Rising incidence of esophageal adenocarcinoma in Western countries: is it possible to identify a population at risk?

Symptomatic gastroesophageal reflux disease (GERD) and Barrett's mucosa are risk factors for esophageal adenocarcinoma (ADC). The aim of this study was to analyze the anthropometric features and prevalence of GERD in patients with ADC compared with patients with squamous cell carcinoma (SCC) and control subjects. A total of 262 patients with ADC and 302 with SCC were enrolled consecutively. A control group of 262 individuals, sex and age matched to the ADC group, and an additional group of 138 patients with GERD confirmed by 24-h pH monitoring were used for comparison. The prevalence of symptomatic GERD was 32.4% in the subgroup of patients with Barrett's ADC (male-female=6.4:1; mean age=62 years) vs. 8% in those with gastric cardia carcinoma (P< 0.01), 3% in the SCC group (P< 0.01), and 10% in the control group (P< 0.01). ADC patients, controls and refluxers had similar body mass index (BMI) that was significantly higher than in the SCC group (P< 0.05). Whether surveillance endoscopy is indicated in men over 50 years with a long-lasting history of GERD and a BMI >25 remains to be determined.

Molecular alterations of Barrett's esophagus on microdissected endoscopic biopsies

Alterations in proto-oncogenes and tumor suppressor genes play a role in the sequence from Barrett's metaplasia to esophageal adenocarcinoma. The present study aims to ascertain whether molecular abnormalities take place in Barrett's metaplasia and low-grade dysplasia and to correlate them with the histological features of the esophageal mucosa. Forty-one formalin-fixed, paraffin-embedded endoscopic esophageal biopsies were classified according to the type of metaplastic changes (noncolumnar fundic and cardial metaplasia; columnar metaplasia, with and without intestinal features). After microdissection samples were examined for loss of heterozygosity (LOH) using polymorphic markers on 5q (D5S82), corresponding to APC (adenomatous polyposis coli) gene, 13q (CA repeat in intron 2 position 14815 to 14998 of the retinoblastoma gene), 17p (D17S513) corresponding to p53 locus, and for p53 mutations. Molecular alterations including LOH, allelic imbalance, and microsatellite instability could be detected in all types of metaplastic changes and sporadically in the squamous epithelium adjacent to the metaplastic tissue. Molecular alterations involving microsatellites D5S82 and the CA repeat inside the retinoblastoma gene were more frequent in nonintestinal metaplasia whereas those involving the p53 locus took place in columnar intestinal metaplasia and in low-grade dysplasia. Clonal changes were demonstrated in different metaplastic areas in three patients. Genetic alterations comprising LOH and microsatellite instability characterize Barrett's mucosa and appear related to the type of metaplastic change. Some of them precede the development of intestinal metaplasia, suggesting that genetic alterations take place earlier than previously thought.

Bone marrow-disseminated tumor cells in patients with carcinoma of the esophagus or cardia

BACKGROUND

The long-term prognosis after surgical therapy for esophageal carcinoma depends on tumor stage and completeness of resection. Similarly to other epithelial tumors, the presence of micro deposits of neoplastic cells in the bone marrow may indicate residual disease and the potential for recurrence. This study assesses the prevalence of bone marrow-disseminated tumor cells in patients undergoing surgical resection for esophageal carcinoma. In addition, we investigated the agreement between immunohistochemical and molecular techniques for the detection of micrometastases in a subgroup of patients.

METHODS

Between January 1998 and November 1999, forty-eight patients with adenocarcinoma of the esophagogastric junction (n = 29) or squamous cell carcinoma of the thoracic esophagus (n = 19) and no evidence of overt metastatic disease entered the study. An immunohistochemical assay (capable of detecting 1 carcinoma cell in 7 x 10(5) bone marrow cells) was used to test bone marrow obtained by flushing a resected rib or by needle aspiration either of the iliac crest or of a rib. A polymerase chain reaction (PCR) molecular technique was also used to identify bone marrow and peripheral blood epithelial cells.

RESULTS

Cytokeratin-positive cells were found in 79.1% of the bone marrow samples obtained from the rib, and in only 8% of the needle aspirates either from the iliac crest or from a contiguous rib: This difference is probably explained by the improved removal of metastatic cells with the flushing of the rib. Comparable results were obtained at a qualitative level by the PCR technique on bone marrow. In addition, PCR-positive results were found in 3 of 18 peripheral blood samples. There was no association with tumor type, neoadjuvant therapy, or lymph node status. Patients with a pT3 or pT4 tumor showed, at a borderline statistical level, a higher proportion of cytokeratin-positive cells in the flushed rib.

CONCLUSIONS

Bone marrow-disseminated tumor cells are present in the resected rib of a high proportion of patients undergoing esophagectomy for carcinoma, and immunohistochemistry seems to be the method of choice for their quantitative assessment. However, the prognostic and therapeutic implications of this finding need further investigation.

Intestinal metaplasia is the probable common precursor of adenocarcinoma in barrett esophagus and adenocarcinoma of the gastric cardia

BACKGROUND

Intestinal metaplasia in the tubular esophagus is the recognized precancerous lesion of adenocarcinoma in Barrett esophagus. However, it is not yet clear whether adenocarcinoma of the gastric cardia arises from the same premalignant lesion, i.e., intestinal metaplasia of the gastric cardia. The purpose of this study was to compare adenocarcinomas in Barrett esophagus and adenocarcinomas of the gastric cardia at an early stage, when it was more likely that intestinal metaplasia had not been completely overgrown by the tumor.

METHODS

The authors compared the epidemiologic, clinical, and pathologic features of early stage adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia from 42 patients who underwent resection surgery. The presence of intestinal metaplasia was assessed in the resected specimens by using Alcian blue (pH 2.5) staining.

RESULTS

Intestinal metaplasia was detected in the mucosa adjacent to neoplasia in 25 of 26 patients with adenocarcinoma in Barrett esophagus and in 11 of 16 (69%) patients with adenocarcinoma of the gastric cardia. Patient and tumor characteristics and survival were comparable in both groups.

CONCLUSIONS

Intestinal metaplasia is a very common finding in the mucosa adjacent to early stage adenocarcinoma of the gastric cardia. Adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia may represent the same disease; the former arises from longer segments of intestinal metaplasia and the latter from intestinal metaplasia of the cardia.

Intestinal metaplasia is the probable common precursor of adenocarcinoma in barrett esophagus and adenocarcinoma of the gastric cardia

BACKGROUND

Intestinal metaplasia in the tubular esophagus is the recognized precancerous lesion of adenocarcinoma in Barrett esophagus. However, it is not yet clear whether adenocarcinoma of the gastric cardia arises from the same premalignant lesion, i.e., intestinal metaplasia of the gastric cardia. The purpose of this study was to compare adenocarcinomas in Barrett esophagus and adenocarcinomas of the gastric cardia at an early stage, when it was more likely that intestinal metaplasia had not been completely overgrown by the tumor.

METHODS

The authors compared the epidemiologic, clinical, and pathologic features of early stage adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia from 42 patients who underwent resection surgery. The presence of intestinal metaplasia was assessed in the resected specimens by using Alcian blue (pH 2.5) staining.

RESULTS

Intestinal metaplasia was detected in the mucosa adjacent to neoplasia in 25 of 26 patients with adenocarcinoma in Barrett esophagus and in 11 of 16 (69%) patients with adenocarcinoma of the gastric cardia. Patient and tumor characteristics and survival were comparable in both groups.

CONCLUSIONS

Intestinal metaplasia is a very common finding in the mucosa adjacent to early stage adenocarcinoma of the gastric cardia. Adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia may represent the same disease; the former arises from longer segments of intestinal metaplasia and the latter from intestinal metaplasia of the cardia.

Intestinal metaplasia is the probable common precursor of adenocarcinoma in barrett esophagus and adenocarcinoma of the gastric cardia

BACKGROUND

Intestinal metaplasia in the tubular esophagus is the recognized precancerous lesion of adenocarcinoma in Barrett esophagus. However, it is not yet clear whether adenocarcinoma of the gastric cardia arises from the same premalignant lesion, i.e., intestinal metaplasia of the gastric cardia. The purpose of this study was to compare adenocarcinomas in Barrett esophagus and adenocarcinomas of the gastric cardia at an early stage, when it was more likely that intestinal metaplasia had not been completely overgrown by the tumor.

METHODS

The authors compared the epidemiologic, clinical, and pathologic features of early stage adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia from 42 patients who underwent resection surgery. The presence of intestinal metaplasia was assessed in the resected specimens by using Alcian blue (pH 2.5) staining.

RESULTS

Intestinal metaplasia was detected in the mucosa adjacent to neoplasia in 25 of 26 patients with adenocarcinoma in Barrett esophagus and in 11 of 16 (69%) patients with adenocarcinoma of the gastric cardia. Patient and tumor characteristics and survival were comparable in both groups.

CONCLUSIONS

Intestinal metaplasia is a very common finding in the mucosa adjacent to early stage adenocarcinoma of the gastric cardia. Adenocarcinoma in Barrett esophagus and adenocarcinoma of the gastric cardia may represent the same disease; the former arises from longer segments of intestinal metaplasia and the latter from intestinal metaplasia of the cardia.

Esophagobronchial fistula after thoracoscopic resection of an epiphrenic diverticulum

We report a case of a 54-year-old man presenting with recurrent epiphrenic diverticulum and esophagobronchial fistula 3 years after thoracoscopic diverticulectomy. Surgical correction required transhiatal stapling of the pouch combined with distal esophageal myotomy and Dor fundoplication.

Achalasia: dilation, injection or surgery?

Achalasia results from irreversible alterations of the esophageal myenteric plexus. The target of treatment in this setting is to reduce lower esophageal sphincter resistance to passage of the bolus. Definitive treatment of the disease requires pneumatic dilation or Heller myotomy. Although no controlled studies comparing modern endoscopic and surgical techniques are available, laparoscopic surgery is emerging as the initial intervention of choice.

Esophageal cancer: a European perspective

A survey was conducted among a group of European surgeons in order to investigate current attitudes and strategies in the management of squamous cell carcinoma of the esophagus. The survey consisted of a questionnaire mailed to surgeons in eight different countries with extensive clinical experience and scientific interest in the field. Eight questionnaires including the data of 6146 operated patients were available for analysis. A consensus emerged among the panelists that protocols of induction therapy should be routinely used in patients with locally advanced disease, especially in supracarinal tumors. Four of the surgeons advocated bilateral neck dissection in these patients. A progressive improvement in survival over the past three decades was noted. After 1990, the postoperative mortality rate was 6.2% after surgery alone and 9.7% after chemoradiation therapy followed by surgery. The 5-year survival rate after a complete resection was 38.5%. In the opinion of the panelists, esophagectomy remains the "gold standard" of therapy and should be regarded as an integral component of the treatment plan for patients with squamous cell carcinoma.

[Staging by immediate preoperative laparoscopy in adenocarcinoma of the distal esophagus and cardia]

Accurate preoperative staging of adenocarcinoma of the esophagus and cardia is critical to select the proper treatment in the individual patients, i.e., resection, neoadjuvant therapy, or endoscopic palliation. Aim of this study was to assess the role of laparoscopy in detecting intra-abdominal metastatic spread in patients with adenocarcinoma of the esophagus and cardia. Between November 1995 and May 1998, 45 patients with histologically-proven adenocarcinoma of the cardia--without any previous treatment--and negative or inconclusive findings at computed tomography (CT) and ultrasonography (US) underwent staging laparoscopy at the same session of the planned surgical resection. The mean operative time of the procedure was 25 minutes (range 15-55 min). Laparoscopy led to change the therapeutic approach in five patients (11.1%): three patients with peritoneal carcinomatosis and one with a liver metastasis undetected at preoperative imaging studies did not have resection; conversely, one individual with liver hemangioma simulating a metastatic mass at CT underwent esophagogastric resection. In patients with adenocarcinoma of the esophagus and cardia, laparoscopy is useful to increase accuracy of detection of metastases; when performed as the first step of a planed resection, it avoids unnecessary laparotomies and does not increase the complexity of preoperative evaluation.

Benign tracheoesophageal fistula: results of surgical therapy

Acquired fistulas between the trachea and the esophagus (TEFs) are unusual, serious and still challenging clinical entities. Between 1980 and 1997, 31 patients with acquired benign TEF were evaluated and treated in our department. The definitive treatment was undertaken when patients were weaned from the ventilator. Dissection of the fistula and closure of the tracheal and esophageal defect was performed in 26 patients. Esophagogastroplasty plus closure of the tracheal defect and omental interposition was performed in two patients. Tracheal resection and reconstruction plus of the sternocleidomastoid muscle interposition was carried out in one patient with circumferential tracheal damage. In two patients, no surgical treatment was carried out. One patient died after surgical treatment. In 23 patients, long-term follow-up was excellent, with normal post-operative function of both the esophagus and the airway. Two failures of treatment occurred which required definitive tracheostomy plus T-tube. Management of TEFs can be safely carried out after weaning patients from the ventilator.

Does previous endoscopic treatment affect the outcome of laparoscopic Heller myotomy?

STUDY AIM

Aim of this study was to assess symptomatic and objective outcome in patients undergoing laparoscopic Heller myotomy after unsuccessful endoscopic treatment, compared to patients having primary surgery.

PATIENTS AND METHOD

Between November 1992 and December 1998, 92 patients with esophageal achalasia underwent laparoscopic Heller myotomy and Dor fundoplication. Intraoperative endoscopy was routinely performed. Sixty patients had primary surgery (PS); 32 patients had surgery after unsuccessful pneumatic dilatation (PD) (n = 22), or botulinum toxin (Botox) injection (n = 10).

RESULTS

The mean operative time and the incidence of postoperative dysphagia were similar in the two groups. The incidence of intraoperative mucosal tears was 5% in the PS group and 12.5% in the PD/Botox group (P = NS). Mucosal tears occurred more frequently during the first 30 operations (17% vs 3.2%, P < 0.05). Median follow-up was 28 months (range 4-76). An abnormal esophageal acid exposure was documented in 2 patients in the PS group (7.7%), and in two patients in the PD/Botox group (13.3%) (P = NS). Lower esophageal sphincter pressure significantly decreased in both groups (P < 0.01). The mean percentage of radionuclide residual activity in the esophagus at 1 and 10 minutes significantly decreased in both groups (P < 0.01).

CONCLUSION

There is only a trend, although not statistically significant, towards an increased risk of complications and adverse effects in patients previously treated by PD and/or Botox. The higher incidence of mucosal tears during the first 30 operations suggests the effect of the learning curve.

Previous endoscopic treatment does not affect complication rate and outcome of laparoscopic Heller myotomy and anterior fundoplication for oesophageal achalasia

BACKGROUND

Anedoctal reports suggest a detrimental effect of pneumatic dilation and botulinum toxin injection in patients who are potential candidates for Heller myotomy.

AIMS

To assess symptomatic and objective outcome in patients undergoing Heller myotomy as a primary procedure or after failed endoscopic treatment.

PATIENTS

Between November 1992 and December 1998, 92 patients with oesophageal achalasia were treated. Sixty patients had primary surgery; 32 patients had surgery after unsuccessful pneumatic dilation (n = 22), or botulinum toxin injection (n = 10).

METHODS

Laparoscopic Heller myotomy plus Dor fundoplication with routine intraoperative endoscopy. Operative records, symptoms, and results of radiological, manometric and scintigraphic assessment in the two groups of patients were compared.

RESULTS

The mean operative time, the rate of intraoperative mucosal tears and the incidence of postoperative dysphagia were similar in the two groups. Mucosal tears occurred more frequently during the first 30 operations (p < 0.05). Median follow-up was 28 months (range 4-76). An abnormal oesophageal acid exposure was documented in 2 patients in the primary surgery group (7.7%), and in 2 patients in the pneumatic dilation/botulinum toxin group (13.3%) (p = ns). Lower oesophageal sphincter pressure significantly decreased in both groups (p < 0.01). The mean percentage of radionuclide residual activity in the oesophagus at 1 and 10 minutes significantly decreased in both groups (p < 0.01).

CONCLUSIONS

There was only a trend, although not statistically significant, towards an increased risk of complications and adverse effects in patients previously treated by pneumatic dilation or botulinum toxin. The higher incidence of mucosal tears during the first 30 operations suggests the effect of the learning curve.

[Cervical esophago-visceral anastomosis with an endoscopic linear stapler. Note on a surgical technique]

The incidence of anastomotic fistula in the neck after esophagectomy and esophagogastroplasty may be as high as 30%; the incidence of anastomotic stenosis may be as high as 10%. To avoid these potential and sometimes serious complications, the authors describe a partially mechanical esophago-visceral anastomosis. The esophageal stump is brought near the anterior wall of the transposed stomach. A small gastrotomy is performed. An endoscopic linear stapler is then inserted in the esophageal and gastric lumen, and fired. The anterior wall of the anastomosis is fashioned with a running suture.

Lymph node micrometastases in patients with adenocarcinoma of the esophagogastric junction

Recurrences of adenocarcinoma of the esophagogastric junction are frequent even in patients who are classified as pN0 after radical resection, suggesting that occult nodal metastases may have been missed on routine histologic examination. Immunohistochemical analysis using antibodies to cytokeratin was retrospectively performed in 1301 lymph nodes from 46 patients who underwent surgical resection for adenocarcinoma of the esophagogastric junction through a laparotomy and a right thoracotomy. Compared to routinely stained sections, the total number of metastatic lymph nodes was significantly (P = 0.0001) increased when both serial sectioning and anticytokeratin immunohistochemical analysis were performed. Overall 6 (33.3%) of the 18 patients previously considered N0 were recategorized as N1 for the presence of micrometastases to lesser curvature nodes. Three of these patients had recurrent disease within the first year of follow-up. Both the probability of survival or no recurrence and the disease-free survival were significantly greater in patients in whom the ratio of invaded to removed lymph nodes was less than 0.2. Anticytokeratin analysis identified occult nodal metastases in one third of our patients with adenocarcinoma of the esophagogastric junction. This modified tumor staging and had an impact on overall and disease-free survival.

Current trends in the surgical treatment of esophageal and cardia adenocarcinoma

Since adenocarcinoma of the esophagus and cardia is increasing at an alarming rate, major efforts are currently oriented to identify patients who may benefit from extensive resection. Between November 1992 and May 1998, 218 patients with histologically proven adenocarcinoma of the distal esophagus or cardia were referred to our Department. In six patients (10.2%) with Barrett's adenocarcinoma, cancer was discovered during endoscopic surveillance program for Barrett's metaplasia. Overall, one hundred-forty-seven patients (67%) underwent resection. Fifty-one underwent an extended mediastinal lymphadenectomy. Median cumulative survival was 25.9+/-3.1 months in patients undergoing resection, and 7+/-1.3 months in patients having palliation (p<0.01). Survival was significantly longer in patients with negative nodes than in those with lymph node metastases (54+/-12.9 versus 17+/-2.8 months, p<0.01). Six of the 51 patients (11.8%) undergoing extended lymphadenectomy had metastatic upper mediastinal nodes. Additional serial sections and immunohistochemistry were performed in 46 patients. In 6 of 18 patients (33.3%) with negative nodes at conventional hematoxylin-eosin examination, immunohistochemistry demonstrated micrometastases in the lesser curve, paracardial, peripancreatic, or lower mediastinal nodes. Early diagnosis remains the prerequisite for curative treatment of adenocarcinoma of the esophagus and cardia. When a curative resection is attempted, extended lymphadenectomy improves tumor staging and may prevent local recurrences. Serial sections and immunohistochemistry provide additional accuracy in the staging of the disease and may prove useful to select patients for adjuvant therapy.

Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy

Endoscopic diverticulotomy for the treatment of Zenker's diverticulum has been reported infrequently in the literature and has engendered considerable controversy. Between March 1992 and September 1996, we attempted to treat 102 patients with endoscopic treatment for pharyngoesophageal diverticula. In 98 patients, the endoscopic surgery was successfully completed. Conversion to open surgery was required in 4 patients (3.92%). One cartridge of staples in 16 patients (16.32%), 2 cartridges in 78 patients (79.59%), and 3 cartridges in 4 patients (4.08%) were used, according to the size of the diverticulum; the median duration of the procedure was 20 minutes (10 to 60 minutes). No postoperative morbidity or mortality was recorded. Oral feeding was started following radiologic control after a median of 2 days; the median hospital stay was 4 days. The median follow-up is 16 months (1 to 45 months). Four patients operated on before the introduction of the modified stapler showed a persistent diverticular pouch: 3 underwent repeat endoscopic operation, and 1 underwent conventional open surgery. All treated patients are asymptomatic. Manometric study performed in 15 patients showed a significant reduction of basal upper esophageal sphincter pressure compared to preoperative data (48.30+/-21.74 versus 29.38+/-5.68 mm Hg; p<.01). We therefore recommend endoscopic diverticulotomy, considering that the procedure is relatively safe and effective, with minimal patient discomfort, and the results are equal to those of the external approach. This procedure offers the advantages of short hospitalization, rapid convalescence, brief operative time, absence of skin incision. predictable resolution of symptoms, and reduced morbidity.

Endoscopic palliation of oesophageal cancer: results of a prospective comparison of Nd:YAG laser and ethanol injection

OBJECTIVE

To evaluate the effectiveness of intratumoral alcohol injection compared with Nd:YAG laser in the treatment of unresectable fungating cancers of the oesophagus.

DESIGN

Prospective, randomised clinical study.

SETTING

University hospital, Italy.

SUBJECTS AND INTERVENTIONS

47 consecutive patients were randomly allocated to have endoscopic Nd:YAG laser treatment (n = 24), or intratumoural injection of 98% alcohol (n = 23).

MAIN OUTCOME MEASURES

Morbidity, mortality, dysphagia score, survival.

RESULTS

One patient in the laser group needed analgesic support during and after the treatment, whereas 18 (78%) of those treated with alcohol experienced mild pain and most of them required analgesics. An improvement of at least 2 points in the dysphagia score was noted in 21 patients (88%) in the laser group and in 18 in the alcohol group (78%). The mean dysphagia-free intervals between each treatment were 30 and 37 days, respectively. The median survival was 6 months in each group. There were no significant differences in the mean dysphagia scores of patients still alive. There were no complications in the laser group, but one oesophageal perforation occurred during the preliminary dilatation before the second session of alcohol injection. There were no procedure-related deaths.

CONCLUSION

The two techniques allowed similar palliation of dysphagia and improvement of quality of life. Intratumoral injection of alcohol is an effective and inexpensive therapeutic option in the palliation of fungating oesophageal lesions.

Endoscopic laser ablation of nondysplastic Barrett's epithelium: is it worthwhile?

The clinical value of endoscopic ablation of nondysplastic Barrett's epithelium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need for endoscopic surveillance in these patients. Eighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pump inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed with noncontact fibers and a power output of 60 watts. The mean number of treatment sessions was three (range 1 to 5), and the mean energy delivered during each session was 2800 joules (range 600 to 4800 joules). All patients were given a standard dose of omeprazole (40 mg/day) throughout the study period. In two patients a mild distal esophageal stricture occurred and required a single dilatation. Macroscopic and histologic eradication of the specialized columnar epithelium was documented in 8 of 12 patients with tongues of Barrett's metaplasia, in one of four patients with circumferential Barrett's metaplasia, and in two of two patients with short-segment Barrett's esophagus. In five patients (28%) only a partial ablation could be achieved despite repeated laser treatment. Two patients (11%), one with tongues and the other with circumferential Barrett's metaplasia, were considered nonresponders. Adenocarcinoma undermining regenerated squamous epithelium was found, 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mean follow-up period of 14 months (range 4 to 32 months), two patients presented with recurrent Barrett's metaplasia: one at 8 months after successful Nissen fundoplication and the other after 1 year of continuous omeprazole treatment. Progression of Barrett's metaplasia was found in two other patients receiving pharmacologic therapy in whom a partial response to laser treatment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplastic Barrett's esophagus, performed in conjunction with omeprazole treatment and followed by antireflux surgery, allows a partial regression of specialized columnar epithelium in most patients. However, this is a time-consuming procedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic surveillance.

Bronchoscopic staging of squamous cell carcinoma of the upper thoracic esophagus

OBJECTIVE

To identify bronchoscopic findings that predict resectability of squamous cell carcinoma of the upper thoracic esophagus.

DESIGN

Tracheobronchoscopy was performed in patients with squamous cell carcinoma of the thoracic esophagus to assess the infiltration of the tracheobronchial tree by the tumor and predict the resectability. Bronchoscopic records were matched with clinical outcome and intraoperative findings.

SETTING

University hospital, tertiary care referral center.

PATIENTS

A total of 113 patients with supracarinal esophageal carcinoma underwent bronchoscopy as part of the preoperative staging. In 47 patients the bronchoscopy was repeated after a regimen of neoadjuvant chemotherapy.

INTERVENTION

A total of 160 bronchoscopies performed by the same operator.

MAIN OUTCOME MEASURES

Bronchoscopic records matched with clinical outcome and intraoperative findings.

RESULTS

Including patients before and after neoadjuvant chemotherapy, 27 of the 46 with no bronchoscopic abnormalities were operated on: in 24 (89%) of them radical surgical resection was possible. Among the 22 patients with a slight compression on the tracheobronchial tree admitted to surgery, a radical surgical resection was possible in 20 cases (91%). In none of the 5 patients with compression/deviation associated with fixation of the tracheobronchial tree but no mucosal infiltration who underwent surgery was a radical surgical resection possible because of tracheobronchial infiltration.

CONCLUSIONS

Compression of the tracheobronchial tree does not necessarily mean infiltration by esophageal carcinoma. If the compression is slight and the mobility of the tracheobronchial tree is normal, a radical esophagectomy is possible in 91% of patients.

Duodeno-gastro-esophageal reflux after gastric surgery: surgical therapy and outcome in 42 consecutive patients

BACKGROUND/AIMS

Duodeno-gastro-esophageal reflux is a common event after gastric surgery and can result in severe symptoms and mucosal injury. Medical therapy is largely ineffective. The most common remedial operation consists of a long isoperistaltic Roux-en-Y limb in order to shunt duodenal contents away from the gastric pouch and the esophagus.

METHODOLOGY

Between 1980 and 1996, 42 patients underwent duodenal diversion after gastric surgery. The presence of severe symptoms and/or endoscopic esophagitis unresponsive to medical therapy was considered an indication for surgery. Functional studies were performed in selected patients in an attempt to objectively document the presence of excessive duodeno-gastro-esophageal reflux. A 40-60 cm Roux-en-Y limb was constructed in all patients.

RESULTS

There was no post-operative mortality. The median follow-up was 28 months (range: 5-114). Symptoms related to delayed gastric emptying persisted in 5 patients (11.9%). Overall, 32 patients (76%) had a Visick I-II score. Best results (90%) were achieved in patients with previous total gastrectomy.

CONCLUSIONS

Roux-en-Y duodenal diversion should be reserved for patients with intractable symptoms and documented reflux, and is mostly effective after total gastrectomy. Patients with a residual stomach are less likely to benefit from the procedure, probably because an underlying motor disorder plays a major role in the pathogenesis of the symptoms than does the reflux of duodenal contents.

Synovial sarcoma of the esophagus simulating achalasia

Synovial sarcoma is a rare malignancy occurring mainly in the extremities. Only seven cases have been described arising in the esophagus. All of them presented as a polypoid mass involving the upper third of the esophagus. A case of infiltrating synovial esophageal sarcoma simulating achalasia in a 63-year-old woman is reported. According to the literature, the location and the clinical pattern of this tumor are exceptional. The clinical features, pathologic findings, differential diagnosis, and management of this condition are discussed.

Echolaparoscopic-guided alcohol injection of liver metastases

Ultrasound-guided percutaneous alcohol injection of liver metastases or hepatocellular carcinoma represents a well-established alternative to surgery when surgical resection is contraindicated. The aim of this report is to describe the technique of echolaparoscopic-guided alcohol injection of liver metastases in a patient undergoing palliative treatment for adenocarcinoma of the cardia. This procedure provides a more accurate staging of the disease and a safe approach to liver metastases with difficult anatomical location in patients unsuitable for surgical resection.

Surgical therapy in patients with failed antireflux repairs

BACKGROUND/AIMS

Failure of antireflux surgery may be due to errors in patient selection, errors in the choice of the operation, or technical errors in the performance of the operation. The purpose of this work was to review a series of patients surgically treated for a failed antireflux procedure over the past two decades.

MATERIALS AND METHODS

Seventy patients (62%) out of 113 consecutive individuals presenting with symptoms after one or more operations for gastroesophageal reflux disease underwent reoperation. Five patients had been operated on laparoscopically. The indications for reoperation were based on severity of symptoms and results of objective investigation. Surgical therapy was tailored to the individual patient based on pathophysiological abnormalities and on the results of intraoperative assessment.

RESULTS

Reflux symptoms and dysphagia represented the major complaint in 62.8% and 35.7% of patients, respectively. The most common pathophysiological abnormality was an incompetent lower esophageal sphincter. Intraoperative assessment showed a disrupted or misplaced repair in 77% of the patients. The most common reoperation performed was a partial or total fundoplication (54.3%), followed by antrectomy and Roux-en-Y anastomosis (25.7%). There was no mortality. Postoperative morbidity rate was 8.5%. At a median follow-up of 48 months, 87% of patients were scored as Visick 1-2 and 90% declared themselves satisfied with the results of reoperation.

CONCLUSIONS

Management of patients with failed antireflux procedures is challenging. However, detailed physiological evaluation and a surgical approach tailored to residual anatomy and function of the foregut can provide excellent results.

Cell cycle-related gene abnormalities and product expression in esophageal carcinoma

In esophageal carcinoma, individual genetic alterations of cyclins, cyclin-dependent kinase inhibitors, and final effectors of the G1-to-S transition have been documented. Our aim was to design a comprehensive analysis of the role and clinical significance of some critical genes, namely cyclin D1, MTS1, and Rb. To this end, cyclin D1 gene amplification and protein accumulation, Rb gene allelic loss and protein expression, and MTS1 gene mutation and DNA methylation were investigated in a series of 74 esophageal carcinomas. Cyclin D1 amplification was documented in 17 of 55 (31 %) cases, being a feature of squamous cell type (14 of 17 amplified cases). Cyclin D1 accumulation significantly correlated with lymph node metastasis (p < 0.02), advanced tumor stage (p < 0.05), and a reduced overall survival rate (p < 0.03). Rb gene loss of heterozygosity occurred in 14 of 39 (36%) informative cases and was associated with an unfavorable survival rate (p < 0.01). MTS1 gene mutations were detected in 2 adenocarcinomas only; gene methylation was observed in 17 of 72 cases (24%) without any correlations with the variables investigated. A direct association between cyclin D1 and Rb gene accumulation (p < 0.0005) and an inverse one between RB loss of heterozygosity and MTS1 abnormalities (p < 0.05) emerged from this study. These results have important clinical implications because both cyclin D1 and Rb gene deregulation are significantly related to an unfavorable survival rate. In addition, cyclin D1 amplification is associated with esophageal carcinoma of squamous cell type, being totally absent in adenocarcinomas (p < 0.01). The combined evaluation of these genes also demonstrates that molecular abnormalities of genes belonging to the same pathway are mutually exclusive and unnecessary for the neoplastic transformation and tumor progression.

Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients

OBJECTIVE

To assess the effectiveness of transoral stapled diverticulum esophagostomy in relieving symptoms and decreasing outflow resistance at the pharyngoesophageal junction in patients with Zenker diverticulum.

DESIGN

Cohort study. From April 1, 1992, until May 31, 1996, the operation was attempted in 95 patients. The median follow-up was 23 months (range, 13-48 months).

SETTING

Tertiary care university hospital.

PATIENTS

There were 74 men and 21 women, with a median age of 64 years (age range, 37-92 years). All complained of dysphagia and pharyngo-oral regurgitation, and 18 (20%) suffered from recurrent aspiration pneumonia. The median size of the pouch measured by flexible endoscopy was 4 cm (range, 2.5-8 cm).

INTERVENTION

The septum between the diverticulum and the esophageal lumen was divided under general anesthesia using a linear endostapler introduced through a Weerda endoscope. In most patients, 2 applications of the endostapler with a modified anvil were used. Operative time averaged 23 minutes.

MAIN OUTCOME MEASURES

Morbidity, symptom score, patient's satisfaction, videofluorographic barium transit, hypopharyngeal intrabolus pressure, upper esophageal clearance of radioisotope.

RESULTS

A switch to open surgery was required in 3 patients (3.1%), due to difficult exposure of the common wall in 2 cases and a mucosal tear in the other. No postoperative morbidity or mortality was recorded. Oral feeding was started the following day and the median hospital stay was 3 days (range, 2-8 days). Five patients complained of persistent symptoms; 3 of them underwent another endosurgical operation, 1 underwent laser treatment by means of flexible endoscopy, and 1 eventually required open surgery. All patients are asymptomatic at the latest follow-up visit. Postoperative radiologic studies showed free flow of barium in all patients. Manometry showed a significant reduction of hypopharyngeal intrabolus pressure over preoperative values (P=.003). Radionuclide studies showed a significant reduction of upper esophageal residual activity at 1 minute compared with preoperative values (P=.006).

CONCLUSIONS

Endosurgical approach to hypopharyngeal diverticula larger than 2 cm is safe and effective. Symptom relief, elimination of the pouch, and decreased outflow resistance at the pharyngoesophageal junction can be obtained without morbidity and with a short hospital stay.

Endoscopic ultrasonography in the evaluation of leiomyoma and extramucosal cysts of the esophagus

BACKGROUND/AIMS

Leiomyoma is the most common type of benign esophageal tumor, whereas extramucosal cysts of the esophagus are congenital anomalies frequently asymptomatic in the adult and in most cases detected incidentally on chest x-ray. It is worthwhile considering these conditions together, because they present similar diagnostic and surgical problems. Conventional imaging tests do not lead to a precise diagnosis. The purpose of this study was to evaluate the use of endoscopic ultrasonography in the diagnosis of, and planning of treatment modalities for, these conditions.

METHODOLOGY

Fifteen patients with esophageal leiomyoma and seven patients with extramucosal esophageal cysts were studied with endoscopic ultrasonography using an Olympus GF- EU-M3 instrument with a 7.5-12 MHz echoprobe. In all patients, the results of endoscopic ultrasonography were compared with the histology of the resected specimens.

RESULTS

The histology of the resected specimens confirmed the endosonographic diagnosis in all patients. No malignancy was found in any specimen.

CONCLUSIONS

Endoscopic ultrasonography is very accurate in visualizing these lesions and differentiating cystic from solid submucosal esophageal masses; in addition, the test can establish the exact location of the mass in relation to the esophageal wall and mediastinum. Therefore, endoscopic ultrasonography has a great impact in confirming the diagnosis of leiomyoma and extramucosal cysts of the esophagus and facilitates therapeutic decision-making because of its capacity to clearly define the size, layer of the origin, and pattern of the mass.

Presentation and surgical management of bronchogenic and esophageal duplication cysts in adults

OBJECTIVE

Bronchogenic and esophageal duplication cysts are congenital anomalies of the tracheobronchial tree and foregut that are often asymptomatic at initial presentation in adults. Surgery is always recommended, even for patients with asymptomatic disease, because of the possible development of symptoms and complications during the natural course of the disease and because definitive diagnosis can be established only on surgical specimen.

METHODS

Twenty-seven patients with bronchogenic and esophageal duplication cysts were treated in our institution over the last 2 decades. Ten patients (37%) were asymptomatic at initial presentation. Chest pain and dysphagia were the most common complaints in symptomatic patients affected by bronchogenic and duplication cysts, respectively.

RESULTS

A complete excision of the cyst was performed in 26 cases, whereas one patient with intrapulmonary cyst underwent a right upper pulmonary lobectomy. A posterolateral thoracotomy was performed in 23 patients, and a video-assisted thoracoscopy using a three-port technique was performed in the last 4 patients. No postoperative morbidity was recorded. All patients, except one, were asymptomatic at a median follow-up time of 4 years.

CONCLUSIONS

Surgery is the treatment of choice for bronchogenic and esophageal duplication cysts. Video-assisted thoracoscopy should represent the first-line approach in these patients.

Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty

Redundancy of the interposed colon used as an esophageal substitute is a common finding in the long-term follow-up of these patients. When symptoms caused by food retention in the colonic loop occur, surgical correction is necessary to improve quality of life and to prevent aspiration. We report a technique to straighten the redundant colon that consists of a side-to-side colocolic anastomosis using a linear stapler. This obviates the need for a redo cologastric anastomosis. Compared with resection of the loop, the operation is quick, safe, and easy to perform, and it may decrease the risk of injury to the marginal vessels of the colon graft.

Evaluating results of laparoscopic surgery for esophageal achalasia

BACKGROUND

Extramucosal myotomy of the lower esophagus and cardia, combined with anterior fundoplication, is, in our opinion, the procedure of choice to treat stage I-III esophageal achalasia.

METHODS

After a successful experience with open surgery in over 280 patients, from January 1992 through February 1997, 61 patients underwent laparoscopic Heller-Dor for stage I-III achalasia. Conversion to laparotomy was done in three cases. All procedures were performed under intraoperative endoscopic control. Intraoperative complications were seven mucosal tears, which were sutured laparoscopically in five cases. The sole postoperative complication was bleeding from an acute gastric ulcer (conservative treatment).

RESULTS

Follow-up consisted of clinical and radiographic study 1 month after surgery, and endoscopy and manometry within 1 year. After a mean follow-up (F.U.) of 21 months (1-62), clinical results range from excellent to good in 98.2%. One patient (1.7%) complaining of recurrent dysphagia improved after endoscopic dilation. Esophageal diameter reduced from 52 to 27 mm. LES pressure reduced from 30.3 +/- 12.4 to 10.7 +/- 3.5 mmHg (basal) and from 14. 8 +/- 9.3 to 2.9 +/- 2.1 mmHg (residual).

CONCLUSIONS

Laparoscopic Heller-Dor operation is feasible, safe, and effective. Special care should be taken in patients with previous endoscopic dilations.

Diverticulectomy, myotomy, and fundoplication through laparoscopy: a new option to treat epiphrenic esophageal diverticula?

OBJECTIVE

To describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap for epiphrenic diverticula of the esophagus.

SUMMARY BACKGROUND DATA

The epiphrenic diverticulum of the esophagus is a rare disease probably caused by a longstanding impairment of the esophageal motor activity. Although there is almost universal agreement to operate only on symptomatic patients, the optimal treatment is controversial. The best-accepted guideline is to treat the underlying motor disorder. This is generally done through a left thoracotomic approach that allows diverticulectomy, esophageal myotomy, and partial fundoplication.

METHODS

From January 1994 through February 1996, 4 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. A thorough preoperative study was done with barium swallow, esophagoscopy, and manometry in all patients; 24-hour pH monitoring was done in one case.

RESULTS

No postoperative complications were observed. Short- and medium-term results are satisfactory.

CONCLUSIONS

No theoretical objection should be made to this approach, because the principle of treatment of the diverticular pouch and the underlying motor disorder and the prevention of reflux is respected. Longer follow-up and a wider series are mandatory to substantiate these initially favorable results.

First-line chemotherapy improves the resection rate and long-term survival of locally advanced (T4, any N, M0) squamous cell carcinoma of the thoracic esophagus: final report on 163 consecutive patients with 5-year follow-up

OBJECTIVE

The objective of this prospective, nonrandomized study was to evaluate the immediate and long-term results of first-line chemotherapy and possible surgery in locally advanced, presumably T4 squamous cell esophageal cancer.

SUMMARY BACKGROUND DATA

Locally advanced esophageal cancer is rarely operable and has a dismal prognosis. For this reason, neoadjuvant cytoreductive treatments are more and more frequently used with the aim of downstaging the tumor, increasing the resection rate, and possibly improving survival.

METHODS

From January 1983 to December 1991, 163 consecutive patients with a presumedly T4 squamous cell carcinoma of the thoracic esophagus (group A) received on average 2.5 cycles (range, 1-6) of first-line chemotherapy with cisplatin (100 mg/m2 on day 1) and 5-fluorouracil (1000 mg/m2 per day, in continuous infusion from day 1 through day 5). Chemotherapy was followed by surgery when adequate downstaging of the tumor was obtained.

RESULTS

Chemotherapy toxicity was WHO grade 0 to 2 in 80% of cases, but 3 toxic deaths (1.9%) occurred. Restaging suggested a downstaging of the tumor in 101 of 163 patients (62%), but only 85 patients (52%) underwent resection surgery; it was complete or R0 in 52 (32%) and incomplete or R1-2 in 33. Overall postoperative mortality was 11.7% (10 of 85), morbidity 41% (35 of 85). Complete pathologic response was documented in 6 patients, and significant downstaging to pStage I, IIA, or IIB occurred in 25 more patients. The overall 5-year survival was 11 % (median, 11 months). After resection surgery, the 5-year survival was 20% (median, 16 months); none of the nonresponders survived 4 years after palliative treatments without resection (median survival, 5 months). The 5-year survival rate of the 52 patients undergoing an R0 resection was 29% (median, 23 months). Stratifying patients according to the R, pT, pN, and pStage classifications, the survival curves were comparable to the corresponding data obtained in the 587 group B patients with "potentially resectable" esophageal cancer who underwent surgery alone during the same period. Furthermore, the results were improved in comparison with 136 previous or subsequent patients with a locally advanced tumor who did not undergo neoadjuvant treatments (group C). In these patients, the R0 resection rate was 7%, and the overall 5-year survival was 3% (median, 5 months).

CONCLUSION

Although nonrandomized, these results suggest that in locally advanced esophageal carcinoma, first-line chemotherapy increases the resection rate and improves the overall long-term survival. In responding patients who undergo R0 resection surgery, the prognosis depends on the final pathologic stage and not on the initial pretreatment stage.

[The value of extensive lymphadenectomy in cancer of the lower esophagus and cardia]

Between 1980 and 1997, 1194 patients with a malignant tumor of the lower esophagus have been observed and treated in our Institution. There were 555 patients (46.5%) presenting with squamous-cell carcinoma, 101 (8.5%), with Barrett's adenocarcinoma and 538 (45%) with cardia adenocarcinoma. Most patient underwent a transthoracic esophagectomy with esophagogastroplasty; transhiatal approach was mainly reserved to high-risk patients. Over the past two years sixty-three patients (42 with adenocarcinoma and 21 with squamous cell carcinoma) underwent enlarged mediastinal lymphadenectomy. Three patients (4.7%) died post-operatively: one sepsis, in pulmonary embolism and one myocardial infarction. Four patients (6.3%) developed pulmonary complications: no patient had recuriential palsy. Pathologic exam revealed 1342 nodes (807 thoracic and 827 abdominal). Twenty patients (31.7%) had mediastinal nodal metastases, of which 8 in the upper mediastinum. Median follow-up was 19 months (2-36 months). Seven of the sixteen patients with recurrent disease (12 systemic, 3 mediastinal and 1 anastomotic) died. The number of metastatic nodes increased with serial section and even more with immunohistochemical staining technique (from 11.7% to 13% to 15.5%, respectively). Two patients were up-staged from M0 to M1 because of peripancreatic nodal micrometastases. We conclude that enlarged mediastinal lymphadenectomy allowed to detect upper mediastinal lymph node metastases in 12.8% of patients without increasing post-operative complication rate. A longer follow-up is required to evaluate the impact on long term survival.

Cervicomediastinal hibernoma

Hibernoma is a benign soft-tissue tumor, derived from the brown fat, that often presents as a painless, slow-growing mass. About 100 cases of hibernomas have been reported in the world literature. Seven cases of intrathoracic hibernoma are reported, of which only 1 was located in the mediastinal region. That tumor was an intramediastinal hibernoma with a cervicomediastinal location, which was excised through an extended left supraclavicular incision without the necessity to perform a sternotomy. No recurrence was evident after 18 months.

Improving results of esophageal stenting: a study on 160 consecutive unselected patients

BACKGROUND AND STUDY AIMS

Esophageal stenting is a valuable treatment in the management of malignant dysphagia. Recently, self-expanding stents have proved effective in reducing morbidity and mortality. The aim of this study was to evaluate the early and late results of esophageal stenting in a series of 160 consecutive unselected patients with unresectable esophageal and cardial carcinoma treated between November 1992 and December 1996.

PATIENTS AND METHODS

The procedure was successful in 159 patients (99.4%). A traditional tube was employed in 84 patients (52.5%). Metallic self-expanding stents have been available since June 1993 and were used in 75 selected patients (46.9%). The tumor was located in the cervical, upper, middle and lower thoracic esophagus, and at the gastric cardia in 16, 16, 56, 22 and 34 patients, respectively. In the remaining 15 patients an esophagovisceral anastomosis was involved. Preoperative chemo- and/or radiotherapy were performed in 82 patients (51.3%).

RESULTS

Overall hospital morbidity was 11.3% (18/159) and included four dislodgments, four incomplete expansions of a self-expanding stent, two perforations, two incomplete sealings of a malignant respiratory tract fistula, two hemorrhages, two persistent foreign body sensations, one arrhythmia and one aspiration pneumonia. Hospital mortality was 1.3% (2/159) and was recorded in patients who underwent traditional intubation. At discharge, dysphagia was improved at least 2 degrees in 152 patients (96.8%). The overall long-term morbidity was 23.5% (37/157). Mean survival after the procedure was 4.7 months.

CONCLUSIONS

Intubation is a safe palliative procedure which can be performed with low morbidity and mortality rates. Self-expanding metallic stents have enhanced the indications and the outcomes of the procedure, resulting in the treatment of strictures where the placement of a traditional tube is difficult or technically impossible.

Preoperative laparoscopy in management of patients with carcinoma of the esophagus and of the esophagogastric junction

BACKGROUND AND OBJECTIVES

Adequate preoperative staging of patients with esophageal and cardia carcinoma offers the potential for a rational choice of the therapy. The aim of this study was to assess the diagnostic value of laparoscopy compared to ultrasonography (US) and computed tomography (CT) in detecting intra-abdominal metastatic spread.

METHODS

Between November 1995 and December 1996, 36 patients with adenocarcinoma of the cardia and 14 patients with squamous cell carcinoma of the lower third of the esophagus were studied with CT scan and US, followed by laparoscopy performed at the same session of planned surgical resection. Mean operative time of laparoscopy was 20 minutes (range 15-55 min). There was no mortality nor morbidity related to the laparoscopic procedure.

RESULTS

Laparoscopy lead to a change of the therapeutic approach in five patients (10%): three patients with peritoneal carcinosis undetected at the imaging examinations, and one patient with advanced liver cirrhosis with signs of portal hypertension did not undergo resection; conversely, one patient with a liver hemangioma simulating a metastatic mass at CT/US underwent esophagogastric resection. Laparoscopy showed a higher sensitivity than US and CT in detecting peritoneal metastases (71% vs. 14% vs. 14%, respectively), macroscopic nodal metastases (78% vs. 11% vs. 55%), and liver metastases (86% vs. 71%).

CONCLUSIONS

Laparoscopy represents a safe and effective diagnostic procedure in the preoperative staging of esophageal and cardia carcinoma; it provides the potential to avoid unnecessary exploratory laparotomies and to select the most appropriate treatment.

Prevalence, management and outcome of early adenocarcinoma (pT1) of the esophago-gastric junction. Comparison between early cancer in Barrett's esophagus (type I) and early cancer of the cardia (type II)

The study compares, in true adenocarcinoma of the cardia and in adenocarcinoma in Barrett's esophagus, the prevalence of early cancers and their outcome in those patients suitable for resection surgery. From 1980 to 1993, 26 of 350 (7.4%) resected adenocarcinomas of the esophago-gastric junction were pathologically staged as early cancer or pT1. The prevalence of early cancer was 3.7% (11/294) for true cancer of the cardia and 27% (15/56) for cancer in Barrett's esophagus (P < 0.001). Ten of the 15 latter cancers were diagnosed during endoscopic surveillance for benign Barrett's esophagus. Among early cancers, there were four mucosal and 22 submucosal tumours; of the latter, eight had lymph node metastasis and seven neoplastic permeation of lympho-hematic vessels. The most frequently used surgical procedure was esophago-gastric resection and gastric pull-up. Postoperative morbidity was 15.4%, and hospital mortality 3.8%. Excluding postoperative deaths, the overall 5-year survival rate was 79% for early cancer of the cardia and 83% for early cancer in Barrett's esophagus (log rank test = 0.0214, P = 0.88). Overall, the survival rate was 100% in the absence of lymph node metastasis and 43% in the presence of node metastasis (log rank test = 15.811, P = 0.0001). Only one of five patients with both node metastasis and vessel infiltration survived longer than 5 years. In conclusion, the prevalence of early cancer was significantly greater for cancer in Barrett's esophagus than for true cancer of the cardia. Prognosis of the two types of tumour after resection surgery was the same and depended on lymph node status and neoplastic permeation of lympho-hematic vessels.

Prognosis of early squamous cell carcinoma of the esophagus after surgical therapy

Between 1980 and 1995, 91 (13.7%) out of 666 patients were determined by pathologic staging to have a superficial squamous-cell esophageal carcinoma of the thoracic esophagus. The male to female ratio was 3.3:1, and the mean age 60 years. Postoperative mortality was 4.3%. The median follow-up was 48 months (range 3-179). Survival was significantly decreased with increased depth of tumour invasion and presence of nodal metastases (P=0.03). Recurrent disease was prevalent in patients with submucosal tumours compared to those with mucosal tumours (P < 0.05). Only intra-epithelial and intramucosal carcinomas deserve the definition of 'early' tumours. Given the relative inaccuracy of current staging modalities and the low morbidity and mortality rates associated with surgical resection, surgery appears to be the mainstay of treatment of superficial squamous-cell esophageal cancer.

Biochemical markers of upper esophageal sphincter compliance in patients with Zenker's diverticulum

The aim of this study was to investigate the biochemical basis of biomechanical and morphological alterations of upper esophageal sphincter, which have been reported in patients with Zenker's diverticulum. 4-L-Hydroxyproline (4-Hyp) (collagen), isodesmosine (Ides), and desmosine (Des) (elastin) contents were measured in samples of cricopharyngeal muscle (CPM) and muscularis propria of the esophagus below the CPM. The specimens were collected from seven patients operated for Zenker's diverticulum and eight cadavers, without esophageal and connective tissue disease, 4-Hyp was assayed colorimetrically, Ides and Des by high-performance liquid chromatography. Mean (+/-SEM) values were compared by Mann-Whitney U test. In patients, collagen content was significantly increased, both in CPM and in the muscularis propria of the esophagus below the CPM (P < 0.05). In CPM, Ides to Des and collagen to elastin ratios were significantly higher in patients than in controls (P < 0.05). Both the CPM and the upper muscular cuff of the esophagus appear to be involved in the pathogenesis of Zenker's diverticulum. This finding supports the extension of the myotomy to the muscularis propria of the esophagus below the CPM. The alterated Ides to Des ratio suggests a primary disease of CPM as a cause of Zenker's diverticulum.

Evaluation of leiomyoma of the esophagus with endoscopic ultrasonography

Fourteen patients with suspected leiomyoma of the esophagus were studied by endoscopic ultrasonography, computed tomography, endoscopy and barium swallow. The results were correlated with the histology of the resected specimens: in 2 patients with a peduncolated leiomyoma originating from the second echographic layer, endoscopic resection was performed. Endoscopic ultrasonography was superior to other imaging techniques in detection and staging of leiomyoma because it can determine the layer of origin, the direction of the growth and the consistency of the tumor.

Current status and trends in laparoscopic antireflux surgery: results of a consensus meeting. The European Study Group for Antireflux Surgery (ESGARS)

Laparoscopic surgery for gastroesophageal reflux disease has replaced the open approach in several institutions, and it is likely to become the "standard" for treatment in the near future. Members of five European surgical centers with extensive experience in pathophysiological research, diagnostic testing, and conventional surgery for esophageal disease met after five years of experience in using laparoscopic antireflux surgery, and established a plan to evaluate the potential for consensus among the centers involved in the surgical management of the disease. The consensus process started with a pathophysiological assessment of the reporting requirements for diagnostic workup. To allow a thorough appreciation of the surgical techniques used by all the participants, experience was exchanged in collaborative operations in an experimental surgical laboratory. It was concluded that the pathophysiological background to the disease is multifactorial, as many publications have shown in recent years. The group's meetings and discussions established a consensus list for the preoperative assessment of patients suspected of having gastroesophageal reflux disease, as well as a common list of operative techniques for successful antireflux surgery.

Mechanical effect of the Angelchik prosthesis on the competency of the gastric cardia: pathophysiologic implications and surgical perspectives

The Angelchik prosthesis appears to be effective in preventing gastroesophageal reflux, although its precise mechanism of action remains controversial. In a unique in vitro model, 10 freshly harvested canine esophagogastric specimens were tested for their ability to remain competent against challenges of intragastric pressure under controlled conditions of intra-abdominal pressure, longitudinal esophageal tension, lower esophageal sphincter pressure and overall length and circumference of the cardia (measure of gastric dilatation). Competency of the specimen was assessed by stepwise variation in the overall length of the sphincter, while keeping constant intraabdominal pressure (20 cm H2O), intragastric pressure (20 cm H2O), esophageal tension (physiologic), lower esophageal sphincter pressure (15 cm H2O) and degree of gastric dilatation (3 cm). With each specimen serving as its own control, the effect produced by the application of an Angelchik prosthesis was evaluated. Results consistently demonstrated that at any lower esophageal sphincter length the percent of competency was increased when the prosthesis was applied (P < 0.01). The findings indicate that the Angelchik prosthesis controls reflux by preventing unfolding of the lower esophageal sphincter when challenged by intragastric pressure.

Endoscopic ultrasonography for preoperative staging of esophageal carcinoma

Endoscopic ultrasonography (EUS) is a relatively new diagnostic method to assess the extent and the depth of infiltration of esophageal carcinoma. Since October 1990, EUS was performed in 55 patients presenting with squamous-cell carcinoma of the esophagus, 40 of whom were operated on. The first 23 patients underwent EUS with an Olympus GF-2/EU-M2 echoendoscope with a 7.5-MHz transducer; the last 32 patients underwent EUS with an Olympus GF-3/EU-M3 instrument with a 7.5-12-MHz echoprobe. In 22 patients, the procedure was not completed because of the impossibility of passing through the neoplastic stenosis. The depth of infiltration (T parameter) was correctly defined by EUS in 36 of 40 patients (90%) compared with 50% of computed tomography (CT). The 12-MHz echoprobe yielded a global accuracy in staging T parameter of 94% compared to 82% of 7.5-MHz transducer. The lymph-node involvement (N parameter) was correctly classified by EUS in 20 of 23 patients (87%) compared with 39% by CT. EUS provides a high degree of accuracy in assessing the T and the N parameter in the staging of squamous-cell esophageal carcinoma. The major problem of the instrument is still the frequent impossibility of passing through the neoplastic stenosis.

p53 protein accumulation and p53 gene mutation in esophageal carcinoma. A molecular and immunohistochemical study with clinicopathologic correlations

BACKGROUND

p53 gene mutation and p53 protein accumulation are common in human cancer. However, their clinical significance is controversial and p53 accumulation may not correlate with gene mutation. The current study investigates the occurrence of p53 alterations in esophageal carcinoma, the correlation between the analyses at the gene and protein level, and their prognostic significance.

METHODS

A series of 74 esophageal carcinomas (46 squamous cell carcinomas, 21 Barrett's adenocarcinomas, and 7 undifferentiated carcinomas) was studied by single strand conformation polymorphism (SSCP) analysis and immunohistochemistry (IHC) to detect p53 mutation and accumulation, respectively.

RESULTS

p53 mutations in exons 5-8 were detected in 53% of the carcinomas whereas p53 accumulation was observed in 57% of cases. Comparing SSCP and IHC, there were 27 discordant cases (38%). Overall, only 20 tumors (27%) did not display p53 mutation and/or p53 accumulation. No associations were found between p53 aberrations and clinicopathologic parameters, including patients age and gender tumor type, stage, and grade. p53 protein accumulation and p53 gene mutation were not related to patient survival by univariate or multivariate analysis in esophageal carcinomas.

CONCLUSIONS

p53 aberrations are very common in esophageal carcinomas. However, p53 gene mutation and p53 protein accumulation have a significant discordance, suggesting that p53 function may be inactivated by mechanisms other than mutation. p53 aberrations do not independently predict prognosis in esophageal tumors.

p53 protein accumulation and p53 gene mutation in esophageal carcinoma. A molecular and immunohistochemical study with clinicopathologic correlations

BACKGROUND

p53 gene mutation and p53 protein accumulation are common in human cancer. However, their clinical significance is controversial and p53 accumulation may not correlate with gene mutation. The current study investigates the occurrence of p53 alterations in esophageal carcinoma, the correlation between the analyses at the gene and protein level, and their prognostic significance.

METHODS

A series of 74 esophageal carcinomas (46 squamous cell carcinomas, 21 Barrett's adenocarcinomas, and 7 undifferentiated carcinomas) was studied by single strand conformation polymorphism (SSCP) analysis and immunohistochemistry (IHC) to detect p53 mutation and accumulation, respectively.

RESULTS

p53 mutations in exons 5-8 were detected in 53% of the carcinomas whereas p53 accumulation was observed in 57% of cases. Comparing SSCP and IHC, there were 27 discordant cases (38%). Overall, only 20 tumors (27%) did not display p53 mutation and/or p53 accumulation. No associations were found between p53 aberrations and clinicopathologic parameters, including patients age and gender tumor type, stage, and grade. p53 protein accumulation and p53 gene mutation were not related to patient survival by univariate or multivariate analysis in esophageal carcinomas.

CONCLUSIONS

p53 aberrations are very common in esophageal carcinomas. However, p53 gene mutation and p53 protein accumulation have a significant discordance, suggesting that p53 function may be inactivated by mechanisms other than mutation. p53 aberrations do not independently predict prognosis in esophageal tumors.

Cricopharyngeal myotomy for neurogenic oropharyngeal dysphagia

BACKGROUND

Forty patients (18 women, 22 men) with incapacitating oropharyngeal dysphagia of neurologic origin underwent cricopharyngeal myotomy. The subjective and objective response to myotomy was analyzed retrospectively with a mean postoperative follow-up of 48 months (range 1 to 255 months).

RESULTS

Radiologic evidence of functional obstruction caused by incoordination and incomplete relaxation of the upper esophageal sphincter was significantly reduced. Manometric recordings of resting and closing pressures of the upper esophageal sphincter were also significantly altered by the myotomy. Resting pressures decreased from 65 to 18 mm Hg and closing pressures dropped from 69 to 22 mm Hg. The relaxation time and poor coordination at the level of the upper esophageal sphincter, observed in the preoperative period, persisted after the operation. Radionuclide emptying studies in which a single liquid bolus was used showed persistent hypopharyngeal stasis with a 20% retention of radioactive material at 120 seconds. Subjectively, 33 patients initially had frequent aspiration episodes. Twenty became free of symptoms after myotomy (p < 0.01) and in six others the symptoms were improved. Overall, seven patients claimed to be free of symptoms of dysphagia and no longer had pharyngo-oral or pharyngonasal regurgitations and aspirations after their operation. Twenty-three other patients had improvement in symptoms. Ten patients reported no change in symptoms. All of them either were unable to swallow voluntarily or had dysarthria when assessed before the operation. One retropharyngeal hematoma is the only postoperative complication recorded. The operative mortality was 2.5% (1/40).

CONCLUSIONS

Cricopharyngeal myotomy palliates neurogenic oropharyngeal dysphagia in patients with intact oral-phase deglutition.

Primary multiple epithelioid leiomyosarcoma of the liver

Sarcomas represent only 1-2% of primary malignant tumors of the liver. We report the twenty first case of primary hepatic leiomyosarcoma in the literature. Metastases from gastrointestinal tract, female genital system and lung have to be excluded before confirming diagnosis of a primary neoplasm. Extensive involvement of the liver parenchyma contraindicated surgery, the treatment of choice when the tumor is solitary or multiple but located in one lobe. Chemotherapy, as employed in our patient, is the alternative therapeutic option in inoperable cases, but its role has to be clarified.