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Query: UMLS:C0154059 (Esophagus)
 2,950 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The new developments in the management of Barrett's esophagus in 2005 result in refinements of decision making. New techniques including magnification endoscopy have been used for real-time recognition of intestinal metaplasia but are not yet validated. The finding of BE in patients lacking GERD symptoms highlights the problems of developing screening criteria for the general population. Many experimental optical techniques are pushing the optical recognition of dysplasia to real time. Availability, cost and validation remain barriers to clinical application. Endoscopic mucosal resection is being more widely applied resulting in more accurate staging of patients with early adenocarcinoma of the esophagus and helping to define patients amenable to endoscopic therapy. The approval of photodynamic therapy for the treatment of high grade dysplasia adds to the non-operative therapeutic arsenal. The impact of medical therapy of GERD and anti-reflux surgery on the development of esophageal adenocarcinoma is disappointing. Technological developments and emerging efforts in chemoprevention offer promise for the future.
Dis Esophagus 2005
PMID:Managing Barrett's esophagus: what is new in 2005? 1577 36

Initial treatment of locally advanced esophageal and gastroesophageal junction (GEJ) malignancies for selected patients at some institutions has recently changed from surgical resection to neoadjuvant therapy. The aim of this study is to evaluate the impact of this change in treatment strategy on both the overall disease profile and locoregional endoscopic ultrasound (EUS) staging accuracy for a cohort of patients managed with primary surgical resection over a 10-year period at our institution. All subjects at our institution who underwent primary esophagectomy from 1993 to 2002 following preoperative EUS for known or suspected esophageal and/or GEJ cancers were identified. Patients with dysplasia alone, prior upper gastrointestinal tract surgery, preoperative neoadjuvant therapy, cancer of the gastric cardia or recurrent malignancy were excluded. EUS findings and staging results were compared to surgical pathology following resection. The impact of the gradually increased use of primary chemoradiation during the second half of the study was assessed. Of the 286 operations performed, 184 subjects were excluded. The remaining 102 underwent primary surgical resection a median of 18 days following EUS staging for adenocarcinoma (88%) or squamous cell carcinoma (12%) of the esophagus (69%) or GEJ (31%). Overall EUS locoregional T and N staging accuracy was 72% and 75% respectively; accuracy for T1, T2, T3 and T4 cancer was 42%, 50%, 88% and 50% respectively. Despite an increased frequency of pathologically confirmed T1 and T2 cancers (P = 0.005) and an insignificant trend toward increased N0 malignancy (P = 0.05) during the second half of the study period, no statistically significant changes in T (P = 0.07) or N (P = 0.82) staging accuracies for EUS or disease characteristics were noted between the first and second half of the study period. Despite both inaccurate radial EUS staging and increased relative use of primary surgery for early cancers, recent increased use of primary neoadjuvant therapy did not change overall disease characteristics and accuracy of locoregional EUS staging of esophageal and GEJ cancers managed with primary surgical resection.
Dis Esophagus 2005
PMID:Endoscopic ultrasound for esophageal and gastroesophageal junction cancer: Impact of increased use of primary neoadjuvant therapy on preoperative locoregional staging accuracy. 1577 37

Treatment for Barrett's esophagus (BE) has consisted of medical treatment (acid suppression medications), surgery (fundoplication) and endoscopic ablative techniques (photodynamic therapy, argon plasma coagulation and multipolar electrocoagulation). Despite the large number of clinical trials of the efficacy of different therapeutic modalities, there is a paucity of published randomized controlled trials. The aim of this review is to evaluate the published randomized therapeutic trials in patients with BE. A comprehensive MEDLINE search was performed to review randomized clinical trials of different therapeutic modalities in BE. Only eight randomized studies have been published. The eight randomized studies reviewed include: two trials that evaluated medical and surgical therapy; two placebo controlled trials for photodynamic therapy (PDT); one placebo controlled trial comparing argon plasma coagulation (APC) versus surveillance; two trials comparing PDT versus APC; and one trial comparing APC versus multipolar electrocoagulation (MPEC). All the studies are prospective, however only one study is double-blinded. Each study has a small sample size, uses a different population of BE patients (dysplasia versus no dysplasia, short segment BE versus long segment BE), has different defined endpoints (endoscopic ablation of BE, number of treatments required for endoscopic ablation of BE, and elimination of high grade dysplasia) and the methodology for the treatment modalities is different among the studies. Though the data to support the use of endoscopic ablative techniques in the treatment of BE are promising, more rigorous double-blind and larger, well designed randomized studies are required to draw any definitive conclusions.
Dis Esophagus 2005
PMID:Randomized trials in the treatment of Barrett's esophagus. 1619 27

Oesophagus resection is adequate treatment for some benign oesophageal diseases, especially caustic and peptic stenosis and end-stage motility dysfunction. However, the most frequent indications for oesophageal resection are the high-grade dysplasia of Barrett oesophagus and non-metastasized oesophageal cancer. Different procedures have been developed for performing oesophageal resection given the 5-year survival rate of only 18% among patients operated on. A disadvantage of the conventional approach is the high morbidity rate, especially with pulmonary complications. Minimally invasive oesophageal resections, which were first performed in 1991, may reduce this important morbidity and preserve the oncologic outcome. The first reports of morbidity and respiratory complications with this approach were disappointing and it seemed likely that the procedure would have to be abandoned. However, in the past 5 years, Japanese groups and the group of Luketich in Pittsburgh have given these techniques an important impetus. The outcomes of the new series are different from those in the beginning period, and are leading to an enormous expansion worldwide. Important factors behind the change are standardization of the operative technique, the experience of many surgeons with more advanced laparoscopic procedures, important improvements in instruments for dissection and division of tissues, a better technique in use of anaesthesia, and a better selection of patients for operation. Two minimally invasive techniques are being perfected: the three-stage operation by right thoracoscopy and laparoscopy, and the transhiatal laparoscopic approach. The former may be applied successfully for any tumour in the oesophagus, whereas the latter seems ideal for distal oesophageal and oesophagogastric junction tumours. This review article discusses all these aspects, giving special attention to indications and operative technique.
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PMID:Minimally invasive oesophageal resection for distal oesophageal cancer: a review of the literature. 1678 31

There has been increasing application of endoscopic ablation therapy for patients with high-grade dysplasia (HGD) and Barrett's esophagus (BE). Three cases are reported in which the patient developed adenocarcinoma of the gastric cardia after thermal ablation of HGD. A definition of BE including endoscopic abnormality and intestinal metaplasia by biopsy was used. Strict and standardized criteria were utilized for the endoscopic landmarks. Three cases are reported with long-segment BE and a nodule or mass in the endoscopic cardia post-thermal ablation. Biopsies documented adenocarcinoma of the gastric cardia. The development of adenocarcinoma of the cardia is unexpected. Speculation is offered as to the potential of increased proliferation and mutations at the new squamocolumnar interface after endoscopic ablation therapy to explain this association.
Dis Esophagus 2006
PMID:Association of ablation of Barrett's esophagus with high grade dysplasia and adenocarcinoma of the gastric cardia. 1686 60

Esophageal dysmotility is common in patients with Barrett's esophagus. Previously we have reported deterioration of esophageal motility after photodynamic therapy (PDT) in a heterogeneous group of patients with esophageal carcinoma. This prospective study in consecutive patients describes changes in motility noted after endoscopic ablation. Forty-seven patients referred to our institution for endoscopic ablation for Barrett's high grade dysplasia or mucosal carcinoma between August 2001 and May 2003 were prospectively evaluated with esophageal manometry before and after porfimer sodium PDT. Six patients did not complete the study. Manometry results were classified as normal, diffuse esophageal spasm, ineffective esophageal motility, or aperistalsis. Abnormal esophageal motility was found in 14 of 47 (30%) patients at study entry ([diffuse esophageal spasm] DES-3, [ineffective esophageal motility] IEM-7, Aperistalsis-4). After PDT, 11 of 41 patients with paired studies experienced a change in manometric diagnosis. Three patients had an improvement in motility, seven a worsening and one changed diagnosis, but did not particularly worsen or improve. No patient developed new aperistalsis. Therefore, abnormal motility was present in 19 of 41 (46%) patients after PDT (DES-2, IEM-14, Aperistalsis-3). There was a statistically significant (P = 0.016) relationship with longer segment Barrett's esophagus and deterioration of function. Baseline abnormalities in motility can occur in patients with Barrett's high-grade dysplasia or mucosal carcinoma. Changes in esophageal function also may occur following photodynamic therapy, but usually are not clinically significant. Worsening in function was more likely to occur in patients with longer segment Barrett's esophagus.
Dis Esophagus 2006
PMID:Changes in esophageal motility after porfimer sodium photodynamic therapy for Barrett's dysplasia and mucosal carcinoma. 1698 28

Oesophageal adenocarcinoma (OA) remains one of the more deadly forms of gastro-intestinal cancer with a mortality rate exceeding 90%. The incidence of OA remains unabated and has a reported fivefold increase since 1970 [Pera M, Cameron AJ, Trastek VF, Carpenter HA & Zinsmeister AR. Increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction. Gastroenterology 1993; 104(2): 510-513]. Gastro-oesophageal reflux disease and its sequelae, Barrett's oesophagus, is one of the principle risk factors in the development of OA, with a 30-fold increased risk in Barrett's patients compared with the general population [Tytgat GNJ. Does endoscopic surveillance in esophageal columnar metaplasia (Barrett's-Esophagus) have any real value. Endoscopy 1995; 27(1): 19-26]. OA is thought to be a microcosm of evolution, developing sequentially along the metaplasia-dysplasia-adenocarcinoma sequence. Progression is attributed to a series of genetic and epigenetic events that ultimately allow for clonal selection of Barrett's cells via subversion of intrinsic control mechanisms regulating cellular proliferation and/or apoptosis. This review will describe the current suppositions of the mechanisms behind the selection and subsequent expansion of Barrett's clones, and focus on some of the principle hallmarks associated with this transition.
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PMID:Molecular biology of Barrett's cancer. 1699 63

High grade dysplasia and early cancer in Barrett's esophagus can be distinguished in vivo by endoscopic autofluorescence point spectroscopy and imaging from non-dysplastic Barrett's mucosa. We used confocal fluorescence microscopy for ex vivo comparison of autofluorescence in non-dysplastic and dysplastic Barrett's esophagus. Unstained frozen sections were obtained from snap-frozen Barrett's esophagus biopsy samples and scanned with confocal fluorescence microscopy (458 nm excitation; 505-550 nm [green] and > 560 nm [red] emission). Digital micrographs were taken from areas with homogenous and specific histopathology. Visual inspection and statistical analysis were used to evaluate the image datasets. Dysplastic and non-dysplastic Barrett's esophagus epithelia fluoresced mainly in the green spectrum and the main sources of autofluorescence were the cytoplasm and lamina propria. High-grade dysplasia was differentiated from non-dysplastic Barrett's esophagus by microstructural tissue changes. However, there were no specific changes in either the locations or average intensities of intrinsic green and red autofluorescence at the epithelial level that could differentiate between dysplastic and non-dysplastic Barrett's esophagus epithelia, ex vivo. Detectable differences in autofluorescence between BE and dysplasia/cancer in vivo are probably not caused by specific changes in epithelial fluorophores but are likely due to other inherent changes (e.g. mucosal thickening and increased microvascularity) attenuating autofluorescence from the collagen-rich submucosa. Furthermore, confocal fluorescence microscopy provides 'histology-like' imaging of Barrett's tissues and may offer a unique opportunity to exploit microstructural tissue changes occurring during neoplastic transformation for in vivo detection of high-grade dysplasia in Barrett's patients using newly developed confocal fluorescence microendoscopy devices.
Dis Esophagus 2007
PMID:Characterization of tissue autofluorescence in Barrett's esophagus by confocal fluorescence microscopy. 1743 98

We aim to determine the expression of the proto-oncogene c-Myc in patients with Barrett's esophagus (BE) and esophageal adenocarcinoma, and to evaluate the prevalence of such expression in relation to the metaplasia-dysplasia-adenocarcinoma sequence. BE develops as a result of a severe esophageal mucosa injury from gastroesophageal reflux. BE is a premalignant lesion and plays an important role in the development of esophageal adenocarcinoma. Several genetic alterations have been identified in the process that transforms a normal cell into a tumorous one. In the development of human tumors, one of the most important genes is the proto-oncogene c-Myc. The c-Myc protein expression was determined by immunohistochemical analysis in four different groups: 31 patients with normal tissue, 43 patients with BE without dysplasia, 11 patients with dysplasia in BE and 37 patients with esophageal adenocarcinoma. The material was obtained from esophageal biopsies or the dissection of patient esophagectomy specimens. Demographic and endoscopic data (sex, age, race and intestinal metaplasia extension), and morphologic and histopathologic tumor characteristics (deep tumor invasion, lymph node status, and tumor differentiation) were analyzed. The c-Myc expression was assessed using the Immunoreactive Scoring System (IRS). Overexpression of c-Myc was found in only 9.6% of normal tissue specimens, 37.2% of Barrett's esophagus, 45.5% of BE patients with dysplasia and 73% of adenocarcinoma samples, with significant statistical difference among these groups. No correlation was identified when the c-Myc expression was compared with morphologic and histologic tumor features or endoscopic data. However, linear correlation of c-Myc overexpression along the metaplasia-dysplasia-adenocarcinoma sequence was observed. This study demonstrates a significant increase in the expression of c-Myc in Barrett's esophagus, dysplasia and adenocarcinoma in relation to the control group, as well as a linear progression of this gene expression in this sequence. These results point out the importance of this marker in the development of esophageal adenocarcinoma from BE.
Dis Esophagus 2007
PMID:c-Myc overexpression is strongly associated with metaplasia-dysplasia-adenocarcinoma sequence in the esophagus. 1750 17

Chyle leak is an unwelcome complication of esophagectomy that is associated with a high mortality. The diagnosis of this condition may be difficult or delayed and requires a high index of suspicion. Management varies from conservative treatment with drainage, intravenous nutrition, treatment and prevention of septic complications, to re-operation, either by thoracotomy or laparotomy to control the fistula. To reduce the mortality, early surgical intervention is advised and a minimally invasive approach has recently been reported in several cases. From June 2002 through August 2005 we have used video-assisted thoracoscopic surgery to diagnose and treat chyle fistulas from 6/129 (5%) patients who underwent esophagectomy for resectable carcinoma of the esophagus or high-grade dysplasia. The fistula was successfully controlled in 5/6 cases by direct thoracoscopic application of a suture, clips or fibrin glue. One patient required a laparotomy and ligation of the cysterna chyli after thoracoscopy failed to identify an intrathoracic source of the leak. An early minimally invasive approach can be safely and effectively applied to the diagnosis and management of post-esophagectomy chylous fistula in the majority of cases. Open surgery may be appropriate where minimally invasive approaches fail or where the availability of such skills is limited.
Dis Esophagus 2007
PMID:Minimally invasive management of chylous fistula after esophagectomy. 1750 23


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