Videoendoscopy and histopathology of the esophagogastric junction in patients with gastroesophageal reflux disease

Preoperative assessment of tumor location and station-specific lymph node status in patients with adenocarcinoma of the gastroesophageal junction

BACKGROUND

In esophageal cancer patients preoperative staging will determine the type of surgical procedure and use of neoadjuvant therapy. Tumor location and lymph node status play a pivotal role in this tailored strategy. The aim of the present study was to prospectively evaluate the accuracy of preoperative assessment of tumor location according to the Siewert classification and lymph node status per station with endoscopy/endoscopic ultrasound (EUS) and computed tomography (CT).

METHODS

In 50 esophagectomy patients with adenocarcinoma of the gastroesophageal junction (GEJ), tumor location according to Siewert and N-stage per nodal station as determined preoperatively by endoscopy/EUS and CT were compared with the histopathologic findings in the resection specimen.

RESULTS

Overall accuracy in predicting tumor location according to the Siewert classification was 70 % for endoscopy/EUS and 72 % for CT. Preoperative data could not be compared with the pathologic assessment in 11 patients (22 %), as large tumors obscured the landmark of the gastric folds. The overall accuracy for predicting the N-stage in 250 lymph node stations was 66 % for EUS and 68 % for CT. The accuracy was good for those stations located high in the thorax, but poor for celiac trunk nodes.

CONCLUSIONS

Given the frequent discrepancy between the endoscopic and pathologic location of the GEJ and the common problem of advanced tumors obscuring the landmarks used in the assessment of the Siewert classification, its usefulness is limited. The overall accuracy for EUS and CT in predicting the N-stage per station was moderate.

The histologic squamo-oxyntic gap: an accurate and reproducible diagnostic marker of gastroesophageal reflux disease

The present definition of gastroesophageal reflux disease (GERD) is based on clinical criteria that are difficult to reproduce accurately. This study provides a method to develop a histologic definition of GERD based on biopsies obtained from the affected esophagus. Pathology reports from 1655 patients who had upper gastrointestinal endoscopy and biopsy according to a systematic protocol were reviewed. Biopsies were obtained from the esophagus, around the gastroesophageal junction and the stomach: proximal, body, and antrum. Patients who had oxyntocardiac±cardiac±intestinal epithelia between the squamous epithelium proximally and the proximal limit of gastric oxyntic mucosa distally were defined as having a squamo-oxyntic gap. The length of the squamo-oxyntic gap varied from less than 1 cm in 1399 (84.5%) patients to greater than 5 cm in 80 (4.8%) of the patients. Only oxyntocardiac epithelium was seen in 190 (11.5%) of the patients, oxyntocardiac and cardiac epithelia in 898 (54.3%), and intestinal metaplasia in addition to the other 2 epithelial types in 567 (34.2%). The prevalence of intestinal metaplasia was directly proportional to length of the squamo-oxyntic gap, being 24.3% (340/1399) when the length was <1 cm, and 83.5% (147/176) with length 1 to 5 cm. All patients with a length more than 5 cm had intestinal metaplasia. The distribution of the 3 epithelia was constant irrespective of the length of the squamocolumnar gap; intestinal metaplasia, when present, was seen maximally in the proximal region of the gap, cardiac epithelium intermediate and oxyntocardiac epithelium in the most distal segment of the gap. The squamo-oxyntic gap started in a dilated region distal to the end of the tubular esophagus and distal to the proximal limit of the rugal folds and extended into the tubular esophagus. Distal gastric biopsies showed no evidence of significant inflammation, intestinal metaplasia or Helicobacter pylori infection in 1543 (93.2%) of the patients, indicating that the squamo-oxyntic gap was largely independent of gastric pathology. We provide evidence that the squamo-oxyntic gap is equivalent to the columnar-lined esophagus. Its presence is a specific and sensitive indicator of reflux and can be used as a cellular criterion to define GERD. The length of the squamo-oxyntic gap provides an accurate assessment of the severity of chronic GERD. The distal limit of the squamo-oxyntic gap, which is the junction between oxyntocardiac and gastric oxyntic epithelium is the true gastroesophageal junction. The presence of intestinal metaplasia within the squamo-oxyntic gap is the most accurate risk indicator for esophageal adenocarcinoma and defines Barrett esophagus.

CO2 insufflation during colonoscopy decreases post-interventional pain in deeply sedated patients: a randomized controlled trial

INTRODUCTION

Air insufflation during colonoscopy is considered the standard method in most endoscopic centers. Notably, several studies have reported reduced abdominal pain after colonoscopy with CO2 insufflation in unsedated and in lightly sedated patients. The present study was designed to assess the efficacy of CO2 insufflation after colonoscopy in moderately and deeply sedated patients. We also evaluated whether CO2 insufflation increases patients' compliance for colorectal cancer screening.

PATIENTS AND METHODS

A total of 300 consecutive patients allocated to colonoscopy were randomly assigned to either CO2 or air insufflation. Propofol was titrated to a level of deep sedation and propofol combined with midazolam was used for moderate sedation. Post-interventional pain levels and satisfaction with the procedure were registered on a 10-point visual analog scale. Compliance for colorectal cancer screening was ascertained separately.

RESULTS

CO2 insufflation was used during colonoscopy in 157 patients; conventional air was used in 143 patients. The two groups were comparable with regard to age, sex and body mass index. Neither major nor minor complications were observed. Pain sensation was significantly lower in the CO2 group at 15 min, 30 min and 6 h after colonoscopy (P<0.01); at 12 h no difference was observed. In contrast, levels of patient satisfaction did not show any significant difference. Voluntary colorectal cancer screening appeared not to be influenced by the type of insufflation gas used.

CONCLUSIONS

CO2 insufflation in deeply and moderately sedated patients during colonoscopy has no impact on patients' satisfaction with the procedure or on their attitude to voluntary colorectal cancer screening. However, the use of CO2 insufflation significantly diminishes abdominal pain after colonoscopy.

Chylous cyst formation following laparoscopic fundoplication

Formation of an abdominal chylous cyst is a rare event, predominantly occurring after spinal, vascular or urologic retroperitoneal surgery. As far as we know, the presented case is the first report in the literature of chylous cyst formation after laparoscopic fundoplication. A 57-year-old man with a history of a conservatively treated spinal compression fracture (T11/12) underwent laparoscopic fundoplication in 1996 for recurrent heartburn with insufficient response to treatment with PPI. His reflux symptoms disappeared but over the following years he developed intermittent abdominal pain in the right upper quadrant. Gastroscopy in 2002 revealed a slight compression of the distal esophagus. CT scan revealed a cystic formation next to the distal esophagus which was initially interpreted to be part of the fundoplicate itself. Aggravation of symptoms and weight loss was noted in 2006. A further CT scan revealed a 7 cm cyst along the fundoplicate and the lesser curvature of the stomach. The cyst was subsequently drained laparoscopically. Cholesterol (351 mg/d), LDL-cholesterol (263 mg/dl), triglycerides (334 mg/dl) and chylomicrons led to the diagnosis chylous cyst and the patient was put on a medium-chain triglyceride diet. After 12 weeks the discharge stopped and the drain was removed. The patient remained symptom-free for seven months but then presented again with the same complaints. This time an even larger cyst was diagnosed, extending from the lesser curvature of the stomach through the esophageal hiatus up to the right atrium. A Roux-en-Y chylous cystojejunostomy was then performed and has solved the problem up to the present. A chylous cyst may develop after laparoscopic fundoplication. If simple drainage fails, a cystojejunostomy can solve this problem.

Histopathology of columnar-lined esophagus in patients with gastroesophageal reflux disease

BACKGROUND AND AIMS

The question of whether an endoscopically normal-appearing esophagogastric junction should be biopsied in patients with gastroesophageal reflux disease is controversial. We have addressed this issue using endoscopy and histopathology.

METHODS

A total of 114 consecutive patients (58 males) with symptoms of gastroesophageal reflux disease prospectively underwent endoscopy, including biopsy sampling from the esophagogastric junction. Endoscopically visible columnar-lined esophagus was defined by the presence of gastric-type mucosa above the level of the rise of the gastric folds. Histopathology was conducted using the Paull-Chandrasoma classification.

RESULTS

Of the 114 patients, 85 (74.6%) had endoscopically visible columnar-lined esophagus of length < or =0.5 cm (n = 82), 1 cm (n = 2) and 7 cm (n = 1); 29 patients (25.4%) had a normal endoscopic junction. All patients had histopathologic columnar-lined esophagus. Intestinal metaplasia and low-grade dysplasia was identified in 26 (22.8%) and 5 (4.4%) individuals, respectively, and was not statistically different in endoscopically normal vs. abnormal junction (P = 0.408 for intestinal metaplasia, P = 0.775 for low grade dysplasia). Intestinal metaplasia was independent from endoscopic esophagitis (P = 0.398) and hiatal hernia (P = 0.405).

CONCLUSIONS

Columnar-lined esophagus cannot be excluded by endoscopy. In patients with gastroesophageal reflux disease, biopsy sampling of normal-appearing junction is recommended for histopathologic exclusion of intestinal metaplasia and low-grade dysplasia.