Early esophageal cancer: pattern of lymphatic spread and prognostic factors for long-term survival after surgical resection

OBJECTIVE

The objective of this study was to assess the prevalence and pattern of lymphatic spread in patients with early squamous cell and adenocarcinoma and identify prognostic factors for long-term survival after resection and lymphadenectomy.

SUMMARY BACKGROUND DATA

Limited endoscopic approaches without lymphadenectomy are increasingly applied in patients with early esophageal cancer.

MATERIAL AND METHODS

A total of 290 patients with early esophageal cancer (157 adenocarcinoma, 133 squamous cell cancer) had surgical resection with systematic lymphadenectomy. Specimens were assessed for prevalence and pattern of lymphatic spread. Prognostic factors were determined by multivariate analysis.

RESULTS

None of the 70 patients with adenocarcinoma limited to themucosa had lymphatic spread, as compared with 2 of 26 with mucosal squamous cell cancer. Lymphatic spread was more common in patients with submucosal squamous cell cancer as compared with submucosal adenocarcinoma (36.4% versus 20.7%). Although lymph node metastases were usually limited to locoregional lymph node stations in early adenocarcinoma, distant lymphatic spread was frequent in early squamous cell cancer. On multivariate analysis, only histologic tumor type and the presence of lymph node metastases were independent predictors of long-term survival. Five-year survival rate was 83.4% for early adenocarcinoma versus 62.9% for early squamous cell cancer and 48.2% versus 79.5% for patients with/without lymphatic spread.

DISCUSSION

Prevalence and pattern of lymphatic spread as well as long-term prognosis differ markedly between early esophageal squamous cell and adenocarcinoma. Limited resection techniques and individualized lymphadenectomy strategies appear applicable in patients with early adenocarcinoma.

Ösophagektomie als chirurgisches Therapieprinzip beim Plattenepithelkarzinom des Ösophagus

The fatalistic approach towards surgical therapy of esophageal squamous cell cancer has been replaced in recent years by a more differentiated view. This was triggered by the establishment of individualized therapeutic modalities based on tumor stage, tumor location, general patient status, and comorbidity. Despite advances in nonsurgical therapy of squamous cell esophageal cancer, esophagectomy remains the central therapeutic modality. Primary subtotal en-bloc esophagectomy with lymphadenectomy is the only curative option with a high likelihood of success for resectable tumors (uT1-3 categories) located below the level of the tracheal bifurcation and for early more proximal tumors. In patients with locally advanced tumors at or above the level of the tracheal bifurcation, surgical resection can still cure those who respond to neoadjuvant radiochemotherapy. Preoperative "conditioning" of risk patients, surgical safety strategies in risk situations, and standardization of both the operative procedure and the perioperative management have resulted in a marked reduction of the previously substantial postoperative mortality to below 3% in experienced centers. In our own experience of 900 esophagectomies for squamous cell esophageal cancer, the 5-year survival rate rose from about 20% to more than 50% in the last two decades. Esophagectomy thus has become a safe operation and remains the only therapeutic option offering cure for a substantial proportion of patients with squamous cell cancer of the esophagus.

[Diagnosis and therapy of weakly-acid/non-acidic gastroesophageal reflux disease]

The therapy of gastroesophageal reflux disease (GERD) is uncomplicated in most cases. However, 20 % of GERD patients suffer from reflux-associated symptoms under therapy with proton pump inhibitors (PPI). The cause of this resistance to PPI-therapy remains unclear. Today, the most discussed theory is the presence of the non- or weakly acidic reflux. Objective measurements of the weakly/non-acidic reflux are available since the development of intraluminal impedance monitoring in combination with pH-monitoring. The therapy of weakly/non-acidic GERD is not well established, so far. In the course of clinical studies the therapeutic spectrum (i. e. modification of the medical therapy, endoscopic anti-reflux procedures or surgical therapy) has to be tested.

Esophageal cancer surgery in heart transplant patients

We herein report about 2 heart transplant patients undergoing surgical resection for esophageal cancer. Both were long-term survivors after orthotopic heart transplantation for dilated cardiomyopathy. One patient underwent a transthoracic esophagectomy and gastric pull-up for an early squamous cell carcinoma of the infracarinal esophagus. The second patient underwent a resection of the cervical esophagus and interposition of a free jejunal segment after neoadjuvant radiochemotherapy for a locally advanced squamous cell carcinoma in the cervical esophagus.

Late hypopharyngo-esophageal perforation after cervical spine surgery: proposal of a therapeutic strategy

BACKGROUND

Hypopharynx and esophagus are occasionally at risk of perforation after cervical spine surgery. Although relatively rare--compared to the frequency of anterior instrumentation--hypopharyngo-esophageal perforation has to be considered as a late complication. An interdisciplinary surgical strategy is required for treatment.

MATERIALS AND METHODS

We herein propose a flow sheet for an interdisciplinary treatment strategy. The concept is based on the authors' personal experiences with this rare complication in a high-volume center for esophageal surgery.

RESULTS

Our interdisciplinary surgical strategy is based on three central parameters that determine the course of treatment: (1) The patient's general condition and signs of systemic infection determine the requirement for critical care management. (2) The stability of the spine (to be addressed by the orthopedic surgeon) determines the requirement for dorsal stabilization, prior to the mandatory removal of the anterior osteosynthesis material that is damaging the hypopharyngo-esophageal structures. (3) The surgical strategy for treatment of the gastrointestinal perforation--the decision to undertake either primary repair or resection--is based on its morphological characteristics; whether it is covered or free, whether it is associated with severe local infection or not, whether the defect is small or large.

CONCLUSIONS

Hypopharyngo-esophageal perforations after spine surgery are an interdisciplinary challenge, best treated by a concert of specialists (ICU, orthopedic surgeon, and gastrointestinal surgeon).

Bile reflux in the constellation of gastroesophageal reflux disease

Gastric acid and bile acids are a particularly noxious combination when they interact with the mucosa of the upper intestinal tract. There is a critical pH range, between 3 and 6, in which bile acids exist in their soluble, un-ionized form, can penetrate cell membranes, and accumulate within mucosal cells. At a lower pH, bile acids are precipitated, and at a higher pH, bile acids exist in their noninjurious ionized form. Experimental, clinical, and immunohistochemical studies show that acid and bile reflux are increased in patients who suffer from GERD, are the key factor in the pathogenesis of Barrett's esophagus, and possibly are related to the development of esophageal adenocarcinoma.

COX2 expression, angiogenesis, proliferation and survival in Barrett's cancer

OBJECTIVES

To examine COX2 expression and its relation to angiogenesis, Ki67 and Bcl2 expression in Barrett's cancer.

METHODS

Specimens from 48 R0-resected Barrett's adenocarcinoma were immunostained for cyclooxygenase 2 (COX2), CD 31 and alpha-sm actin to discriminate between mature and immature vessels, Mib-1 and Bcl2. COX2 staining, angiogenesis, Ki67 expression and Bcl2 expression were also measured.

RESULTS

COX2 expression was increased in 25 of 48 cases. There was no significant correlation between COX2 expression and age, sex and tumor differentiation. A significant association was found between lymph node positive cases and elevated COX2 expression (p=0.008). The percentage of Ki67 positive cancer cells was 43.8% (range 15.4-67.5%) in the low COX2 group and 57.8% (range 12.0-84.6%) in the high COX2 group. The difference was statistically significant (p=0.046). The median neovascularisation coefficient in the low COX2 group was 11.68 (range 8.22-43.64) and 25.47 (range 8-38.3) in the high COX2 group. The difference was statistically significant (p=0.012). A significant difference in survival was observed between patients in the COX2 low category when compared with the COX2 high category (log-rank test p=0.013).

CONCLUSIONS

Elevated COX2 expression is associated with lymph-node metastases and reduced survival in Barrett's cancer. This appears to be related to the induction of angiogenesis and proliferation.

Coexpression of cyclooxygenases (COX-1, COX-2) and vascular endothelial growth factors (VEGF-A, VEGF-C) in esophageal adenocarcinoma

Cyclooxygenases (COX), especially COX-2, are considered to be involved in carcinogenesis. Our study was initiated to test whether expression of COX isoforms (COX-1 and COX-2) is linked to expression of potent inducers of angiogenesis [vascular endothelial growth factor (VEGF)-A] and lymphangiogenesis (VEGF-C) in esophageal adenocarcinoma. One hundred twenty-three esophageal adenocarcinomas were investigated by means of quantitative reverse transcription-PCR for expression of COX-1, COX-2, VEGF-A, and VEGF-C. Additionally, COX-2 protein expression was determined using immunohistochemistry. Three esophageal cancer cell lines (OE-33, OSC-1, and OSC-2) were treated with COX-inhibiting substances (diclofenac, rofecoxib, and SC-560) and the effect on expression of the four genes was determined. COX-2 protein expression was found in all carcinomas under analysis. RNA expression levels of COX-1 and COX-2 varied markedly in carcinoma tissues and correlated significantly with each other (P < 0.001, r = 0.726). Furthermore, COX expression correlated with expression of VEGF-A (COX-1: P < 0.001, r = 0.753; COX-2: P < 0.001, r = 0.764) and VEGF-C (COX-1: P < 0.001, r = 0.778; COX-2: P < 0.001; r = 0.613). Exposure of esophageal cancer cell lines OE-33, OSC-1, and OSC-2 with three COX-inhibiting substances (diclofenac, rofecoxib, and SC-560) resulted in significantly reduced expression of VEGF-A and VEGF-C. In conclusion, our data suggest that both COX isoforms may be involved in the pathogenesis of esophageal adenocarcinoma, as they are linked to the expression of important modulators of angiogenesis (VEGF-A) and lymphangiogenesis (VEGF-C).

Staging and treatment of advanced esophageal cancer

PURPOSE OF REVIEW

To evaluate the recent developments in treatment of advanced esophageal cancer since January 2004.

RECENT FINDINGS

Today's stage-adjusted treatment of advanced esophageal cancers requires a meticulous diagnostic work-up. The use of standard staging tools (endoscopy, endoscopic ultrasound, computed tomography) is increasingly supplemented with additional use of positron emission tomography with fluoro-desoxyglucose. Positron emission tomography with fluoro-desoxyglucose improves detection of systemic metastases, but assessment of locoregional lymph node metastases remains poor.Multimodal (especially neoadjuvant) strategies have gained far-reaching impact on advanced esophageal cancer treatment: A recent meta-analysis of randomized trials suggests a survival benefit at 3 years with preoperative radio-chemotherapy compared with surgery alone. Patients who respond to neoadjuvant treatment appear to benefit most from subsequent surgical resection. This makes response evaluation and prediction most desirable. Positron emission tomography with fluoro-desoxyglucose appears to provide reliable information on response as early as 14 days after initiation of treatment. Several studies have contributed to controversies regarding surgical technique (e.g. extent of lymphadenectomy, shape of gastric tube, location of anastomosis). Surgical complications have been directly correlated with long-term prognosis. In patients with systemic metastases, all therapeutic attempts remain palliative. In a multicenter trail, investigating the best palliation of dysphagia, brachytherapy was found superior over placement of self-expanding metal stents.

SUMMARY

Positron emission tomography with fluoro-desoxyglucose is established as an additional staging tool and appears useful for response prediction during multimodal treatment. Brachytherapy should be considered as an alternative to stent placement for palliation of dysphagia.

Biologic and clinical variations of adenocarcinoma at the esophago-gastric junction: relevance of a topographic-anatomic subclassification

A topographic-anatomic subclassification of adenocarcinomas of the esophago-gastric junction (AEG) in distal esophageal adenocarcinoma (AEG Type I), true carcinoma of the cardia (AEG Type II), and subcardial gastric cancer (AEG Type III) was introduced in 1987 and is now increasingly accepted and used worldwide. Our experience with now more than 1,300 resected AEG tumors indicates that the subtypes differ markedly in terms of surgical epidemiology, histogenesis and histomorphologic tumor characteristics. While underlying specialized intestinal metaplasia can be found in basically all patients with AEG Type I tumors, this is uncommon in Type II tumors and virtually absent in Type III tumors. Stage distribution and overall long-term survival after surgical resection also shows marked differences between the AEG subtypes. Surgical treatment strategies based on tumor type allow a differentiated approach and result in survival rates superior to those reported with other approaches. The subclassification of AEG tumors thus provides a useful tool for the selection of the surgical procedure and allows a better comparison of treatment results.

Abdomino-rechts-thorakale Ösophagusresektion mit intrathorakaler Anastomose beim Barrett-Karzinom

The modified technique of abdomino-right-thoracic esophagectomy (the Lewis-Tanner approach) is increasingly being favoured as the surgical procedure of choice in patients with resectable adenocarcinoma of the distal esophagus, so-called Barrett's cancer. The technical details of this procedure and the reconstruction of gastrointestinal continuity using a gastric tube with high intrathoracic anastomosis are illustrated, as they have proved useful in our own practice during recent years.

Esophageal adenocarcinomas in heterotopic gastric mucosa: review and report of a case with complete response to neoadjuvant radiochemotherapy

Adenocarcinomas are exceedingly rare in the cervical esophagus (26 reported cases), where squamous cell cancer (SCC) is the predominant tumor type. Esophageal heterotopic gastric mucosa (HGM) - a frequent remnant of incomplete replacement of the original columnar epithelium during the embryonic period - is suspected as cellular origin of cervical esophageal adenocarcinomas. As in any rare tumor entity, no standard treatment strategy is available for cervical esophageal adenocarcinomas. We herein report about the case of a 52-year-old man with a locally advanced, irresectable cervical esophageal adenocarcinoma originating in HGM. We decided on a neoadjuvant therapy (48.6 Gy + 5-FU/cisplatin) derived from experiences with SCC. Restaging showed an extraordinary good clinical response of the previously irresectable tumor. Subsequently the patient underwent limited cervical esophageal resection, lymphadenectomy and interposition of a free jejunal loop for reconstruction. Postoperative histopathological work-up of the specimen showed no residual tumor tissue, but unchanged HGM. This is the first case with complete response of a rare cervical esophageal adenocarcinoma to a neoadjuvant protocol. On 3-year follow-up the patient is doing fine with no complaints of dysphagia and no evidence of local or systemic recurrence.

Reduced medication dependency and improved symptoms and quality of life 12 months after enteryx implantation for gastroesophageal reflux

BACKGROUND

The need is well recognized for additional data on endoluminal therapies for gastroesophageal reflux disease (GERD). This prospective multicenter clinical trial was designed to assess safety and effectiveness of Enteryx, a nonresorbable copolymer implanted into the lower esophagus, in reducing usage of proton pump inhibitors (PPIs) and improving reflux symptoms and quality of life.

METHODS

Enteryx implantation was performed under fluoroscopic visualization without general anesthesia in 93 patients with symptomatic GERD responsive to and relapsing upon cessation of PPI therapy. Subjective and objective data were collected up to 12 months postprocedure. The criterion for treatment success was reduction in PPI dosage of > or =50%.

RESULTS

At 12 months, treatment success was attained in 86% (confidence interval, 77%-93%) of 74 evaluable patients and elimination of PPI therapy in 65% (confidence interval, 53%-76%). The treatment success rate by intent-to-treat analysis was 69% (confidence interval, 58%-78%). Reflux-related heartburn (P < 0.0001), regurgitation symptoms (P = 0.0005), and physical (P < 0.0001) and mental quality of life (P = 0.0012) scores improved. The most frequent complications were chest pain (77%), dysphagia/odynophagia (27%), and sensation of fever (26%).

CONCLUSIONS

Enteryx implantation provides an effective and safe alternative for management of gastroesophageal reflux, reducing medication dependency and symptoms and enhancing quality of life.

Carcinoma of the cardia: classification as esophageal or gastric cancer?

INTRODUCTION

The cardia is the anatomical borderland between the esophagus and stomach. Carcinomas of the cardia are regarded to share features of both, esophageal and gastric cancers. Controversy exists concerning their appropriate classification and whether these tumors comprise--in respect to tumor biology, pathophysiology as well as clinical features--an entirely separate entity.

CLASSIFICATION

In order to distinguish cardia carcinomas from other adenocarcinomas arising within the vicinity of the esophagogastric junction, a classification system has been introduced from a surgical viewpoint, and is now well established and increasingly used worldwide. According to the topography of the main tumor mass, cardia carcinomas (AEG II) are distinguished from adenocarcinomas of the distal esophagus (AEG I) and subcardiac gastric cancers (AEG III). The tumor-node-metastasis (TNM) staging system by the International Union Against Cancer (UICC) does not provide a separate classification for tumors of the esophagogastric junction. The use of the classification for esophageal or for gastric cancers is recommended, irrespective of the elementary differences in the classification of lymphatic spread implemented herein.

DISCUSSION

New aspects concerning this controversial debate are discussed based on current insights into the pathogenesis and the cellular origin of these entities. The controversies concerning the classification of cardia carcinomas and the failure of the current esophageal and gastric cancer staging systems to reflect the peculiarities of this entity accurately, present a strong argument in favor of a new classification system.

Measurement of the analyzing power in p-->d-->(p p)n with a fast forward 1S0 proton pair

A measurement of the analyzing power A(y) of the p-->d--> (p p) + n reaction was carried out at the ANKE spectrometer at COSY at beam energies of 0.5 and 0.8 GeV by detection of a fast forward proton pair of small excitation energy E(pp) < 3 MeV. The S-wave dominance in the fast diproton is experimentally demonstrated in this reaction. While at T(p) = 0.8 GeV the measured analyzing power almost vanishes, it rises to nearly unity at T(p) = 0.5 GeV for neutrons emitted at theta(c.m.)(n) = 167 degrees. The results are compared with a model taking into account one-nucleon exchange, single scattering, and Delta(1232) excitation in the intermediate state. The model describes fairly well the unpolarized cross section obtained earlier and the analyzing power at 0.8 GeV; it fails to reproduce A(y) at 0.5 GeV.

[Anastomotic leaks in the upper gastrointestinal tract]

Anastomotic leaks are still among the most common severe postoperative complications and account for the majority of postoperative deaths after esophagectomy and gastrectomy. Every disturbance of the normal postoperative course should trigger surgeons to consider an underlying anastomotic leak and initiate a specific diagnostic workup. This includes direct endoscopic inspection of the anastomosis to evaluate the vitality of the anastomosed organs and the size of the leak. Adequate external drainage of the leak and prevention of further contamination are the primary therapeutic goals. Selection of therapy is guided by the available modalities for sufficiently draining the leak and avoiding sepsis. The spectrum of therapeutic options ranges from simple opening of the neck incision in cervical esophageal anastomoses, interventional placement of drains, to endoscopic intervention with closure of the fistula or placement of stents, and reoperation with exclusion, diversion, or discontinuity resection.

Lymphatic Vessel Invasion As a Prognostic Factor in Patients With Primary Resected Adenocarcinomas of the Esophagogastric Junction

Purpose

To evaluate the value of lymphatic vessel invasion (LVI) as a predictor of survival in patients with primary resected adenocarcinomas of the esophagogastric junction (AEG).

Patients and Methods

We prospectively evaluated 459 patients undergoing primary surgical resection for tumors of the esophagogastric junction at our institution between 1992 and 2000 (180 adenocarcinomas of the distal esophagus, AEG I; 140 carcinomas of the cardia, AEG II; and 139 subcardial gastric cancers, AEG III). Median follow-up was 36.8 months. The prevalence of LVI was evaluated by two independent pathologists. Univariate and multivariate analysis of prognostic factors was performed.

Results

The total rate of LVI was 49.9%, with a significant difference between AEG I (38.9%) and AEGII/III (57.0%, P = .0002). Univariate analysis showed a significant correlation between LVI and T category (P < .0001), N category (P < .0001), and resection status (R [residual tumor] category; P < .0001). This was shown for the group of all AEG tumors, as well as for the subgroups AEG I and AEG II/III. On multivariate analysis, LVI was identified as a significant and independent prognostic factor (P = .050) in the population of all patients and in patients with AEG II/III, but not in the subgroup with AEG I.

Conclusion

These data demonstrate the prognostic significance of LVI in patients with AEG tumors, with marked differences between the subgroups AEG I versus AEG II/III. The lower prevalence and lack of prognostic significance of LVI in AEG I might be explained by inflammation involved in the pathogenesis of this entity.

Current concepts of percutaneous abscess drainage in postoperative retention

In recent years, percutaneous abscess drainage (PAD) of intraabdominal abscesses has become an important tool with regard to the treatment of intraabdominal sepsis. The aim of this study is to assess the value of PAD in the treatment of postoperative retentions. Between 1995 and 1999, the postoperative course of 3346 patients undergoing major abdominal surgery was analyzed. Mortality, morbidity, and comparison of different locations of intraabdominal abscesses were assessed. PAD was considered successful when the patient improved clinically within 24 hours, a decrease in the size of the abscess formation was noted, and complete recovery without further surgical intervention occurred. Out of 3346 operated patients, 174 (5.2%) were diagnosed as having an intraabdominal abscess formation and were treated by PAD. In 63 patients the abscess developed within the upper quadrants, in 66 patients the abscess developed within the lower quadrants, and in the remaining 45 patients the abscess developed within the retroperitoneal cavity or pelvis. The success rate of PAD was 85.6% with a morbidity rate of 4.6%. The least successful location for PAD was the left upper quadrant. Patients with abscess drainage in the right upper and lower quadrant experienced a high success rate. One patient died due to the PAD procedure. Unsuccessful PAD was closely related to an increase in mortality. In the case of intraabdominal abscess formation after visceral surgery, PAD should be the primary procedure. Attention should be paid to abscess formations in the left upper quadrant because there is an increased likelihood of complications caused by PAD.

Surgery for early stage esophageal adenocarcinoma

Current treatment recommendations for early esophageal adenocarcinoma range from radical esophagectomy with extensive lymphadenectomy, limited surgical resection with/without regional lymphadenectomy to endoscopic mucosectomy or ablation. A comparison of treatment associated morbidity, tumor recurrence rates, and functional outcome suggests that none of these alternatives can be universally recommended. Rather, an individualized strategy should be employed based on depth of tumor penetration into the mucosa/submucosa, presence of lymph node metastases, multicentricity of tumor growth, length of the underlying Barrett mucosa and comorbidity of the affected patient. Endoscopic mucosectomy may suffice for an isolated focus of high-grade neoplasia or mucosal cancer, provided the neoplasia and underlying Barrett mucosa can be removed completely. Surgical resection is the treatment of choice for tumors invading the submucosa, multicentric tumors and recurrence after endoscopic mucosectomy. The extent of surgical resection must be guided by the length of the Barrett mucosa. In most instances a complete tumor resection and removal of the entire Barrett mucosa can be achieved by a limited transabdominal approach, and therefore subtotal esophagectomy may not be necessary. Application of the sentinel node technology may in the future allow to limit systematic lymphadenectomy to the rather small subgroup of patients who in fact have lymph node metastases.

[Barrett's esophagus]

INTRODUCTION

It is widely accepted that long segments of Barrett's esophagus are caused by end-stage gastroesophageal reflux disease (GERD), but little is known about the correlation of severity of GERD and extent of metaplasia.

METHODS

Twenty normal volunteers and 142 patients with different extent of intestinal metaplasia (39 with intestinal metaplasia limited to the esophagogastric junction, 48 with short segments of Barrett's esophagus, and 55 with long segments) underwent manometry and combined pH-bilirubin monitoring.

RESULTS

The extent of intestinal metaplasia correlated to the exposition of gastric and duodenal juice in the esophagus and inversely with a competent lower esophageal sphincter.

CONCLUSIONS

The extent of intestinal metaplasia is related to the severity of GERD.

Malignant degeneration of Barrett's esophagus: the role of the Ki-67 proliferation fraction, expression of E-cadherin and p53

Barrett's columnar epithelium with dysplasia is the most important risk factor for adenocarcinoma of the distal esophagus. The molecular mechanisms responsible for progression of columnar metaplasia to dysplasia and invasive carcinoma are mostly unknown. We investigated expression of the tumor suppressor gene p53, E-cadherin expression and cell proliferation in the metaplasia-dysplasia-carcinoma sequence of esophageal adenocarcinoma. In 24 patients with R0-resected adenocarcinomas of the distal esophagus we evaluated the expression of E-cadherin (antibody HECD-1), mutated p53 (antibody DO1) and cell proliferation (antibody MiB1) by immunohistochemistry in sections of adenocarcinoma, columnar metaplasia, with and without dysplasia, and in squamous epithelium of the esophagus. No p53 immunoreactivity was seen in sections of normal squamous epithelium or columnar metaplasia. Fifty per cent of invasive adenocarcinomas stained positive for mutated p53. The p53 expression correlated with the T-category (P = 0.048) and the N-category (P = 0.024). There was a significant decrease in the expression of E-cadherin from columnar metaplasia to dysplasia and to esophageal adenocarcinoma (P < 0.0001). Expression of E-cadherin in columnar metaplasia without dysplasia was similar to that seen in normal squamous epithelium of the esophagus. The Ki-67 proliferation fraction increased significantly from normal squamous epithelium to columnar metaplasia to dysplasia and to invasive carcinoma (P < 0.001), with a marked expansion of the proliferative component. There was no correlation between cell proliferation, E-cadherin expression and the tumor stage. In contrast to the alterations in the p53 expression, a decreased E-cadherin expression and the expansion of the proliferative component represent an early phenomenon in the malignant degeneration of Barrett's esophagus. This might aid in the early detection of esophageal adenocarcinoma.

'Efficacy' of esophageal peristalsis: a manometric parameter to quantify esophageal body dysfunction

Esophageal motor abnormalities are currently categorized into separate entities based on standard manometry. The clinical significance of these categories is controversial. We evaluated whether ambulatory 24-h esophageal motility monitoring improves the assessment of patients thought to have a primary esophageal motor disorder. Standard and ambulatory 24-h esophageal motility records of 30 healthy volunteers and 136 symptomatic patients were compared. Regression analysis was used to identify parameters that relate to the presence of nonobstructive dysphagia. Prolonged ambulatory esophageal monitoring showed a marked circadian variation in the esophageal motor pattern and significant discrepancies to the findings on standard manometry in 47% of the 136 patients. Discrepancies were particularly frequent in patients categorized on standard manometry as having a 'nutcracker esophagus' or a nonspecific motor disorder. Of all data obtained, the prevalence of 'effective contractions', i.e. peristaltic contractions with an amplitude > 30 mmHg, during meal periods provided the best correlation with the presence of nonobstructive dysphagia. Of the 78 patients with nonobstructive dysphagia 71 (92%) had less than 50% of 'effective contractions' during meals. In five patients who had frequent simultaneous wave forms and less than 70%'effective contractions' during meals a long myotomy markedly reduced the severity of dysphagia. The 'efficacy' of esophageal contractions during meals best relates to patients' symptoms and allows expression of esophageal body dysfunction on a linear scale. This obviates the need for the current categories of esophageal motor disorders, permits an objective assessment of medical therapy and may improve the identification of patients that benefit from a surgical myotomy of the esophageal body.

[Esophageal perforation by portions of a wild boar]

We report a case of esophageal perforation by impacted portions of a wild boar. The 77-year-old patient was admitted 5 days after an opulent dinner. He complained of dysphagia and retrosternal pain and showed signs of severe sepsis. Endoscopy revealed meat and bone portions impacted in the esophagus. Surprisingly, impactation had not happened near any of the anatomical narrowings, but in the middle third. A CT scan showed penetration of the foreign body into the mediastinum and purulent mediastinitis. The patient underwent transthoracic esophagectomy and drainage of the severe, purulent mediastinal infection. Postoperative multi organ failure required a prolonged treatment in the intensive care unit. After recovery the gastrointestinal continuity was restored with gastric pull-up in the anterior mediastinum. The further course was uneventful.