Endobrachyesophagus and adenocarcinoma of the esophagus

The columnar epithelium lined esophagus is usually the result of a chronic reflux disease. In the literature one can find more and more references to a malignant transformation of this columnar epithelium. Our own observations of 14 patients with an adenocarcinoma in a columnar-lined esophagus support this suspicion. Because the adenocarcinoma of the esophagus has therapeutic consequences other than a squamous carcinoma of the esophagus, the surgery has to give attention to this malignant transformation of the columnar-lined esophagus.     

Intestinal metaplasia in patients with columnar lined esophagus is associated with high levels of duodenogastroesophageal reflux

OBJECTIVE: To evaluate the rate of duodenogastroesophageal reflux in patients with columnar lined esophagus compared with patients with gastroesophageal reflux disease without columnar lined esophagus, and to analyze whether it is related to the presence of specialized columnar epithelium in the metaplastic segment. SUMMARY BACKGROUND DATA: The carcinomatous degeneration of columnar lined esophagus originates from a specialized columnar epithelium. The appearance of this metaplastic phenomenon is clearly related to severe prolonged gastroesophageal reflux, but only some of these patients finally develop columnar lined esophagus. For this reason other factors have been suggested, particularly the role played by the reflux of duodenal contents into the esophagus. METHODS: The authors studied 15 healthy volunteers (control group), 10 patients with reflux symptoms but without endoscopic lesions, 20 patients with reflux esophagitis without columnar lined esophagus, and 35 patients with columnar lined esophagus (complicated with ulcers or stenosis in 8 cases), of whom 22 had intestinal metaplasia. To assess the reflux of duodenal contents into the esophagus, all the patients underwent Bilitec 2000 and 24-hour esophageal pH monitoring. RESULTS: The presence of bilirubin in the material refluxed into the esophagus was greater in the patients with columnar lined esophagus than in the rest of the groups. Likewise, duodenogastroesophageal reflux was greater in the columnar lined esophagus patients who had intestinal metaplasia. CONCLUSIONS: Duodenogastroesophageal reflux may play a major role in the development of columnar lined esophagus, especially in patients with intestinal metaplasia.     

Carcinoma of the esophagus engrafted on corrosive stricture of the esophagus

A highly significant incidence of esophageal cancer engrafted on corrosive stricture of the esophagus has been statistically evaluated. So far, only 8 cases in Japan and over 100 cases in foreign literatures have been reported. In 1976, we reported the first case of carcinoma of the esophagus associated with corrosive stricture of the esophagus in Japan. Our second case operated in 1975 was pathologically confirmed to be adenosquamous carcinoma of the esophagus which has never been reported in the literatures. In this paper surgical and pathological problems of the carcinoma of the esophagus associated with corrosive stricture of the esophagus were discussed adding to the analysis of 8 reported cases in Japan.     

A surgically recovered case of spontaneous rupture of the esophagus. —The significance of preoperative esophagoscopy for direct sture—

A 65-year-old man with spontaneous rupture of the esophagus survived with a direct suture of the esophagus 15 hours after the onset of symptoms. Endoscopic examination of the esophagus was especially of great help in determining the surgical procedure in this patient, and we want to stress the importance of prompt diagnosis and immediate surgery for this disease.     

Diagnosis and treatment of iatrogenic and criminal injuries of the esophagus

An experience with treatment of iatrogenic and criminal traumas of the esophagus included 57 patients. There were 36 patients with iatrogenic traumas (perforation of the esophagus during diagnostic and curative manipulations and operations on the lungs and esophagus). Different kinds of operations were made depending on the localization of the injury. Three patients of this group died. Criminal traumas of the esophagus (wounds with cold steel) were treated in 21 patients, sutures on the esophagus were put in 19 of them, drainage--in 2 patients. All the patients recovered. Better results of treatment of the penetrating iatrogenic and criminal injuries of the esophagus can be achieved by timely diagnosis and operation using the proper volume and method.     

Correlations between esophageal diseases and manometric length: A study of 617 patients

The purpose of this study was to measure the length of the esophagus and assess its relationship to sex, weight, age, height, and various esophageal disorders. A retrospective analysis was undertaken of 617 esophageal manometric studies, which included 51 normal control subjects (27 males and 24 females) and 566 patients (297 males and 269 females) with esophageal disorders (50 with achalasia, 6 with diffuse esophageal spasm, 64 with strictures, 38 with nutcracker esophagus, 398 with gastroesophageal reflux disease [GERD] with positive 24-hour pH monitoring, and 66 with possible GERD but negative 24-hour pH monitoring). Manometry was performed in all of them by the station pull-through technique. The length of the esophagus was defined as the distance between the proximal end of the upper esophageal sphincter and the distal end of the lower esophageal sphincter. In the control group the mean (± standard deviation) length of the esophagus was 28.3±2.41 cm. In patients with esophageal disorders the mean length of the esophagus was 28.0 ±2.87 cm. Length of the esophagus is related to height but not to weight, sex, age, diffuse esophageal spasm, or nutcracker esophagus. Achalasia is associated with a longer esophagus, and GERD is associated with a shorter esophagus. Stricture is associated with a shorter esophagus, but this is in part due to the association between stricture and GERD. Patients with possible GERD but negative 24-hour pH monitoring have an esophageal length similar to that of GERD patients with positive 24-hour pH monitoring. Patients with GERD and stricture formation showed esophageal shortening in shorter patients. Achalasia, GERD, and GERD with stricture formation influence esophageal length. GERD-related strictures shorten the esophagus more significantly in short patients.     

Length of the esophagus in patients with gastroesophageal reflux disease and Barrett's esophagus compared to controls

BACKGROUND: It is a current opinion among surgeons that the esophagus is shorter in patients with reflux disease and particularly in those with complicated Barrett's esophagus. However, objective evidence of this is scarce. Therefore we attempted to determine the occurrence and magnitude of this phenomenon among our patients. METHODS: One hundred ninety control subjects, 77 patients with severe erosive esophagitis, 74 with Barrett's esophagus, and 29 with complicated Barrett's esophagus (ulcer, stenosis) were grouped according to height. The length of the esophagus was determined by standard manometric study, measuring the distance from the crycopharingeal sphincter to the distal limit of the lower esophageal sphincter. Values were expressed in cm as the mean +/- SD. RESULTS: The esophageal length according to height was 1 to 2 cm shorter in patients compared to controls, but these differences were not significant. CONCLUSIONS: No differences were found between patients with progressive severity of the disease. This study confirms that the presence of a so-called "short esophagus" does not exist or is not relevant in our patients with gastroesophageal reflux disease, including those with complicated Barrett's esophagus.     

Modern principles of diagnosis and surgical treatment of cancer of the esophagus

On the basis of results of treatment of 430 patients with cancer of the esophagus a conclusion was made that radical surgery for this disease consisted in extirpation of the esophagus with a single stage gastroplasty with a gastric tube from the greater curvature. The abdominal-cervical access is thought to be justified when the tumor is located on the border between the middle and lower third, in the lower third of the thoracic part of the esophagus, in the abdominal part of the esophagus. In cases of marked dysphagia, distant metastases, profound invasion into the neighboring organs the endoscopic diathermal tunnelization of the tumor followed by placing of endoprosthesis is necessary.     

Possibilities of chromoesophagoscopy for diagnosis of Barrett's esophagus

When the distal esophagus is covered with columnar gastric mucosa up to 2 cm from the esophagogastric junction it is considered normal. If the distal esophagus is covered with columnar epithelium more than 2 cm from the esophagogastric junction, it is called Barrett's esophagus. We have developed a new chromoesophagoscopic method to improve diagnostic testing for Barrett's esophagus. The distinctive feature of this method is that 4 to 5 ml of a 1% solution of neutral red is administered intravenously, after which excretion of the stain by the esophageal mucosa is examined by endoscopy. Chromoesophagoscopy has been carried out in 11 patients with reflux esophagitis. It revealed Barrett's esophagus in four patients, which was proved by histologic evaluation of biopsy specimens obtained from the stained zone of the esophageal mucosa. These observations suggest that chromoesophagoscopy is an effective, accessible, feasible, safe method for diagnosing Barrett's esophagus. It allows us to determine the length of the metaplastic epithelium and the topography of gastric glands; it also allows us to examine parietal cells in the esophagus and estimate the functional activity of these parietal cells in metaplastic epithelium.     

Distal-end esophagostomy of the excluded esophagus in the palliation of upper and mid-esophageal carcinoma.

The gastric bypass of the excluded esophagus in the palliative treatment of carcinoma of the esophagus carries a considerable mortality. One of the most significant events that contributes to this mortality is the disruption of the distal closure of the excluded esophagus. In order to avoid this, a distal-end esophagostomy accompanying the gastric bypass procedure was created in six patients with advanced carcinoma of the upper and middle third of the esophagus. This distal esophagostomy is carried out by extrapleural dissection and is developed to the back, at the level of the eighth rib, just lateral and adjacent to the spinal muscles. Operative survival of all these sick patients proves this to be a safe operation that avoids the fatal complication described.     

Columnar mucosa and intestinal metaplasia of the esophagus: fifty years of controversy

OBJECTIVE: To outline current concepts regarding etiology, diagnosis, and treatment of intestinal metaplasia of the esophagus and cardia. SUMMARY BACKGROUND DATA: Previously, endoscopic visualization of columnar mucosa extending a minimum of 3 cm into the esophagus was sufficient for the diagnosis of Barrett's esophagus, but subsequently the importance of intestinal metaplasia and the premalignant nature of Barrett's have been recognized. It is now apparent that shorter lengths of intestinal metaplasia are common, and share many features of traditional 3-cm Barrett's esophagus. METHODS: Themes and concepts pertaining to intestinal metaplasia of the esophagus and cardia are developed based on a review of the literature published between 1950 and 1999. RESULTS: Cardiac mucosa is the precursor of intestinal metaplasia of the esophagus. Both develop as a consequence of gastroesophageal reflux. Intestinal metaplasia, even a short length, is premalignant, and the presence of dysplasia indicates progression on the pathway to adenocarcinoma. Antireflux surgery, as opposed to medical therapy, may induce regression or halt progression of intestinal metaplasia. The presence of high-grade dysplasia is frequently associated with an unrecognized focus of adenocarcinoma. Vagal-sparing esophagectomy removes the diseased esophagus and is curative in patients with high-grade dysplasia. Invasion beyond the mucosa is associated with a high likelihood of lymph node metastases and requires lymphadenectomy. CONCLUSIONS: Despite improved understanding of this disease, controversy about the definition and best treatment of Barrett's esophagus continues, but new molecular insights, coupled with careful patient follow-up, should further enhance knowledge of this disease.     

Effect of Slip Time in Forming Neo‐Esophageal Stenosis After Replacement of a Thoracic Esophagus With Nitinol Artificial Esophagus

Attempts have been made to investigate the effect of slip time of nitinol artificial esophagus for forming neo‐esophageal stenosis after replacement of a thoracic esophagus with nitinol artificial esophagus in 20 experimental pigs. The pigs whose slip time was less than 90 days postoperatively had severe dysphagia (Bown's III) immediately after they were fed, and the dysphagia aggravated gradually later on (Bown's III–IV). The pigs whose slip time was more than 90 days postoperatively had mild/moderate dysphagia (Bown's I–II) immediately after they were fed, and the dysphagia relieved gradually later on (Bown's II‐I‐0). The ratios between the diameter of neo‐esophagus in different slip time and normal esophagus were 25% (at 2 months postoperatively), 58% (at 4 months postoperatively), and 93% (at 6 months postoperatively), respectively. The relationship between nitinol artificial esophagus slip time and neo‐esophageal stenosis showed a positive correlation. After replacement of a thoracic esophagus with nitinol artificial esophagus, the artificial esophageal slip time not only affected the original diameter of the neo‐esophagus immediately, but also affected the neo‐esophageal scar stricture forming process later on. The narrowing of neo‐esophagus is caused by overgrowth of scar tissue. But there is the positive correlation between artificial esophagus slip time and neo‐esophageal stenosis, so this can be a way of overcoming neo‐esophageal stenosis by delaying slip time of artificial esophagus.     

Six Cases of Barrett's Esophagus after Gastric Restrictive Surgery for Massive Obesity: An Extended Case Report

Objective: The purpose of this study is to report and characterize six patients who have developed Barrett's esophagus after a gastric restrictive procedure for massive obesity. Method: Retrospective analysis of patients operated with gastric banding (GB) and vertical banded gastroplasty (VBG) between 1981 and 1994. Results: Four patients (4/92) initially operated with GB have developed Barrett's esophagus a mean of 9 years post-operatively. Two patients (2/198) operated with VBG developed Barrett's esophagus 18 and 47 months post-operatively. The histopathological type of Barrett's esophagus was cardia-like in three cases, gastric-like in two cases and intestinal-like columnar epithelium in one case. None of the biopsies showed signs of dysplasia. Conclusion: Gastric banding is again gaining popularity with the development of adjustable bands that can be placed laparoscopically. The development of Barrett's esophagus after GB and VBG, a premalignant lesion, is cause for some concern. Prospective long-term studies are needed to further address this complication.     

Reconstructive surgery of the esophagus in patients with combined chemical burns of the esophagus and stomach

The article generalizes the experience in the treatment of 317 patients with burns of the esophagus and stomach, 140 of them underwent restorative operations on the esophagus. The indications for the choice of the restorative operations are determined by the character of the burn and the condition of the patient's organism before the accident. Retrosternal plastics of the esophagus with the colon is the operation of choice in this group of patients. The elaboration of rational therapeutic tactics, improvement of preoperative management, and the introduction of effective methods of treatment into practice with the use of microsurgical and laser techniques improved considerably the results of restorative operations on the esophagus in patients with combined burn pathology.     

Plastic tube prosthesis for the surgical treatment of perforations in esophageal strictures

A method of plastic tube intubation is described for the treatment of perforation of strictures in the lower esophagus. The tube occludes the esophageal tear and keeps the lower esophagus and cardia open, allowing spontaneous healing of the tear. Of the 5 patients treated by this method, 4 had perforations of a fibrotic esophagus and 1 had perforation of a carcinoma of the lower third of the esophagus. All patients survived. In patients without malignancies, the tube can be removed from the esophagus after a few weeks provided there is no danger of rapid stricture formation in the lower esophagus.     

A black perforated esophagus treated with surgery:Report of a case

A case of a perforated black esophagus treated with minimal invasive surgery is presented.A 68-year-old women underwent a right-sided hemihepatectomy and radio frequency ablation of two metastasis in the left liver lobe.Previous history revealed a hemicolectomy for an obstructive colon carcinoma with post-operative chemotherapy.Postoperatively she developed severe dyspnea due to a perforation of the esophagus with leakage to the pleural space.Video-assisted thoracoscopic surgery(VATS) to adequately drain the perforation was performed.Gastroscopy revealed a perforated black esophagus.The black esophagus,acute esophageal necrosis or Gurvits syndrome is a rare entity with an unknown aetiology which is likely to be multifactorial.The estimated mortality rate is high.To our knowledge,this is the first case published of early VATS used in a case of perforated black esophagus.     

The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery

OBJECTIVE: To discuss the pathophysiology and incidence of the short esophagus, to review the history of treatment, and to describe diagnosis and possible treatments in the era of laparoscopic surgery. SUMMARY BACKGROUND DATA: The entity of the short esophagus in antireflux surgery is seldom discussed in the laparoscopic literature, despite its emphasis in the open literature for more than 40 years. This may imply that many laparoscopic patients with short esophagi are unrecognized and perhaps treated inappropriately. Intrinsic shortening of the esophagus most commonly occurs in patients with chronic gastroesophageal reflux disease that involves recurring cycles of inflammation and healing, with subsequent fibrosis. The actual incidence of the short esophagus is estimated to be approximately 10% of patients undergoing antireflux surgery. Of this group, 7% can be appropriately managed with extensive mediastinal mobilization of the esophagus to achieve the required esophageal length. The remaining 3% require an aggressive surgical approach, including the use of gastroplasty procedures, to create an adequate length of intraabdominal esophagus to perform a wrap. Several effective minimally invasive techniques have been developed to deal with the short esophagus. CONCLUSIONS: Because a short esophagus is uncommon, there is a natural concern that many surgeons will not perform enough antireflux procedures to become familiar with its diagnosis and management. A complete understanding of the short esophagus and methods for surgical correction are critical to avoid "slipped" wraps and mediastinal herniation and to achieve the best patient outcome.     

Lipoma of the esophagus—Report of a case and review of the literature

We report herein, a rare case of esophageal lipoma and review the Japanese literature on this subject. Lipoma of the alimentary tract is relatively uncommon but that of the esophagus is extremely rate with only 17 cases having been reported in Japan. The majority of these cases occurred in the cervical esophagus with the most serious symptom being regurgitation of the pedunculated tumor which lead to asphyxia and death in one case. Only 2 cases occurred in the thoracic esophagus and these tumors were small in size and resected endoscopically. This is the first reported case of an esophageal lipoma being located in the thoracic esophagus which was resected through a thorocotomy. The clinical features of esophageal lipoma are also described herein.