A rare case of achalasia coexistent with sigmoid megacolon and associated with epilepsy

A case of achalasia coexistent with sigmoid megacolon in a 38-year-old man with known epilepsy is described. The patient was referred to the Ryukyu University Hospital with a 4-year history of dysphagia and heartburn and a 1-year history of abnormal bowel movement. On admission, upper gastrointestinal (GI) series demonstrated a dilated, tortuous thoracic esophagus with a flask-type configuration. Barium enema studies showed a dilated sigmoid colon from the rectosigmoid junction to the descending colon. Myotomy (modified Jekler-Lhotka's procedure) for achalasia and simple sigmoidectomy for sigmoid megacolon were carried out. The biopsied wall of the narrowed esophageal segment at operation showed decreased numbers of ganglion cells in Auerbach's plexus and atrophy of the muscle fibers. The resected dilated sigmoid colon revealed degeneration and markedly decreased numbers of ganglion cells in Auerbach's and Meissner's plexuses. The patient's postoperative course was uneventful and he has been doing well since surgery. The present case is very interesting and to our knowledge, such a case is rare in the literature. We believe that the abnormalities of the ganglion cells may be due to the same etiologic factor as the sigmoid megacolon. The association of the two pathologic processes is discussed, together with a brief review of the literature.

[Photodynamic therapy--its application for the treatment of esophageal cancer]

Effect of Photodynamic therapy (PDT) for esophageal cancer was discussed in this study. PDT has been performed on 9 cases of superficial esophageal cancer. All cases were followed periodically by endoscopy for 2 years 2 months to 6 years and no case has any local recurrence. But in 2 cases invaded submucosal layer, lymph node metastasis was recognized. We think PDT is one of the very effective therapies in the treatment of intramucosal cancer.

[Combined chemotherapy with cisplatin in esophageal cancer]

Combined chemotherapy with cisplatin was performed in patients with advanced esophageal cancer. Two types of administration schedule were used: method I (three-drug combination of cisplatin, bleomycin and methotrexate) and method II (combination of cisplatin, peplomycin and methotrexate). Of 16 cases, 6 (37.5%) showed partial remission. With regard to the method of administration, the response rate for method I was 33%, and that for method II was 43%. Nausea (84%), vomiting (56%), loss of appetite (94%), malaise (75%) and alopecia (25%) were observed as side effects. Nausea and vomiting were ameliorated by use of metoclopramide. In bloodchemistry, anemia (87%), leukopenia (56%), thrombopenia (31%) and increase of BUN (63%) were observed. However, these changes were ameliorated by hydration or blood transfusion. Combined chemotherapy with CDDP should be a more useful future treatment for esophageal cancer.

[A 6-day subrenal capsule assay for predictive testing of primary esophageal cancers]

Subrenal Capsule Assay (SRCA) as a chemosensitivity test was performed on 14 esophageal squamous cell carcinomas in order to select a more effective form of chemotherapy. Of the 14 assays, 12 were evaluable. Mice were treated with anticancer agents (e.g. Cisplatin, Bleomycin, Methotrexate, Vindesine) on days 1 and 3 after transplantation, and on day 6, the sensitivities were determined. Fresh esophageal cancers yielded an evaluable assay rate of 74%. The implant grew progressively for six days in the remaining group of control mice. Histologically, host cell infiltration at the border of the implant was observed from day 3 after transplantation, and cells had degenerated or had been partially replaced by scar tissue by day 6. The results of chemosensitivity tests differed according to the anticancer agent used or from case to case. Clinically, correspondence between the assay results and clinical results was obtained in 5 out of 7 cases. SRCA is a new promising chemosensitivity test which is clinically useful, and the present results indicated the feasibility of its use in developing an effective chemotherapy for esophageal cancer.

[A few important aspects in the treatment of early esophageal cancer]

The Japanese Society for Esophageal Cancer has defined mucosal and submucosal cancer as superficial cancer of the esophagus. Superficial cancer without metastasis was defined as early cancer of the esophagus. Of 104 cases of superficial cancer resected in these twenty years, early cancer was 62 cases, the incidence being 4.9% of all resected cases. The operative mortality rate and 5-year-survival rate of early cancer were 1.9% and 62%, respectively. As for the depth of the cancerous invasion, 14 of 104 superficial cancer cases were mucosal cancer. Twelve of 14 mucosal cancer belonged to early cancer. Vascular invasion was noted in one of 12 early mucosal cancer cases. No cancer death has been encountered in the early mucosal cancer cases. So the discovery of the mucosal cancer is mandatory to obtain the excellent results. For this purpose the value of endoscopy including the dying method, should be emphasized. In terms of treatment of the early cancer no special surgical procedure has been considered. The lymph node dissection has been carried out systematically. Some kinds of postoperative combined treatments are performed for early cancer cases with vascular invasion. The reduction surgery and the noninvasive treatment will be advisable for the small mucosal lesions.

[Controversies on the treatment of early esophageal cancer]

Early cancer of the esophagus was defined as the mucosal and the submucosal cancer without any metastasis. The five-year-survival rate for early cancer cases was 61%. From our experience with nine cases of early mucosal cancer, not only no lymph node metastasis but also no vascular invasion was observed. So the diagnosis and the surgical treatment of mucosal carcinoma and further intraepithelial carcinoma must be important to obtain the long term survivals. The post operative combined treatments, such as the irradiation and the immunochemotherapy, were necessary for the early submucosal cancer with vascular invasion to improve the postoperative survivals.