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.     

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.     

Caustic injury of the oesophagus. Sixteen years experience, and introduction of a new model oesophageal stent

Caustic ingestion can lead to oesophageal stenosis. We studied 251 patients, 205 of whom were children, in a sixteen-year period. Seventeen patients, of whom one was an adult, acquired deep burns in the oesophagus which had to be treated, to prevent the development of oesophageal strictures. These patients were treated with long-term stenting of the oesophagus with specially designed, silicone rubber stents, impregnated with silicone oil 20 cS, designed by one of us (R.N.P.B.) as the only treatment. Of all models, the twin-tube dilator was the most satisfactory. No corticosteroids were administered. Only one patient developed a mild stenosis. It is therefore our opinion that, when life-saving operations are not indicated, twin-tube stenting of the oesophagus is helpful in treating caustic lesions of the oesophagus and will prevent stricture formation. Corticosteroids were not given in this series, and should be abandoned in the treatment of caustic lesions.     

Characterization of two Chinese hamster ovary cell lines expressing the COOH-terminal domains of sterol regulatory element-binding protein (SREBP)-1

BACKGROUND: To assess surgical outcome after oesophagectomy, we reviewed operative techniques and postoperative course among 90 patients who underwent oesophageal resection for malignancies from January 1989 to December 1995. METHODS: There were 73 males and 17 females; mean age was 64.2 years. Indications were squamous cell carcinoma in 49 patients and adenocarcinoma in 41. Preoperatively 7 patients had chemotherapy and 18 benefited from radiochemotherapy. There were 56 total thoracic oesophagectomies, with anastomosis in the neck in 34 patients and at the thoracic inlet in 22. In 34 cases operation was limited to distal oesophageal resections. Digestive continuity was restored with the stomach in 62 patients, with the colon in 24, and with a jejunal loop in 4. A feeding jejunostomy was constructed in 48 patients with a gastric transplant. RESULTS: Mortality was 10% (9 patients), decreasing from 18.5% (before 1993) to 3.8% (since 1993). One patient died in the colonic graft group and 8 in the gastric pull-up group. Postoperative complications occurred in 9 patients after colonic interposition and in 23 after gastric pull-up; they consisted in pulmonary infection or insufficiency in 26 patients, cerebrovascular accident in one, renal insufficiency in 2, recurrent nerve palsy in 4, and anastomotic leakage in 6. Transhiatal approach was not associated with a decreased incidence of postoperative deaths or complications. Eighteen patients (72%) developed postoperative pulmonary complications after preoperative chemotherapy. CONCLUSION: Oesophagectomy can be performed with low mortality. A colonic graft is not associated with an increased incidence of perioperative deaths or complications and is the substitute of choice when there is any question regarding gastric vascularization, or in young patients with long life expectancy. Preoperative neoadjuvant treatment significantly increases postoperative pulmonary complications.     

Esophageal cancer on the increase. Is Barrett esophagus the cause?

At the Dept of Surgery, Lund University, during the 10-year period 1985-95, 54 patients with adenocarcinoma of the gastro-oesophageal junction (17 with Barrett's epithelium, and 37 without) underwent oesophageal resection: oesophagectomy and gastric pull-up (n = 10), extended total gastrectomy (n = 37), or oesophageal resection and interposition of colon (n = 2) or jejunum (n = 5). Hospital mortality was 3.7% (2/54), and the mean duration of hospitalisation 13 days (range, 9-42). Long-term survival was significantly better in the Barrett's oesophagus subgroup than in the carcinoma of the cardia (non-Barrett's oesophagus) subgroup, the respective rates being 50% vs. 10% (p = 0.0052; Log rank test). The better survival in the Barrett's oesophagus subgroup is probably to be explained by the earlier stage of disease among these patients, in turn due to a history of gastro-oesophageal reflux, whereas the predominant symptom in the cardia carcinoma subgroup was dysphagia.     

Prolonged survival follows resection of oesophageal SCC downstaged by prior chemoradiotherapy

BACKGROUND: The poor survival rate of surgically treated patients with oesophageal cancer has not improved substantially over the last 25 years, but combined modality therapy has shown early promising results. METHODS: A prospective study was undertaken to determine the effect of pre-operative synchronous chemoradiotherapy followed by oesophagectomy in 53 patients with squamous cell carcinoma (SCC) of the oesophagus. The patient group was unselected, other than by fitness for surgery. RESULTS: In 25% of patients, complete pathological regression of the tumour was achieved. All but one of the patients in this subgroup had T2 tumours on pre-operative clinical staging and two had evidence of lymph node involvement, but postoperative pathological examination revealed that pre-operative chemoradiotherapy had downstaged their disease to T0N0. There was no hospital mortality in this subgroup and the actuarial 7 year survival was 69%. CONCLUSIONS: For squamous oesophageal tumours deep to the submucosa this is an extremely good survival. For the present, this form of therapy for SCC of the oesophagus appears capable of achieving results comparable to, or better than, those reported for 3-field lymphadenectomy.     

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.     

Transabdominal extensive oesophagogastric devascularization with gastro-oesophageal stapling in the management of acute variceal bleeding

BACKGROUND: Operation is required for patients with portal hypertension who have failed to respond to emergency sclerotherapy for control of acute variceal bleeding. This study evaluates the role of transabdominal extensive oesophagogastric devascularization combined with gastro-oesophageal stapling for control of acute variceal bleeding in patients with portal hypertension of different aetiologies. METHODS: Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling was performed in 65 patients (28 with cirrhosis, 17 with non-cirrhotic portal fibrosis and 20 with extrahepatic portal venous obstruction) in whom emergency endoscopic sclerotherapy, and/or pharmacotherapy and balloon tamponade had failed. The Sugiura procedure was modified to minimize operating time and to reduce the operative difficulties due to oesophageal wall necrosis after sclerotherapy. RESULTS: The operative mortality rate was higher in patients with cirrhosis (P = 0.0003); sepsis was the leading cause of death (in nine of 18). A high mortality rate (12 of 15) was seen in patients with Child grade C cirrhosis. Control of bleeding was achieved in all patients. The procedure-related complication rate was 17 per cent with a 6 per cent oesophageal leak rate; four of 47 surviving patients developed oesophageal stricture. During a mean follow-up of 33 months, residual varices, recurrent varices and rebleeding were seen in three, two and three of 47 survivors. CONCLUSION: Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling is an effective and safe procedure for control of acute variceal haemorrhage with satisfactory long-term control, especially in patients without cirrhosis and low-risk patients with cirrhosis.     

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.     

Oesophageal cancer associated with other primary cancers: a study of 31 patients

The aim of this study was to investigate the characteristics of oesophageal cancer associated with other primary cancers and the survival rate after surgery for the patients with these cancers. Of 202 patients with oesophageal cancer treated in the Second Department of Surgery, Shinshu University School of Medicine between 1981 and 1995, 31 patients (15.3%) had oesophageal cancer associated with other primary cancers. Twenty-one synchronous and 10 metachronous associated cancers were found and 25 of them were resected. Early-stage oesophageal cancer was much more frequent in the associated cases than in the non-associated cases. The stomach was the most frequently associated organ. The numbers of cases with triple and quadruple cancers were three and one, respectively. Three of these cases had intervals of over 6 years between tumours. Three cases with other primary cancers which had intervals of over 7 years after oesophagectomy were found, and two were carcinomas of the reconstructed gastric tube. In the outcome after surgery for oesophageal cancer, there was no difference between the associated and the non-associated cases, and also no difference between the synchronous and metachronous associated cases. Regarding the five-year and 10-year survival rates after surgery for the first cancers, the synchronous cases had a poorer outcome than did the metachronous cases. In conclusion, oesophageal cancer with other primary cancers is not always rare, and its outcome is not poor compared with that of the non-associated cases. These patients may achieve survival by early detection of both lesions and positive treatment. It is important to consider the risk of other primary cancers after oesophagectomy, and the success of the reconstructed gastric tube should be followed by endoscopy.     

False positive MIBG scan

OBJECTIVE: An increased age-related incidence of oesophageal cancer in people with intellectual disability has been suggested by studies in the Netherlands. Gastro-oesophageal reflux disease (GORD), as documented by pH testing, occurs frequently in the intellectually disabled population, being found in nearly 50% of those with an IQ less than 50, while Barrett's oesophagus is found in about 15-26%. DESIGN: We compared the age-related incidence of oesophageal cancer in institutionalized, intellectually disabled individuals in the Netherlands with the age-related incidence in the general Dutch population. METHODS: Data were provided by the Netherlands Cancer Registry. The patient's institute physician was asked to complete a questionnaire about the diagnosis, which was endoscopically and histologically confirmed. RESULTS: The incidence of oesophageal carcinoma was 20 in 168,000 person-years. The expected incidence for oesophageal cancer, based on age-related incidence in the general population, was 7.0, resulting in a standardized morbidity ratio in the population with intellectual disability of 2.9 (confidence limits, 1.8-4.1; P < 0.001). Endoscopic findings were as follows: in 18/20 intellectually disabled carcinoma patients an adenocarcinoma was found; the remaining two patients had a squamous cell carcinoma. Barrett's epithelium was observed in nine patients (45%), eight (42%) of whom showed a peptic stricture as well. In 15 (75%) cancer patients reflux oesophagitis was found, accompanied in 14 cases by a hiatal hernia. CONCLUSION: A standardized morbidity ratio for oesophageal carcinoma of 2.9 was found in the intellectually disabled population as compared to the general population. Early detection and treatment of GORD in the population with intellectual disability is of paramount importance to prevent the development of Barrett's dysplasia and carcinoma.     

Reconstructive operations on the biliary tract

Fifty cases in which reconstruction of the biliary system was carried out were reviewed. In 25 cases the operation was done during the treatment of malignant neoplasms. The other 25 patients were treated for benign conditions. Delayed stricture of the biliary anastomosis occurs more frequently following operation for benign post-traumatic obstruction than following reconstruction for other conditions. This is probably a result of: (1) greater regional scarring, (2) local infection, and (3) technical imperfections in the reconstituted biliary anastomosis. Certain primary malignant tumors may be difficult to recognize by both gross and microscopic examination. In six cases of biliary obstruction resulting from malignant neoplasms in the present series, exploration had been carried out some time previously, and in four of them an erroneous diagnosis of benign biliary obstruction was made.End-to-end anastomosis of the duct above and below the point of obstruction is the method preferred in the treatment of benign biliary stricture. Intrahepatic and extrahepatic biliary-enteric anastomoses have been used successfully in selected cases.     

Biliary reflux can be a contributory cause of esophagitis

In recent years duodenogastric reflux has been recognised as a possible cause of oesophagitis. Alone or in combination, bile salts, trypsin, pepsin, and hydrochloric acid have all been shown to cause oesophagitis. Duodenal content in the oesophagus can be measured by means of a new fibre-optic sensor, Bilitech 2000, a device measuring the occurrence of bilirubin and yielding 24-hour readings from the distal oesophagus. Studies in which the device has been used have shown oesophageal bilirubin to be increased in patients with oesophagitis, especially in the subgroup with such complications as oesophageal stricture or ulceration, or Barrett's oesophagus. The evidence suggests that unsatisfactory response to proton pump inhibitors in reflux patients might be due to an increase in duodenal reflux, and should be treated surgically with fundoplication or biliary diversion. This may also be true of oesophagitis patients with complications, though this remains to be shown in clinical studies.     

Surgery of esophageal cancer in Liège: III. Clinical and radiographic evaluation of long-term quality of life after esophagectomy

OBJECTIVE: Functional evaluation of digestive transplants after oesophagectomy for cancer. MATERIAL AND METHODS: We evaluated alimentary comfort and quality of life and performed a videofluoroscopy (radiocinema) in 34 patients who were alive and disease-free one year or more after oesophagectomy for malignancy. There were 22 males and 12 females; mean age was 64 years. Twenty-three patients had a gastric pull-up and 11 a colonic graft. Mean follow-up was 36 months (range: 12-100 months). Possible correlations between clinical symptoms and radiographic observations were studied with Fisher's exact test. RESULTS: Most-cited symptoms were gurgling in 16 patients, early fullness during eating in 15, diarrhea in 14, postprandial sweating in 9, pyrosis in 8, nocturnal cough in 7, and dysphagia in 5. Most patients considered the side effects of the operation as mild to moderate and mean rating of alimentary comfort was 7.6/10. Twenty-five patients qualified their quality of life as good, 8 as satisfactory, and 1 as poor. Twenty-nine patients led active lives. Videofluoroscopic evaluation showed that colonic grafts emptied mainly by gravity, while active contractions were observed in the antrum of gastric transplants. There was a significant correlation between alimentary symptoms and radiographic distension of the transplant. Oro-pharyngeal abnormalities, site of proximal anastomosis, nature, motility, or active versus passive emptying of the transplant did not correlate with clinical complaints. CONCLUSIONS: In most patients quality of life and alimentary comfort are good after oesophagectomy and gastric or colonic interposition. Radiocinema is an adequate method to evaluate the dynamic of the transplant and shows a better emptying of gastric grafts, compared to colonic grafts, particularly when the proximal portion of the oesophagus triggers the progression.     

Rapid typing and elucidation of new secondary metabolites of intact cyanobacteria using MALDI-TOF mass spectrometry

Cervical leakage, occurring on average in 20-50% of the patients, is one of the major causes of morbidity following oesophagectomy for cancer. We report on a new technique of gastroplasty, namely fundus rotation gastroplasty which was used in 53 patients. There were 49 patients with oesophageal cancer and 4 with benign lesions. Hospital mortality was 5.7% (3/53) and the leakage rate 7.5% (4/53). The advantages of fundus rotation gastroplasty over conventional gastroplasty are the better blood supply and the greater length of the gastric tube. Controlled clinical trials will be necessary to confirm the advantages of fundus rotation gastroplasty versus conventional gastroplasty.     

Oesophageal replacement in the management of corrosive strictures: when is surgery indicated?

The accidental ingestion of corrosive agents is a major cause of oesophageal strictures in children. The mainstay of treatment is repeated dilatations. Despite this, a significant number of patients eventually require oesophageal bypass. We reviewed the records of all cases managed with this condition at the University of Cape Town teaching hospitals between 1976 and 1994. Dilatation therapy alone was successful in 14 out of 39 patients (41%). Morbidity of failed dilatation therapy included repeated hospital admissions over an average 11.5 months and 17 dilatations each. Oesophageal perforations occurred in 7 cases (18%). Early factors predictive of failure of conservative treatment were: delay in presentation of more than 1 month; severe pharyngo-oesophageal burns requiring a tracheostomy; oesophageal perforation; and a stricture longer than 5 cm on radiological assessment. The size of dilators accepted during early bougienage also correlated with eventual outcome. These criteria may be useful in predicting which patients will not respond to repeated dilatations. Early surgical intervention in such cases will prevent fruitless dilatations and related complications.     

Comparison of selected canine vaccines for their ability to induce protective immunity against canine parvovirus infection

BACKGROUND AND AIMS: The ingestion of a corrosive agent including strong alkaline material causes serious caustic damage to the upper gastrointestinal tract. We describe four cases in patients who had ingested alkaline substances. MATERIAL AND METHODS: During the years 1992-1996, four patients who had ingested strong alkali were treated in the Oulu University Hospital. The patients were reviewed retrospectively. RESULTS: In one case a third-degree, in two cases a second-degree and in one case a first-degree injury developed in the oesophagus. The patient with first-degree injury was treated with repeated endoscopic dilatations and he refused any more aggressive surgical therapy. The patients with more severe injuries were operated, on all with good end results. CONCLUSION: Aggressive surgical treatment of severe corrosive injuries involving the upper gastrointestinal tract is recommended.     

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.     

Oesophagogastrectomy for carcinoma of the oesophagus and cardia

A retrospective review was undertaken of all oesophagectomies performed within a single unit over a 12-year period. In all, 298 patients with primary oesophageal cancer underwent resection between March 1979 and December 1991. Four patients had a three-stage oesophagogastrectomy, 27 a thoracoabdominal oesophagogastrectomy and 267 a Lewis procedure. Dysphagia was the predominant presenting symptom. The duration of symptoms was not related to the stage of disease. Before diagnosis, 52 per cent of patients tolerated symptoms for 2-4 months. Adenocarcinoma was found in 180 tumours and squamous cell carcinoma in 103. Half of the patients had evidence of metastatic spread at the time of laparotomy or thoracotomy. The 30-day mortality rate was 10 per cent and the overall actuarial 5-year survival rate of all patients 23 per cent. The actuarial 5-year survival rate of patients without lymph node involvement was 39 per cent compared with 17 per cent for those with positive nodes (P < 0.05). Five of eight patients who had anastomotic leakage died. The almost unselected nature of this series, coupled with the favourable results of oesophagectomy, support the contention that resection remains the preferred mode of treatment for carcinoma of the oesophagus of all histological types.