Heartburn and multiple-site foregut perforations as primary manifestation of Crohn's disease.

SUMMARY: Crohn's disease may affect any segment of the digestive tract, more commonly the distal ileum, colon and/or perianal region. There is an increasing number of reports dealing with foregut Crohn's disease. We present the case of a patient with a history of heartburn and multiple spontaneous perforations of the esophagus, duodenum and jejunum as a primary manifestation of Crohn's disease who required emergency surgical and endoscopic procedures. Early detection of Crohn's disease may decrease the incidence of acute life-threatening complications provided that appropriate medical treatment is administered and a multidisciplinary approach is offered to these patients.

Esophageal involvement as an uncommon modality of relapse of Hodgkin lymphoma.

We present a case of systemic Hodgkin's lymphoma, relapsed with esophageal involvement after 3 years of complete remission. The importance of an accurate diagnostic work-up is emphasized. Esophagectomy and chemotherapy followed by bone marrow transplantation allowed a complete response and the long-term survival of the patient.

Candida colonization in patients with esophageal disease: a prospective clinical study.

The incidence of Candida infection has significantly increased over the recent years, becoming the fourth most common pathogens isolated in patients admitted to intensive care units (ICU). Mortality rates ranging between 6 and 38% have been reported to be associated with candidemia. Esophageal surgery may increase the risk of systemic Candida infection in critical patients requiring postoperative ICU admission. The aim of the present study was to assess the prevalence of Candida colonization in patients with esophageal disease undergoing surgery. Between April 1999 and April 2001, 131 patients with esophageal disease and 40 healthy volunteers were prospectively tested for Candida colonization by oral and pharyngeal swab. Candida colonization was significantly more frequent in patients with esophageal disease than in control subjects (38.9 vs 7.5%, P < 0.01); the prevalence was higher in individuals with carcinoma than in those with benign disease (51.8 vs 24%, P < 0.02), and in patients undergoing neoadjuvant chemoradiation therapy compared to those having primary surgery (55.5 vs 34.4%, P < 0.01). These data suggest that Candida colonization of the gastrointestinal tract is common in patients with esophageal disease. Pharmacological attempts to prevent or reduce the magnitude of this event may be worthwhile before surgery. However, the hypothesis that antifungal oral prophylaxis with nonabsorbable drugs may lower the incidence of candidemia in patients with gastrointestinal Candida colonization, especially in those candidates to postoperative ICU admission, should be tested by randomized double-blinded studies.

Clinical outcome and survival after esophagectomy for carcinoma in elderly patients.

Advances in perioperative management have allowed more and more elderly patients to undergo major surgery with postoperative morbidity and mortality rates comparable to those of younger individuals. The aim of this study was to evaluate the impact of age on the clinical outcome and long-term survival of patients with esophageal carcinoma undergoing esophagectomy. Nine-hundred patients with esophageal carcinoma were divided into two groups: A (n = 403) with age > or = 65 years, and B (n = 497) with age < 65 years. One-hundred and fifty three (38%) patients of group A underwent surgery compared to 272 (55%) of group B (P < 0.01). Postoperative mortality, and the prevalence of anastomotic leak and respiratory complications were similar in both groups; conversely, there was a higher prevalence of cardiovascular complications in group A (13% vs 3%, P < 0.01). Five-year survival was about 35% in both groups. In conclusion, advanced age should no longer be considered an absolute contraindication to esophagectomy for carcinoma in selected patients. In fact, the postoperative mortality and long-term survival rates of elderly patients undergoing resection are comparable to that of younger individuals.

Outcome of esophageal adenocarcinoma detected during endoscopic biopsy surveillance for Barrett's esophagus.

BACKGROUND: In an attempt to reduce mortality from esophageal adenocarcinoma, it has been recommended to enroll patients with Barrett's esophagus in endoscopic surveillance programs in order to detect malignant degeneration at an early and possibly curable stage. The aim of this study was to assess the impact of endoscopic biopsy surveillance on outcome of Barrett's adenocarcinoma. METHODS: Between November 1992 and June 2000, 312 patients with histologically proven esophageal adenocarcinoma were referred to our department. Ninety-seven of these patients had Barrett's adenocarcinoma. In 12 (12.2%) patients, cancer was discovered during endoscopic surveillance for Barrett's metaplasia. RESULTS: The prevalence of gastroesophageal reflux disease in the Barrett's group was 38.8% versus 8% (p < 0.01) in non-Barrett's patients. In the surveyed group, there were 9 (75%) early stage tumors (Tis-1/N0) versus 9 (10.6%, p < 0.01) in the nonsurveyed patients. Three of 5 surveyed patients operated on for high-grade dysplasia proved to have invasive carcinoma in the esophagectomy specimen. All surveyed patients were alive at a median follow-up of 48 months; the median survival in the nonsurveyed group was 24 +/- 3 months (p < 0.01). CONCLUSION: Endoscopic surveillance of Barrett's esophagus provides early detection of malignant degeneration and a better long-term survival than in nonsurveyed patients.

Does previous endoscopic treatment affect the outcome of laparoscopic Heller myotomy?

STUDY AIM: Aim of this study was to assess symptomatic and objective outcome in patients undergoing laparoscopic Heller myotomy after unsuccessful endoscopic treatment, compared to patients having primary surgery. PATIENTS AND METHOD: Between November 1992 and December 1998, 92 patients with esophageal achalasia underwent laparoscopic Heller myotomy and Dor fundoplication. Intraoperative endoscopy was routinely performed. Sixty patients had primary surgery (PS); 32 patients had surgery after unsuccessful pneumatic dilatation (PD) (n = 22), or botulinum toxin (Botox) injection (n = 10). RESULTS: The mean operative time and the incidence of postoperative dysphagia were similar in the two groups. The incidence of intraoperative mucosal tears was 5% in the PS group and 12.5% in the PD/Botox group (P = NS). Mucosal tears occurred more frequently during the first 30 operations (17% vs 3.2%, P < 0.05). Median follow-up was 28 months (range 4-76). An abnormal esophageal acid exposure was documented in 2 patients in the PS group (7.7%), and in two patients in the PD/Botox group (13.3%) (P = NS). Lower esophageal sphincter pressure significantly decreased in both groups (P < 0.01). The mean percentage of radionuclide residual activity in the esophagus at 1 and 10 minutes significantly decreased in both groups (P < 0.01). CONCLUSION: There is only a trend, although not statistically significant, towards an increased risk of complications and adverse effects in patients previously treated by PD and/or Botox. The higher incidence of mucosal tears during the first 30 operations suggests the effect of the learning curve.

Rising incidence of esophageal adenocarcinoma in Western countries: is it possible to identify a population at risk?

Symptomatic gastroesophageal reflux disease (GERD) and Barrett's mucosa are risk factors for esophageal adenocarcinoma (ADC). The aim of this study was to analyze the anthropometric features and prevalence of GERD in patients with ADC compared with patients with squamous cell carcinoma (SCC) and control subjects. A total of 262 patients with ADC and 302 with SCC were enrolled consecutively. A control group of 262 individuals, sex and age matched to the ADC group, and an additional group of 138 patients with GERD confirmed by 24-h pH monitoring were used for comparison. The prevalence of symptomatic GERD was 32.4% in the subgroup of patients with Barrett's ADC (male-female=6.4:1; mean age=62 years) vs. 8% in those with gastric cardia carcinoma (P< 0.01), 3% in the SCC group (P< 0.01), and 10% in the control group (P< 0.01). ADC patients, controls and refluxers had similar body mass index (BMI) that was significantly higher than in the SCC group (P< 0.05). Whether surveillance endoscopy is indicated in men over 50 years with a long-lasting history of GERD and a BMI >25 remains to be determined.

Current trends in the surgical treatment of esophageal and cardia adenocarcinoma.

Since adenocarcinoma of the esophagus and cardia is increasing at an alarming rate, major efforts are currently oriented to identify patients who may benefit from extensive resection. Between November 1992 and May 1998, 218 patients with histologically proven adenocarcinoma of the distal esophagus or cardia were referred to our Department. In six patients (10.2%) with Barrett's adenocarcinoma, cancer was discovered during endoscopic surveillance program for Barrett's metaplasia. Overall, one hundred-forty-seven patients (67%) underwent resection. Fifty-one underwent an extended mediastinal lymphadenectomy. Median cumulative survival was 25.9+/-3.1 months in patients undergoing resection, and 7+/-1.3 months in patients having palliation (p<0.01). Survival was significantly longer in patients with negative nodes than in those with lymph node metastases (54+/-12.9 versus 17+/-2.8 months, p<0.01). Six of the 51 patients (11.8%) undergoing extended lymphadenectomy had metastatic upper mediastinal nodes. Additional serial sections and immunohistochemistry were performed in 46 patients. In 6 of 18 patients (33.3%) with negative nodes at conventional hematoxylin-eosin examination, immunohistochemistry demonstrated micrometastases in the lesser curve, paracardial, peripancreatic, or lower mediastinal nodes. Early diagnosis remains the prerequisite for curative treatment of adenocarcinoma of the esophagus and cardia. When a curative resection is attempted, extended lymphadenectomy improves tumor staging and may prevent local recurrences. Serial sections and immunohistochemistry provide additional accuracy in the staging of the disease and may prove useful to select patients for adjuvant therapy.

Duodeno-gastro-esophageal reflux after gastric surgery: surgical therapy and outcome in 42 consecutive patients.

BACKGROUND/AIMS: Duodeno-gastro-esophageal reflux is a common event after gastric surgery and can result in severe symptoms and mucosal injury. Medical therapy is largely ineffective. The most common remedial operation consists of a long isoperistaltic Roux-en-Y limb in order to shunt duodenal contents away from the gastric pouch and the esophagus. METHODOLOGY: Between 1980 and 1996, 42 patients underwent duodenal diversion after gastric surgery. The presence of severe symptoms and/or endoscopic esophagitis unresponsive to medical therapy was considered an indication for surgery. Functional studies were performed in selected patients in an attempt to objectively document the presence of excessive duodeno-gastro-esophageal reflux. A 40-60 cm Roux-en-Y limb was constructed in all patients. RESULTS: There was no post-operative mortality. The median follow-up was 28 months (range: 5-114). Symptoms related to delayed gastric emptying persisted in 5 patients (11.9%). Overall, 32 patients (76%) had a Visick I-II score. Best results (90%) were achieved in patients with previous total gastrectomy. CONCLUSIONS: Roux-en-Y duodenal diversion should be reserved for patients with intractable symptoms and documented reflux, and is mostly effective after total gastrectomy. Patients with a residual stomach are less likely to benefit from the procedure, probably because an underlying motor disorder plays a major role in the pathogenesis of the symptoms than does the reflux of duodenal contents.

[Staging by immediate preoperative laparoscopy in adenocarcinoma of the distal esophagus and cardia]. / Staging par laparoscopie pré-opératoire immédiate dans l'adénocarcinome de l'oesophage distal et du cardia.

Accurate preoperative staging of adenocarcinoma of the esophagus and cardia is critical to select the proper treatment in the individual patients, i.e., resection, neoadjuvant therapy, or endoscopic palliation. Aim of this study was to assess the role of laparoscopy in detecting intra-abdominal metastatic spread in patients with adenocarcinoma of the esophagus and cardia. Between November 1995 and May 1998, 45 patients with histologically-proven adenocarcinoma of the cardia--without any previous treatment--and negative or inconclusive findings at computed tomography (CT) and ultrasonography (US) underwent staging laparoscopy at the same session of the planned surgical resection. The mean operative time of the procedure was 25 minutes (range 15-55 min). Laparoscopy led to change the therapeutic approach in five patients (11.1%): three patients with peritoneal carcinomatosis and one with a liver metastasis undetected at preoperative imaging studies did not have resection; conversely, one individual with liver hemangioma simulating a metastatic mass at CT underwent esophagogastric resection. In patients with adenocarcinoma of the esophagus and cardia, laparoscopy is useful to increase accuracy of detection of metastases; when performed as the first step of a planed resection, it avoids unnecessary laparotomies and does not increase the complexity of preoperative evaluation.

Esophagobronchial fistula after thoracoscopic resection of an epiphrenic diverticulum.

We report a case of a 54-year-old man presenting with recurrent epiphrenic diverticulum and esophagobronchial fistula 3 years after thoracoscopic diverticulectomy. Surgical correction required transhiatal stapling of the pouch combined with distal esophageal myotomy and Dor fundoplication.

Previous endoscopic treatment does not affect complication rate and outcome of laparoscopic Heller myotomy and anterior fundoplication for oesophageal achalasia.

BACKGROUND: Anedoctal reports suggest a detrimental effect of pneumatic dilation and botulinum toxin injection in patients who are potential candidates for Heller myotomy. AIMS: To assess symptomatic and objective outcome in patients undergoing Heller myotomy as a primary procedure or after failed endoscopic treatment. PATIENTS: Between November 1992 and December 1998, 92 patients with oesophageal achalasia were treated. Sixty patients had primary surgery; 32 patients had surgery after unsuccessful pneumatic dilation (n = 22), or botulinum toxin injection (n = 10). METHODS: Laparoscopic Heller myotomy plus Dor fundoplication with routine intraoperative endoscopy. Operative records, symptoms, and results of radiological, manometric and scintigraphic assessment in the two groups of patients were compared. RESULTS: The mean operative time, the rate of intraoperative mucosal tears and the incidence of postoperative dysphagia were similar in the two groups. Mucosal tears occurred more frequently during the first 30 operations (p < 0.05). Median follow-up was 28 months (range 4-76). An abnormal oesophageal acid exposure was documented in 2 patients in the primary surgery group (7.7%), and in 2 patients in the pneumatic dilation/botulinum toxin group (13.3%) (p = ns). Lower oesophageal sphincter pressure significantly decreased in both groups (p < 0.01). The mean percentage of radionuclide residual activity in the oesophagus at 1 and 10 minutes significantly decreased in both groups (p < 0.01). CONCLUSIONS: There was only a trend, although not statistically significant, towards an increased risk of complications and adverse effects in patients previously treated by pneumatic dilation or botulinum toxin. The higher incidence of mucosal tears during the first 30 operations suggests the effect of the learning curve.

Esophageal function studies in the management of gastroesophageal reflux disease.

BACKGROUND: Esophageal function testing, i.e. esophageal manometry and 24-h pH monitoring, are usually carried out to diagnose gastroesophageal reflux disease (GERD) in patients with atypical symptoms, when there is no evidence of esophagitis at endoscopy, or following previous unsuccessful surgery. Additionally, these studies should be considered mandatory before surgery to confirm the diagnosis and to tailor the procedure to the motility pattern of the individual patient. AIM: The aim of this study was to assess the role of esophageal function studies in the management of patients with GERD. METHODS: Patients with a mechanically defective lower esophageal sphincter (LES) and abnormal esophageal acid exposure proven at 24-h pH monitoring were considered for surgery. A 360 degrees fundoplication (Nissen) was performed in patients with good esophageal motility, whereas a partial 180 degrees fundoplication (Toupet) in patients with a defective motility. Five hundred and eighty-six patients were referred to our laboratory for symptoms suggestive of GERD between November 1992 and April 1999. RESULTS: Twenty-four hour esophageal pH monitoring was positive in 65.5% of these patients; manometry showed a defective lower esophageal sphincter and a defective esophageal body motility in 57.8% and 21.7% respectively. One hundred and two patients underwent a total fundoplication, and 43 patients a partial wrap. At a mean follow-up of 36 months (range 5-69) the actuarial success rate in the control of reflux was 90%. Three (2.9%) patients undergoing a Nissen fundoplication complained of persistent dysphagia; two of them had preoperative esophageal body dysfunction. CONCLUSION: Esophageal function studies allow proper selection of patients for surgery and guide in the choice of the antireflux operation.

Surgical therapy in patients with failed antireflux repairs.

BACKGROUND/AIMS: Failure of antireflux surgery may be due to errors in patient selection, errors in the choice of the operation, or technical errors in the performance of the operation. The purpose of this work was to review a series of patients surgically treated for a failed antireflux procedure over the past two decades. MATERIALS AND METHODS: Seventy patients (62%) out of 113 consecutive individuals presenting with symptoms after one or more operations for gastroesophageal reflux disease underwent reoperation. Five patients had been operated on laparoscopically. The indications for reoperation were based on severity of symptoms and results of objective investigation. Surgical therapy was tailored to the individual patient based on pathophysiological abnormalities and on the results of intraoperative assessment. RESULTS: Reflux symptoms and dysphagia represented the major complaint in 62.8% and 35.7% of patients, respectively. The most common pathophysiological abnormality was an incompetent lower esophageal sphincter. Intraoperative assessment showed a disrupted or misplaced repair in 77% of the patients. The most common reoperation performed was a partial or total fundoplication (54.3%), followed by antrectomy and Roux-en-Y anastomosis (25.7%). There was no mortality. Postoperative morbidity rate was 8.5%. At a median follow-up of 48 months, 87% of patients were scored as Visick 1-2 and 90% declared themselves satisfied with the results of reoperation. CONCLUSIONS: Management of patients with failed antireflux procedures is challenging. However, detailed physiological evaluation and a surgical approach tailored to residual anatomy and function of the foregut can provide excellent results.

Echolaparoscopic-guided alcohol injection of liver metastases.

Ultrasound-guided percutaneous alcohol injection of liver metastases or hepatocellular carcinoma represents a well-established alternative to surgery when surgical resection is contraindicated. The aim of this report is to describe the technique of echolaparoscopic-guided alcohol injection of liver metastases in a patient undergoing palliative treatment for adenocarcinoma of the cardia. This procedure provides a more accurate staging of the disease and a safe approach to liver metastases with difficult anatomical location in patients unsuitable for surgical resection.

Preoperative laparoscopy in management of patients with carcinoma of the esophagus and of the esophagogastric junction.

BACKGROUND AND OBJECTIVES: Adequate preoperative staging of patients with esophageal and cardia carcinoma offers the potential for a rational choice of the therapy. The aim of this study was to assess the diagnostic value of laparoscopy compared to ultrasonography (US) and computed tomography (CT) in detecting intra-abdominal metastatic spread. METHODS: Between November 1995 and December 1996, 36 patients with adenocarcinoma of the cardia and 14 patients with squamous cell carcinoma of the lower third of the esophagus were studied with CT scan and US, followed by laparoscopy performed at the same session of planned surgical resection. Mean operative time of laparoscopy was 20 minutes (range 15-55 min). There was no mortality nor morbidity related to the laparoscopic procedure. RESULTS: Laparoscopy lead to a change of the therapeutic approach in five patients (10%): three patients with peritoneal carcinosis undetected at the imaging examinations, and one patient with advanced liver cirrhosis with signs of portal hypertension did not undergo resection; conversely, one patient with a liver hemangioma simulating a metastatic mass at CT/US underwent esophagogastric resection. Laparoscopy showed a higher sensitivity than US and CT in detecting peritoneal metastases (71% vs. 14% vs. 14%, respectively), macroscopic nodal metastases (78% vs. 11% vs. 55%), and liver metastases (86% vs. 71%). CONCLUSIONS: Laparoscopy represents a safe and effective diagnostic procedure in the preoperative staging of esophageal and cardia carcinoma; it provides the potential to avoid unnecessary exploratory laparotomies and to select the most appropriate treatment.

[The value of extensive lymphadenectomy in cancer of the lower esophagus and cardia]. / Intérêt de la lymphadénectomie étendue dans le cancer du bas oesophage et du cardia.

Between 1980 and 1997, 1194 patients with a malignant tumor of the lower esophagus have been observed and treated in our Institution. There were 555 patients (46.5%) presenting with squamous-cell carcinoma, 101 (8.5%), with Barrett's adenocarcinoma and 538 (45%) with cardia adenocarcinoma. Most patient underwent a transthoracic esophagectomy with esophagogastroplasty; transhiatal approach was mainly reserved to high-risk patients. Over the past two years sixty-three patients (42 with adenocarcinoma and 21 with squamous cell carcinoma) underwent enlarged mediastinal lymphadenectomy. Three patients (4.7%) died post-operatively: one sepsis, in pulmonary embolism and one myocardial infarction. Four patients (6.3%) developed pulmonary complications: no patient had recuriential palsy. Pathologic exam revealed 1342 nodes (807 thoracic and 827 abdominal). Twenty patients (31.7%) had mediastinal nodal metastases, of which 8 in the upper mediastinum. Median follow-up was 19 months (2-36 months). Seven of the sixteen patients with recurrent disease (12 systemic, 3 mediastinal and 1 anastomotic) died. The number of metastatic nodes increased with serial section and even more with immunohistochemical staining technique (from 11.7% to 13% to 15.5%, respectively). Two patients were up-staged from M0 to M1 because of peripancreatic nodal micrometastases. We conclude that enlarged mediastinal lymphadenectomy allowed to detect upper mediastinal lymph node metastases in 12.8% of patients without increasing post-operative complication rate. A longer follow-up is required to evaluate the impact on long term survival.

A prospective randomized comparison of the metabolic and stress hormonal responses of laparoscopic and open cholecystectomy.

BACKGROUND: In a relatively short period of time, therapeutic laparoscopy has become an everyday part of the general surgeon's life. Although laparoscopy provides distinct clinical advantages, it is not yet clear that it lessens the stress response typical of elective surgical procedures, and as such, the morbidity of surgery. The hypothesis that laparoscopic cholecystectomy produces less of a metabolic and stress hormonal response than open cholecystectomy was tested in a prospective randomized trial. STUDY DESIGN: Twenty otherwise healthy women between 18 and 45 years of age with a history of uncomplicated symptomatic cholelithiasis undergoing either laparoscopic (n = 10) or open cholecystectomy (n = 10) were studied. The hormonal response of the adrenocortical (serum adrenocorticotropic hormone, cortisol, and urinary free cortisol), adrenomedullary (plasma and urinary epinephrine and norepinephrine), thyroid (thyroid-stimulating hormone, thyroxine, and triiodothyronine), pituitary (antidiuretic hormone and growth hormone), and glucose (serum glucose, glucagon, and insulin) homeostatic axes were measured serially over a 24-hour period. RESULTS: No difference was seen between the laparoscopic and open groups in operative time (mean plus or minus standard error of the mean, 70 +/- 6 minutes compared with 77 +/- 6.3 minutes) or hospital stay 1.3 +/- 0.2 compared with 1.1 +/- 0.1 days). Assessment of postoperative pain using an analog pain score was less in the laparoscopic group (4.9 +/- 1.3 compared with 12.3 +/- 2.5, p = 0.01). The response of the adrenocortical, adrenomedullary, thyroid, and glucose axes were similar or identical in both groups. Antidiuretic hormone levels were greater in the laparoscopic group at one hour intraoperatively (281 +/- 79 pg/mL compared with 54 +/- 18 pg/mL, p < 0.01), and at extubation (122 +/- 18 pg/mL compared with 36 +/- 7 pg/mL, p < 0.01). Serum glucose levels were greater immediately following laparoscopic cholecystectomy. Glucose and insulin levels were greater at four, 12, and 24 hours after open cholecystectomy. CONCLUSIONS: Elective laparoscopic and open cholecystectomy for uncomplicated cholelithiasis result in similar degrees of perioperative hormonal stimulation. The different hormonal responses in the immediate and later postoperative periods after laparoscopic and open cholecystectomy suggest differential stressful stimuli between the two procedures.

A selective therapeutic approach to gastric cancer in a large public hospital.

BACKGROUND: Gastric cancer is a common malignancy with a poor prognosis. The improved survival reported from Japan may be due to earlier detection or to more radical surgery, or both. The relevance of their methods to gastric cancer seen in Western countries is uncertain. PATIENTS AND METHODS: The study involved 204 patients with gastric carcinoma. Preoperative staging by computed tomography scan and endoscopic ultrasound showed that 120 patients (59%) had stage IV disease. RESULTS: Curative resection was performed in 66 patients, palliative resection in 32, bypass/intubation in 39, chemotherapy alone in 41, and supportive treatment in 26. Neoadjuvant chemotherapy was given to 40 of 66 patients treated with curative resection. The mortality of gastrectomy was 3%. Survival was significantly improved after curative resection compared with palliative resection, which in turn was improved over non-resectional or nonsurgical therapy. Postoperative morbidity included four intra-abdominal abscesses, all associated with splenectomy. CONCLUSIONS: Curative surgery for gastric cancer is worthwhile, but the advanced stage of the disease in a public hospital should encourage the establishment of a screening program in high risk populations.