Endoscopic features of the columnar-lined esophagus

Electrophysiological characterization of neurons within the rat subiculum was carried out with intracellular recordings in an in vitro slice preparation. Subicular neurons responded to threshold pulses of depolarizing current delivered at a resting membrane potential (RMP) of 45.7+/-5.8 mV (mean+/-SD, n=85) with an initial burst of three to five fast action potentials that rode on a depolarizing envelope and was terminated by an afterhyperpolarization (burst AHP) (duration 113+/-35 ms; peak amplitude 2.7+/-0.6 mV, n=10). Tonic firing replaced the bursting mode at membrane potential less negative than -55 mV. Suprathreshold depolarizing pulses evoked at RMP both an initial burst and successive tonic firing. Intracellular staining with biocytin showed morphological features typical of pyramidal cells (n=8). The relationship between frequency of repetitive firing and injected current (f-I) revealed that the burst firing frequency (250-300 Hz) was only slightly influenced by the amount of injected current. By contrast, the f-I curve of the tonic firing phase depended upon current intensity: it displayed an initial segment that increased at first linearly and then turned into a plateau for both the early and the late inter-spike intervals. The frequency of the tonic firing declined only slightly with time, thus suggesting a lack of adaptation. During tonic firing, each single action potential was followed by a fast AHP and a depolarizing afterpotential. Termination of repetitive firing was followed by an AHP (spike-train AHP; duration 223+/-101 ms, peak amplitude 5.6+/-2.4 mV, n=17). Fast spike-train and burst AHPs were reduced by bath application of the Ca2+-channel blockers Co2+ (2 mM) and Cd2+ (1 mM) (n=8), thus suggesting the participation of Ca2+-dependent K+ conductances in these AHPs. Subicular bursting neurons generated persistent, subthreshold voltage oscillations at 5.3+/-1 Hz (n=20) during steady depolarization positive to -60 mV; at values positive to -55 mV, the oscillatory activity could trigger clusters of single action potentials with a periodicity of 0.9-2 Hz. Oscillations were not prevented by application of excitatory amino acid receptor and GABA(A) receptor antagonists (n=5), Ca2+-channel blockers (n=5), or Cs+ (3 mM; n=4), but were abolished by the Na+-channel blocker tetrodotoxin (1 microM; n=6). Our findings demonstrate that pyramidal-like subicular neurons generate both bursting and non-adapting tonic firing, depending upon their membrane potential. These neurons also display oscillatory activity in the range of theta frequency that depends on the activation of a voltage-gated Na+ conductance. These electrophysiological properties may play a role in the process of signals arising from the hippocampal formation before being funnelled towards other limbic structures.     

Endoscopic assessment in the treatment of chemical burns of the esophagus in children

The esopagofibroscopy was conducted in 37 children, hospitalized for the chemical burn of esophagus. The substantiation of the treatment tactics in injured persons was permitted due to the method applied for the burn extent and stage determination.     

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.     

Endoscopic biopsies and cytologic brushings of the esophagus are diagnostically complementary

Assessment of compliance in drug taking is a problem in a crowded Outpatient Department. Using riboflavin as a urinary marker is a simple and rational method. Identifying riboflavin in the urine by fluorescence on exposure to ultraviolet (UV) rays or torch light is being used in medical practice but not extensively. In this study, the validity and reliability of these methods were assessed. The sensitivity and specificity of this test by UV method was 86% and 82% for Reader I (medical person) and 82% and 94% for Reader II (paramedical person). For Reader I, the accuracy of reading by UV lamp was the same as torch light (85%) whereas for Reader II the accuracy was better with UV lamp (87%) than with torch (79%). In reading the fluorescence by UV lamp the crude agreement between the 2 readers was 82% and chance corrected agreement was 64%. UV lamp method appears to be a reliable way of assessing compliance both by medical and paramedical persons whereas torch method appears to be more reliable when used by a medical person than by a paramedical person.     

Endoscopic ultrasonography in the evaluation of leiomyoma and extramucosal cysts of the esophagus

BACKGROUND/AIMS: Leiomyoma is the most common type of benign esophageal tumor, whereas extramucosal cysts of the esophagus are congenital anomalies frequently asymptomatic in the adult and in most cases detected incidentally on chest x-ray. It is worthwhile considering these conditions together, because they present similar diagnostic and surgical problems. Conventional imaging tests do not lead to a precise diagnosis. The purpose of this study was to evaluate the use of endoscopic ultrasonography in the diagnosis of, and planning of treatment modalities for, these conditions. METHODOLOGY: Fifteen patients with esophageal leiomyoma and seven patients with extramucosal esophageal cysts were studied with endoscopic ultrasonography using an Olympus GF- EU-M3 instrument with a 7.5-12 MHz echoprobe. In all patients, the results of endoscopic ultrasonography were compared with the histology of the resected specimens. RESULTS: The histology of the resected specimens confirmed the endosonographic diagnosis in all patients. No malignancy was found in any specimen. CONCLUSIONS: Endoscopic ultrasonography is very accurate in visualizing these lesions and differentiating cystic from solid submucosal esophageal masses; in addition, the test can establish the exact location of the mass in relation to the esophageal wall and mediastinum. Therefore, endoscopic ultrasonography has a great impact in confirming the diagnosis of leiomyoma and extramucosal cysts of the esophagus and facilitates therapeutic decision-making because of its capacity to clearly define the size, layer of the origin, and pattern of the mass.     

Endoscopic treatment of gastric carcinoids

Carcinoids are the most common endocrine tumours, and arise from a multipotential primitive stem cell; the gastric location represents 2% of all carcinoids. From 1979 to 1992 at the Endoscopy Division of Istituto Nazionale Tumori, Milan, 2 patients suffering from single gastric carcinoid were endoscopically treated by electro-resection. No complication occurred during the treatment; 2 year- and 5-year-follow-up was performed in these patients, and no recurrence are observed. Surgical treatment represents the therapy of choice for gastric carcinoids, but endoscopic resection can represent an alternative in selected cases (lesions less than 1 cm or carcinoids with multicentric growth). Endoscopy can be used also in patients at high surgical risk.     

Endoscopic treatment of malignant dysphagia

Palliative endoscopic treatment of dysphagia in patients with inoperable oesophageal cancer includes: dilation, Nd:YAG laser photocoagulation and intubation, used alone or in combination. Such procedures are usually performed on an outpatient basis and are associated with a low rate of morbidity and mortality. From 1978 to 1988, 476 patients (401 males, 75 females) were treated at the Endoscopy division of the National Cancer Institute of Milan for inoperable primary or recurrent malignancies of the oesophagus or cardia or for extra-oesophageal neoplasms causing dysphagia. Dilation was used in 172 cases, Nd:YAG laser photocoagulation in 90, prosthesis insertion in 72, dilation and laser in 97, and prosthesis and laser in 45. Functional improvement was reported in 75% of patients after dilation, in 89% after laser treatment, in 80% after intubation, in 80% after dilation and photocoagulation, and in 89% after laser and intubation. The median duration of dysphagia-free interval was 4 weeks in dilated patients, 6-8 weeks in photocoagulated patients and 20 weeks intubate patients. Overall median survival was 6.2 months. The complication rate was: 1.4% in dilation treatment, 1.4% in laser photocoagulation, and 8.8% in prosthesis intubation. Mortality related to endoscopic treatment was 2.1% (10/476 patients). Relief of dysphagia is one of the most important goals of palliative treatment in patients with inoperable oesophageal neoplasms. Moreover, endoscopic palliation improves the quality of life in the patients, with a low complication rate.     

Endoscopic treatment of symptomatic choledocholithiasis

BACKGROUND/AIMS: Today, different endoscopic techniques are available to treat choledocholithiasis. These techniques include mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), laserlithotripsy (LL), and extracorporal shock-wave lithotripsy (ESWL). These techniques have to compete with laparoscopic stone removal which is performed with increasing frequency at some centers. METHODOLOGY: We report the results of treatment of choledocholithiasis and compare the results with a meta-analysis of studies in whom endoscopic and laparoscopic techniques were applied. From 1994-1995, 217 patients with symptomatic choledocholithiasis were treated using endoscopic retrograde cholangiography (ERC). RESULTS: Overall, complete stone removal was successful in 98% of all patients and only 5 patients had to undergo surgery. Complete endoscopic removal of stones was achieved in 70% during the first ERC session. In 47 patients consecutive ERC sessions with application of EML, EHL, or ESWL were necessary to completely remove the stones. Complication rate was 5% and included pancreatitis and bleeding from papillotomy. There was no procedure-related mortality. CONCLUSION: The study suggests that today ERC remains the treatment of choice in most patients with symptomatic choledocholithiasis.     

p53 and p21(WAF1/CIP1/SDI1) gene products in Barrett esophagus and adenocarcinoma of the esophagus and esophagogastric junction

The WAF1 (CIP1/SDI1) gene encodes a cyclin-dependent kinase inhibitor which is induced by wild-type, but not mutated, p53 gene product. WAF1 immunohistochemistry has been suggested to clarify the phenotype of overexpressed p53 gene product. We evaluated both p53 and WAF1 gene products by immunohistochemistry in 98 esophagectomy specimens with Barrett esophagus and/or adenocarcinoma of the esophagus and esophagogastric junction. Diffuse positive p53 staining was found in 40 of 88 adenocarcinomas (45%) and in dysplastic Barrett epithelium in 20 of 65 cases (31%), but not in Barrett mucosa without dysplasia (n = 36, P = .0004). Eighty-eight percent of cancers exhibited WAF1 expression, but there was no association with p53 and WAF1 staining. WAF1 protein was also identified in Barrett epithelium and in esophageal squamous and gastric epithelium. In contrast to carcinomas, a unique pattern of mutually exclusive p53 and WAF1 expression was found in five cases of dysplastic Barrett epithelium; a missense mutation at codon 175 of p53 was identified in one. p53 staining of adenocarcinoma was associated with shorter patient survival but was not independent of stage; WAF1 status added no prognostic information. Our findings show that WAF1 immunohistochemistry complements p53 immunohistochemistry in some cases of Barrett dysplasia but not in adenocarcinomas. Positive p53 immunostaining can serve to confirm a neoplastic process in Barrett mucosa. Positive staining of adenocarcinomas may be an indication of advanced stage.     

Endoscopic treatment of prenatally diagnosed ureteroceles

INTRODUCTION: The authors report a series of 16 infants presenting with an antenatally diagnosed ureterocele, treated immediately, during the neonatal period, by endoscopic incision. The objective of this treatment is to ensure effective decompression of the ureterocele. MATERIAL AND METHODS: The immediate postnatal assessment revealed 17 ureteroceles, including 7 intravesical ureteroceles (with one bilateral form) and 10 ectopic ureteroceles. Endoscopic opening allowed collapse of all of the ureteroceles and usually ensured improvement of renal function. Vesicoureteric reflux was observed secondarily in 7 infants with an ectopic form of the disease, and was present primarily in two other patients. RESULTS: In patients with an intravesical form, endoscopic treatment was found to be effective on its own and no complementary procedure was required. In contrast, in ectopic forms, a second operation was required in 9 cases: presence of vesicoureteric reflux (8 cases) required resection of the ureterocele with vesical reconstruction and ureteric reimplantation according to Cohen's technique. In one case, total ureteronephrectomy was performed due to complete absence of function of the kidney concerned. CONCLUSION: Endoscopic opening, performed soon after birth, can be considered to be the first-line treatment of antenatally diagnosed ureteroceles. Its main complication remains the secondary development of vesicoureteric reflux Radiological surveillance therefore appears to be essential.     

Barrett esophagus--an increasing problem

There has been a considerable increase in the incidence of adenocarsinoma in the proximal stomach (cancer of the cardia) and distal oesophagus (Barrett's cancer) for the past 20 years. There is probably also a parallel increase in the pathogenetically related conditions reflux oesophagitis and Barrett's oesophagus. In patients with classical Barrett's oesophagus, i.e., metaplastic changes in the mucosa more than 3 cm up from the gastro-oesophageal junction, a follow-up programme with endoscopy and adequate biopsies is recommended in cases where a finding of premalignant changes or malignancy will have therapeutic consequences. In "short segment" Barrett's oesophagus it is still not clear how extensive the biopsy and follow-up programme should be. It is also not clear whether other tests should be performed. Screening for malignancy, possibly by means of cancer-markers, and local treatment modalities of (pre-) malignant changes, are interesting possibilities that are being investigated.     

Endoscopic surveillance of Barrett's esophagus: a cost-effectiveness comparison with mammographic surveillance for breast cancer

OBJECTIVE: Endoscopic surveillance of Barrett's esophagus is commonly practiced to detect malignancy in an early and curable stage. However, the cost-effectiveness of this practice has been questioned. To clarify this issue, we undertook a cost analysis of endoscopic surveillance to detect adenocarcinoma in Barrett's esophagus compared with mammography used to detect occult carcinoma of the breast, a widely accepted cancer surveillance technique. METHODS: The rate of esophageal adenocarcinoma detected by endoscopic surveillance was calculated for Duluth Clinic patients with Barrett's esophagus seen from 1980 to 1995 and compared with published rates. The rate of occult breast cancer detection was calculated for all women undergoing surveillance mammography at the Duluth Clinic for the year 1994 and compared with published rates. Costs for screening studies and therapy for cancer treatment for both cancers were calculated based on clinical results and assumptions regarding outcomes derived from published reports, and the costs were compared. RESULTS: Endoscopic surveillance of 149 patients with benign Barrett's esophagus was performed for a total of 510 patient-yr, during which time seven patients developed adenocarcinoma, an incidence of one case per 73 patient-yr of follow-up. Occult breast cancer was detected in 50 of 12,537 mammograms, a detection rate of 0.4%. The incidences in both cases were comparable to published figures. The costs of detecting a case of adenocarcinoma in Barrett's esophagus and occult breast cancer were $37,928 and $54,513, respectively, and those for treatment resulting in cure were $83,340 and $83,292. Cost per life-yr saved was $4,151 for adenocarcinoma in Barrett's esophagus and $57,926 for breast cancer. CONCLUSION: Endoscopic surveillance of patients with Barrett's esophagus compares favorably with the common practice of surveillance mammography to detect early breast cancer, and should therefore be considered to be as cost-effective as surveillance mammography.     

Endoscopic sympathectomy treatment for craniofacial hyperhidrosis

OBJECTIVE: To present endoscopic T-2 sympathectomy as a minimally invasive therapy for craniofacial hyperhidrosis (CH). DESIGN: Follow-up study of 30 patients with CH treated by the new method in a 4-year period. The duration of follow-up was from 8 to 44 months (mean, 15 months). SETTING: University hospital. PATIENTS: Thirty consecutive patients with CH (18 men, 12 women) treated by the new method. All patients were essentially in good health except that they suffered from distressing CH to the extent that their daily activities were often disturbed. Their ages ranged from 7 to 63 years (mean age, 42.8 years). INTERVENTION: Endoscopic sympathectomy on both sides was carried out in a 1-stage operation for all patients. MAIN OUTCOME MEASURES: The patients were interviewed 1 week and then 3 months after surgery and then followed up by telephone interview about the alleviation or recurrence of CH and complications. RESULTS: All of the treated patients obtained a satisfactory alleviation of CH. One case was complicated by a mild and transient ptosis of the left eye. No recurrence of CH was noticed during the follow-up period. CONCLUSIONS: This therapeutic procedure is minimally invasive and effective. It causes minimal discomfort and was associated with no major complications in this series. The patients require only an overnight hospital stay and the operation scars are small. Endoscopic sympathectomy has proven to be an effective method in treating patients with distressing CH.     

Leiomyosarcoma of the esophagus: results of surgical treatment

BACKGROUND: This study examined the results of surgical treatment of leiomyosarcoma of the esophagus. METHODS: Between January 1920 and December 1996, 17 patients (9 men and 8 women) with leiomyosarcoma of the esophagus were treated surgically at the Mayo Clinic. Median age was 58 years and ranged from 26 to 76 years. Symptoms included dysphagia in 11 patients (64.7%) and odynophagia in 6 (35.3%). The tumor was located in the middle third of the esophagus in 10 patients (58.8%) and in the cervical esophagus in 7 (41.2%). Procedures performed included esophagogastrectomy in 9 patients (Ivor Lewis in 5, left thoracoabdominal in 3, and transhiatal in 1), enucleation in 3, transgastric excision in 1, and exploration without resection in 4. RESULTS: The procedure was considered curative in 11 patients (64.7%). There was one operative death (mortality, 5.9%). Complications occurred in 3 patients (17.6%) and included anastomotic leak in 2 and bleeding requiring reoperation in 1. Growth pattern was infiltrating in 7, polypoid in 5, and intramural in 5. Histologically, the tumor was grade 1 in 6 patients, grade 2 in 2, grade 3 in 7, and grade 4 in 2. The tumor was postsurgically classified as stage I in 2 patients, stage IIA in 7, stage IIB in 1, stage IIIA in 5, stage IV in 1, and unknown in 1. Six patients (35.3%) received adjuvant treatment. Follow-up was complete in 16 patients (94.1%) and ranged from 1 to 182 months (median, 48 months). Five- and 10-year actuarial survivals were 47.0% and 31.0%, respectively. Seven patients (41.2%) are currently alive (median survival, 72 months); all underwent curative resection. Factors affecting survival included completeness of resection, growth pattern, postsurgical stage, tumor grade, and tumor location (p < 0.05). CONCLUSIONS: We conclude that leiomyosarcoma of the esophagus is rare. Complete resection provides long-term survival.     

Surgical treatment of cancer of the esophagus and cardia

The purpose of the present study was to evaluate the results following surgical resection for cancer of the gastro-oesophageal junction. From 1. january 1988 to 1. april 1996 radical resection was intended in 107 patients at the Department of Thoracic and Cardiovascular Surgery at Odense University Hospital. Resection was possible in 75 patients. The operative mortality was 6.7% insufficiency of the gastro-oesophageal anastomosis was found in 6.7%. Five year survival was 24.1%. However in 52 patients where the resection was found to be radical the five-year survival was 35.3%. The results show that oesophago-gastrectomy could be performed with low mortality and morbidity. Long term survival is still low. To improve the results efforts should be directed toward earlier diagnosis, better selection and minimising post-operative complications.     

Endoscopic diagnosis and treatment of early colorectal cancer

Colorectal adenomas and early cancers are grossly classified into three groups: protruded, flush or slightly elevated (so-called flat adenomas), and depressed. Protruded lesions and flat adenomas are not invasive until they are rather large, whereas depressed lesions can invade the submucosa even when very small. It is not difficult to detect protruded and flat adenomas, but depressed carcinomas are often overlooked. Keys to the detection of depressed carcinomas are a slight color change, bleeding spots, interruptions of the capillary network pattern, slight deformation of the colonic wall, shape change of the lesion with insufflation and deflation of air, and interruption of the innominate grooves by the lesion. Spraying of indigo carmine dye helps to clarify the lesions. Pit pattern analysis with magnifying colonoscopy is useful for diagnosis of early colorectal cancer. Pit pattern analysis and histologic examination suggest that depressed carcinomas probably have arisen de novo, without going through an adenomatous step. Some adenomas appear at first to have a depression, but such cancer-mimicking adenomas with pseudodepression must be distinguished from depressed carcinomas because they are quite different in nature. Protruded and flat adenomas can usually be removed with polypectomy or hot biopsy techniques. Depressed carcinomas are treated with an endoscopic mucosal resection (EMR) technique; but when they massively invade the submucosa, surgical resection is indicated. Some neoplastic lesions, which we call laterally spreading tumors, extensively and circumferentially spread along the colonic wall, although they are short in height. They tend to have a rather benign nature despite their large size; therefore EMR or a piecemeal EMR method is indicated.     

Endoscopic injection treatment of gastrointestinal bleeding in hemophiliacs

The aims of this prospective study were to determine the patterns of gastrointestinal (GI) bleeding in hemophiliacs and to assess the hemostatic effect of injection therapy with alcohol. During a 5-year period (1990-1994) 89 hemophiliacs were admitted to our department with acute GI bleeding. Among these patients duodenal ulcer was found endoscopically to be the most common (42.7%) cause of hemorrhage; gastric ulcer was the source of the bleeding in only three patients (3.4%). A group of 46 patients met the criteria of active or recent bleeding and underwent injection therapy with alcohol. The injected bleeding lesions were duodenal ulcer in 32 patients, duodenal erosion in 2, gastric ulcer in 3, and other gastric lesions (Mallory-Weiss tear, Dieulafoy lesion, stomal ulcer, erosions) in 9 patients. Initial hemostasis was achieved in 100% and permanent hemostasis in 82.6%. Rebleeding was observed in eight patients (17.4%), with five of them successfully treated by reinjections. Three patients (6.5%) required emergency surgery. The mortality rate in the group of injected patients was 2.2%. One patient died of stroke on day 10 after partial gastrectomy. All injected patients were given replacement therapy with factor VIII or IX for 2 days (29 patients) or 7 to 14 days (17 patients). Analysis of the hemostatic effect achieved in these two subgroups indicate that short-term replacement therapy (2 days) may be sufficient to ensure adequate hemostasis in hemophiliacs. The results of the present study indicate that injection therapy with alcohol is an effective, safe, proved method to control GI bleeding in hemophiliacs.     

Effectiveness and patient satisfaction with nurse-directed treatment of Barrett's esophagus

OBJECTIVE: Using clinical practice guidelines, a registered nurse adjusted antireflux medications, evaluated esophageal biopsy reports, determined the interval between surveillance endoscopies, and provided education for patients with Barrett's esophagus. No previous reports have assessed the effectiveness or patient satisfaction associated with registered nurse-provided primary care. Because estimates of the incidence of dysplasia and adenocarcinoma vary widely, we also prospectively followed a cohort of patients with Barrett's esophagus. METHODS: Charts were reviewed to determine the frequency of variation from guidelines, the annual incidence of dysplasia and adenocarcinoma, and frequency of reflux symptoms. Patients were mailed a questionnaire to assess satisfaction with their medical care and with the nurse. RESULTS: Variation by the nurse from the guidelines on surveillance endoscopy (1.9%) and the treatment of reflux (1.3%) was rare. Most patients were very satisfied (score of 6 on 0-6-point Likert scale) with overall medical care (88%), and patient education (76%), and most patients did not think that increased physician involvement would improve their care (93%). Ninety-seven percent of patients had control of reflux symptoms. Two patients with long segment Barrett's esophagus (n = 67) developed high grade dysplasia over 323 patient-yr of follow-up (1 of 162 patient-yr for an annual incidence of 0.6%). No patients with short segment Barrett's esophagus (n = 56) developed high grade dysplasia or adenocarcinoma over 172 patient-years of follow-up. CONCLUSION: The registered nurse in our clinical setting effectively administered clinical practice guidelines for the management of Barrett's esophagus without clinically significant morbidity or patient dissatisfaction. Before these results can be generalized to other settings, further studies will need to be performed.