

for evaluating oesophageal cancer 158

B lymphocytes

IgA-producing 203

increase in Crohn’s disease 102

of the white pulp of the spleen 60

Body mass index

gastro-esophageal junction cancer associated with

188

oesophageal adenocarcinoma risk and 182

See also Obesity

Boerhaave’s syndrome, site of 5

Bombesin (gastrin-releasing peptide), effect of, on

gastrin release from G cells 34

Bowel preparation, before surgery for Crohn’s

Breast cancer, metastasis to the small bowel 205

Breathing, quiet, contraction of the diaphragm

during 50–51

Bristol Royal Infirmary, study of the resistance of

the small bowel to carcinogens 194

British Stomach Cancer Group

comparison of radiotherapy, chemotherapy, and

no further treatment, in stomach cancer 366

evaluation of chemoradiation after gastric cancer

Burkitt’s lymphoma, primary gastric 231

Bursectomy, to avoid tumour exposure 341

C

Cadherin-catenin complexes, changes in, with

squamous epithelial dysplasia 266

Cajal cells, gastrointestinal stromal tumour origin in

208

Calcification, viewing, on plain film for

gastrointestinal evaluation 291

Calcitonin, release from C cells of the thyroid gland,

effect on gastric activity 35

Calcium, reabsorption of, in the stomach 97Calcium channel blockers, for treating diffuseoesophageal spasm 81

Calcium ion (Ca2+) pumping, by the sarcoplasmicreticulum, in relaxation of the diaphragmmuscle 53–54

Carbonic anhydrase, of the mucosa of the stomach31

Carcinoid syndrome 204Carcinoid tumoursdefined 254

of the small intestine, association with coeliacdisease 196, 203–204

Carcinomabronchiogenic, metastasis to the small bowel 205

of the cardia 318oesophageal, metastasis of 7small cell 253

squamous, in achalasia 242risk of, in high grade dysplasia 251–252salivary gland, tumours resembling 253undifferentiated 253

See also Cancer; Neoplasms

Carcinoma in situ, of the oesophagus and upperaerodigestive tract 250

Carcinosarcoma, of the oesophagus 247–250Cardiac orifice, communication of the oesophaguswith the stomach via 20

Cardiac zone, of the gastric mucosa 29Cardiovascular defects, association withoesophageal malformations 2ß-Carotene, diet level of, and incidence of squamousepithelial dysplasia and carcinoma 265Carotenoids, role in development of intestinalmetaplasia of the stomach 275Catenin

ß, over-expression of, and outcome in gastriccancer 169

role in diffuse gastric cancer 275Caustic injury, oesophagitis due to 76–77Caval foramen, of the diaphragm 118Central tendon, of the diaphragm 46Cephalic phase, of gastric acid secretion 33–34C-erbB2 over-expression, association with intestinalcancer 169

Chagas’ disease, achalasia caused by 79Chemoradiotherapy (CRT) 360–366for adenocarcinoma of the duodenum 193–194definitive, for oesophageal cancer 361–364for oesophageal cancer 163–164

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preoperative, for adenocarcinoma of the

duodenum and pancreas 202for stomach cancer 367

Chemotherapy

adjuvant, in adenocarcinoma of the small bowel

193–194after antibiotic therapy for mucosal associated

lymphoid tissue lymphoma 237combination regimens, for oesophagogastric

cancer 350–351for gastric cancer 179

for immunoproliferative small intestinal disease

203palliative, for gastric cancer 180

for oesophageal cancer 162

after surgery for adenocarcinoma of the stomach,

randomised trial 366for upper gastrointestinal neoplasms 349–358

Chest, imaging with plain radiology 287–289

Chimeric monoclonal antibody, mouse-human, for

treating Crohn’s disease 106China, incidence of oesophageal cancer in 182

Chloramphenicol, for treating typhoid enteritis

110Chloroquine, perioperative administration of, in the

tropics 143Cholecystography, oral 292

Cholecystokinin (CCK)

effects of, on pancreatic enzymes and bile

production 42production of, in crypts of the intestine 40

release in the intestine, suppression by

somatostatin 32release in the small intestine, effect on gastric

activity 35Cholesterol, accumulation of, in Niemann-Pick

disease 145Cholestyramine, for bile salt diarrhoea in Crohn’s

disease 105Cholinergic excitation, in peristalsis 11

Chromosomes

3, trisomy in mucosal associated lymphatic

disorders 2345q, gene for adenomatous polyposis coli on 197

6, IBD3 locus of, association with Crohn’s disease

1029p13.3, association with Peutz-Jeghers syndrome

See also Genes; Genetic disorders

Chronic lymphocytic leukaemia (CLL) 63splenomegaly in 223–224

Chronic myeloid leukaemia (CML), splenomegaly

in 223Chronic obstructive airway disease, pneumatosiscystoides intestinalis associated with 111

Chylothorax, from damage during mobilisation ofthe oesophagus 4

Cimetidine, effects of, on acid secretion 34Cisplatin

in a definitive chemoradiotherpy trial 361for management of gastric cancer, in acombination regimen 350for palliation in oesophageal cancer 162c-KIT positive gastrointestinal neoplasmsorigins of 212–214

as stromal tumours 208treating with imatinib mesylate 215

C-kit positive tumours, gastrointestinal stromal

tissue 254Classificationfor gastric cancer 338Lauren, for gastric tumours 167–169, 250Revised European-America Lymphoma (REAL),203

TNM 157–158for oesophageal lymph nodes 8Clinical presentation

of Brunner’s gland adenoma 201

Coeliac axis, embryology of 2Coeliac disease (non-tropical sprue)lymphocytic gastritis associated with 244

as a predisposing factor for gastrointestinalmalignancies 196, 203–204

Coeliac plexus, nerves supply of the stomachderived from 26–27

Colon cancer, resection of the spleen in 225Colonisation, in progression of Barrett’soesophagus, after metaplasia occurs 261

Colostomy enema 296

Complement activation, in the spleen 60

Complications

after achalasia surgery 81

acute gastric dilatation, after upper abdominal

for diagnosis, of oesophageal cancer 159

of small bowel tumours 199–200

of splenic artery aneurysm 146

of splenic neoplasms 225

of splenic cysts 137

for staging, in gastric cancer 173

in upper gastrointestinal cancer 297–299

Condensed dynamic image (CDI), from

oesophageal transit study data 309

hereditary non-polyposis colorectal cancer 197

involving the stomach 19, 91

von Recklinghausen’s disease, adenocarcinoma

of the small bowel and 197–198

See also Chromosomes; Genetic disorders

Congenital diaphragmatic hernia (CDH)

to antireflux surgery 74–75

to infliximab therapy 106

to laparoscopic splenectomy 64, 227Contrast radiography, gastrointestinal 292–296Costal elements, of the diaphragm 117Costodiaphragmatic recesses, formation of 47–48COX-2 expression, in Barrett’s metaplasia andoesophageal adenocarcinomas 262–263Cricopharyngeus (upper oesophageal sphincter) 5Criteria, for endoscopy 282

Crohn’s disease (regional ileitis) 101–109

as a predisposing factor for small bowelneoplasms 195

Cross-sectional imaging, gastrointestinal 296–302Crural diaphragm

attachment of 45–46development from muscle fibres 47repair of 75

in the sphincter mechanism at theoesophagogastric junction 13Culling, of red cells from the blood 128, 135Curvatura ventriculi, major and minor, anatomy of20

Curvatures, of the stomach 20Cyclin D1, interaction with nitrosamines, insquamous epithelial dysplasia 266Cysts, of the spleen 136–137

Cytogenetic abnormalities, in the lymphoidpopulation 234

Cytokeratin, changes in binding of in squamousepithelial dysplasia 266

Cytokeratin antibodies, monoclonal, forimmunohistochemical staining of lymphnodes 325–327

Cytokines

in Barrett’s oesophagus 262

release of, in Helicobacter pylori infection 92

Cytology, for staging in gastric cancer 173Cytomegalovirus (CMV) infectionoesophagitis associated with infection by 77oesophagitis caused by 243–244

Cytotoxin-associated gene A (Cag A), gastricatrophy related to 272

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Desmoid tumours, association with adenomatous

polyposis coli 197Developmental anomalies, affecting the diaphragm,

table 120Diagnosis

of achalasia 242

of diaphragmatic rupture 124–125

of eventration of the diaphragm 123

of gastric cancer 171–172

of gastrointestinal stromal tumours 212–214

of mucosal associated lymphoid tissue lymphoma

233

of neoplasms involving the spleen 225–226

of oesophageal cancer, tests for 157

of peptic ulcers 92

of perforation in gastric ulcer 95

of phrenic palsy 123

of small bowel tumours 198–201

of squamous epithelial dysplasia 266

with upper gastrointestinal endoscopy 279–282

Diaphragm

anatomy of, surgical 117–126

anatomy and physiology of 45–58

and risk of chronic gastritis 170

role in squamous epithelial dysplasia and

carcinoma development 265

See also Nutrition

Dieulafoy syndrome, gastrointestinal bleeding in 94

Differential diagnosis

of spleen lesions 222

of tropical splenomegaly syndrome 142

Differentiation, of gastric cancers 167–169

Diffuse oesophageal spasm (DES), oesophageal

transit scintigraphy for identifying 309Dilatation

D1 versus D2, in gastric cancer 175

Diverticular disease, small bowel 111

DNA repair gene, ERCC1, resistance to cisplatin bytumours with high levels of 357

Docetaxel, in a multiple drug regimen for treatingoesophagogastric cancer 351

Dor fundoplication, for treating achalasia 81Dorsal mesogastrium, embryonic development of18–19

Dorsal yolk sac, development of the oesophagusfrom 1–2

Drainage See Lymphatic drainage

Drugscapecitabine, for oesophagogastric cancer 351chloramphenicol, for treating typhoid enteritis110

chloroquine, perioperative administration of, inthe tropics 143

cholestyramine, for bile salt diarrhoea in Crohn’sdisease 105

cimetidine, effects on acid secretion 34cisplatin, in a definitive chemoradiotherpy trial361

for management of gastric cancer, in acombination regimen 350

for palliation in oesophageal cancer 162cocetaxel, in a multiple drug regiment for treatingoesophagogastric cancer 351

epirubicin, cisplatin, 5-fluorouracil regimen fortreating oesophagogastric cancer 351for gastric cancer, in a combination regimenfor chemotherapy 350

ethambutol, for treating tuberculous enteritis 109etoposide, for management of gastric cancer, in acombination regimen 350

5-fluorouracil, in a definitive chemoradiotherapytrial 365

in management of adenocarcinoma of thejejunum and ileum 202

in management of gastric cancer 350for palliation in oesophageal cancer 162imatinib mesylate, for treating gastrointestinalstromal tumours 215

iminodiacetic acid (IDA) derivatives 303infliximab, contraindications to therapy with 106for treating Crohn’s disease 106

irinotecan, for chemoradiotherapy in oesophagealcancer 364

in a multiple drug regimen for treatingoesophagogastric cancer 351isoniazid, for treating tuberculous enteritis 109lansoprazole, for treating peptic ulcer disease 93leucovorin, in adenocarcinoma management 202

in gastric cancer management 350lidocaine throat spray, using in endoscopy 281methotrexate, for management of gastric cancer350

metronidazole, for perianal disease 106mitomycin-C, for management of gastric cancer,

octreotide, for radiopharmaceutical imaging 304

oxaliplatin, for chemoradiotherapy in

penicillin, after splenectomy 150–151, 228

pentostatin, for treating hairy cell leukemia 63

ranitidine, effects on acid secretion 34

for treating peptic ulcer disease 93

rifampicin, for treating tuberculous enteritis 109

sulfasalazine, for treating Crohn’s disease

after gastric surgery 96

Duodenal ampulla, role in digestion 41

Duodenal diverticula 111

Duodenal mucosa, production of the

cholecystokinin in 42

Duodenogastric reflux, after gastric surgery 97

Duodenopancreatectomy, partial, for treating

gastrointestinal stromal tumours 215 See

therapeutic endoscopy for cancer of 285

vasoactive intestinal peptide of 32

Duplications

accessory spleens 132–134

of the embryological oesophagus 86

of the stomach, complete and incomplete 19

Dyes, as diagnostic adjuncts in uppergastrointestinal endoscopy 280–281Dysphagia, after antireflux surgery 76Dysplasia

defined 274and gastric cancer 97, 274glandular, in the oesophagus and stomach251–253

high grade, and risk of adenocarcinoma 263natural history of 263

E

Eastern Cooperative Oncology Group (ECOG),randomised trial of chemoradiotherrapyversus radiotherapy, for squamouscarcinoma 361

E-cadherinrole in Barrett’s oesophagus 262role in diffuse gastric cancer 169, 275ECF (epirubicin, cisplatin, 5-fluorouracil) regimen,for treating oesophagogastric cancer 351Efficacy, of lymph node dissection in stomachcancer 338–339

Elastic properties, of the diaphragm 50Elastin fibres, of the body of the oesophagus 6Electrical activity, resting, within the stomach 35Embolisation

of the spleen, risks and utility of 151–153splenic infarct resulting from 146–147Embryology

of the diaphragm 46–48

of the oesophagus 1–2anomalies arising during development 241

of the small intestine 43–44

of the spleen 59, 127–128

of the stomach 17–19

En bloc resection, defined 340Encephalin, of the gastrointestinal tract 33Endopeptidases, in the stomach 30Endoscopic anatomy, of the oesophagus 5Endoscopic mucosa resection (EMR)for gastric cancer 174

for oesophageal dysplasia and cancer, outcomes266

for tumours of the distal oesophagus 332–333Endoscopic treatment, of oesophageal cancer162–163

Endoscopic ultrasound (EUS)for assessing mucosal associated lymphoid tissuelymphoma 235–236

for diagnosing gastrointestinal cancer 211for diagnosing oesophageal cancer 159–161gastrointestinal evaluation using 297Endoscopy

appearance of gastric lymphoma on 231oesophageal, for diagnosing cancer 157small bowel, for diagnosing tumours 200–201upper gastrointestinal 279–286

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Enteric neurones, secretion of acetylcholine by 35

Enterochromaffin cells, of the pyloric zone of the

stomach 30Enteroclysis, for diagnosing small bowel tumours

200, 301–302Enterocrinin, secretion of, from the duodenal

mucosa 42Enteroendocrine cells, location and function of 40

Enterogastric reflex 35

Enteroglucagon, as a factor in adaptation of the

small bowel after resection 113Enterokinase, secretion of, in the small intestine 40

Enteropathy-associated T-cell lymphoma (EATL)

203Enteroscopy, techniques of 285

Environmental factors, in development of gastric

atrophy 271–272Eosinophilic oesophagitis 77

Epidemiology

of Barrett’s oesophagus 259–264

of Crohn’s disease 101

of gastric cancer 170–171

of gastrointestinal stromal tumours 210

of oesophageal squamous papilloma 267

of small bowel neoplasms 194

of squamous epithelial dysplasia 264–265

Epidermal growth factor (EGF)

duodenal juice as a source of 113

R2 receptor for, overexpression in gastric cancer

274receptor for, potential for drugs targeting 351

Epidermolysis bullosa, association with pyloric

atresia 19Epigastric arteries, path between the sternal and

costal margins of the diaphragm 48Epiphrenic diverticula 84

Epirubicin, for gastric cancer, in a combination

regimen for chemotherapy 350Epithelial dysplasia, squamous oesophageal, as a

premalignant lesion 259Epithelial neoplasms, of the stomach 167–180

Epithelial tumours, of the small bowel

benign 201

malignant 201–202

Epithelium

lining the stomach 28

squamous, of the oesophageal mucosa 6

Eradication therapy

for Helicobacter pylori infection, in mucosal

associated lymphoid tissue 235

for peptic ulcer disease caused by Helicobacter

pylori 93 Escherichia coli, infection by, after splenectomy 66

Ethambutol, for treating tuberculous enteritis 109

Ethyl alcohol, absorption from the stomach 33

Etoposide, for management of gastric cancer, in a

combination regimen 350Eventration of the diaphragm 122–123

Exocrine secretions, suppression of release in thepancreas, by somatostatin 32

Extended lymph node dissection (D2 dissection),indications for 339–340

Extracorporeal membrane oxygenation (ECMO), formanaging infants with congenital

diaphragmatic hernia 121Extraintestinal features, of Crohn’s disease 104Extramural system, of zones of lymphatic drainage

of the stomach 24–25Extraperitoneal lymph vessels, path across thediaphragm 48

F

Familial adenomatous polyposis (FAP)association with small bowel neoplasms 196–197duodenal polyps in 201

Familial oesophageal and upper gastrointestinalleiomyomatosis 209

Fas gene, effect of mucosal inflammation onexpression of 262–263

Fasting state, physiology of the oesophagus in 8–9Fiberoptic direct visualisation endoscopy, fordiagnosing gastrointestinal disease 279Finney type stricturoplasty, in Crohn’s disease 108Fistulas

of the small bowel 112–113splenic, as a complication of splenic abscess137–138

tracheo-oesophageal 2Fitness, assessment of, in treating gastric cancer173

Flow cytometry, for evaluating biopsy specimen,oesophageal 264

Fluid retention, after D2 dissection 3405-Fluorouracil

in a definitive chemoradiotherapy trial 365

in management of adenocarcinoma of thejejunum and ileum 202

in management of gastric cancer 350for palliation in oesophageal cancer 162Focal disease, of the spleen 136–137Follicular lymphoma, splenic, relationship withhepatic schistosomiasis 143

Follow-up, in achalasia management 313–314Foramen

of Morgagni 117

of Winslow, anatomy of 21formation of 19Foramen, diaphragmatic 118–119Foramen ovale, failure to close in neonates withcongenital diaphragmatic hernia 120–121

Foreign bodies, ingestedremoval from the stomach 283small bowel damage from 114Free radicals, in ulcerated gastro-oesophagealmucosa, effects of 262

French University Association for Surgical

Research, randomised trial, radiotherapy or

no further treatment after oesophagectomy

360

Fryns syndrome, diaphragmatic hernia in 119

Functional foregut disorder (FFD), association with

upper gastrointestinal dysfunction 78–79

Fundic glands (principal glands), of the oxyntic

zone of the stomach 29

Fundoplication, in treating gastro-oesophageal

Ganglionated sympathetic trunks, transmission

through the diaphragm 48

Gastrectomy

Billroth II, for treating bleeding gastric ulcers 94

total versus subtotal 335–336

Gastric acid

formation and secretion of, in parietal cells of the

stomach 31

secretion of, control mechanisms 33–35

suppression of release in the stomach, by

somatostatin 32

Gastric artery

left, oesophageal branches of 4–5

supply of blood to the stomach by 21–22

right, anatomy of 22

Gastric atrophy, defined 271

Gastric cancer

adjuvant therapy for 352

association with gastric surgery 97

direct spread to the spleen 225

distal, pandemic 170

lymph node dissection in 337–339

neoadjuvant chemotherapy for 353

therapeutic endoscopy for 284–285

Gastric dilatation, acute, as a complication of

surgery 98

Gastric emptying

delayed, after truncal vagotomy 97

radiopharmaceuticals for studying 304–305

Gastric epithelium, characteristics of, versus

intestinal epithelium 243

Gastric glands, cells of the epithelial lining of the

stomach continuing into 28

and hunger contraction 35–36

Gastric mucosa, zones of 28–30

Gastric nodes, drainage from the stomach into24–25

Gastric outlet obstruction, barium meal to indicatethe nature of 172

Gastric phase, of stimulated secretion 35Gastric pits, glands of the stomach opening into28–29

Gastric polyps 275–276Gastric secretions 30–31effect of vasoactive intestinal peptide on 32regulation of 33–36

Gastric Surgical Adjuvant Radiotherapy ConsensusReport, on planning postoperative

chemoradiotherapy 367Gastric therapy

endoscopic 283types of resection 335–337Gastric tone, effects of abnormalities in 35–36Gastric ulcer, differentiating from gastric cancer172

Gastric varices, management of, endoscopically 283

Gastric veins, anatomy of 23Gastric volvulus, association of, with para-oesophageal hiatus hernia 98Gastrin

secretion of, increase in Helicobacter pylori

infection 92

in the stomach 30sources and characterisation of 31–32suppression of release in the stomach, bysomatostatin 32

Gastrin peptide vaccine G17dt, for treating gastriccancer 180

Gastritisacute, gastrointestinal haemorrhage from 97chronic, risk of gastric cancer associated with 98

of the oesophagus 244–246reactive 244

Gastroduodenal artery, anatomy of 22Gastroduodenal Crohn’s disease, surgery for 108

Gastroduodenal junction, anatomy of 20Gastroenteric reflex 41–42

Gastroenterostomy, outcomes of 178–179Gastroepiploic arteries 22

left, branch of the splenic artery 60Gastroepiploic nodes

left, drainage from the stomach into 25right, drainage from the stomach into 24Gastroepiploic veins, anatomy of 23–24Gastro-esophageal junction, cancer at 187–191Gastroileal reflex 41–42

Gastrointestinal autonomic nerve tumours (GANT),c-KIT positive 209

Gastrointestinal features, of Crohn’s disease103–104

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