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.

Surgery for inflammatory tumor of the lung caused by pulmonary actinomycosis.

BACKGROUND: Actinomycosis is an uncommon chronic suppurative bacterial infection caused by anaerobic bacteria. Pulmonary actinomycosis is even more infrequent and generally simulates a wide variety of pulmonary disorders including tuberculosis and lung cancer. Therefore delayed diagnosis and misdiagnosis is common. Here, actinomycosis was initially confused with pulmonary carcinoma. METHODS: We report on three cases of inflammatory tumors caused by pulmonary actinomycosis. All three patients were male and had a history of alcoholism and poor oral hygiene associated with dental disease. Clinical symptoms were nonspecific and radiographic imaging showed tumor-like mass lesions not distinguishable from neoplasms. Preoperative bronchoscopy, sputum culture, laboratory tests and bronchoalveolar lavage neither confirmed an infectious disease nor ruled out lung cancer. Hence all patients underwent thoracotomy for both diagnosis and definitive treatment. Intraoperatively we encountered a necrotizing infection forming cavitary as well as tumorous lesions and a lobectomy was performed due to destroyed lung tissue. In one case the tumorous lesion involved the chest wall so that partial resection of the 3rd rib with the adjacent soft tissue was mandatory. RESULTS: Histological examination of the pulmonary specimen established the diagnosis of pulmonary actinomycosis. All patients recovered well and received antibiotic therapy with oral penicillin. CONCLUSIONS: The diagnosis of pulmonary actinomycosis remains challenging. In cases of an inflammatory tumor imitating lung cancer, surgical resection is mandatory, both to confirm the diagnosis and for the definitive treatment in cases with irreversible parenchymal destruction. Here, surgery in combination with medical treatment offered reliably excellent results.

Dating the rise of atmospheric oxygen.

Several lines of geological and geochemical evidence indicate that the level of atmospheric oxygen was extremely low before 2.45 billion years (Gyr) ago, and that it had reached considerable levels by 2.22 Gyr ago. Here we present evidence that the rise of atmospheric oxygen had occurred by 2.32 Gyr ago. We found that syngenetic pyrite is present in organic-rich shales of the 2.32-Gyr-old Rooihoogte and Timeball Hill formations, South Africa. The range of the isotopic composition of sulphur in this pyrite is large and shows no evidence of mass-independent fractionation, indicating that atmospheric oxygen was present at significant levels (that is, greater than 10(-5) times that of the present atmospheric level) during the deposition of these units. The presence of rounded pebbles of sideritic iron formation at the base of the Rooihoogte Formation and an extensive and thick ironstone layer consisting of haematitic pisolites and oölites in the upper Timeball Hill Formation indicate that atmospheric oxygen rose significantly, perhaps for the first time, during the deposition of the Rooihoogte and Timeball Hill formations. These units were deposited between what are probably the second and third of the three Palaeoproterozoic glacial events.

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.

[Leiomyoma of the esophagus : A further indication for robotic surgery?] / Das Leiomyom des Ösophagus : Eine weitere Indikation für den Roboter?

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.

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.

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.

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.

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.

Management of early esophageal cancer.

In early esophageal cancer, squamous cell cancer and early adenocarcinoma must be managed differently because they have different origins, pathogenesis. and clinical characteristics. The current treatment options vary widely, from extended resection with lymphadenectomy to endoscopic mucosectomy or ablation. None of these treatment options can be recommended universally. Instead, an individualized strategy should be based on the depth of tumor infiltration into the mucosa or submucosa, the presence or absence of lymph node metastases, the multicentricity of tumor growth, the length of the segment of intestinal metaplasia, and comorbidities of the patient. Endoscopic mucosectomy may be sufficient in a subset of patients who have m1 or m2 squamous cell carcinoma and in patients who have isolated foci of high-grade intraepithelial neoplasia or mucosal cancer. Surgical resection is the treatment of choice for carcinomas invading the submucosal and multicentric tumors. Limited resection with jejunal interposition provides an effective treatment option for patients who have early esophageal adenocarcinoma. The onset of lymph node involvement is later in patients who have early adenocarcinoma than in patients who have squamous cell cancer, probably because chronic injury and repair mechanisms obliterate the otherwise abundant lymph vessels.

[Laparoscopic Heller myotomy after failed POEM and multiple balloon dilatations : Better late than never]. / Laparoskopische Heller-Myotomie nach erfolgloser POEM und multiplen Ballondilatationen : Besser spät als nie.

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.

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.

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.

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.

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.

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.

[Esophagectomy as therapeutic principle for squamous cell esophageal cancer]. / Osophagektomie als chirurgisches Therapieprinzip beim Plattenepithelkarzinom des Osophagus.

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.