[Leiomyoma of the esophagus : A further indication for robotic surgery?]

BACKGROUND

Leiomyomas of the esophagus are rare tumors but the most common benign lesion of the esophagus originating from smooth muscle cells. The symptoms are mainly determined by the size of the tumor and are caused by dysphagia and/or retrosternal pain. The majority of patients are however asymptomatic. The diagnostics include esophagoscopy, endosonography and chest computed tomography. Surgery is considered the treatment of choice and ideally involves enucleation of the tumor but may lead to esophagectomy. In addition to the classical open procedures, minimally invasive procedures are also used. Regardless of the selected procedure, a lesion of the mucosa should be avoided.

OBJECTIVE

A review of the literature on thoracoscopic and robotic resections in the treatment of leiomyomas was carried out and an illustration of a clinical case is presented.

MATERIAL AND METHODS

A review of minimally invasive surgical treatment of esophageal leiomyomas is presented. The literature search was carried out in PubMed for publications of thoracoscopic and robotic-assisted thoracic enucleation of leiomyomas of the esophagus. In addition, the robotic-assisted thoracic enucleation of a horseshoe-shaped leiomyoma in the middle third of the esophagus is described.

RESULTS

The enucleation of the esophageal leiomyoma was carried out through a right-sided robotic-assisted operation with one lung ventilation. The surgery time was 143 min. There were no intraoperative or postoperative complications. On the 3rd postoperative day a light diet was started and the thorax drainage was removed. Histopathology confirmed a leiomyoma. The patient was discharged on the 5th postoperative day and free of complaints.

CONCLUSION

Robotic-assisted surgery for leiomyomas of the esophagus is a safe procedure. Taking the available data into account, robotic-assisted thoracic enucleation of leiomyomas was characterized by less mucosal lesions, general complications and a lower conversion rate as well as a shorter hospital stay compared to classical thoracoscopic enucleation. Thus, robotic-assisted surgery can be the method of choice for leiomyomas of the esophagus.

[Laparoscopic Heller myotomy after failed POEM and multiple balloon dilatations : Better late than never]

BACKGROUND

Despite the lack of long-term results, peroral endoscopic myotomy (POEM) has been increasingly propagated as a feasible alternative to pneumatic balloon dilatation (BD) and laparoscopic Heller myotomy (LHM) in patients with achalasia. After a long-term follow-up, a large percentage of patients reported recurrence of dysphagia. It is unclear which kind of procedure (redo POEM or LHM) should be utilized in these patients with failed POEM.

CASE REPORT AND RESULTS

We report the case of a 37-year-old female patient with type I achalasia who was successfully treated with LHM after a failed POEM procedure. After the manometric diagnosis of type I achalasia, the patient was treated with six balloon dilatations within a period of 5 months. Because of the persistence of symptoms a POEM procedure was performed with no relief and the patient was referred for surgical treatment. An esophagography showed a pronounced widening of the middle and the distal esophagus with a persistent narrowing of the lower esophageal sphincter (LES) and because of these indications LHM was performed. The intraoperative examination revealed extensive scarring of the submucosal layer with the muscularis mucosae of the distal esophagus; nevertheless, it was possible to carry out a 5 cm long cardiomyotomy without mucosal injury. The operation was completed with a Dor fundoplication. There were no postoperative complications. After surgery the patient reported an immediate and complete relief of dysphagia.

DISCUSSION AND CONCLUSION

The published experiences with POEM seem to show promising short-term results in terms of dysphagia relief; however, the few available mid-term analyses demonstrated no essential advantages when compared to LHM; therefore, the LHM must still be considered the gold standard procedure for definitive treatment of achalasia. According to our case report, LHM was shown to be a safe and effective although laborious treatment option due to scarring even after failed treatment by POEM.

Emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal cancer

INTRODUCTION

Oesophageal perforation following chemoradiotherapy for oesophageal cancer is a devastating condition but there have been no studies investigating the role of emergency oesophagectomy for this life threatening situation.

METHODS

This retrospective study comprised all cases of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal carcinoma at a major centre for oesophageal surgery in Germany between 2004 and 2013.

RESULTS

A total of 13 patients (mean age: 58.9 years) were identified. During the same time period, 356 elective oesophagectomies were performed. Tumour entities were squamous cell carcinoma (n=12) and adenocarcinoma of the oesophagus (n=1). Alcoholism (odds ratio [OR]: 25.79, 95% confidence interval [CI]: 6.70-121.70, p<0.0001) and chronic pulmonary disease (OR: 3.76, 95% CI: 1.06-14.96, p=0.027) were more common among the emergency cases. Oesophageal rupture was caused by perforation of an oesophageal stent (10 cases) or perforation during implantation of a percutaneous endoscopic gastrostomy tube (3 cases). Emergency oesophagectomy was carried out either as discontinuity resection (10/13) or oesophagectomy with immediate reconstruction (3/13). Compared with the elective cases, patients undergoing emergency oesophagectomy had significantly higher odds for sustaining perioperative sepsis (OR: 4.42, 95% CI: 1.23-16.45, p=0.01), acute renal failure (OR: 6.49, 95% CI: 1.57-24.15, p=0.005) and pneumonia (OR: 24.33, 95% CI: 3.52-1,046.65, p<0.0001). Furthermore, slow respiratory weaning was more common and there was a significantly higher tracheostomy rate (OR: 4.64, 95% CI: 1.14-16.98, p=0.02). Oesophageal discontinuity was eventually reversed in eight patients. Emergency oesophagectomy patients had odds that were three times higher for fatal outcome (OR: 3.59, 95% CI: 0.77-13.64, p=0.05). The overall mortality was 4/13. The remaining nine patients had a mean survival of 25.1 months (range: 5-46 months). The two-year-survival-rate was 38.5% (5/13).

CONCLUSIONS

Despite the most unfavourable preconditions, the results of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy are not desperate. The procedure is not only justified but life saving.

Does the Incidence of Adenocarcinoma of the Esophagus and Gastric Cardia Continue to Rise in the Twenty-First Century?—a SEER Database Analysis

BACKGROUND

The rising incidence and histological change to adenocarcinoma in esophageal cancer over the past four decades has been among the most dramatic changes ever observed in human cancer. Recent reports have suggested that its increasing incidence may have plateaued over the past decade. Our aim was to examine the latest overall and stage-specific trends in the incidence of esophageal adenocarcinoma.

PATIENTS AND METHODS

We used the Surveillance Epidemiology and End Results (SEER) database of the National Cancer Institute to identify all patients with adenocarcinoma of the esophagus and gastric cardia between 1973 and 2009. Both overall and stage-specific trends in incidence were analyzed using joinpoint regression analysis.

RESULTS

The overall incidence of adenocarcinoma of the esophagus and the gastric cardia increased from 13.4 per million in 1973 to 51.4 per million in 2009, a nearly 400 % increase. Jointpoint analysis demonstrated that the yearly increase in incidence has slowed somewhat from 1.27 per million before 1987 to 0.97 between 1987 and 1997 and 0.65 after 1997. Stage-specific analysis suggests that the incidence of noninvasive cancer has actually declined after 2003 with a yearly decrease of 0.22. The percentage of patients diagnosed with in situ cancer declined after 2000 and remained under 2.5 % through the study period.

CONCLUSIONS

The incidence of esophageal adenocarcinoma continues to rise in the USA. The percentage of patients diagnosed with in situ cancer has declined in the twenty-first century.

Time trends and disparities in lymphadenectomy for gastrointestinal cancer in the United States: a population-based analysis of 326,243 patients

BACKGROUND

The value of lymphadenectomy in most localized gastrointestinal (GI) malignancies is well established. Our objectives were to evaluate the time trends of lymphadenectomy in GI cancer and identify factors associated with inadequate lymphadenectomy in a large population-based sample.

METHODS

Using the National Cancer Institute's Surveillance Epidemiology and End Results Database (1998-2009), a total of 326,243 patients with surgically treated GI malignancy (esophagus, 13,165; stomach, 18,858; small bowel, 7,666; colon, 232,345; rectum, 42,338; pancreas, 12,141) were identified. Adequate lymphadenectomy was defined based on the National Cancer Center Network's recommendations as more than 15 esophagus, 15 stomach, 12 small bowel, 12 colon, 12 rectum, and 15 pancreas. The median number of lymph nodes removed and the prevalence of adequate and/or no lymphadenectomy for each cancer type were assessed and trended over the ten study years. Multivariate logistic regression was employed to identify factors predicting adequate lymphadenectomy.

RESULTS

The median number of excised nodes improved over the decade of study in all types of cancer: esophagus, from 7 to 13; stomach, 8-12; small bowel, 2-7; colon, 9-16; rectum, 8-13; and pancreas, 7-13. Furthermore, the percentage of patients with an adequate lymphadenectomy (49 % for all types) steadily increased, and those with zero nodes removed (6 % for all types) steadily decreased in all types of cancer, although both remained far from ideal. By 2009, the percentages of patients with adequate lymphadenectomy were 43 % for esophagus, 42 % for stomach, 35 % for small intestine, 77 % for colon, 61 % for rectum, and 42 % for pancreas. Men, patients >65 years old, or those undergoing surgical therapy earlier in the study period and living in areas with high poverty rates were significantly less likely to receive adequate lymphadenectomy (all p < 0.0001).

CONCLUSIONS

Lymph node retrieval during surgery for GI cancer remains inadequate in a large proportion of patients in the USA, although the median number of resected nodes increased over the last 10 years. Gender and socioeconomic disparities in receiving adequate lymphadenectomy were observed.

Endoscopic stent insertion for anastomotic leakage following oesophagectomy

INTRODUCTION

Intrathoracic anastomotic leakage following oesophagectomy is a crushing condition. Until recently, surgical re-exploration was the preferred way of dealing with this life threatening complication. However, mortality remained significant. We therefore adopted endoscopic stent implantation as the primary treatment option. The aim of this study was to investigate the feasibility and results of endoscopic stent implantation as well as potential hazards and pitfalls.

METHODS

Between January 2004 and December 2011, 292 consecutive patients who underwent an oesophagectomy at a single high volume centre dedicated to oesophageal surgery were included in this retrospective study. Overall, 38 cases with anastomotic leakage were identified and analysed.

RESULTS

A total of 22 patients received endoscopic stent implantation as primary treatment whereas a rethoracotomy was mandatory in 15 cases. There were no significant differences in age, frequency of neoadjuvant therapy or ASA grade between cases with and without a leak. However, patients with a leak were five times more likely to have a fatal outcome (odds ratio: 5.10, 95% confidence interval: 2.06-12.33, p<0.001). Stent migration occurred but endoscopic reintervention was feasible. In 17 patients (77%) definite closure and healing of the leak was achieved, and the stent was removed subsequently. Two patients died owing to severe sepsis despite sufficient stent placement. Moreover, stent related aortic erosion with consecutive fatal haemorrhage occurred in three cases.

CONCLUSIONS

Stent implantation for intrathoracic oesophageal anastomotic leaks is feasible and compares favourably with surgical re-exploration. It is an easily available, minimally invasive procedure that may reduce leak related mortality. However, it puts the already well-known risk of stent-related vascular erosion on the spot. Awareness of this life threatening complication is therefore mandatory.

Surgical management of pleural empyema in the very elderly

INTRODUCTION

Parapneumonic pleural empyema is a critical illness. Age is an acknowledged risk factor for both pneumonia and pleural empyema. Furthermore, elderly patients often have severe co-morbidity. In the case of pleural empyema, their clinical condition is likely to deteriorate fast, resulting in life threatening septic disease. To prevent this disastrous situation we adapted early surgical debridement as the primary treatment option even in very elderly patients. This study shows the outcome of surgically managed patients with pleural empyema who are 80 years or older.

METHODS

The outcomes of 222 consecutive patients who received surgical therapy for parapneumonic pleural empyema at a German tertiary referral hospital between 2006 and 2010 were reviewed in a retrospective case study. Patients older than 80 years were identified.

RESULTS

There were 159 male and 63 female patients. The mean age was 60.5 years and the overall in-hospital mortality rate was 7%. Of the 222 patients, 37 were 80 years or older (range: 80–95 years). The frequencies of predominantly cardiac co-morbidity and high ASA (American Society of Anesthesiologists) grades were significantly higher for very elderly patients (p<0.001). A minimally invasive approach was feasible in 34 cases (92%). Of the 37 patients aged over 80, 36 recovered while one died from severe sepsis (in-hospital mortality 3%). There was no significant difference in mortality between the very elderly and the younger sufferers (p=0.476).

CONCLUSIONS

Early surgical treatment of parapneumonic pleural empyema shows excellent results even in very elderly patients. Despite considerable co-morbidity and often delayed diagnosis, minimally invasive surgery was feasible in 34 patients (92%). The in-hospital mortality of very elderly patients was low. It can therefore be concluded that advanced age is no contraindication for early surgical therapy.

[Newly recognized side-effects of proton pump inhibitors. Arguments in favour of fundoplication for GERD?]

Among other indications proton pump inhibitors (PPIs) are used as medical treatment of gastroesophageal reflux disease (GERD) and are the most frequently prescribed and most frequently used drugs in gastroenterology. Until recently PPIs were regarded as very safe and associated with very few side-effects. However, during recent years study results have revealed many severe adverse events associated especially with long-term PPI use. We review the currently available evidence, regarding the side-effects of PPIs and discuss the potential impact on treatment strategies for GERD (conservative treatment vs. antireflux surgery). Currently available data suggest that PPIs are associated with osteoporosis-related fractures, Clostridium difficile associated diarrhea (CDAD), community and hospital-acquired pneumonia, pharmacologic interaction with clopidogrel and acetylsalicylic acid with subsequent increased rate of cardiovascular events, refractory hypomagnesemia and rebound reflux symptoms etc. The risk-benefit ratio of PPIs is increasingly recognized as being less favourable. This leads to a more critical viewpoint and raises the question whether the side-effects of PPIs may outweigh the benefits, especially with long-term use. The side-effects of PPIs seem to make a strong argument in favour of laparoscopic fundoplication in the treatment of GERD.

[Early esophageal cancer: pro surgical resection]

Endoscopic methods are increasingly propagated as oncologically adequate and less invasive treatment modalities for early esophageal cancer compared to surgery. The superiority or equality of endoscopic treatment has, however, so far not been proven by controlled trials. Current guidelines and an analysis of recently published data support surgical resection and lymphadenectomy as the standard of care for early esophageal cancer. This is based on the following arguments: 1) a reliable complete tumor resection with clear margins in all directions (R0 resection) including removal of all precancerous and precursor lesions can currently only be achieved by surgical resection, 2) none of the currently available staging tools allows definitive exclusion of lymphatic spread. A potentially curative surgical lymphadenectomy should thus only be omitted in well-defined subgroups. 3) In experienced hands surgical resection and lymphadenectomy can be performed with low mortality and morbidity, 4) reproducible and reliable data on long-term recurrence-free survival and quality of life are currently only available for surgical series. Thus, endoscopic therapy for early esophageal cancer is an alternative to surgical resection with lymphadenectomy only in patients unfit for surgery and in strictly defined low-risk situations.

Infected mediastinal bronchogenic cyst in a 12 year old girl

Bronchogenic cysts are an uncommon congenital malformation deriving from the primitive foregut. They are mainly unilocular, and respiratory distress is the most common presentation in pediatric patients. We describe the case of a 12-year-old girl with a huge infected mediastinal bronchogenic cyst which was resected via an axillary muscle-sparing thoracotomy.

The effect of ultrasound dissection in thyroid surgery

BACKGROUND

One of the most important aspects of thyroid surgery is hemostasis. The ultrasonically activated scalpel is described as a very useful instrument in thyroid surgery for the dissection and sealing of vessels. Our study compares the short-term results of endocrine surgery, with and without the use of ultrasonic devices.

METHODS

In a prospectively randomized trial, 96 patients with endemic goiter were operated by the same surgeon, one study group (n = 54 patients) being operated with the ultrasonic scalpel as an additional instrument. We measured the operating time, the number of ligatures needed as well as intraoperative and postoperative bleeding as surrogate markers for improvement of the surgical technique.

RESULTS

The ultrasound dissection technique significantly reduces surgery time (p = 0.048; ultrasound procedure average 68 min, conventional procedure average 83 min), intraoperative bleeding (p = 0.028) and the number of ligatures (p = 0.008; ultrasound procedure average 8.2, conventional procedure average 26.4).

CONCLUSIONS

The use of an ultrasonically activated scalpel significantly improves bleeding control during thyroid resections and may also be beneficial with respect to cost reduction. Clinical application and further studies to characterize its role are justified.

Critical reappraisal of current surveillance strategies for Barrett's esophagus: analysis of a large German Barrett's database

Endoscopic surveillance is recommended for patients with Barrett's esophagus (BE). Based on a large database, gathered from predominantly community-based practices in Germany, we aimed to investigate the time-course of malignant progression and apply these findings to current clinical practice. Data of 1438 patients with BE from a large German BE database were analyzed. Patients with at least one follow-up endoscopy/biopsy were included. Detection of 'malignant Barrett' (either high-grade intra-epithelial neoplasia or invasive adenocarcinoma) was considered as study end-point. Of 1438 patients with BE, 57 patients had low-grade intra-epithelial neoplasia (LG-IN) on initial biopsy and 1381 exhibited non-neoplastic BE. 'Malignant Barrett' was detected in 28 cases (1.9%) during a median follow-up period of 24 months (1-255), accounting for an incidence of 0.95% per patient year of follow-up. The frequency of 'malignant Barrett' was significantly higher (P < 0.001, chi(2)-test) in the LG-IN group (n = 11, 19.3%) compared with the non-neoplastic BE group (n = 17, 1.2%). In the non-neoplastic BE group, 'malignant Barrett' was predominantly found during re-endoscopy within the first year of follow-up (12 of 17; 70.6%), in contrast to the LG-IN group, in which 'malignant Barrett' was observed predominantly after a time exceeding 12 months (8 of 11, 72.7%; P = 0.05, Fisher's exact test). Initial endoscopic evaluations seem to play the most crucial role in managing BE. After 1 year of follow-up, endoscopic surveillance should be focused on patients with LG-IN. In patients with repeatedly proven non-neoplastic BE, elongation of the follow-up intervals to the upper limit of current guidelines, that is, 5 years, might be justified.

Expression of prostaglandin E synthase in Barrett's cancer

Expression of prostaglandin E synthase (PGES) - an enzyme of the prostaglandin biosynthetic pathway with suspected impact on carcinogenesis--was studied in Barrett's cancer to determine its pathogenetic role and prognostic impact in this entity. Expression analysis of PGES was performed on mRNA level (quantitative reverse transcription polymerase chain rection [RT-PCR]) in a large surgical series of 123 primary resected adenocarcinomas of the distal esophagus (Barrett's cancer). Gene expression results were correlated with clinical parameters, overall survival and expression levels of previously analyzed target genes of the cyclooxygenase (COX) pathway (COX-1, COX-2) and mediators of angiogenesis (vascular endothelial growth factor [VEGF]-A) and lymphangiogenesis [VEGF-C]. Expression of PGES was demonstrated in all 123 tumors (100%) on mRNA level (quantitative RT-PCR). Relative mRNA expression levels were highly variable between different cases. Gene expression showed a strong positive correlation with both COX isoforms (COX-1: r = 0.502, P < 0.001; COX-2: r = 0.679, P < 0.001), with the angiogenetic VEGF-A (r = 0.583, P < 0.001) and with the lymphangiogentic VEGF-C (r = 0.465, P < 0.001). PGES mRNA expression showed no significant correlation with clinicopathologic parameters (i.e. pTNM categories, UICC stage, survival). Variable overexpression of PGES seems to be potentially implicated in Barrett's carcinogenesis. Gene expression of PGES is strongly correlated with other mediators of the prostaglandin biosynthetic pathway, that is both COX isoforms (COX-1 and COX-2). However, no impact on patients' outcome in relation to PGES expression was found.

Predictors of response and survival for neoadjuvant treated patients with esophageal adenocarcinoma

Mainly patients with advanced esophageal adenocarcinoma who respond to neoadjuvant chemotherapy show a significant survival benefit after resection. Therefore, prediction of response before treatment is desirable. The aim of this study was to assess genetic predictors of response and survival for patients with esophageal adenocarcinoma prior to neoadjuvant therapy. Thirty-two patients with advanced esophageal adenocarcinoma who underwent neoadjuvant therapy with resection of their tumor were analyzed for thymidylate synthase (TS), excision repair cross complementing (ERCC1) and Gluthatione S-transferase (GSTP-1) mRNA levels prior to the treatment. These results were analyzed in regards of response and survival. In total, 18 patients responded to this protocol. Seventeen of those did show a gene expression level at or below the respective median of at least one gene. This had a profound impact on survival, demonstrating an increase in survival for patients who have TS, ERCC1, or GSTP-1 mRNA level at or below the median. These results demonstrate a potential predictive value of a gene expression profile available prior to therapy. These data have to be confirmed by a larger prospective trial.

Local excision and endoscopic posterior mesorectal resection versus low anterior resection in T1 rectal cancer

Background

Rectum-preserving endoscopic posterior mesorectal resection (EPMR) removes the local lymph nodes in a minimally invasive manner and completes tumour staging after transanal local excision (TE). The aim of this study was to compare the morbidity and mortality of TE and EPMR with those of low anterior resection (LAR) in patients with T1 rectal cancer.

Methods

Between 1996 and 2006 EPMR was performed 6 weeks after TE in 18 consecutive patients with a T1 rectal cancer. Morbidity and mortality were recorded prospectively and compared with those in a group of 17 patients treated by LAR. Lymph node involvement and local recurrence rate were analysed in both groups.

Results

Two major and three minor complications were noted after EPMR, and four major and four minor complications after LAR (P = 0·402 for major and P = 0·691 for minor complications). Median number of lymph nodes removed was 7 (range 1–22) for EPMR and 11 (range 2–36) for LAR (P = 0·132). Two of 25 patients with a low-risk rectal cancer were node positive. No patient developed locoregional recurrence.

Conclusion

EPMR after TE is a safe option for T1 rectal cancer. This two-stage procedure has a lower morbidity than LAR and may reduce locoregional recurrence compared with TE alone.

Transoral access for endoscopic thyroid resection

BACKGROUND

Endoscopic neck surgery is requested by an increasing number of patients. The access trauma of the axillary, breast, and chest approaches is greater than with open or video-assisted surgery. The authors tested the feasibility of the sublingual transoral access, which they believe is the most promising minimally invasive endoscopic access to the thyroid gland from outside the neck region.

METHODS

The sublingual transoral access was first evaluated in two fresh human cadavers. An experimental investigation then was performed using a porcine model. A total of 10 endoscopic transoral thyroidectomies were performed in 10 pigs using a modified axilloscope with an obturator, ultrasonic scissors, and a neuromonitoring system to identify the recurrent laryngeal nerve.

RESULTS

A complete transoral thyroid resection was achieved with both the human cadavers and all the living pigs. Despite the complexity of the anatomic region, the transoral procedure was astonishingly easy to perform. In the animal study, the time from the introduction of the obturator just above the larynx to its removal was 59 s. The average overall operation time was 50 min. The neuromonitoring system permitted the regular function of the recurrent laryngeal nerves on both sides to be proved after removal of the thyroid gland. The pigs were observed for another 2 h after the operation. No complications occurred during the operation or afterward.

CONCLUSIONS

Endoscopic transoral thyroid resection is possible. It proved to be a safe procedure in living pigs and astonishingly easy to perform. The results may be helpful for thyroid resections in humans using a similar access, as suggested by the thyroidectomies in human cadavers preceding this study.

Precision study of the eta3He system using the dp--> 3Heeta reaction

The differential and total cross sections for the dp--> 3Heeta reaction have been measured in a high precision high statistics COSY-ANKE experiment near threshold using a continuous beam energy ramp up to an excess energy Q of 11.3 MeV with essentially 100% acceptance. The kinematics allowed the mean value of Q to be determined to about 9 keV. Evidence is found for the effects of higher partial waves for Q >or= 4 MeV. The very rapid rise of the total cross section to its maximum value within 0.5 MeV of threshold implies a very large eta3He scattering length and hence the presence of a quasibound state extremely close to threshold.

Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus

BACKGROUND

The use of either flexible endoscopy (FE) or rigid endoscopy (RE) for removal of ingested foreign bodies (FBs) impacted in the esophagus is still discussed controversially.

METHODS

We report a consecutive series of 139 patients with FB impaction in the esophagus. During a 6-year period, 69 men and 70 women (median age, 64 [0.7-97] years) requiring removal of an impacted FB underwent either RE (n = 63) in the Otolaryngology Department of our hospital or FE (n = 76) in the Surgical Endoscopy Unit.

RESULTS

Foreign body removal was equally effective with FE (success rate 93.4%) and RE (95.2%, p = n.s.). The cases in which foreign body removal failed (5 FE cases [6.6%] and 3 RE cases [4.8%]) were all subsequently successfully managed with "conversion" and use of the other technique. No severe complications occurred when FB removal was attempted with FE (0 of 76 cases; 0.0%), whereas RE was associated with esophageal rupture requiring immediate surgical intervention in 2 of 63 cases (3.2%; p < 0.002). Patient comfort differed significantly between the two procedures (p < 0.0001); RE was always performed under general anesthesia (100.0%), whereas only a minority of patients undergoing FE required general anesthesia (13.0%; p < 0.0001) or mild analgosedation (20.0%). The better patient comfort with FE was also reflected in a significantly lower rate of dysphagia (15%) compared to RE (48%; p < 0.0001). Rigid endoscopy was more frequently used in removal of FBs of the upper esophagus (p < 0.0001), whereas FE was the predominate approach to FBs in the lower esophagus (p < 0.0001).

CONCLUSIONS

A tailored approach to treatment of FB impaction is recommended. Because of the lower rate of severe complications, better patient comfort with a lower rate of dysphagia, and lack of requirement for general anesthesia, FE should be the "first line" approach to FBs, although RE has its place as the "second line" therapy.

Adenocarcinoma of the esophago-gastric junction

BACKGROUND

The border between the esophagus and stomach gives rise to many discrepancies in the current literature regarding the etiology, classification and surgical treatment of adenocarcinoma arising at the esophago-gastric junction. We have consequently used the AEG-criteria (adenocarcinoma of the esophago-gastric junction) for classification and have based the selection of the surgical approach on the anatomic topographic subclassification.

METHODS

In the following we report an analysis of a large and homogeneously classified population of 1602 consecutive patients with adenocarcinoma of the esophago-gastric junction, with an emphasis on the surgical approach, the pattern of lymphatic spread, the outcome after surgical treatment and the prognostic factors. Demographic data, morphologic and histopathologic tumor characteristics, and long-term survival rates were compared among the three tumor subclassifiations.

RESULTS

The study confirms the marked differences in sex distribution, associated specialized intestinal metaplasia in the esophagus, tumor grading, tumor growth pattern, lymphatic spread, and stage between the three tumor entities. The degree of resection and lymph node status were the dominating independent prognostic factors by multivariate analysis. The data show no significant differences of long-term survival after abdomino-thoracic esophagectomy and extended total gastrectomy in these patients.

CONCLUSION

The classification of adenocarcinomas of the esophago-gastric junction in three types, AEG type I, type II and type III shows marked differences between the tumor entities and is recommended for selection of a proper surgical approach. Complete tumor resection and adequate lymphadenectomy are associated with good long-term prognosis. Better surgical management and standardized procedures will improve the outcome also of patients who need to undergo more radical surgery, i.e. abdomino-thoracic esophagectomy.

Lack of EGFR gene mutations in exons 19 and 21 in esophageal (Barrett's) adenocarcinomas

Epidermal growth factor receptor is over-expressed in several tumors and is the target for the tyrosine kinase inhibitor gefitinib. This receptor is also over-expressed in esophageal adenocarcinomas. In non-small cell lung cancer, specific somatic mutations residing in the epidermal growth factor receptor tyrosine kinase in the activation loop and the glycine-rich P-loop, are responsible for an enhanced sensitivity toward gefitinib. We analyzed exons 19 and 21 coding for the receptor tyrosine kinase of the epidermal growth factor gene in 105 samples of esophageal (Barrett's) adenocarcinoma by denaturing high-pressure liquid chromatography. We found only one silent mutation in exon 19 of adenine to guanine in codon 754 leading to a substitution of K to K, the rest of the sample being wild-type genotype. In conclusion, mutations within the tyrosine kinase domain of EGFR associated with sensitivity of non-small cell lung cancer patients to gefitinib are not present in esophageal (Barrett's) adenocarcinoma.

Squamous cell carcinoma and Zenker diverticulum

Squamous cell carcinoma in a Zenker diverticulum is a very rare condition. We report a case of a patient with a Zenker carcinoma, who was primarily functionally inoperable and therefore received neoadjuvant radiochemotherapy before cardiac bypass surgery. After a complicated course with cardiogenic shock and myocardial infarction, a re-evaluation of functional risk analysis and the tumor situation revealed operability. Subsequently, partial hypopharyngectomy and partial cervical esophageal resection with lymphadenectomy was performed. Reconstruction of the gastrointestinal continuity was made by interposition of a free small bowel graft and microvascular anastomosis. The postoperative course showed a small anastomotic leakage of the hypopharyngeal-small bowel anastomosis, which was successfully treated conservatively.

Expression of cyclo-oxygenase 1 and 2, prostaglandin E synthase and transforming growth factor beta1, and their relationship with vascular endothelial growth factors A and C, in primary adenocarcinoma of the small intestine

BACKGROUND

Primary adenocarcinomas of the small intestine are rare. The prostaglandin biosynthetic pathway plays a major role in carcinogenesis and is linked with angiogenesis in various tumours. Promotion of tumour growth by transforming growth factor (TGF) beta may be mediated through the prostaglandin pathway.

METHODS

Expression of cyclo-oxygenase (COX) 1 and 2, prostaglandin E synthase (PGES), TGF-beta1 and vascular endothelial growth factor (VEGF) A and C genes was analysed in 54 primary adenocarcinomas of the small intestine and corresponding normal intestinal mucosa. All patients had undergone surgical resection without previous antineoplastic therapy. Target gene expression was analysed at the mRNA level by reverse transcriptase-polymerase chain reaction and correlated with clinicopathological parameters as well as survival. COX-2 protein expression was examined by immunohistochemistry.

RESULTS

Expression of COX-2 protein was detected immunohistochemically in 98 per cent of the carcinomas. COX-1, COX-2, VEGF-A, VEGF-C, PGES and TGF-beta1 mRNA expression varied markedly in different tumours, but all were overexpressed compared with levels in normal intestinal mucosa. There were significant associations between levels of COX-1, COX-2, TGF-beta1 and PGES mRNAs and those of VEGF-A and VEGF-C.

CONCLUSION

Correlations between levels of mRNA for COX-1, COX-2, TGF-beta1 and PGES and those for proangiogenic factors VEGF-A and VEGF-C suggest a role for these factors in the propagation of primary adenocarcinomas of the small intestine.

Precision measurement of the quasifree pn-->dvarphi reaction close to threshold

The quasifree pn-->dvarphi reaction has been studied at the Cooler Synchrotron COSY-Jülich, using the internal proton beam incident on a deuterium cluster-jet target and detecting a fast deuteron in coincidence with the K+K- decay of the varphi meson. The energy dependence of the total and differential cross sections are extracted for excess energies up to 80 MeV by determining the Fermi momentum of the target neutron on an event-by-event basis. Though these cross sections are consistent with s-wave production, the kaon angular distributions show the presence of p waves at quite a low energy. Production on the neutron is found to be stronger than on the proton but not by as much as for the eta meson.

Prognostic significance of expression patterns of c-erbB-2, p53, p16INK4A, p27KIP1, cyclin D1 and epidermal growth factor receptor in oesophageal adenocarcinoma: a tissue microarray study

AIMS

To correlate immunohistochemical expression patterns and prognosis in oesophageal adenocarcinoma.

METHODS

The expression of c-erbB-2, p53, p16INK4A, p27KIP1, cyclin D1 and epidermal growth factor receptor (EGFR) was studied in a series of 137 primarily resected oesophageal adenocarcinoma samples. The expression analysis on protein level was performed on routine paraffin wax-embedded material, with immunohistochemical staining of the samples, assembled on a tissue microarray. The results were correlated with clinicopathological features (pT, pN and G) and survival.

RESULTS

22 (16%) tumours showed an overexpression of the c-erbB-2 oncoprotein. Expression of EGFR was observed in 72 (55%) cases, accumulation of p53 in 68 (52%) cases and of cyclin D1 in 102 (77%) cases. Loss of p16INK4A expression was observed in 101 (76%) cases and low expression of p27KIP1 in 91 (71%) cases. Expression of these proteins did not correlate with tumour stage, grade, Lauren's or World Health Organization classification or lymph node status. On univariate survival analysis, more advanced tumour stage (p = 0.002), lymph node involvement (p = 0.003), high tumour grade (p = 0.017) and lack of EGFR expression (p = 0.034) were found to be associated with poorer survival. On multiple regression analysis, only tumour stage (p = 0.03) and lymph node involvement (p = 0.004) were shown to have an association with the survival of the patient.

CONCLUSION

The immunohistochemical expression of c-erbB-2 oncoprotein, cylin D1, p16INK4A, p27KIP1, p53 and EGFR in most oesophageal adenocarcinomas suggests their implication in the pathogenesis of this entity. None of the molecular markers assessed, however, was of prognostic value. Identification of any marker superior to or even approaching the prognostic value of conventional histopathological markers (pT and pN) was therefore not possible.

The prognostic impact of O6-Methylguanine-DNA Methyltransferase (MGMT) promotor hypermethylation in esophageal adenocarcinoma

Promotor hypermethylation is a common event in human cancer. O6-Methylguanine-DNA Methyltransferase (MGMT) is a gene involved in DNA repair, which is methylated in a variety of cancer types. In colorectal cancer and lung cancer, hypermethylation of MGMT has been correlated with p53 mutation. In the present study, 132 samples of esophageal adenocarcinoma and 58 samples of normal esophageal tissue were investigated for MGMT hypermethylation status by methylation-specific real-time PCR and results were correlated to clinicopathological parameters, patient's survival, p53 mutation and expression of p53 protein and MGMT protein. In the carcinomas, hypermethylation of MGMT was found in 63.6% of cases and loss of MGMT protein expression in 48.5% of cases. Furthermore, MGMT hypermethylation was found in 5.7% of normal esophageal smooth muscle tissue, in 20.0% of esophageal squamous epithelium and in 61.5% of nonneoplastic Barrett's mucosa. In the carcinomas, hypermethylation of the MGMT gene was correlated with loss MGMT protein expression (p < 0.0001) and with high tumor differentiation (p = 0.0079). In contrast, no correlation between MGMT hypermethylation, Lauren's classification, WHO classification, tumor size, gender, age, pT category and pN category, and p53 status was found. Neither MGMT hypermethylation nor loss of MGMT protein expression was correlated with patient's survival. In conclusion, MGMT hypermethylation in esophageal adenocarcinoma is a frequent event that is associated with loss of MGMT protein expression but not with patient's outcome.

Near-threshold production of phi mesons in pp collisions

The pp-->ppphi reaction has been studied at the Cooler Synchrotron COSY-Jülich, using the internal beam and ANKE facility. Total cross sections have been determined at three excess energies epsilon near the production threshold. The differential cross section closest to threshold at epsilon=18.5 MeV exhibits a clear S wave dominance as well as a noticeable effect due to the proton-proton final-state interaction. Taken together with data for ppomega production, a significant enhancement of the phi/omega ratio of a factor 8 is found compared to predictions based on the Okubo-Zweig-Iizuka rule.

Limitierte chirurgische Resektion versus lokale endoskopische Therapie beim Frühkarzinom des ösophagogastralen Übergangs

BACKGROUND

Adenocarcinomas of the esophagogastric junction (especially Barrett's cancers) are increasingly diagnosed at early stages. The current standard treatment - radical resection with extensive lymphadenectomy - has been challenged. Limited resection or endoscopic mucosal ablation have been proposed as less invasive alternatives.

METHODS

Available data regarding limited surgical resections and endoscopic interventional procedures are evaluated with respect to short- and long-term results (mortality, morbidity, oncologic adequacy, quality of life).

RESULTS

Limited resection of the esophagogastric junction has been proven as safe (low morbidity and mortality) and oncologically adequate procedure (low rate of recurrence/excellent long-term survival) with good quality of life. The procedure meets the oncological requirements (R0-resection, complete resection of potentially tumor-infiltrated lymph nodes and the entire precancerous Barrett's esophagus). Reconstruction with interposition of a pedicled isoperistaltic jejunal loop prevents reflux and is crucial for achieving good postoperative quality of life. In contrast, endoscopic mucosal resection (EMR) carries the risk of high recurrence rates (at least 30 %). This has to be regarded as an effect of the frequent incomplete resection, multicentric tumor growth, the persistence of precancerous Barrett's mucosa and persistence of gastroesophageal reflux. Consequently, from the oncological view point, EMR is only suited for unicentric mucosal tumors (T1a) in short segments of Barrett's esophagus. Reliable preoperative identification of such tumors is, however, currently not possible.

CONCLUSION

For adequately selected patients with early Barrett's cancer, limited resection of the esophagogastric junction is an appropriate procedure. Endoscopic mucosa resection (EMR) might gain importance as staging tool.

Preferred location for the development of esophageal adenocarcinoma within a segment of intestinal metaplasia

BACKGROUND

Barrett's metaplasia is the predominant precursor for the development of esophageal adenocarcinoma. This precancerous lesion has become the focus of various surveillance programs aimed at detecting earlier and therefore potentially curable lesions. However, sampling error by missing invasive cancer lesions is a common problem. This study aimed to identify preferred locations within a segment of Barrett's mucosa for the development of esophageal adenocarcinoma.

METHODS

The study group consisted of 213 patients with histologically proven esophageal adenocarcinoma. Of those, there were 134 cases of early cancer and 79 cases of locally advanced lesions. These patients received neoadjuvant chemotherapy. The frequency of intestinal metaplasia and the location of the tumor occurrence within the segment of intestinal metaplasia were assessed.

RESULTS

Intestinal metaplasia was found in 83% of the early lesions and in 98% of the advanced tumors after neoadjuvant chemotherapy. In 82.2% of the cases, the tumor was located at the distal margin of the intestinal metaplasia in patients with early tumor manifestations. The remaining tumor mass after neoadjuvant therapy also was located predominantly at the distal margin of the segment of intestinal metaplasia (85% of the cases).

CONCLUSIONS

The results demonstrate that almost all adenocarcinomas of the esophagus are based on the development of a segment of intestinal metaplasia. The distal margin of Barrett's mucosa seems to be the most vulnerable location for the development of invasive cancer.

Surgical strategies for early esophageal adenocarcinoma

The need for extensive surgical resection for early-stage esophageal adenocarcinoma has been challenged by the increasing frequency of early detection in patients with Barrett's esophagus undergoing surveillance endoscopy. Limited endoscopic or surgical procedures are promoted as alternatives to radical esophagectomy and lymphadenectomy in such patients. Currently available data show that limited surgical resection of the distal esophagus with regional lymphadenectomy and interposition of an isoperistaltic jejunal segment is a safe and oncologically adequate procedure in this situation and provides good quality of life. This is in contrast to endoscopic ablation or endoscopic mucosal resection, which are associated with high tumour recurrence rates and persistence of premalignant Barrett esophagus. New technologies for accurate prediction of the presence and pattern of lymphatic spread-e.g. sentinel node techniques and artificial neural networks-may allow a further reduction of the invasiveness of surgical resection without compromising cure rates.

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.

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.

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.

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.

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.

Responders benefit from neoadjuvant radiochemotherapy in esophageal squamous cell carcinoma: results of a prospective phase-II trial

BACKGROUND

We present the results of a prospective phase-II-study of neoadjuvant combined radiochemotherapy followed by surgical resection in patients with histological proven locally advanced squamous cell carcinoma of the esophagus located at or above the level of the tracheal bifurcation.

METHODOLOGY

Between February 1995 and March 2000 a total of 76 patients with esophageal squamous cell carcinoma (uT3/4N0/+-categories) received simultaneous combined neoadjuvant radiochemotherapy consisting of a continuous intravenous infusion of 5-fluorouracil (300 mg/m2/day) 7 day per week concurrently with conventional fractioned external beam radiation therapy (2 Gy/day), five fractions per week up to a total dose of 30 Gy.

RESULTS

Radiochemotherapy related acute severe toxicity rate (CTC-grade-III) occurred in 34 patients, two patients died. Sixty-four patients underwent surgery with a complete resection in 48 patients. Three patients died during a 90-day post-operative course. The histopathological workup revealed no viable residual tumour cells in eight patients (ypCR) and according to the modified criteria of Mandard in 26 patients a histopathological response. Twenty-two of these patients underwent a R0-resection. The median follow-up time was 5.4 years with an overall median survival time of 20.6 months. The median survival in the 26 responders was 32.3 months versus 19.5 months in 38 non-responders (p=0.03).

CONCLUSIONS

Patients with locally advanced squamous cell carcinoma of the esophagus, who respond to preoperative neoadjuvant combined radiochemotherapy, seem to have more benefit from subsequent resection than non-responding patients.

[Sentinel lymph node mapping in gastric and esophageal carcinomas]

During the last 5 years, the concept of sentinel lymph nodes has been investigated in a variety of solid tumors. Despite the multidirectional and complex lymphatic drainage of the stomach, early gastric cancer has been shown to be a suitable model for sentinel lymph node mapping. In contrast, sentinel lymph node mapping of esophageal cancer is compromised by the anatomic location of the esophagus and its lymphatic drainage in the closed space of the mediastinum. The technique and clinical application of sentinel lymph node mapping thus differ between esophageal and gastric cancer. Reliable detection of sentinel lymph nodes in the mediastinum requires radioisotope labelling, while blue dye and radioisotope labelling are both feasible for gastric cancer. In patients with early gastric cancer, laparoscopic resection with sentinel node negative status is already under investigation in clinical trials. In esophageal cancer, sentinel node mapping is still considered an experimental technique. Preliminary data, however, indicate that it may be reliable and feasible in patients with early adenocarcinoma of the distal esophagus.

Angiogenesis and neoplastic transformation of Barrett's epithelium

Angiogenesis has significance in neoplastic transformation, prognosis and future therapy