经食管电生理检查中的裂隙现象

在165例食管电生理检查中发现39例患者存在心脏传导系统多部位的裂隙现象共46例次(占24%),其中7例同时发生在2个部位.根据发生部位的不同试将其分成6型,探讨其发生部位及产生机理.     

食管测压指导Nissen胃底折叠术31例

目的:评价食管下括约肌压力(LESP)、食管下括约肌总长度(LESL)在Nissen胃底折叠术中的监测价值.方法:2003-2007年利用食管测压指导短松式Nissen手术治疗滑动型食管裂孔疝31例.采用台式高分辨八通道胃肠动力监测系统液导法测定.对患者术前、术中及术后LESP和LESL、术后并发症、手术远期疗效等进行观察记录.结果:术中LESP较术前升高10-12 mmHg.LESL较术前长1-1.5 cm.术后随访2年以上,手术有效率96.5%.全组仅1例24 h pH监测有明显酸反流,但无症状.结论:通过抗反流手术加术中测压,能够更准确判断胃底折叠缝合的松紧程度,有利于避免或减少术后并发症.     

Role of Intraoperative Sentinel Lymph Node Mapping in the Management of Carcinoma of the Esophagus

Background/Aim:

Precise evaluation of lymph node status is one of the most important factors in determining clinical outcome in treating gastro-intestinal (GI) cancer. Sentinel lymph node (SLN) mapping clearly has become highly feasible and accurate in staging GI cancer. This study aims to investigate the feasibility and accuracy of detection of SLN using methylene blue dye in patients with carcinoma of the esophagus and assess its potential role in determining the rational extent of lymphadenectomy in esophageal cancer surgery.

Materials and Methods:

Thirty-two patients of esophageal cancer diagnosed on endoscopic biopsy were enrolled in this prospective study. After laparotomy, patent methylene blue was injected into the subserosal layer adjacent to the tumor. SLNs were defined as blue stained nodes within a period of 5 min. Standard radical esophagogastrectomy with lymphadenectomy was performed in all the patients. All the resected nodes were examined postoperatively by routine hematoxylin and eosin stain for elucidating the presence of metastasis, and the negative SLNs were examined further with cytokeratin immunohistochemical staining.

Results:

SLNs were detected in 26 (81.25%) patients out of 32 patients who were studied. The number of SLNs ranged from 1 to 4 with a mean value of 1.7 per case. The SLNs of esophageal cancer were only found in N1 area in 21 (80.77%) cases, and in N2 or N3 area in only 19.33%. The overall accuracy of the procedure was 75% in predicting nodal metastasis. SLN had a sensitivity of 85.71% in mid esophageal tumors and 93.33% in lower esophageal tumors. The SLN biopsy had sensitivity of 87.5% in the case of squamous cell carcinoma and 92.86% in the cases of adenocarcinoma of the esophagus. The accuracy of the procedure for squamous cell carcinoma and adenocarcinoma was 60% and 76.47%, respectively.

Conclusion:

SLN mapping is an accurate diagnostic procedure for detecting lymph node metastasis in patients with esophageal cancer and may indicate rational extent of lymphadenectomy in these patients. SLN mapping provides “right nodes” to the pathologists for detailed analysis and appropriate staging, thereby helping in individualizing the multi-modal treatment for esophageal cancer.     

Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network

The aim of this study was to determine the contemporary prevalence, outcome, and survival after esophagogastric anastomotic leakage (EGAL) following esophagectomy by a regional upper gastrointestinal cancer network and to investigate etiological factors. Two hundred forty consecutive patients underwent esophagectomy over a 10‐year period (median age 61 [31–79] years, 147 transthoracic and 93 transhiatal esophagectomy, 105 neoadjuvant chemotherapy, 49 chemoradiotherapy). The primary outcome measures were the development of EGAL and survival. Twenty patients developed EGAL (8.3%, 15 managed conservatively, 5 reoperation). Overall operative mortality was 2% (5 patients in total, 1 after EGAL). Median, 1 and 2‐year survival was 22 months, 73% and 50%, in patients after EGAL, compared with 31 months, 80% and 56%, in patients who did not suffer EGAL (P= 0.314). On multivariate analysis, low body mass indices (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.11–0.79, P= 0.016), individual surgeon (HR 1.21, 95% CI 1.02–1.43, P= 0.02), and neoadjuvant chemotherapy (HR 3.28, 95% CI 1.16–9.22, P= 0.024) were significantly associated with the development of EGAL. EGAL following esophagectomy remained common, but associated mortality was less common than reported in earlier Western series and long‐term survival was unaffected.     

High‐dose definitive concomitant chemoradiotherapy in non‐metastatic locally advanced esophageal cancer: toxicity and outcome

This study is a retrospective analysis of high‐dose definitive concomitant chemoradiotherapy in locally advanced esophageal cancer in a single institution. The aim of the study was to identify and quantify the toxicity associated with the high‐dose treatment and to analyze the outcome of this treatment. Forty‐six patients (41 men and 5 women, median age of 67.5 years) with disease stage IIA–III esophageal cancer were treated with high‐dose definitive chemoradiotherapy. Thirty patients had squamous cell carcinomas and 16 had adenocarcinomas. The patients were treated with three courses of chemotherapy. Each chemotherapy course consisted of cisplatin 100 mg/m², day 1 and 5‐Fluorouracil 1000 mg/m²/day, day 1–5. One course was given every 3 weeks. Concurrent radiotherapy (66 Gy/33 fractions) was administered during the last two courses of chemotherapy. Toxicity grades three and four were seen in 47.5% and 40% of the patients, respectively. Treatment related mortality occurred in one patient (2.5%) due to neutropenic septicemia. Follow‐up time for surviving patients (2/46) was 45 and 112 months. For the entire study population, the median time to local recurrence in the radiotherapy field was 33 months and the median time to distant metastasis was 8.7 months, whereas median overall survival was 10.8 months and median disease‐specific survival 11 months. For responders to chemoradiotherapy, the median time to local recurrence was 76 months, the median time to distant metastasis 16.8 months, the median overall survival and the median disease‐specific survival for the responders were both 17 months. The 2, 3 and 5‐year survival rates were 22%, 15% and 11% for the entire study population, and 31%, 24% and 17% for the responders to chemoradiotherapy, respectively. By multivariate analysis response to chemoradiotherapy and lower disease stage were positive prognostic factors for survival. The results of our study have shown that concurrent high‐dose chemoradiotherapy provides long‐term local tumor control in locally advanced esophageal cancer. However, toxicities following this high‐dose treatment, while manageable, were significant. Survival rates were not improved by high‐dose chemoradiotherapy compared with what is reported in previous studies applying lower doses of definitive chemoradiotherapy.     

Polymorphisms of HLA-A and HLA-B genes in genetic susceptibility to esophageal carcinoma in Chaoshan Han Chinese

Esophageal carcinoma (EC) occurs at high rate in Chaoshan region of southern China. Human leukocyte antigen (HLA) polymorphism has been implicated in risk for various cancers. To investigate the impact of HLA-A and HLA-B polymorphisms on susceptibility to EC, a case–control study was conducted among 206 patients with esophageal squamous cell carcinoma and 524 controls from Chaoshan Han population. HLA-A and HLA-B polymorphisms were genotyped by polymerase chain reaction-sequence-specific primers. Genotypic association tests for dominant, recessive, and additive models, and haplotypic association were calculated using unconditional logistic regression. A*11 was identified in a recessive model as an only allele strongly associated with EC risk (odds ratios [OR]= 2.10, 95% confidence interval [CI]= 1.33–3.31) even after correction for multiple test. The haplotypes A*02-B*46 (OR = 1.53, 95% CI = 1.04–2.24) and A*11-B*51 (OR = 2.29, 95% CI = 1.20–4.40) showed association with increased risk for EC, whereas A*11-B*58 (OR = 0.00, 95% CI = 0.00–0.82) was associated with decreased risk, though the significance of these haplotypes was lost after correction. This is a first association study at genetic level identifying HLA-A and HLA-B-related variations in genetic susceptibility to EC among Chaoshan population. The variation pattern is likely to be EC-specific because it is different from that observed for nasopharyngeal carcinoma in the same study population and might, at least in part, explain the high rate of EC in this ethnic group.     

Toxicity and outcomes after chemoradiation for esophageal cancer in patients age 75 or older

Randomized trials of chemoradiation for esophageal cancer have included very few patients age ≥ 75. In this retrospective study, we describe the outcomes and toxicity of full‐dose chemoradiation in elderly patients with esophageal cancer. Patients, age ≥ 75, treated with full‐dose chemoradiation for esophageal carcinoma from 2002 to 2008 were retrospectively reviewed. Thirty‐four patients were identified with a median age of 79.5 (range 75–89). The median Eastern Cooperative Oncology Group performance status was 1 (range 0–3) and the median Adult Comorbidity Evaluation‐27 score was 1 (range 0–3). Twenty‐eight patients received definitive and six received neoadjuvant chemoradiation. The median radiation dose delivered was 50.4 Gray (range 3.6–68.4 Gray). Platinum‐based chemotherapy was used in 79.4% of patients. Fifty percent of the patients completed all planned radiation therapy (RT) and chemotherapy; 85.3% completed RT. Acute toxicity ≥ grade 4 occurred in 38.2% of patients, and 70.6% of the patients required hospitalization, emergency department visit, and/or RT break. Median follow‐up was 14.5 months among 7 survivors, and median survival was 12.0 months (95% confidence interval [CI]: 9.7 to 24.1 months). The actuarial overall survival at 2 years was 29.7% (95% CI: 16.6 to 52.6%). There were four treatment‐related deaths. The median time to any recurrence was 10.4 months. Nineteen patients had a local and/or distant recurrence. In conclusion, elderly patients experienced substantial morbidity from chemoradiation, and long‐term survival was low. Future efforts to improve treatment tolerability in the elderly are needed.     

Atypical esophageal vascular lesions observed in liver cirrhosis

Chronic liver disease is known to be associated with several vascular alterations including portal hypertension and hepato-pulmonary insufficiency. We report a case of esophageal vascular lesions resembling spider naevi in a patient with nonalcoholic cirrhosis who underwent an upper gastrointestinal (GI) endoscopy. We observed the presence of multiple white round elevations, 5–6 mm in size, with radiating thin-walled vessels, in the middle and distal esophagus. The histological examination documented the presence of multiple dilated blood vessels in the mucosal layer of the esophagus, with striking thickening of the endothelium wall. There was no evidence of esophagogastric varices, but only of a moderate congestive antral gastropathy. To our knowledge, these endoscopic esophageal findings have not yet been described in cirrhosis.     

Effect of bolus volume on proximal esophageal contractions of patients with Chagas' disease and patients with idiopathic achalasia

Chagas' disease and idiopathic achalasia patients have similar impairment of distal esophageal motility. In Chagas' disease, the contractions occurring in the distal esophageal body are similar after wet or dry swallows. Our aim in this investigation was to evaluate the effect of wet swallows and dry swallows on proximal esophageal contractions of patients with Chagas' disease and with idiopathic achalasia. We studied 49 patients with Chagas' disease, 25 patients with idiopathic achalasia, and 33 normal volunteers. We recorded by the manometric method with continuous water perfusion the pharyngeal contractions 1 cm above the upper esophageal sphincter and the proximal esophageal contractions 5 cm from the pharyngeal recording point. Each subject performed in duplicate swallows of 3‐mL and 6‐mL boluses of water and dry swallows. We measured the time between the onset of pharyngeal contractions and the onset of proximal esophageal contractions (pharyngeal‐esophageal time [PET]), and the amplitude, duration, and area under the curve (AUC) of proximal esophageal contractions. Patients with Chagas' disease and with achalasia had longer PET, lower esophageal proximal contraction amplitude, and lower AUC than controls (P≤ 0.02). In Chagas' disease, wet swallows caused shorter PET, higher amplitude, and higher AUC than dry swallows (P≤ 0.03).There was no difference between swallows of 3‐ or 6‐mL boluses. There was no difference between patients with Chagas' disease and with idiopathic achalasia. We conclude that patients with Chagas' disease and with idiopathic achalasia have a delay in the proximal esophageal response and lower amplitude of the proximal esophageal contractions.     

Study of abnormal chromosome regions in esophageal squamous cell carcinoma by comparative genomic hybridization: relationship of lymph node metastasis and distant metastasis to selected abnormal regions

Squamous cell carcinoma of the esophagus (ESCC) has a poor prognosis among digestive tract cancers. Lymph node metastasis and distant metastasis are the major factors determining its prognosis. We used comparative genomic hybridization (CGH) to evaluate primary tumor lymph nodes and metastatic areas from ESCC patients in order to determine the relationship between abnormal chromosome regions and outcome. Tumor tissues and lymph nodes were collected from 51 patients with ESCC, and abnormal chromosome regions were detected by CGH. We searched for regions that were significantly more common in patients with lymph nodes metastases (n≥ 6) or distant metastases, and correlated those chromosomal changes with survival. Regions showing amplification in more than 65% of esophageal squamous cell cancers were as follows: 17q12 (90.2%), 17q21 (86.3%), 3q29 (82.4%), 3q28 (78.4%), 8q24.2 (76.5%), 22q12 (76.5%), 3q27 (74.5%), 8q24.3 (74.5%), 1q22 (70.6%), 5p15.3 (70.6%), 22q13 (70.6%), 3q26.3, 8q23, 8q24.1, 9q34, 11q13, 17p12, 17q25, 20q12, 20q13.1 (68.6%), 1q32, 1q42, and 20q13.2 (66.7%). Regions showing deletion in more than 50% of the tumors were as follows: Yp11.3 (62.7%), 3p26 (56.9%), Yq12 (54.9%), 13q21 (52.9%), 4q32 (51.0%), and 13q22 (51.0%). When Fisher's test was used to assess associations of these regions with metastases to lymph nodes, amplification at 2q12–14 (P= 0.012), 3q24–26 (P= 0.005), and 7q21–31 (P= 0.026) were significant. Survival was worse for patients with amplification at all 3 regions. In patients with distant organ metastases, amplification at 7p13–21 was significant (P= 0.008), and survival was worse. Chromosomal amplifications in ESCC at 2q12–14, 3q24–26, and 7q21–31 were associated with lymph node metastasis, while amplification at 7p13–21 was related to distant metastasis. Amplification at these regions correlated with worse survival. Genes involved in the phenotype of ESCC may exist in these regions. Identification of these genes is a theme for future investigation.