[Local curative treatment of superficial adenocarcinoma in Barrett's esophagus. First results of photodynamic therapy with a new photosensitizer]

Pre-cancerous lesions and mucosally confined superficial cancers can benefit from local therapy given with curative intent due to the absence of near metastatic lymph nodes. Photodynamic therapy (PDT) which acts by laser irradiation with an appropriate wave-length after administration of a photosensitiser retained preferentially by the cancerous tissue can destroy tumour cells selectively, but its efficiency depends upon the photosensitiser. The results presented concern 10 sites on Barrett's mucosa (BO). They consisted of either an association of intramucosal cancer (IMC) with high-grade dysplasia (HGD) or of high-grade dysplasia alone. The method consisted of intravenous injection of Temoporfin 0,15 mg/kg 4 days before irradiation of the lesion with a green laser light emitting 514 nm through a windowed diffuser. The light fluence was 75 J per cm2 and irradiation 100 mW per cm2. Irradiation time was 12,5 mn. Omeprazole was routinely prescribed after treatment at a dose of 40 mg daily. The follow-up protocol was 2 years with endoscopic surveillance at 2, 3, 6, 12, 18 and 24 months. Biopsies obligatory at 2 and 3 months were in fact carried out at all the other delays. Efficacy was judged on the absence of high-grade dysplasia or intra mucosal carcinoma on biopsies at treated sites. Undesirable side effects noted have been moderate for the most part. No stenosis appeared. Treatment has been 100% successful for the 10 lesion after 15 treatments with PDT. The follow up varies from 6-36 months and was more than 18 months for 6 lesions on 5 patients. Our series has demonstrated a great heterogeneity in lesions which were sometimes visible and highly localised, but more often invisible, multi-focal and diagnosable only by biopsy at different levels. In keeping with the literature and our experience, PDT has several advantages over the other locally curative therapies, mucosectomy and thermocoagulation. These are the possible treatments without general anaesthesia, selectively for cancer cells, an action on more extensive areas with eradication of non visible lesions. Temoporfin has contributed notably to the field of photodynamic therapy compared to previously used sensitisers. It is a pure, synthetic product which guarantees more reproducible results. Compared with Photofrin, Temoporfin has many advantages with smaller doses of drugs and less energy, better selectivity and rapid elimination which reduce the risk period for photosensitisation. The frequency of important undesirable side effects is diminished. Finally, it produces a consistent effect on the surface and in depth producing a complete reepithelialisation of the treated zones. Subject to validation of the method on a greater number of patients, the first results obtained on superficial cancer in Barrett's aesophagus allow us to propose green light Temoporfin PDT as an alternative first line therapy with curative intent.

[Palliative treatment of adenocarcinoma of the cardia: is there a role for surgery?]

OBJECTIVES

The value of palliative surgery for adenocarcinoma of the cardia (AC) is controversial, and specific studies are lacking. The aim of this study was to report the results of a palliative resection for AC in 69 patients.

METHODS

From 1980 to 1993, 69 patients (mean age 59 +/- 10 years) underwent a palliative resection for AC. Palliative resection was defined by macroscopically incomplete resection, tumoral involvement of resection margins, visceral or serosal metastasis, or N3 metastatic nodes. Patients were classified according to the diagnosis of palliation established preoperatively (group A, n = 26), peroperatively (group B, n = 35), or postoperatively (group C, n = 8) respectively.

RESULTS

Six patients (8.7%) died postoperatively. Mortality rates were 3.8%, 8.6% and 25% in groups A, B and C, respectively. Twenty one patients (30%) had postoperative non-fatal complications. Median global survival was 9 months (mean 11 +/- 7 months) without significant difference between groups A, B and C. Forty-four out of 51 patients (86%) followed until death did not have dysphagia. The other patients were free of dysphagia during an average of 70% of the follow-up duration. Among the 14 patients surviving postoperatively with a tumoral esophageal margin, none experienced dysphagia from anastomotic recurrence during follow-up.

CONCLUSIONS

In selected patients with AC, a palliative resection can be achieved with an acceptable mortality and a very good functional result. This result can justify a prospective comparison between palliative surgery and alternative treatments.

[Total duodenal diversion in the treatment of complex peptic esophagitis]

AIMS OF THE STUDY

The aims of this study was to report the results of total duodenal diversion in patients with complex peptic esophagitis (peptic stenosis, acquired short esophagus, columnar lined esophagus, previous surgery).

PATIENTS-METHODS

Total duodenal diversion has been performed in 107 patients with complex peptic esophagitis. The standard procedure--including a troncular vagotomy, an antrectomy and a 70 cm Roux-en-Y gastro-jejunostomy--was used in 68 cases (64%). Technical adjustments were necessary in the 39 others patients.

RESULTS

Two patients (1.8%) died postoperatively. Permanent healing of esophagitis was observed within 3 months in 88% of patients. Esophagitis healed in all patients operated with the standard technique. Three hours postprandial pH-monitoring was normal postoperatively in 92% of patients. Four anastomotic ulcers occurred in patients who did not have vagotomy. Among patients with columnar lined esophagus, one complete and six partial regressions were observed; no malignant degeneration was observed with a 210-patient-year follow-up. Among the 39 peptic stenoses, all except one (2.6%) resolved. Functional disorders occurred in 27% of patients within the first postoperative months; these disorders persisted in 14% of patients (Visick III or IV) after 3 years. The main disorders (dumping syndrome, anastomotic ulcer, diarrhea) were observed when a two-thirds distal gastrectomy has been performed to avoid the dangerous completion of vagotomy after a previous Heller's myotomy.

CONCLUSION

These results suggest that total duodenal diversion is a suitable treatment of complex peptic esophagitis.

Somatic deletion of the 5' ends of both the COL4A5 and COL4A6 genes in a sporadic leiomyoma of the esophagus

Leiomyomata of the esophagus are sporadic benign tumors of unknown etiology. We studied a collection of nine tumors for the expression of extracellular matrix components and found the same aberrant expression pattern as previously observed in inherited diffuse leiomyomatosis. We demonstrate here the occurrence of a somatic deletion at the COL4A5/COL4A6 locus at Xq22 in a frozen leiomyoma sample. These data confirm the hypothesis that the same underlying etiology is responsible for circumscribed smooth muscle proliferation in sporadic leiomyomata as for diffuse smooth muscle cell proliferation in inherited diffuse leiomyomatosis.

[Late perforation of pre-sternal coloplasty: echocardiography diagnosis]

The authors report a previously non described case of late rupture of a presternal colon esophagoplasty in a patient with history of caustic ingestion. The role of sonography was the diagnosis of the rupture due to presternal position of the coloplasty.

[Results of the surgical treatment of cancer of the cardia]

OBJECTIVES

In the curative treatment of the adenocarcinoma of the cardia (AC), the extent of the esogastrectomy and the need for lymph node dissection are still debated. The palliative treatment of AC is now currently non-surgical. The aim of this study was (a): to assess early results of palliative surgery; and (b) to evaluate the results of curative resection with reference to the influence of the extent of gastrectomy and lymph node dissection on early results and long-term survival. Methods. From 1979 to 1989, 179 patients (mean age = 60 +/- 12 years) with AC had 45 palliative resections (mean age = 56 +/- 15) and 134 curative resections (mean age = 61 +/- 12). Thirty-eight proximal subtotal esogastrectomy (PSOG) and 7 total esogastrectomy (TOG) were palliative; 72 PSOG and 62 TOG extended to the spleen were curative and associated with lymphadenectomy.

RESULTS

The operative mortality rate was 8.9% regardless of the palliative or curative intent of resection. After palliative resection, the mortality rate was 2.6% (1/38) after PSOG and 42.9% (3/7) after OGT = (p = 0.01); the median survival was 8 months. After curative resection, the mortality rate was 12.5% (9/72) after PSOG and 4.8% (3/62) after extended TOG (p = 0.2); actuarial 5-year survival rate was 42% after PSOG and 39% after extended TOG.

CONCLUSIONS

These results suggests that: (a) palliative PSOG for AC can be performed with a low mortality; and (b) resection with extensive lymphadenectomy allows substantial survival regardless of the extent of gastrectomy.

Pseudotumor developing in heterotopic pancreas

Cystic dystrophy in heterotopic pancreas (CDHP) is characterized by the presence of cystic formations surrounded by inflammation and scarring. It usually involves the duodenal wall and can be responsible for strictures and pain. The diagnosis of this disorder was previously based on pancreatoduodenectomy specimens removed for a suspected pancreatic tumor. Six cases were observed in young men (mean age 40 years) between 1989 and 1993. Computed tomography (CT) and endoscopic ultrasonography (EUS) features allowed definitive preoperative diagnosis of CDHP. After surgical resection of the tissue-bearing segments that included five pancreatoduodenectomies and one antrectomy, symptoms disappeared in all patients. Patients were followed 2 to 45 months; one patient experienced recurrence of pain and hyperamylasemia 17 months after surgery. The preoperative diagnosis of CDHP is presently possible because of modern imaging procedures and improved knowledge of specific signs. Resection is the most appropriate treatment.

[Adenocarcinoma of the cardia: does the extent of gastric resection and lymph node excision influence survival?]

OBJECTIVES

In the curative treatment of the adenocarcinoma of the cardia (AC), the extent of the esogastrectomy and the need for lymph node dissection are still debated. The palliative treatment of AC is now currently non-surgical. The aim of this study was: a) to assess early results of palliative surgery; b) to evaluate the results of curative resection with reference to the influence of the extent of gastrectomy and lymph node dissection on early results and long-term survival.

METHODS

From 1979 to 1989, 179 patients (mean age = 60 +/- 12 years) with AC had 45 palliative resections (mean age = 56 +/- 15) and 134 curative resections (mean age = 61 +/- 12). Thirty-eight proximal subtotal esogastrectomies (PSOG) and 7 total esogastrectomies (TOG) were palliative; 72 PSOG and 62 TOG extended to the spleen were curative and associated with lymphadenectomy.

RESULTS

The operative mortality rate was 8.9% regardless of the palliative or curative intent of resection. After palliative resection, the mortality rate was 2.6% (1 case out of 38) after PSOG and 42.9% (3 cases out of 7) after OGT (P = 0.01); the median survival was 8 months. After curative resection, the mortality rate was 12.5% (9 cases out of 72) after PSOG and 4.8% (3 cases out of 62) after extended TOG (P = 0.2); actuarial 5-year survival rate was 42% after PSOG and 39% after extended TOG.

CONCLUSIONS

These results suggest that: a) palliative PSOG for AC can be performed with a low mortality; b) resection with extensive lymphadenectomy allows substantial survival regardless of the extent of gastrectomy.

Surgical pathology of adenocarcinoma arising in Barrett's esophagus. Analysis of 67 cases

Numerous reviews of adenocarcinoma arising in Barrett's esophagus have been reported, but detailed pathologic findings or survival analysis have rarely been provided. This retrospective study analyzed 67 patients (mean age, 64 years; male-to-female ratio, 10:1) with an adenocarcinoma arising in Barrett's esophagus treated by surgical resection. Prevalence of smokers was 63%, alcohol users, 45%, and patients with hiatal hernia, 73%. Five patients had another synchronous cancer, and seven patients, previous esophageal surgery. Forty percent of the tumors were well differentiated, 31% moderately differentiated, 15% poorly differentiated, 7% mucinous, and 6% composed of signet-ring cells. Depth of invasion in the esophageal wall was limited to mucosa in 13% of cases and submucosa in 18%. Invasive adenocarcinomas extended to the muscular layer in 12% of cases, to adventitia in 33%, and to periesophageal tissue in 24%. Vascular and perineural neoplastic invasion was present in 67 and 38% of cases. Regional lymph node involvement and distant metastases were found in 51 and 9% of cases. Overall, 1-, 2-, and 5-year survival rates were 63, 41, and 32%, respectively. Five-year survival rate was significantly better for patients with superficial cancer limited to mucosa or submucosa (82 vs. 12%) or without regional lymph node involvement (59 vs. 10%). Tumor differentiation, vascular and perineural invasion, extranodal spread, distant metastases, and resection margins status also had a significant prognostic value on univariate analysis. In a multivariate Cox regression analysis for overall survival, depth of invasion in the esophageal wall and regional lymph node involvement were independent prognostic factors. Careful pathologic staging is of value in determining the prognosis of patients with adenocarcinoma arising in Barrett's esophagus.

Overexpression of the p53 tumor suppressor gene product in esophageal and gastric carcinomas

PURPOSE

p53 protein has been reported as frequently overexpressed in esophageal and gastric carcinomas. However, the correlation between p53 protein expression and clinico-pathological features of the tumors is debated in this heterogeneous group of cancers. The aim of this study was to establish the prevalence of p53 protein overexpression in a series of resected esophageal squamous carcinomas (n = 78), adenocarcinomas developed on Barrett's esophagus (n = 20), adenocarcinomas of the cardia (n = 36), and adenocarcinomas of the antrum (n = 30), and to correlate this expression with the clinico-pathological and flow-cytometric characteristics of the tumors.

METHODS

Immunohistochemical staining was performed on frozen sections with a monoclonal antibody directed against wild type and mutated p53 protein (Pab 1801). An adjacent frozen specimen was used for flow cytometric determination of the DNA-ploidy and S phase fraction.

RESULTS

p53 protein nuclear expression was detected in 76% of esophageal squamous carcinomas, in 75% of adenocarcinomas developed in Barretts esophagus, in 56% of adenocarcinomas of the cardia, and in 27% of adenocarcinomas of the antrum. Only the number of positive adenocarcinomas of the antrum was significantly lower when compared to the other three types of tumors (p = 0.001). No significant correlation was observed between p53 protein expression and most of the clinico-pathological and flow-cytometric parameters (sex, age, tobacco smoking, chronic alcohol consumption, size of the tumor, grade of differentiation, depth of infiltration, presence of lymph node metastases, UICC stage, DNA-ploidy, S phase fraction). p53 protein expression was more frequent in Lauren's intestinal adenocarcinomas (67%) when compared to the diffuse type tumors (24%) (p = 0.002).

CONCLUSIONS

Our results confirm that overexpression of p53 protein is a common feature of esophageal and gastric carcinomas. The high prevalence of p53 protein overexpression found in cardiac adenocarcinoma when compared to antral adenocarcinoma reinforces the hypothesis of distinct carcinogenetic mechanisms in these two cancers. In particular the lack of correlation between p53 expression and tumor stage suggests that p53 protein overexpression is an early event in these tumors.

TP53 gene mutations and p53 protein immunoreactivity in malignant and premalignant Barrett's esophagus

BACKGROUND/AIMS

Limited data are available regarding TP53 gene alterations in Barrett's esophagus. This study was undertaken to characterize TP53 mutations and p53 protein immunoreactivity in cancers and preinvasive lesions of Barrett's esophageal mucosa.

METHODS

Seventeen Barrett's adenocarcinomas were examined by polymerase chain reaction amplification, denaturant gradient gel electrophoresis, and sequencing for the presence of TP53 mutations in exons 5-8. In 9 cases, Barrett's epithelium adjacent to the cancer was investigated. p53 protein immunoreactivity was studied with PAb 1801.

RESULTS

Sixteen mutations were found in 15 adenocarcinomas, including 10 missense, 3 nonsense, 1 frameshift, and 2 mutations located within consensus splice donor and acceptor sequences. All nucleotide substitutions were transitions. Eight of the 12 transitions involving a GC base pair occurred within the context of a CpG dinucleotide. p53 immunostaining was present in all 10 cases with missense mutations and in 1 case without a detectable mutation. The surrounding Barrett's mucosa showed TP53 mutations identical to that observed in the carcinoma in only 3 of 5 specimens showing high-grade dysplasia.

CONCLUSIONS

TP53 gene mutations and p53 protein immunostaining are present in a majority of Barrett's adenocarcinomas. Our results suggest that these mutations are involved at an early stage during malignant transformation of Barrett's esophagus.

Associated primary esophageal and lung carcinoma: a study of 39 patients

From 1979 to 1992, of 1,294 patients with esophageal squamous cell carcinoma, 39 patients (3.2%) (38 male patients, 1 female patient; mean age, 58 years) had associated primary lung carcinoma. Criteria for the diagnosis of primary lung carcinoma were: (1) non-squamous cell carcinoma tumors, (2) tumors existing before the esophageal squamous cell carcinoma, and (3) solitary squamous cell carcinoma presenting with endobronchial involvement. The two tumors were observed synchronously in 22 patients (56%) and metachronously in 17, with a mean tumor-free interval of 46 months (range, 18 to 77 months). In patients with synchronous disease, 10 underwent nonoperative treatment or a palliative surgical procedure, and 12 (55%) underwent a curative operation. In patients with metachronous disease, a curative operation was performed in all for the first tumor and in 9 (53%) for the second tumor. The overall postoperative mortality rate was 15%. Two patients (10%) died after the curative operation. None of the patients died who underwent curative esophagectomy combined with lobectomy. For the patients with synchronous disease, the 5-year survival rate was 11% in those who underwent a curative operation, and the longest survival in those who received palliative treatment was 18 months. For the patients with metachronous disease, the 5-year survival rates from the date of the diagnosis of the second tumor were 17% for those who had a curative operation and 11% for those who received palliative treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of choledocholithiasis by endoscopic ultrasonography

BACKGROUND/AIMS

Endoscopic ultrasonography is a promising procedure for the diagnosis of extrahepatic cholestasis. Accuracy for the diagnosis of choledocholithiasis by ultrasonography and computed tomography were prospectively compared with endoscopic ultrasonography in 62 consecutive patients.

METHODS

Final diagnosis was determined by endoscopic retrograde cholangiography with or without sphincterotomy or intraoperative cholangiography with or without choledochoscopy. All of the patients had abdominal ultrasonography, computed tomography, endoscopic ultrasonography, and either an endoscopic retrograde (n = 40) or intraoperative cholangiography (n = 32) performed.

RESULTS

Choledocholithiasis was confirmed in 22 patients. Thirteen patients had a stone with a diameter < 1 cm, and 14 had a nonenlarged common bile duct. Endoscopic ultrasonography was more sensitive (97%) than ultrasonography (25%; P < 0.0001) and computed tomography (75%; P < 0.02). Specificity and positive predictive value were not significantly different. Negative predictive value of endoscopic ultrasonography (97%) was better than that of ultrasonography (56%; P < 0.0001) and computed tomography (78%; P < 0.02). Results were unchanged after six patients in whom the absence of choledocholithiasis was considered probable after follow-up were excluded. Endoscopic ultrasonography results did not depend on stone diameter or common bile duct dilatation.

CONCLUSIONS

Endoscopic ultrasonography appears to be the best diagnostic tool for the diagnosis of choledocholithiasis compared with other noninvasive procedures.

Portosystemic shunt in Budd-Chiari syndrome: long-term survival and factors affecting shunt patency in 25 patients in Western countries

BACKGROUND

In Budd-Chiari syndrome (BCS) treated by portosystemic shunt, postoperative shunt thrombosis is associated with high morbidity and mortality rates. The aim of this study was to determine factors associated with shunt thrombosis.

METHODS

From 1985 to 1991, 25 patients underwent portosystemic shunt for BCS. According to the patency of the shunt during the postoperative period and follow-up, patients were divided into two groups including 17 patients with patent shunt and 8 (32%) with shunt thrombosis.

RESULTS

In patients with patent shunt, actuarial survival rate at 5 years was 87% versus 38% in patients with shunt thrombosis (p < 0.05). Duration of symptoms before operation was higher in patients with shunt thrombosis than in patients with patent shunt (315 +/- 483 vs 109 +/- 168 days, p < 0.05). In patients with patent shunt, extensive fibrosis or cirrhosis was observed in 3 of 17 (18%) versus in 5 of 8 (63%) of patients with shunt thrombosis (p < 0.05). Shunt thrombosis was observed in 3 of 3 patients (100%) with the combination of myeloproliferative disorder, duration of symptoms more than 100 days, and cirrhosis versus 0 of 6 (0%) patients without this combination (p < 0.05).

CONCLUSIONS

In acute form of BCS (with short history of the disease and absence of extensive fibrosis or cirrhosis), early portal decompression is mandatory, with low risk of shunt thrombosis and good long-term results. In chronic form of BCS, the risk of shunt thrombosis is high and long-term results are bad; in these patients, orthotopic liver transplantation must be considered.

[Total duodenal diversion in reoperations for gastroesophageal reflux. Indications and results in 29 patients]

From January 1980 to December 1991, among 75 patients operated on for failed antireflux procedures, 29 (39%) underwent total duodenal diversion and are the basis of this report. Ten (34%) patients underwent several procedures for reflux disease before admission. Symptoms were observed during the first postoperative year in 80% of the patients. Total duodenal diversion was performed because of: oesophageal stricture (n = 11), hiatal hernia recurrence with impossibility to perform a new antireflux procedure (n = 9), columnar lined oesophagus (n = 6), alkaline reflux (n = 2), and oesophageal motricity disorder (n = 1). At follow-up (mean 32 months), 24 patients (83%) were a symptomatic or had only moderate symptoms.

Expression of c-erbB-2 oncogene product in Barrett's adenocarcinoma: pathological and prognostic correlations

AIMS

To establish the prevalence of c-erbB-2 protein expression in a surgical series of Barrett's adenocarcinomas; and to correlate this expression with clinicopathological data and prognosis.

METHODS

Sixty six surgical specimens of Barrett's adenocarcinomas were included in this retrospective study. Blocks of the tumour and of non-dysplastic Barrett's mucosa were stained with a polyclonal antibody specific for the intracytoplasmic domain of the c-erbB-2 protein.

RESULTS

Seven of 66 tumours showed membrane staining for the c-erbB-2 protein. The non-dysplastic Barrett's mucosa was negative in all cases. There was no difference between c-erbB-2 positive and negative tumours with regard to mean age, sex ratio, percentage of alcohol misusers, percentage of smokers, tumour differentiation, depth of invasion, lymph node response, and proliferative activity, assessed by the percentage of tumour cells positive with the MIB-1 antibody directed against the Ki-67 antigen. All c-erb B2 positive tumours were of Lauren's intestinal type compared with negative c-erbB-2 tumours. Patients with c-erbB-2 positive tumours had a significantly poorer prognosis than patients with negative tumours.

CONCLUSIONS

The prevalence of Barrett's adenocarcinomas expressing c-erbB-2 found in this study (11%) was similar to that observed in published series of gastric adenocarcinomas. c-erbB-2 protein expression could be an important prognostic indicator in Barrett's adenocarcinoma.

Symptomatic duodenal stenosis in chronic pancreatitis: a study of 17 cases in a medical-surgical series of 306 patients

The aim of this study was to assess the prevalence, presentation, cause, and location of symptomatic duodenal stenosis, and its relation to the natural course of chronic pancreatitis in a medical-surgical series of 306 patients (86% alcoholics). Mean follow-up of the series was 7.9 years. Symptomatic duodenal stenosis occurred in 17 patients (5.6%). Diagnosis was confirmed by a barium series. The cause of stenosis was compression by the pancreatic head in all patients, associated with a pancreatic abscess in two. No pseudocysts were found at the time of diagnosis. The location was the 1st and 2nd part of the duodenum or the entire duodenal loop in 4, 6, and 7 patients, respectively. Cholestasis due to common bile duct stenosis occurred in association with duodenal stenosis in 9 patients. Fifteen patients were treated surgically; 11 for gastroenterostomy, and 4 for duodenopancreatectomy. Two patients were not treated surgically. We conclude that during the course of chronic pancreatitis, symptomatic duodenal stenosis occurred in 5.6% of patients, mainly during the first years of the clinical course of chronic pancreatitis, was due to pancreatic head compression and not pseudocysts, usually involved the 2nd part of the duodenum and, was associated with biliary stenosis in half of the cases. Since these two complications require surgery, common bile duct stenosis should be investigated when symptomatic duodenal stenosis is diagnosed.

Pancreaticogastrostomy after pancreatoduodenectomy

The aim of this study was to evaluate the place of pancreaticogastrostomy (PG) in reducing pancreatic fistula after pancreatoduodenectomy. From January 1988 to June 1991, 32 consecutive patients (mean age, 57 years) were operated on, 25 for malignant disease (78%). The pancreatic remnant was normal in 17 patients (53%) and sclerotic in the others. There was one operative death (3.1%) unrelated to PG. Post-operative complications occurred in five patients (16%). Only two complications were related to PG: 1 patient had anastomotic intra-gastric bleeding and was reoperated on, 1 patient with a normal pancreatic remnant developed a pancreatic fistula (3.1%) treated conservatively.

Reported series of PG, as well as our results, demonstrates that PG is associated with a dramatic decrease of both pancreatic fistula and mortality rates. The risk of anastomotic haemorrhage can be reduced by preventative ligation of submucosal gastric vessels.

In conclusion, PG appears as a simple and reliable method of management of the pancreatic remnant after pancreatoduodenectomy.

Overexpression of p53 protein in Barrett's syndrome with malignant transformation

AIMS

To study the overexpression of p53 protein in Barrett's oesophagus with adenocarcinoma, and to correlate this expression with the pathological features of Barrett's syndrome.

METHODS

Immunohistochemical staining was performed on frozen sections with a monoclonal antibody directed against wild type and mutated p53 protein (Pab 1801). Eleven cases of Barrett's adenocarcinoma were studied, seven of which had extensive sampling of benign Barrett's mucosa.

RESULTS

Eight of 11 adenocarcinomas overexpressed the p53 protein. Both early and advanced tumours were positive. In Barrett's mucosa around the p53 positive tumours, high grade dysplasia was positive; low grade dysplasia and non-dysplastic mucosa were negative.

CONCLUSIONS

P53 gene mutation with ensuing p53 protein overexpression is a common feature of Barrett's adenocarcinoma, both at early and advanced stages. This mutation appears as a relatively late event during the neoplastic transformation of Barrett's oesophagus.

Cystic dystrophy of the gastric and duodenal wall developing in heterotopic pancreas: an unrecognised entity

Ten patients in whom cystic dystrophy developed in a heterotopic pancreas of the duodenal (nine patients) or gastric (one patient) wall are reported. All were young or middle aged white men, only two of whom were alcoholic. The symptoms were caused by intestinal or biliary stenosis, or both, secondary to the inflammation and fibrosis. Only endosonography provided strong evidence for the diagnosis in three patients. All patients underwent surgery: a pancreaticoduodenectomy was performed in eight patients. The surgical specimen showed cystic lesions of the gut wall, occurring in inflammatory and fibrous heterotopic pancreatic tissue. The pancreas proper was normal in all patients. It is suggested that cystic dystrophy is an uncommon and serious complication of heterotopic pancreas. Similar cases associated with chronic pancreatitis of the pancreas have been observed and it is suggested that this process could be responsible for some of the chronic pancreatitis encountered in young, non-alcoholic patients.

Resection of presumed benign liver tumours

The surgical treatment of benign liver tumours (focal nodular hyperplasia (FNH) and hepatic adenoma) remains controversial. From 1984 to 1990, all 51 women aged below 50 years who presented with presumed benign liver tumours and without chronic liver disease underwent tumour resection. Preoperative assessment included liver tests, ultrasonography and dynamic computed tomography in all patients, plus angiography (n = 20), magnetic resonance imaging (n = 22) and technetium-sulphur colloid liver scintigraphy (n = 19). The aims of this study were to compare preoperative and final pathological diagnosis and determine whether surgical treatment was justified. Preoperative assessment suggested FNH in 18 patients and hepatic adenoma in 11. In 22 patients, the distinction between FNH and adenoma could not be determined before operation. Operative procedures included resection of one segment or less in 22 patients, two segments in 14 and three or more segments in 15. There was no postoperative death and no serious complication. The final diagnosis after pathological examination of resected specimens was FNH in 36 patients (71 per cent), including the 18 presumed before operation to have FNH, hepatic adenoma in 12 (24 per cent) and malignant lesions in three (6 per cent): hepatocellular carcinoma (HCC) arising in normal liver, fibrolamellar carcinoma, and adenoma containing areas of HCC in one patient each.

IN CONCLUSION

(1) precise preoperative diagnosis of benign liver tumours remains difficult despite new imaging methods; (2) malignant liver tumours can go unrecognized; and (3) resection of all these lesions can be carried out safely. Resection of presumed benign liver tumours should be performed in young women when a preoperative diagnosis of FNH is not firmly established.

[The Senning procedure in Budd-Chiari syndrome associated with complete portal vein thrombosis]

The authors report their experience of one case of Budd-Chiari syndrome with total thrombosis of the portal vein. The patient was undergoing hepatico-atrial anastomosis with Senning's procedure. The original technique utilised extracorporeal circulation with hypothermia; the authors utilised venovenous bypass from femoral vein to axillary vein. Anastomosis function is proved with nuclear magnetic resonance and echo-Doppler on year after operation. Senning's procedure is feasible in the case of Budd-Chiari syndrome with total portal thrombosis with venovenous bypass without extracorporeal circulation with hypothermia.

[Prognostic value of pre- and postoperative alpha-fetoprotein in the follow-up of patients with surgically-treated hepatocellular carcinoma]

A percentage ranging from 60 to 80% of hepatocarcinomas are associated with increased levels of alphafetoprotein (AFP). In the three years following surgical resection there was a 80% possibility of recidivation. The aims of the present study were: a) to evaluate the significance of preoperative AFP assay as a prognostic index of recidivation; b) to evaluate the importance of repeated assays during the postoperative period in order to ensure an early diagnosis of recidivation. Between 1982 and 1989, 62 patients underwent surgery for hepatocarcinoma. Thirty-one patients who had undergone so-called curative surgery were periodically controlled for a period varying between 6 and 55 months, and were included in the present study. The remaining 32 patients were excluded for the following reasons: palliative surgery, postoperative death, postoperative complications unrelated to tumoral recidivation. In all cases AFP assay was carried out preoperatively, one month after surgery, and then every six months. Recidivation was always confirmed on the basis of tomodensitometric and arteriographic data. Before surgery out of a group of 30 patients, 11 showed normal AFP levels (below 20 mg/ml), while 19 had levels between 49 and 7350 mg/ml. Twenty-three patients (74%) reported one case of recidivation during the period between 6 and 40 months. Among the 11 patients who had showed normal preoperative AFP levels, 5 had a recidivation between 12 and 36 months, and 3 of these showed high AFP levels. In 18 out of the 19 patients (90%) with high preoperative AFP levels recidivation was diagnosed between 4 and 40 months following surgery; 4 of these were not associated with a rise in AFP.(ABSTRACT TRUNCATED AT 250 WORDS)

Polymorphonuclear count in ascitic fluid after laparotomy in cirrhotic patients

In order to establish whether an ascitic polymorphonuclear count greater than 250/mm3 remains a diagnostic criterion for postoperative bacterial peritonitis, a prospective study of 16 patients with cirrhosis and ascites undergoing hepatectomy (n = 4), portocaval shunt (n = 5) and biliary and digestive surgery (n = 7) was carried out. Sixty-four consecutive specimens of ascitic fluid were obtained through abdominal one-way suction tubes left in situ. In 17 (26%) specimens, ascitic fluid was blood stained and the polymorphonuclear count was unreliable; none of these specimens demonstrated positive ascitic fluid culture. In the remaining 47 specimens the polymorphonuclear count ranged from 5 to 5,920/mm3. Positive ascitic fluid culture was significantly higher in polymorphonuclear > or = 250/mm3 group (5/13: 38%) than in polymorphonuclear < 250/mm3 group (2/34: 6%) (p < 0.02). These results suggest that, as in non-operated cirrhotic patients: (a) polymorphonuclear count should be taken in account in the diagnosis of postoperative bacterial peritonitis; (b) polymorphonuclear count greater than 250/mm3 is a good criterion for the diagnosis of bacterial postoperative peritonitis.

Adenomas arising in Barrett's esophagus with adenocarcinoma. Report of three cases

Adenocarcinoma of the esophagus is a well known complication of Barrett's esophagus, and results from a dysplasia-carcinoma sequence. This report describes 3 patients with adenomatous polyps arising in Barrett's esophagus. One patient presented with multiple sessile or pedunculated polyps giving a polyposis appearance; the other two patients had single polyps associated with distinct adenocarcinoma arising in Barrett's esophagus. Polyps consisted of adenomatous proliferation with adenocarcinoma in the 3 patients. Review of the literature identified twelve previously reported cases. These cases show that although rare, adenomas may arise in Barrett's esophagus, and are most likely premalignant lesions such as other adenomas of the gastrointestinal tract.

[Liver transplantation without clamping the vena cava inferior]

An original technique of orthotopic liver transplantation with preservation of the recipient's entire inferior vena cava and side-to-side caval anastomosis is described. The procedure was used in 21 consecutive patients. It has permitted to avoid vena cava occlusion and the need for venous bypass. No consequences on caval flow were observed during the anhepatic phase. Such technique avoids retrocaval dissection and requires only one caval anastomosis, reducing the duration of the anhepatic phase.

[Gastroesophageal reflux treated by posterior hemifundoplication. 251 cases]

Between September 1983 and March 1991, 251 consecutive patients with gastro-oesophageal reflux resistant to medical treatment underwent posterior hemifundoplication (modified Toupet procedure). One hundred and seventy-seven patients (71 percent) had peptic oesophagitis. pH monitoring showed a mean Kaye's score of 278 +/- 245 with a 29 percent part of total recording time at pH < 4. The mean low oesophageal sphincter pressure was 8.5 +/- 6.5 cm H2O. No patient died in the postoperative period. Morbidity consisted of 8 splenic injuries, as well as 8 pulmonary and 23 thromboembolic complications. Assessment of 199 patients (79 percent) with a mean follow-up of 32 +/- 21 months showed complete symptomatic relief in 96.5 percent, and complete endoscopic healing of oesophagitis was noted in 96 percent. Restoration of the pH profile to normal levels was obtained in 86 percent of the cases. The mean low oesophageal sphincter pressure had risen to 17 +/- 6 cm H2O. Early postoperative dysphagia was noted in 46 patients (18 percent); one of them required reoperation. Reflux symptoms persisted in 9 patients (4.5 percent). pH monitoring revealed abnormal levels in 3 patients. The results of this study demonstrate that effective gastro-oesophageal reflux control can be achieved with the modified Toupet procedure.

Esophageal squamous carcinoma in five patients with Barrett's esophagus

Adenocarcinoma of the esophagus is a well-known complication of Barrett's esophagus. This report describes five patients (three men and two women) with Barrett's esophagus and squamous carcinoma of the esophagus. All patients had hiatal hernia, and three had a history of tobacco and alcohol use. The tumors were located in the Barrett's mucosa in one case, at the squamocolumnar junction in two cases, and in the squamous-lined mucosa above the Barrett's mucosa in two cases. One patient also had focal adenocarcinoma associated with the squamous carcinoma of the esophagus. Review of the literature identified 11 previously reported cases. Occurrence of esophageal squamous carcinoma in Barrett's esophagus patients suggests a possible relationship between these two conditions, and the need for a careful evaluation of the squamous esophageal mucosa and the squamocolumnar junction at the time of endoscopy.

[Liver transplantation without clamping of the inferior vena cava]

An original technique of orthotopic liver transplantation with preservation of the recipient's entire inferior vena cava and side-to-side caval anastomosis is described. This procedure was used in 21 consecutive patients. It has permitted to avoid vena caval occlusion and the need for venous bypass. No consequences on caval flow were observed during the anhepatic phase. Our technique avoids retrocaval dissection and requires only one caval anastomosis, reducing the duration of the anhepatic phase.

'Natural history' of hepatectomy

The aim of this study was to describe biochemical and liver function test changes after hepatectomy in 33 patients with the following characteristics: absence of underlying liver disease, no blood or plasma transfusion during the perioperative period, uneventful postoperative course. Resection with a temporary pedicle inflow occlusion (10-45 min) consisted of unisegmentectomy or less in 15 patients and bisegmentectomy or more in 18. Blood tests showed: a correlation between aminotransferase rise and duration of ischaemia, and a fall in prothrombin time and factor V levels correlating with the weight of resected specimen at day 1; a moderate gamma-glutamyl transpeptidase and alkaline phosphatase elevation and a rise in fibrinogen level correlating with the extent of resection at day 7. Changes in haemoglobin level, white cell count, platelet count, prothrombin time, factor V level and serum bilirubin level tended to return to preoperative levels by day 7. For gamma-glutamyl transpeptidase and alkaline phosphatase, increased levels persisted for 8-12 weeks after resection. These results, in this selected group of patients, allow a description of the 'natural history' of hepatectomy. The knowledge of these 'natural' changes may contribute to the early detection of postoperative complications.

Splenic and portal venous obstruction in chronic pancreatitis. A prospective longitudinal study of a medical-surgical series of 266 patients

The aim of this study was a prospective search for splenoportal venous obstruction (SPVO) in a medical-surgical series of 266 patients with chronic pancreatitis who were followed up a mean time of 8.2 years. SPVO was systematically searched for using ultrasonography and then confirmed by angiography or computed tomography. SPVO was found in 35 patients (13.2%) but was symptomatic in only two. Initial obstruction involved the splenic vein in 22 patients, the portal vein in 10, and the superior mesenteric vein in three. Since venous obstruction extended from the splenic to the portal vein in five patients, the prevalence of portal obstruction was 5.6% (15/266). Acute pancreatitis and pseudocysts were the probable cause of SPVO in 91.4% of our cases. Half the cases of splenic venous obstruction were related to pseudocysts of the caudal pancreas. Esophageal varices were found in two patients and gastric varices in four at the time of diagnosis and during follow-up. At the end of follow-up, 12 patients had undergone splenopancreatectomy (N = 11) or splenectomy (N = 1). Only one patient was operated on for massive esophageal variceal bleeding, and another patient died due to intractable colic variceal bleeding. In four of six patients operated on with portal vein obstruction, surgery was difficult due to venous collaterals. Ten patients were not operated on and 13 patients operated on were not treated for SPVO. The mean follow-up after diagnosis of SPVO for these final 23 patients was 28.9 months. None of these patients bled.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cancer on an esophageal diverticulum]

Carcinoma is one of the most severe complications of oesophageal diverticula. Its incidence varies from almost zero to 4 percent. The authors report 4 cases of carcinoma arising in a pharyngo-oesophageal diverticulum and 2 cases involving a diverticulum of the oesophageal body. In this disease, the diagnosis is often delayed, which may be the reason for the low long-term survival rate. The risk of carcinoma is another justification for resection of the pharyngooesophageal diverticulum. The post-surgical morbidity of the oesophageal body diverticula is an obstacle to systematic resection of these lesions.

[Contribution of fibrin glue to the reinforcement of esophageal anastomoses]

A prospective randomized study was conducted on 100 patients operated upon for oesophageal diseases to evaluate the usefulness of fibrin glue in reinforcing oesophageal anastomoses. The anastomoses were located in the neck, the chest or the lower mediastinum. The operative mortality rate, the number and severity of fistulae and the incidence of anastomotic stenosis were studied. This series was insufficient to demonstrate that fibrin glue was effective in this type of surgery.

Surgical management of failed esophagomyotomy (Heller's operation)

An analysis of the causes of failure of Heller's operation is necessary in order to arrive at appropriate treatment. We retrospectively studied 100 reoperations for failed esophagomyotomy. Usually, a repeat myotomy was performed via an abdominal approach if the initial Heller's operation proved a failure, or via a thoracic approach if extensive motor disorders were discovered at manometry. Until 1978, esophagogastric resections were performed for severe esophageal injuries due to reflux after Heller's operation, but since then, duodenal diversion has obviated the need for resection. Antrectomy with Roux-en-Y gastrojejunostomy and vagotomy might be performed via an abdominal approach because the latter, always mandatory, is feasible through a transdiaphragmatic approach. Esophageal resection was reserved for major esophageal asystole, some cases of sclerosis, and carcinomas occurring or discovered after Heller's operation.

Cholangitis associated with cholecystitis in patients with acquired immunodeficiency syndrome

Four patients with acquired immunodeficiency syndrome developed severe abdominal pain and fever due to acute acalculous cholecystitis. In all patients, preoperative laboratory data showed elevation of alkaline phosphatase and gamma-glutamyltransferase levels. Endoscopic or intraoperative cholangiography showed signs of intrahepatic and extrahepatic cholangitis. Cholecystectomy was performed and prompt relief of symptoms was achieved in all patients; no postoperative complication was observed. One patient did not develop any recurrence during an 18-month period of follow-up; two patients died 2 and 3 months after the operation. One patient developed recurrent abdominal pain and cholestasis 4 months after the operation, with dilatation of the common bile duct and papillary stenosis due to progression of cholangitis. These observations suggest that cholangitis is frequently associated with cholecystitis in patients with the acquired immunodeficiency syndrome. Its pathogenesis is not known.

Esophagogastrectomy for carcinoma in cirrhotic patients

Esophagogastrectomy for carcinoma of the esophagus or cardia has been performed in 32 patients with histologically proven hepatic cirrhosis. Thirty-one esophagogastrectomies were performed through a separate abdominal and right thoracic approach in 25 patients, a left thoracoabdominal approach in five patients, and without thoracotomy in two patients. One patient had a colon interposition. Seven patients died after operation (21%) as a result of anastomotic leakage in two patients, hepatorenal in four patients and portal thrombosis in one patient. The type of procedure did not influence mortality. The most common postoperative complication was the development of ascites (68%), and when associated with hepatorenal syndrome (in four patients) there was significant mortality (p less than 0.05). Sepsis was present in the terminal stages of all nonsurvivors. A prothrombin time less than or equal to 60% of normal values was the only significant preoperative predictive factor of mortality, with none of the three patients surviving below this level (p less than 0.05). It is concluded that the presence of cirrhosis is not a contraindication to esophagogastrectomy for carcinoma when curative resection can be undertaken. Hepatic reserve is the determinant factor of operative prognosis. Operative risk is acceptable if patients are classified as Child's class A, and prothrombin time is over 60% of normal values. Operation should be delayed when acute alcoholic hepatitis is present. Intraoperative discovery of cirrhosis is not a contraindication to resection when the above criteria are met.

Herniorrhaphy and concomitant peritoneovenous shunting in cirrhotic patients with umbilical hernia

From 1981 to 1987, a total of 40 cirrhotic patients with umbilical hernia were treated either by conventional herniorrhaphy (26) or by herniorrhaphy and concomitant insertion of a peritoneovenous (PV) shunt (14). The aim of concomitant PV shunt insertion was to reduce postoperative complications of herniorrhaphy in those patients with intractable ascites, or in whom difficulty to control postoperative ascites was contemplated. In the group of patients with PV shunt, 8 were class B and 6 were class C according to Child's classification; 7 patients had complicated hernia including 2 patients with skin ulceration, 4 with rupture, and 1 with incarceration. In the group with standard herniorrhaphy, 5 patients were class A and 21 were class B; 13 patients were operated on electively for uncomplicated hernia without ascites, 6 had incarceration, and 7 had skin ulceration. The technical procedure of concomitant PV shunting and hernia repair included: insertion of the valve, surgical repair of the hernia, and insertion of the venous tube. In that order, in-hospital mortality was nil. Postoperative complications included sepsis in 2 patients who had concomitant insertion of a PV shunt, and massive ascitic fluid production in 5 patients treated by conventional herniorrhaphy, resulting in ascitic leak from the surgical wound in 1 case. Recurrence of the hernia was observed in 6 patients treated by conventional herniorrhaphy, and in none who had a patent PV shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pancreatic intraductal adenoma, adenomatosis and adenocarcinoma]

Three cases of adenomatous lesions of the pancreatic ducts are reported. There was 1 case each of adenoma of the main pancreatic duct, adenomas of the uncinate process and diffuse adenomatosis of the cephalic pancreatic ducts with ampullary involvement. On ultrasound and computerized tomography, the main pancreatic duct was enlarged in all cases, associated in 2 cases with a mass in the head of the pancreas, and in 1 case, with pseudocystic dilation of the uncinate process ducts. At duodenoscopy, the papilla was tumoral in 1 case, enlarged with mucous flow in 1 case and normal in the third case in which cytologic examination of secretions disclosed glandular cells. Endoluminal lesions were diagnosed by endoscopic retrograde pancreatography in 2 cases and on gross pathologic examination in 1 case. Treatment was surgical: cephalic pancreatoduodenectomy in 2 cases and local resection in 1 case, which relapsed 3 years later. At pathology, lesions were benign in all 3 cases including 1 case of severe dysplasia. On the basis of these 3 cases and a review of the literature, distinctive features of pancreatic endoluminal adenomas and adenocarcinomas are specified. Pancreatic resection is mandatory because of the risk of pancreatic obstruction and malignant degeneration.

Total duodenal diversion in the treatment of complicated peptic oesophagitis

Total duodenal diversion (TDD) has been carried out in 59 patients with complicated forms of peptic oesophagitis (acquired short oesophagus, columnar lined oesophagus, previous oesophagogastric surgery, stenosis). A standard procedure (truncal vagotomy, antrectomy and gastrojejunal anatomosis using a 70 cm Roux-en-Y loop) was performed in 41 patients, and some technical adjustments were required in 18 patients previously operated on. One patient died from postoperative pulmonary embolism. Bowel movements were resumed before the fifth postoperative day in 93 per cent of patients (54/59). Early postoperative complications (gastroparesis, 5; fistula, 1; subsequent operation, 1) occurred in 12 per cent of patients. Stabilization of the oesophagitis was achieved in less than 3 months in 95 per cent of cases (55/58). There were two cases of regression of columnar lined oesophagus. A 3-h postprandial pH assessment showed that the reflux had been controlled in 92 per cent of cases (47/51). One patient who still had an acid reflux died subsequently of a perforated oesophageal ulcer. Three anastomotic ulcers occurred in eight patients who did not have vagotomy. Digestive side-effects have been observed in nine patients, but only in one case were they crippling. Our results suggest that TDD is a suitable form of treatment for complicated forms of peptic oesophagitis.

[Bronchogenic esophageal cysts in the adult. Four cases]

Bronchogenic oesophageal cysts possess a mucosa of the airway type but are unconnected to the tracheobronchial tree; they are in close anatomical relation with the oesophageal wall. These characteristics are explained by the fact that the respiratory and digestive tract share the same embryonic development. Four cases of bronchogenic oesophageal cyst are reported, and 21 well-documented cases from the literature are reviewed. The lesion is extremely rare in adults, often complicated and responsible for gastrointestinal, respiratory and sometimes even cardiac symptoms. Its features at radiology, endoscopy and computerized tomography are suggestive of the diagnosis. Treatment consists of excision by enucleation. Excision must be complete for recurrences to be avoided.

[Value of x-ray computed tomography in cancer of the esophagus. Prospective and blind study]

Most complementary investigations assessing the resectability of esophageal carcinoma are not very accurate. In approximately half of the patients who undergo surgery, the surgeon discovers unknown growth extension of the tumor. The aim of this study was to define the place of CT scan in the assessment of esophageal cancer. A prospective study concerning 54 cases of squamous cell carcinoma was conducted during 18 months. We consecutively tested the sensitivity and the specificity of information supplied by a CGR 10000 CT scan. The reading was done by the same radiologist who was unaware of the other preoperative findings. All cases of carcinoma were proved histologically. The characteristics of the tumor itself were accurately described by CT scan. Tracheobronchial spread was correctly assessed in 96.2 p. 100 of cases; specificity was 100 p. 100. On the contrary, the sensitivity of the nodal involvement was weak (less than 55 p. 100) for the abdominal as well as the mediastinal areas. Moreover, CT scan identified 48 out of 49 patients without metastases. The results of this study did not allow to determine the value of signs of tumoral spread to the aorta, pericardium, and intra-abdominal regions and therefore CT scan can not be used to determine invasion of the pleural or peritoneal serosa. These results suggest that: a) CT scan alone is not sufficient in the assessment of patients for surgery, b) CT scan facilitates the choice of operative strategy, c) oncologic classification of non operative carcinoma, correct fields of radiation therapy, and follow-up of malignancy through chemotherapy are improved.

[Early treatment of biliary lithiasis in biliary pancreatitis]

Since 1982, 38 consecutive patients with biliary pancreatitis were treated prospectively in order to prevent recurrent migration of gallstones. Removal of the stones was achieved by "early surgery" i. e. within the first week after admission or by endoscopic sphincterotomy in patients with severe pancreatitis. Gallstones were visualized by ultrasonography in 31 patients (82 p. 100). Microlithiasis was present in 14 (37 p. 100) and was missed at ultrasonography in 7 patients. According to Ranson's prognostic signs, only 4 patients had 4 or more signs. These 4 patients and 2 additional patients aged more than 85 underwent urgent retrograde cholangiography and endoscopic sphincterotomy. No complications could be attributed to this technique. Among the 4 patients with severe pancreatitis, 3 developed an abscess which required delayed surgery without further complications. The 32 other patients underwent a biliary operation within the first week after admission. Common bile duct calculi were present in 14 patients being discovered by cholangioscopy in 6. One patient died after operation and one was reoperated on for a pseudocyst on day 40. No recurrent attack of pancreatitis was observed in either group. Our study suggests that slightly delayed biliary operation with cholangioscopy during the same hospitalization can be performed safety in patients with mild pancreatitis. In patients with severe attack and/or poor general condition, endoscopic sphincterotomy is a safe technique and deserves wider consideration in the management of severe acute pancreatitis for which delayed drainage of pancreatic necrosis may occasionally be required.