Clinical significance of esophageal histologic findings after antireflux surgery.

HYPOTHESIS: Only limited and controversial information exists regarding the histologic effect of successful antireflux surgery on esophageal mucosa and its clinical significance. DESIGN AND SETTINGS: A randomized, blinded follow-up study conducted in a university hospital between January 1, 1992, and December 31, 1997, with a mean follow-up of 8 months. PATIENTS: Forty patients with severe symptomatic gastroesophageal reflux disease (24 men and 16 women; mean age, 50 years). MAIN OUTCOME MEASURES: Microscopic signs and severity of esophagitis analyzed by 2 blinded histopathologists. RESULTS: Histopathologist 1 interpreted 22 (69%) of 32 postoperative biopsy specimens as normal; 7 (22%), as showing mild changes; 1 (3%), moderate changes; and 2 (6%), severe changes of reflux esophagitis. Histopathologist 2 interpreted 25 (78%) of 32 postoperative biopsy specimens as normal (P =.001); 1 (3%), as showing mild changes (P =.003); 4 (13%), moderate changes; and 2 (6%), severe changes. Between histopathologist 1 (90.6%) and histopathologist 2 (81%), the absence of esophageal mucosal inflammation correlated best with normalized pH monitoring. CONCLUSIONS: These findings suggest that, if other findings such as those from fundic wrap at endoscopy and 24-hour pH monitoring are normal, the clinical significance of routine esophageal histologic examination after successful fundoplication is limited.

The epidemiology of oesophageal adenocarcinoma: has the cancer of gastric cardia an influence on the rising incidence of oesophageal adenocarcinoma?

BACKGROUND: Owing to overgrowth and definitional problems in classification, the cancer of gastric cardia may affect significantly the epidemiological analysis of oesophageal adenocarcinoma. The purpose of the present study was to evaluate the changes in the incidence of all the adenocarcinomas near the gastrooesophageal junction. METHODS: Trends in the incidence rates of adenocarcinoma of the oesophagus and the gastric cardia were described through the Finnish Cancer Registry. The annual age-standardized incidence rates during 1976-95 were analysed by a linear regression technique. RESULTS: The total incidence of oesophageal carcinoma remained around 3.5/100,000 in men, and decreased from 2.8 to 1.3/100,000 in women. The incidence of oesophageal adenocarcinoma increased from 0.28 to 0.77/100,000 (nearly 300%) in males, and from 0.08 to 0.11 per 100,000 in females. There were no significant changes with time in the incidence rate of gastric cardia cancer in either sex. Combined gastric cardia and oesophageal adenocarcinoma incidence rates remained stable in women, and increased slightly, but significantly, from 2.4 to 2.9/100,000 in men. CONCLUSION: Oesophageal adenocarcinoma has increased significantly in men in Finland, but the combined incidence of cancers of the gastro-oesophageal junction has increased only slightly. To overcome the difficulties in classification of oesophageal adenocarcinoma and the cancer of gastric cardia in the epidemiological studies, the focus should be on all adenocarcinomas at or near the oesophagogastric junction.

Expandable metallic stents in the management of malignant oesophageal obstruction.

BACKGROUND: Malignant oesophageal obstruction with an advanced disease presents a difficult challenge. A new class of metal stents have been developed to overcome the limitations of existing treatment modalities. METHODS: We present our first 58 patients, who have been treated with self-expandable metallic stents, using sedation anaesthesia, with fluoroscopic and endoscopic control. Both kinds of stents, covered and uncovered, were applied. RESULTS: There was no procedure-related mortality. The immediate relief of dysphagia was 98%. All four oesophageal fistulas were successfully sealed with covered stents. Due to stent migration, tumour overgrowth, or ingrowth, twelve (21%) of the patients needed re-intervention. Restenting or laser therapies were used against recurrent dysphagia. CONCLUSION: The palliation of oesophageal malignant obstruction with metal stents is a rapid, effective, and relatively safe single treatment which can be employed as part of a multimodal treatment program.

Oesophageal acid exposure: higher in Barrett's oesophagus than in reflux oesophagitis.

Oesophageal acid exposure at different pH intervals between 0 and 8 in patients with Barrett's oesophagus (n = 24) was compared with that in patients with reflux oesophagitis (n = 19) by using 24-h pH monitoring. Prior to the monitoring, the position and pressure of the lower oesophageal sphincter was measured by manometry. Columnar epithelium with intestinal metaplasia and goblet cells was verified histologically in all Barrett patients and grade I-III oesophagitis in patients with reflux oesophagitis. Acid exposure (percentage of total time at pH < 4) in the Barrett group was significantly greater than in the oesophagitis group: 21.5+/-20.0% SD vs 11.1+/-11.7% SD (P < 0.01). The number of reflux episodes lasting longer than 5 min (representing oesophageal body clearance function) was also significantly greater in the Barrett group (8.3+/-5.9 SD) than in the oesophagitis group (4.5+/-4.7 SD) (P < 0.01). In the Barrett group the acid exposure time was greater at all pH intervals 0-1, 1-2, 2-3 and 3-4, (P < 0.01) but in the oesophagitis group the exposure time was greater at pH interval 5-6 (P < 0.01). There was no significant difference in exposure at pH values above 7. The mean lower oesophageal sphincter pressure was equal in both groups (11.0 vs 11.9 mmHg). In conclusion, oesophageal acid exposure was significantly greater in Barrett's oesophagus than in reflux oesophagitis, and this was associated with decreased oesophageal clearance function. In addition, the results indicated the need for special attention and perhaps higher dosages of drugs to suppress acid production in patients with Barrett's oesophagus.

Functional outcome after laparoscopic or open Nissen fundoplication: a follow-up study.

OBJECTIVE: To compare the results of open and laparoscopic fundoplication. DESIGN: Nonrandomized controlled study with a 3-year follow-up. PATIENTS AND METHODS: Fifty-seven consecutive patients with erosive reflux esophagitis underwent laparoscopic (30 patients) or open (27 patients) fundoplication. INTERVENTIONS: Interview by an independent person. In addition, 52 patients (91%) underwent postoperative endoscopy, and 38 patients (67%) underwent esophageal 24-hour pH recording. RESULTS: Temporary dysphagia was reported by 20 patients (67%) after laparoscopic and by 11 (41%) after open fundoplication (P = .05). There were no differences between groups concerning incidence of persistent dysphagia (20% vs 18%, respectively) and mild to no reflux symptoms (97% vs 100%, respectively). In addition, bloating (50% vs 63%, respectively) and increased flatus (77% vs 78%, respectively) were equally common. Visual analog scale scores for dysphagia, bloating, and increased flatus were 0.6, 2.4, and 4.3, respectively, in the laparoscopic and 0.6, 3.5, and 3.4, respectively, in the open groups. Normal belching ability was reported by 12 patients (40%) after laparoscopic and by 20 (74%) after open fundoplication (P = .01). Visick grade 1 or 2 was reported by 21 patients (70%) after laparoscopic and by 24 (89%) after open fundoplication (P = .08). Defective fundic wrap was detected in 4 patients (13%) in the laparoscopic and in none in the open group. In addition, abnormal results of 24-hour pH recording were found in 4 patients (22%) after laparoscopic and in 2 (10.5%) after open fundoplication. CONCLUSION: From a functional point of view, both techniques were equally effective except concerning belching ability and temporary dysphagia.

Endoscopic ultrasonography in the preoperative staging of adenocarcinoma of the distal oesophagus and oesophagogastric junction.

BACKGROUND: Endoscopic ultrasonography is considered to be the most accurate procedure in the preoperative staging of oesophageal carcinoma. Its accuracy was evaluated in the preoperative staging of adenocarcinoma of the distal oesophagus and oesophagogastric junction. METHODS: Thirty-two consecutive patients with adenocarcinoma of the distal oesophagus and oesophagogastric junction were preoperatively examined and staged by means of endoscopic ultrasonography. All patients underwent radical en bloc resection of the oesophagus and proximal stomach (or total gastrectomy) with standard lymphadenectomy including thoracic duct and mediastinal fat tissue. The postoperative histopathologic TNM stage was taken as reference. RESULTS: An endoscopic ultrasonography examination could be completed in 26 of the patients; the other 6 had obstructive tumour. In two patients infiltration of the tumour into the vital organs (in one patient aortic infiltration and in a second patient pericardial infiltration) was incorrectly suspected. The ability to predict T stage was 65.6%. T stage was overstaged in 31.2% and understaged in 3.1% of the cases. The ability to predict N stage was 71.9%. N stage was overstaged in 25.0% and understaged 3.1% of the cases. CONCLUSIONS: In adenocarcinoma of the oesophagus and oesophagogastric junction endoscopic ultrasonography helps in predicting resectability, but the exact TN staging is not accurate. Since early detection of tumour and aggressive surgical intervention constitute the only curative treatment, caution must be exercised when judging a patient to be inoperable solely on the basis of endoscopic ultrasonography findings without proven distant metastases.

Subacute primary Candida lung abscess.

A case of primary subacute Candida lung abscess is described. The most reliable way to diagnose a rare pulmonary disease is to perform an open lung biopsy. A review of the literature suggests that the diagnosis of a primary subacute abscess due to Candida albicans in vivo is unique.

Treatment of Barrett's esophagus by endoscopic laser ablation and antireflux surgery.

OBJECTIVE: The regeneration of intestinal metaplasia by squamous epithelium in 17 patients with Barrett's esophagus after endoscopic laser ablation in a reflux-free environment after successful antireflux surgery was prospectively examined. METHODS: All patients had antireflux surgery, and healing of reflux was verified at postoperative endoscopy and 24-hour esophageal pH monitoring. Thereafter, in 11 patients, the whole Barrett's epithelium was ablated using endoscopic Nd-YAG laser energy in 1 to 8 sessions (mean, 4). The needed energy was 965 to 11,173 joules (mean 4709), or about 1000 joules per centimeter of Barrett's esophagus. Six patients had no laser ablation but were treated by antireflux surgery and served as a control group. RESULTS: In all laser-treated patients, the regenerated epithelium was histologically of squamous type in the tubular esophagus, but two patients still had intestinal metaplasia in the gastric cardia. In controls, the length of Barrett's esophagus and intestinal metaplasia remained unchanged. The length of follow-up was 26 months after the last laser session and 21 months in the control group. CONCLUSIONS: The regenerated esophageal epithelium arising after laser ablation in reflux-free environment surgery is of squamous type. This treatment may have a role in preventing the development of esophageal adenocarcinoma arising in Barrett's esophagus.

pH-metric analysis after successful antireflux surgery: comparison of 24-hour pH profiles in patients undergoing floppy fundoplication or Roux-en-Y duodenal diversion.

Fundoplication is the most widely used antireflux method, whereas Roux-en-Y duodenal diversion (partial gastrectomy, vagotomy, and Roux-en-Y reconstruction) has been used in fewer patients with more complicated gastroesophageal reflux disease. Abnormal esophageal pH values are normalized after successful fundoplication. However, very little is known about possible changes in the pH profile after successful Roux-en-Y duodenal diversion. A total of 37 patients with severe gastroesophageal reflux disease were treated by fundoplication (n=22) or Roux-en-Y duodenal diversion (n=15). Postoperatively all patients in both groups were symptom free and healing of esophagitis was verified endoscopically. After fundoplication, the 24-hour esophageal acid exposure decreased significantly (P=0.03) and the pH profile normalized (pH<4 in 5.8%+/-2.4% of the recorded time). However, the decrease in esophageal acid exposure was not significant (P=0.77) after successful Roux-en-Y reconstruction and the pH profile remained abnormal (pH<4 in 15.1%+/-4.3%). It was concluded that 24-hour esophageal pH monitoring is a reliable means of assessing the results of fundoplication, but the current test criteria should be reexamined in evaluating the results of Roux-en-Y duodenal diversion. Healing of esophagitis after Roux-en-Y duodenal diversion despite abnormal acid reflux, as shown by 24-hour pH measurements, suggests that duodenal contents also have a role in the pathogenesis of esophagitis in an acid milieu.