Involvement of antizyme-like regulatory protein in polyamine-caused repression of ornithine decarboxylase in insect-derived Trichoplusia ni 5 cells

BACKGROUND: The diagnosis and classification of oesophageal motility disorders is currently based on assessment of the phasic contractile activity of the oesophagus. Tonic muscular contraction of the oesophageal body (oesophageal tone) has not been well characterised. AIM: To quantify oesophageal tonic activity in healthy subjects and in patients with achalasia. PATIENTS: Oesophageal tone was measured in 14 patients with untreated achalasia and in 14 healthy subjects. In eight patients with achalasia, oesophageal tone was again measured one month after either endoscopic or surgical treatment. METHODS: Tonic wall activity was quantified by means of a flaccid intraoesophageal bag, 5 cm long and of 120 ml maximal capacity, which was placed and maintained 5 cm above the lower oesophageal sphincter and connected to an external electronic barostat. The experimental design included measurement of oesophageal basal tone and compliance as well as the oesophageal tone response to a nitric oxide donor (0.5 ml amyl nitrite inhalation). RESULTS: Oesophageal basal tone, expressed as the intrabag (intraoesophageal) volume at a minimal distending pressure (2 mm Hg), did not differ significantly between patients with achalasia and healthy controls (6.6 (2.5) ml versus 4.1 (0.8) ml, respectively). Oesophageal compliance (volume/pressure relation during intraoesophageal distension) was significantly increased in achalasia (oesophageal extension ratio: 3.2 (0.4) ml/mm Hg versus 1.9 (0.2) ml/mm Hg; p < 0.01). Amyl nitrite inhalation induced oesophageal relaxation both in patients and in controls, but the magnitude of relaxation was greater in the latter (intrabag volume increase: 15.3 (2.4) ml versus 36.2 (7.1) ml; p < 0.01). CONCLUSION: In patients with achalasia, oesophageal tonic activity, and not only phasic activity, is impaired. Although oesophageal compliance is increased, residual oesophageal tone is maintained so that a significant relaxant response may occur after pharmacological stimulation.     

Azygography in the pre-treatment evaluation of oesophageal carcinoma

Azygography is a useful technique for the pre-operative detection of unresectability of oesophageal malignancies. Invarison of the azygos vein by oesophageal carcinoma occurs because of the anatomic proximity of the thoracic oesophagus and the azygos vein. Azygography may be performed by either intraosseous injection of a rib or by direct retrograde catheterization. Complete obstruction of the azygos vein indicates that an oesophageal carcinoma is unresectable if no other intrathoracic disease is evident.     

100 years guarding the health of the border guards

A Heller-Dor procedure was performed by laparotomy (group A: n = 8) or by laparoscopy (group B: n = 12) after failure of one to 17 sessions of intraluminal dilatations (n = 13) or as a primary treatment of oesophageal achalasia (n = 7). The oesophagomyotomy was extended over the thoracic oesophagus by thoracoscopy in two patients having vigorous achalasia. Injury to the oesophageal mucosa occurred in two group A patients who had previously been dilated. At follow-up (range: 1 to 113 months), 6 patients of group A (75%) and 10 of group B(83.3%) had no residual dysphagia. The four patients (group A: n = 2; group B: n = 2) who complained of heartburn prior to the operation were asymptomatic, only one group A patient developed symptoms of reflux, and oesophageal pH-monitoring was normal in the 6 group B patients investigated at follow-up. The laparoscopic approach reduces the magnitude of the operation, and the magnified overview permits precise dissection of the intraparietal adhesions which may develop after numerous sessions of dilatation.     

Oesophageal cancer coexisting with colorectal lesions

OBJECTIVE: To investigate the incidence of colorectal lesions in patients who present with oesophageal cancer. DESIGN: Prospective open study. SETTING: University hospital, Japan. SUBJECTS: 135 of 218 patients who presented with squamous cell carcinoma of the oesophagus during the seven year period 1988-1994 were randomly allocated to have a barium enema examination. INTERVENTIONS: Barium enema examinations, and if colorectal lesions were found, colonoscopy and biopsy. MAIN OUTCOME MEASURE: Incidence of coexistent colorectal lesions. RESULTS: No abnormal findings were found in 52 (39%), diverticula were present on 37 (27%), benign polypoid lesions in 51 (38%), and malignant lesions in 6 (4%). We examined the clinical and histopathological details of all patients to see if it was possible to distinguish the patients at high risk of developing oesophageal and colorectal cancer but could find no differences among the groups. CONCLUSION: Asymptomatic colorectal lesions are relatively common in patients with squamous cell carcinoma of the oesophagus in Japan.     

Malignant esophageal-respiratory fistula and esophageal stenosis treated with a Gianturco-Z-stent

Oesophago-respiratory fistula in most instances in a complication of advanced malignant tumours of the oesophagus or the lung. In our patient group eleven oesophago-respiratory and one gastro-respiratory fistulas were encountered. Three patients were operated upon. In one of them with achalasia, early oesophageal carcinoma was discovered in the background of the fistula. Two patients had fistulas without of oesophageal narrowing, therefore, stent implantation into the trachea and bronchus was performed. One of them was previously managed endoscopically with lyodura plug and fibrin glue, but only temporary occlusion of the fistula was obtained. In five patients, seven conventional oesophageal prosthesis (6 Cook, 1 Rüsch) were used to close the fistulas. In one of these patients, three oesophago-respiratory fistulas developed one after the other at the level of the prosthesis funnel. They were closed with three prostheses connected with short silicone tubes. In the last two patients, Gianturco-Z stent was employed. Its advantages over the plastic prostheses include small basic and lager final luminal diameter, lesser predilatation, easier implantation, lower complication and mortality rate. The silicone coated and double funnel stent with expansile force is effective in fistulas closure. On implantation, stent shortening in minimal, allowing precise placement of the stent even in proximal malignant oesophageal stenosis with oesophago-bronchial fistula. The high price of the stent is compensated for by the lower complication rate, shorter hospitalization and subsequent reduction is hospital expenses. Therefore these metal stents should be financed by the National Health Service, at least in specialized centers for managing patients with dysphagia.     

Primary malignant melanoma of the oesophagus

We report the case of a 74-year-old female patient in whom a primary malignant melanoma of the oesophagus was detected at the time of investigation of phlebothrombosis. Therapy of choice for this extremely rare tumour is radical surgical resection of the oesophagus. Even after surgical resection, primary oesophageal melanomas have a very poor prognosis. According to the present state of knowledge, it remains unclear to what extent the prognosis could be improved by adjuvant therapeutic procedures with radiotherapy or chemotherapy and immunostimulation.     

An efficient method for cloning in-frame fusion protein genes

BACKGROUND: Transhiatal oesophagectomy is an accepted approach for the treatment of carcinoma of the oesophagus. However, experience of this technique in benign diseases is limited. METHODS: Transhiatal oesophagectomy was done in 29 patients for benign oesophageal conditions including corrosive stricture (21), achalasia of the cardia (four), tuberculosis (one), mediastinal fibrosis (one), Crohn's disease (one) and peptic stricture (one). Dysphagia was the predominant symptom in all patients; strictures had all previously been dilated repeatedly. The stomach was used as an oesophageal substitute in 24 patients; in five with a scarred stomach due to damage by a corrosive agent, oesophagocoloplasty was performed. Resection and reconstruction were done in one stage in 25 patients; four with poor nutritional status had a two-stage procedure. RESULTS: There was no perioperative death. Complications encountered were recurrent laryngeal nerve palsy (six patients) which was mostly transient, anastomotic leak (seven) and stenosis (eight). Postoperative function of the intrathoracic stomach was satisfactory. CONCLUSION: Transhiatal oesophagectomy is a safe and satisfactory procedure for benign obstructive conditions of the oesophagus.     

Risk factors for the development of oesophageal cancer as a second primary tumour

Exposure to irradiation or chemotherapy as well as prolonged exposure to risk factors, such as alcohol and tobacco, may induce a second primary carcinoma of the oesophagus. To estimate the potential risk of previous treatment regimens, we performed a case-control study. In the Tumour Registry of The Netherlands Cancer Institute, from 1955, 27 cases of squamous cell carcinoma of the oesophagus were identified following treatment for malignant lymphoma (n = 11), breast cancer (n = 8) and lung cancer (n = 8). The median interval was 6.6 years (range 1-16). Preferably 3 controls from the same tumour registry were matched to each case on the basis of sex, age, primary tumour, location of primary treatment (academic or general hospital), calendar year at diagnosis of primary tumour and duration of follow-up. Clinical data and details of treatment were obtained from the medical records. In patients who had smoked for more than 5 years, there was a 3.2-fold increased risk of oesophageal carcinoma (P = 0.04); for those with a regular alcohol intake the relative risk was 3.3 (P = 0.01). There was no significant relationship between irradiation of the mediastinum and subsequent risk for oesophageal cancer. The number of chemotherapy-treated patients was too small to calculate the relative risk associated with cytostatic drugs. In conclusion, oesophageal cancer as second primary cancer is extremely rare. Risk factors include the well known abuse of alcohol and tobacco. No significant relationship with previous mediastinal irradiation could be demonstrated.     

Radiological manifestations of oesophageal involvement in acanthosis nigricans

Radiologic features of two cases of acanthosis nigricans with oesophageal involvement are reported. The first case demonstrated diffuse, granular shadows throughout the oesophagus which were difficult to differentiate from oesophageal moniliasis. Another case showed many discrete and tiny elevations resembling pseudopolyposis of the colon. Emphasis is placed on radiological differential diagnosis from moniliasis and leukoplakia of the oesophagus.     

Esophagogastric bypass anastomosis for benign stricture of cardia

The aim of the study is to discuss our observations concerning oesophagogastric bypass anastomosis in cases with scar stricture of cardia in long-term achalasia (megaoesophagus). The Heller operation is ineffective in such patients and the resection of cardia with oesophagogastric anastomosis is a large and controversial operation. 16 patients were operated (6 of them after ineffective cardiomyotomy). In all cases long-term dysphagia, big loss of weight and large, S-shaped oesophagus lying on the diaphragm were found. The left side thoracotomy was performed and fundus of the stomach was dislocated to the chest through dilatatored oesophageal hiatus and with the oesophagus above the cardia. There were no postoperative complications. However, dysphagia regressed. The remote results (from 1 year to 7 years) in 11 patients were analysed. The general condition was satisfactory. No dysphagia and gastrooesophageal reflux was revealed. Anastomosis was efficient in X-ray examination. Our observations indicate that oesophagogastric anastomosis is a procedure of choice in the treatment of long-term achalasia with stricture of cardia and megaoesophagus.     

Predictive value of symptom profiles in patients with suspected oesophageal dysmotility

The main aim of the study was to determine prospectively, in patients referred for oesophageal manometry, whether certain combinations of oesophageal symptoms are more likely than others to predict the presence of oesophageal dysmotility or a positive response to acid perfusion testing. In 524 consecutive patients, presenting predominantly with (non-cardiac) chest pain (n = 277), dysphagia (n = 186), or heartburn (n = 61), a standardized symptom assessment was completed before oesophageal manometry and acid perfusion testing. Half the patients in each group reported additional ('secondary') oesophageal symptoms as well as the predominant symptom. Oesophageal dysmotility was categorized in accordance with standard manometric criteria for achalasia, diffuse oesophageal spasm, nutcracker oesophagus, hypertensive lower oesophageal sphincter, or non-specific oesophageal motility disorder. In the predominant chest pain group, the prevalence of abnormal manometry was 33%; in the presence of secondary symptoms, especially dysphagia rather than heartburn, however, the prevalence was significantly (p < 0.01) increased. Also in the predominant chest pain group the prevalence of positive acid perfusion testing (44%) was significantly greater (p < 0.05) in those with than in those without secondary symptoms. In the predominant dysphagia group, the prevalence of abnormal manometry was higher than in the other two groups (56%; p < 0.001) but was not affected by the presence or absence of secondary symptoms; this latter finding was also true for the predominant heartburn group. The distribution of specific manometric disorders in any group was not related to the presence or type of secondary symptoms, although a combination of dysphagia and chest pain discriminated achalasia from other manometric disorders.(ABSTRACT TRUNCATED AT 250 WORDS)     

Neck abscess: an unusual presentation of a thoracic malignancy

In general, malignancies presenting as abscesses are uncommon. We report on a patient that presented with a neck abscess originating in a cluster of metastatic lymph nodes from a primary squamous cell carcinoma arising in the thoracic oesophagus.     

Functional and structural properties of Na+/K(+)-ATPase enzyme in neonatal erythrocytes

Achalasia is a relatively infrequent disorder of oesophageal motility, and is most often easily diagnosed by stationary manometry showing absence of peristalsis and incomplete lower oesophageal sphincter (LOS) relaxation. In rare cases manometric findings may be inconclusive or a malignant underlying disease is suspected. In such cases direct visualization of the LOS by endoscopic ultrasound (EUS) could contribute to securing the diagnosis and possibly lead to earlier diagnosis and treatment. With lower frequency EUS, increased thickness of the inner circular layer of the muscularis propria may be difficult to detect. Available data suggest that high frequency (20 MHz) and 3-D EUS has a potential to reliably discriminate between achalasia patients and normal subjects, and thereby be of diagnostic value.     

Clinical and bacteriologic impact of rifabutin prophylaxis for Mycobacterium avium complex infection in patients with human immunodeficiency virus infection

Carcinoma of the oesophagus is the seventh most common malignancy worldwide. It is a disease with a poor prognosis; more than half of the patients present with surgically irresectable tumours. For such patients, palliative therapy is directed towards the relief of dysphagia. Expandable metallic stents have recently been developed for use in the oesophagus. These have the advantage of being introduced through small diameter delivery catheters. Once released, they can expand to as much as 25 mm in diameter, potentially allowing patients to consume a normal diet. The current designs of metallic stents include the Strecker stent, the Wallstent endoprosthesis, and the Gianturco-Rosch stent. The Strecker is an uncovered stent while the other two are covered on the outside of the stent with plastic to prevent tumour ingrowth. A review of the literature indicates that deployment of these stents is associated with a high technical success rate. Improvement in swallowing function is seen in 83% to 100% of these patients. The overall complication rates are low. However, covered stents are prone to migration while uncovered stents are vulnerable to tumour ingrowth. Further improvements in design promise to expand the role of these endoprostheses in the management of oesophageal carcinoma.     

What is the infection risk of oesophageal dilatations?

Oesophageal dilatation is the most widely used treatment option for the management of oesophageal strictures. Complications include bleeding, a slight increase in body temperature, thoracic or abdominal pain, oesophageal perforation, brain abscess and bacteraemia. We performed a prospective study to evaluate the frequency of post-dilatation bacteraemia in nine patients subjected to a total of 50 dilatations. Bacteraemia was detected in 36 cases (72%), In all but three cases, however, it was transient and not associated with fever or other clinical complications. The organisms most commonly responsible (64%) were alpha-haemolytic streptococci (Streptococcus viridans), probably originating as contaminants from the oropharynx and oesophagus and introduced into the bloodstream during dilatation. Despite the relatively low incidence of bacteraemia-related postdilatation complications, the potential severity of such complications argues for the use of antibiotic prophylaxis as a routine measure prior to oesophageal dilatation. CONCLUSION: Oesophageal dilatation is associated with a high incidence of bacteraemia. The organisms most commonly responsible were alpha-haemolytic streptococci. We recommend the use of antibiotic prophylaxis as a routine measure prior to oesophageal dilatation.     

Cancer of the oesophagus

Oesophageal cancer is the fourth most common tumour in developing countries, comprising mainly squamous cell tumours, although the incidence of adenocarcinoma has increased enormously over the last decades. Surgical resection has long been acknowledged as the mainstay of treatment, and developments in surgical technique are reviewed. The roles of radiotherapy and chemotherapy in the management of oesophageal cancer remain unclear, especially as the majority of studies to date have been uncontrolled trials. We present an analysis of 601 patients who underwent resection for carcinoma of the oesophagus between 1970 and 1994 in the Department of Clinical Surgery, St James's Hospital, Dublin. The analysis shows clearly that, while peri-operative mortality continues to improve, conventional surgery offers little prospect of cure in the majority of cases. We have therefore embarked upon a prospective controlled trial of neoadjuvant chemoradiotherapy followed by surgery versus surgery alone in patients with adenocarcinoma or squamous cell tumours of the oesophagus. Preliminary results indicate that multi-modality treatment may have a valuable role to play in the treatment of carcinoma of the oesophagus.     

The etiopathogenesis of esophageal cancer

Cancer of the oesophagus is a challenging clinical problem. Overall survival is poor, but patients who present early are eminently curable. Most cancers of the middle and upper oesophagus are squamous cell carcinoma. Adenocarcinoma is the most common cancer of the third of the oesophagus; this is not surprising when the usual distribution of Barrett's mucosa is considered. The geographical variation in the prevalence of oesophagus cancer is important. In most parts of the world, alcohol consumption and tobacco usage are the principal risk factors. Other risk factors have been identified in "the high-risk areas": a diet high in nitrosamines, deficient in trace elements, in vitamins (C.A, E) and the hereditary conditions like: Barrett's oesophagus, achalasia, caustic strictures.     

Review: Barrett's oesophagus in Taiwan

Barrett's oesophagus is the eponym applied to the columnar epithelium-lined lower oesophagus which is acquired as a complication of chronic gastro-oesophageal reflux (GER). Various complications seen in the Barrett's oesophagus, such as peptic ulcer, stricture, adenocarcinoma are named as Barrett's ulcer, Barrett's stricture-and Barrett's carcinoma, respectively. It is now generally accepted that Barrett's oesophagus is an acquired condition resulting from chronic repetitive GER. The frequency of Barrett's oesophagus seems to be higher in Caucasian than in Oriental or Negro populations. There is a tendency towards increasing prevalence rates all over the world, including Taiwan, due to the Westernization of diet, rapid growth in the elderly population, obesity etc. Almost 6% of the patients who manifest heartburn in GI clinics in Taiwan now suffer from GER, which is almost similar to the 7% reported by Nabel, (USA) in 1976. During the last 30 years, the incidence of esophageal adenocarcinoma has increased rapidly. Patients with Barrett's oesophagus have an increased risk of developing oesophageal adenocarcinoma and should be kept under surveillance. Regular follow-up, at least twice a year or preferably, every 2-3 months, for those patients with SCE using endoscopic surveillance and biopsy for those with severe dysphasia (oesophageal columnar intraepithelial neoplasia) in the surrounding area to detect Barrett's oesophagus cancer, is very important.     

A gene for FG syndrome maps in the Xq12-q21.31 region

AIMS: An increased risk of adenocarcinoma of the oesophagus has been demonstrated in patients with long segments of Barrett's mucosa. The risk of cancer associated with short segments of metaplasia of the oesophagogastric junction is not known. METHODS AND RESULTS: We report a case of early adenocarcinoma of the oesophagus arising on short tongues of Barrett's mucosa associated with an oesophageal cyst. The patient was a 68-year-old man with no previous clinical history of gastro-oesophageal reflux disease. The fortuitous discovery of an oesophageal cyst lead to the diagnosis of short tongues of Barrett's mucosa with high-grade dysplasia. On pathological examination of the resected specimen, an early adenocarcinoma had developed in Barrett's mucosa, localized just above the oesophageal cyst. CONCLUSIONS: As oesophageal cysts can cause symptoms suggestive of reflux, we hypothesize that this association may not be fortuitous.     

Circular myotomy and Belsey repair for acquired shortening of the oesophagus

Fourteen patients with shortening of the oesophagus due to chronic reflux oesophagitis have been treated by a combination of an oesophageal lengthening procedure with a standard anti-reflux repair. Their ages ranged from 18 to 78 years and eight were male. Thirteen patients had a reflux stricture (with additional penetrating ulcer in six) and one had a columnar-lined oesophagus. A complete circular myotomy was performed just below the level of the aortic arch, in combination with a Belsey Mark IV anti-reflux repair. There were no deaths post-operatively but one patient required re-operation for haemorrhage and one underwent oesophageal dilatation before discharge. All patients have now been followed up for over 5 years. Nine patients have required no further treatment for their oesophageal problems, two required two early dilatations each, two required multiple dilatations and one required oesophageal resection for stricture. We suggest that this combination merits further evaluation in the management of patients with short oesophagus due to reflux.