Experience in oesophageal substitution in Lagos, Nigeria

This is an audit of five years work (1996 - 2001), in oesophageal substitution at the Cardiothoracic Surgery Unit of Lagos University Teaching Hospital, Nigeria. The study aimed at highlighting the current trends in indication and methods of oesophageal substitution in the context of our experience. We did a retrospective study of all who required oesophageal substitution during the period of study. We studied the various aspects of the patients' care including the indications for oesophageal substitution, the substituting organs and the results of surgery. We saw fifty-nine patients comprising 19 patients oesophageal carcinoma, 31 corrosive strictures of the oesophagus, 4 peptic strictures and 3 achalasia cases. Two patients had oesophageal substitution because of mediastinitis. Fifty-five patients underwent oesophageal substitution. The substituting organs were stomachs in 36 patients and colon in 19 patients. There were three anastomotic strictures, two grafts failed, and five cases of anastomotic leaks. In all, operative mortality was 9.1% . We concluded that oesophageal substitution was done more for benign reasons in our centre. We also emphasised the positive aspects of colon interposition and the prospects of doing more of it in the near future.     

Upper gastrointestinal bleeding in Malawian adults and value of splenomegaly in predicting source of haemorrhage

Fibreoptic endoscopy was carried out on 100 Malawian adults consecutively admitted to the department of medicine, Kamuzu Central Hospital, Lilongwe, with acute upper gastrointestinal bleeding. The principal causes of haemorrhage were oesophageal varices (45%), duodenal ulcer (16%), gastritis/erosions (9%) and gastric ulcer (7%). 69% of 29 patients with oesophageal varices who were investigated had S. mansoni infection. A palpable spleen positively predicted oesophageal varices in 91% of cases, while no palpable spleen predicted a source of haemorrhage other than varices in 97% of cases. In Malawi oesophageal varices are the major cause of upper gastrointestinal bleeding in adults, and the presence or absence of splenomegaly is a useful clinical pointer respectively to the presence or absence of oesophageal varices.     

Effect of tumour and chemoradiotherapy on oesophageal motility

Background The contribution of dysmotility to dysphagia in oesophageal cancer is unclear. Aim To examine oesophageal motility in patients with oesophageal carcinoma and to assess the effect of chemoradiotherapy on motility. Methods Stationary manometry and 24-hour pH-metry were performed in 12 patients with oesophageal carcinoma and one week following completion of chemoradiotherapy using 5-fluorouracil (5-FU), cisplatin and 40Gy radiotherapy. Results All patients had abnormal motility prior to treatment. Peristalsis was impaired in 11 patients with a mean (SD) of 25% (9) of waves normally propagated. Eight patients had 20% or more simultaneous waves. Following chemoradiotherapy, the percentage of waves normally propagated increased from 25% (9) to 52% (10) (p < 0.03) and normal peristalsis was restored in four patients. The percentage of simultaneous waves decreased from 38% (11) to 21.6% (10) (p=0.129) while the percentage of dropped or increased waves decreased from 20% (11) to 8.3% (4) (p=0.264). Conclusions Oesophageal motility is disturbed in oesophageal cancer. Dysphagia in oesophageal cancer may be partly explained by oesophageal dysmotility. This is improved by chemotherapy.     

Primary oesophageal Ki (CD30)-positive ALK+ anaplastic large cell lymphoma of T-cell phenotype

Primary oesophageal lymphoma is a very rare entity, with fewer than 30 reported cases worldwide. It represents an important cause of dysphagia. Most of the oesophageal lymphomas are diffuse large B-cell type, with only one reported case of anaplastic large cell lymphoma (ALCL) of T-cell phenotype. Primary oesophageal lymphomas that are not associated with an immunocompromised state tend to affect elderly patients. We describe the first case of primary oesophageal Ki (CD30)-positive ALK+ALCL of T-cell phenotype in a 34-year-old immunocompetent woman, who presented with a two-year history of dysphagia. She was treated with chemotherapy and endoscopic oesophageal dilations and stenting, resulting in complete remission of the lymphoma and resolution of the dysphagia. She then underwent autologous peripheral blood haematopoietic stem cell transplantation and remained disease-free two years after the diagnosis.     

Oral presentation of an oesophageal mucosal tear

Tears of the oesophageal wall following sudden forceful vomiting are well documented in literature. In Boerhaave's syndrome there is transmural rupture associated with complications including pneumothorax, pneumomediastinum, surgical emphysema and shock. In Mallory-Weiss syndrome mucosal tears are associated with haematemesis and shock. In neither of these conditions has intraluminal obstruction been described as an aetiological factor. We present a case with similar pathophysiology where oesophageal obstruction by a meat bolus followed by forceful vomiting led to an oesophageal mucosal tear and presentation of a band of oesophageal mucosa in the oral cavity. The patient did not develop any complications and made an uneventful recovery following conservative management.     

Leiomyoma of the oesophagus managed by thoracoscopic enucleation

The authors document two patients with oesophageal leiomyoma. In the first patient, a 41-year-old man, enucleation of the oesophageal leiomyoma was initially attempted by a thoracoscopic approach, but because of adherence of the tumour to the oesophageal mucosa, enucleation was completed by thoracotomy. Thoracoscopic enucleation was successfully performed in the second patient, a 62-year-old man. This paper includes a literature review on the pathology, diagnosis and surgical approach in the management of oesophageal leiomyoma. In conclusion, prudent use of thoracoscopic approach in the enucleation of oesophageal leiomyoma could potentially result in shorter hospital stay, decreased postoperative pain and reduced requirement for postoperative analgesia.     

非开胸全咽喉食管切除术治疗颈段食管癌10例

目的：探讨切除颈段食管癌、胃上提重建消化道的手术方法和疗效。方法：2001年3月至2004年8月,对10例颈段食管癌患者实施全咽喉食管切除,非开胸食管拔脱,经食管床胃上提,行胃咽吻合重建消化道,术后辅助放疗。结果：病理诊断均为鳞癌;无手术死亡;咽瘘1例。3例患者已分别生存7年6个月、7年、4年1个月,均为手术＋放疗的病例。结论：全咽喉食管切除、非开胸食管拔脱并胃上提胃咽吻合术,是治疗晚期颈段食管癌的有效的手术方法。术后结合放射治疗非常重要。     

Medication-induced oesophageal injury leading to broncho-oesophageal fistula

Medication-induced oesophageal injury is one of the least recognised side-effects of oral medication and, in contrast to other oesophageal pathologies, is rarely considered in the differential diagnosis of chest pain. We describe a case of medication-induced oesophageal injury with a rare complication in which the diagnosis was not considered until the characteristic features were demonstrated at endoscopy.


     

Coronary flow reserve and oesophageal dysfunction in syndrome X.

The relative prevalence of abnormalities of coronary flow reserve and oesophageal function was ascertained in 32 syndrome X patients with typical angina chest pain, a positive exercise test, and normal coronary arteries. Coronary flow reserve in response to a hyperaemic dose of papaverine was measured using an intracoronary Doppler catheter positioned in the left anterior descending coronary artery. An abnormal coronary flow reserve was defined as being < 3.0. Patients were investigated for oesophageal dysfunction by manometry and 24-hour pH monitoring. Thirteen patients had an impaired coronary flow reserve (group 1) and 19 patients had a normal flow reserve (group 2). Eight of the 13 group 1 patients (62%) and 13 of the 19 group 2 patients (68%, p = NS) had evidence of oesophageal dysfunction on either manometry or pH studies. Therefore, a total of 26 (81%) syndrome X patients had either an abnormality of coronary flow reserve or oesophageal dysfunction suggesting that chest pain in these patients may be due to myocardial ischaemia or oesophageal dysfunction, thus confirming the heterogeneous nature of this syndrome. The prevalence of oesophageal abnormalities was independent of any abnormalities of coronary flow reserve.     

接头蛋白SH2B1在食管癌中的表达及意义

目的:研究接头蛋白SH2B1在食管癌组织中的表达水平及其临床病理意义。方法:选取120例食管癌患者手术切除的标本中的食管癌组织、癌旁组织及正常组织,分别采用免疫组织化学SABC法及Western印迹检测SH2B1的表达水平,同时分析SH2B1在食管癌组织中的表达水平与临床病理特征的关系。采用RT-PCR和Western印迹检测SH2B1在食管癌细胞株TE-1,Eca-109和正常人食管上皮细胞株HEEC中的表达水平。结果:SH2B1蛋白在食管正常组织、癌旁组织、癌组织中表达逐步增强(P<0.05),并且SH2B1蛋白在食管癌组织中的表达水平与食管癌患者的肿瘤浸润程度、TNM分期、淋巴结转移密切相关(P<0.05),而与性别、年龄、饮酒与否、肿瘤类型、分化程度均无明显相关(P>0.05);SH2B1在食管癌细胞株TE-1,Eca-109和正常人食管上皮细胞株HEEC中均表达,但在食管癌细胞株TE-1,Eca-109中均较正常人食管上皮细胞株HEEC中表达明显增高(P<0.05)。结论:SH2B1在人类食管癌中过量表达,并可能与食管癌侵袭和转移密切相关。     

Corrosive-like strictures caused by ingestion of aluminium phosphide

Aluminium phosphide ingestion is a major cause of poisoning-related mortality in tropical countries. Local oesophageal complications due to aluminium phosphide have been reported to occur rarely. We describe 3 patients who survived the intake of aluminium phosphide tablets and developed oesophageal strictures.     

Aperistaltic oesophageal disorders unmasked by severe post-fundoplication dysphagia

Two patients were referred because of persistent dysphagia which developed for the first time after Nissen fundoplication. Investigations, including oesophageal manometry, demonstrated the presence of achalasia in one case, confirmed histologically, and aperistaltic oesophagus associated with an underlying connective tissue disorder in the other case. Our observations highlight the importance of assessing oesophageal motility before referring patients for anti-reflux surgery and illustrate the effect of such surgery on patients in whom oesophageal dysmotility was not suspected.     

Oesophageal stricture associated with emepronium bromide therapy.

Emepronium bromide, a drug used to control urinary frequency, has been reported as causing oesophageal ulceration but not stricture formation. This paper presents 3 cases in which the use of emepronium bromide preceded development of an oesophageal stricture and suggests that the drug played a causative role.     

Isolated oesophageal cyst connected with the bronchus

We report an unusual case of a patient with an oesophageal cyst connected to the bronchus. A 24-year old male with a two-year history of repeated attacks of chest infection and haemoptysis was found to have a cyst of 4 x 4 cm affecting the anterior and apical segments of the right upper lobe. The cyst was excised in its entirety and the histopathological study of the cyst showed stratified squamous epithelium with submucosal and muscular layer but no cartilage. The pathological diagnosis was an oesophageal cyst. No previous case of isolated oesophageal cyst connected to the bronchus has been reported according to the available literature.     

Oesophageal haematoma and associated Mallory-Weiss tear

Intramural oesophageal haematoma is a rare condition that may present as vomiting or haematemesis. Mallory-Weiss tear has been proposed as a possible aetiology but the evidence to support this is circumstantial. A case of oesophageal haematoma associated with evidence of Mallory-Weiss tear on endoscopy that helps to support this hypothesis is presented.     

Achalasia-like disturbance of oesophageal motility following truncal vagotomy and antrectomy

This report describes a patient who developed radiological and manometric evidence of an achalasia-like disturbance of oesophageal motility following transabdominal truncal vagotomy and antrectomy. The patient presented with severe dysphagia which spontaneously resolved after 8 weeks. Subsequent barium swallow and oesophageal manometry demonstrated a return to normal function.     

Exertional gastro-oesophageal reflux: a mechanism for symptoms in patients with angina pectoris and normal coronary angiograms

During 24 hour oesophageal pH monitoring 52 patients who had angina pectoris and normal coronary angiograms underwent exercise testing, as far as their symptoms allowed, on a treadmill to determine whether gastro-oesophageal reflux occurred during exertion. In 11 patients the 24 hour oesophageal pH score was abnormally high; 10 of these showed exertional gastro-oesophageal reflux, and in nine this was associated with their usual chest pain. A further 13 patients had a normal 24 hour pH score but had exertional reflux coincident with chest pain during exercise testing. The mean lower oesophageal sphincter pressure in both of these groups of patients was appreciably lower than that in 28 patients who had a normal 24 hour pH score and no exertional reflux. These findings suggest that exertional gastro-oesophageal reflux accounts for the symptoms of a large proportion of patients who have angina pectoris and normal coronary angiograms and that oesophageal pH monitoring during exercise testing on a treadmill enables this group of patients to be identified.     

Non-steroidal anti-inflammatory drugs and benign oesophageal stricture

Drug histories were obtained from 76 patients at the time of initial Eder-Puestow dilatation for benign oesophageal stricture. Six patients had consumed drugs known to cause oesophageal ulceration (emepronium bromide and potassium preparations). Of the remaining 70 patients, 22 had regularly taken a non-steroidal anti-inflammatory drug before the onset of dysphagia compared with 10 patients in a control group matched for age and sex; this difference was significant (p less than 0.02). Non-steroidal anti-inflammatory drugs may have a causative role in the formation of oesophageal stricture in patients with gastro-oesophageal reflux, in whom they should be prescribed with caution.     

Successful outcome of gestation in a young woman with severe oesophageal varices throughout the pregnancy

During normal pregnancy there is an increase in the maternal blood volume leading to portal hypertension with some changes in liver functions. However, in an apparently healthy woman without known liver cirrhosis or other advanced liver disease, severe oesophageal varices with along with repeated variceal bleeding during pregnancy is rare. In this paper we described a case of severe oesophageal variceal bleeding in a young woman without having any pre-existing liver pathology. Due to repeated pregnancy with short intervel bleeding the patient developed severe anaemia. Packed cell transfusion was done repeatedly and oesophageal variceal ligation (EVL) was done three times. In spite of these measures variceal bleeding continued and patient's condition was deteriorating progressively; so caesarean section was at 33rd week of gestation and a preterm but healthy baby was delivered. The puerperium was uneventful with no haematemesis and there was gradual improvement of the condition. A brief review of the literature on pregnancy with oesophageal varices is also presented.     

A tale of two cities - oesophageal cancer in Malawi and Scotland

The high incidence of oesophageal cancer in both Scotland and Malawi can be attributed to a combination of environmental and lifestyle factors. The aim of this study is to give a perspective on the comparative epidemiology of oesophageal cancer in these two very different populations (Blantyre, Malawi and Aberdeen, Scotland).