Search

Achalasia is an esophageal motor disorder in which the primary morphologic changes are found in the myenteric plexus. However, a number of secondary alterations are characteristically found in esophagectomy specimens, including the mucosa. In addition, these patients are at increased risk of developing esophageal squamous cell carcinoma. We studied the squamous mucosal alterations in 35 esophagectomy specimens from patients with end-stage achalasia and compared them with those found in the squamous mucosa near the esophagogastric junction from pediatric autopsies (

The barium esophagram is an essential component in the workup of a patient with dysphagia and gastroesophageal reflux disease, especially when considering antireflux surgery or after such surgery. The examination requires a flexible approach with an emphasis on the motility portion of the examination. When properly performed, the examination should identify the following: normal or impaired esophageal emptying; normal or abnormal motility; the presence and type of hiatal hernia; the presence of a distal stricture or mucosal ring; and in many instances, the presence of gastroesophageal reflux. In patients after antireflux surgery, the examination should identify the following: normal of impaired esophageal emptying; normal or abnormal motility; the location, tightness, and length of the fundoplication; the presence of a recurrent hernia; and the presence of gastroesophageal reflux., (Copyright 2001 by W.B. Saunders Company)

Esophageal diverticula are best classified by their anatomic location: pharyngoesophageal (Zenker's diverticula), midthoracic, and epiphrenic. Most diverticula result from esophageal motility disorders. Although some patients are asymptomatic and diverticula are incidental findings, most patients are symptomatic. Dysphagia, regurgitation, and pain are common complaints, however, symptoms are often nonspecific and may be the result of an associated esophageal motility disorder. Contrast radiography is the prime diagnostic tool; evaluation of the diverticulum, associated esophageal abnormalities, and complications are assessed by a barium esophogram. Esophagoscopy adds little to the evaluation of the diverticulum but may be indicated in the assessment of other esophageal abnormalities. Motility studies, which may be difficult or hazardous to perform, are of little use in the diagnosis and treatment of Zenker's diverticula. Manometric evaluation of midthoracic or epiphrenic diverticula usually show an associated motility disorder and may influence treatment decisions.

The histological distinction between intestinal metaplasia involving the distal esophagus (Barrett's esophagus [BE]) and intestinal metaplasia of the stomach has important clinical implications and can be difficult even with the use of histochemical mucin stains. Cytokeratin (CK) 7 and 20 are cytoplasmic structural proteins that show restricted expression in normal and malignant epithelia of the gastrointestinal tract. The aim of this study was to determine the use of CK7 and 20 expression in the histological distinction of BE from gastric intestinal metaplasia. CK7 and 20 immunostaining was performed on randomly selected surgical resection (n = 31) and biopsy specimens (n = 34) from patients with long-segment BE and gastric resection specimens (n = 11) and gastric cardia biopsy specimens (n = 13) in patients with histological evidence of intestinal metaplasia. A unique pattern of immunoreactivity designated the Barrett's CK7/20 pattern showed superficial CK20 staining and strong CK7 staining of both superficial and deep glands in 29 of 31 (94%) esophageal resection specimens and 34 of 34 (100%) esophageal biopsy specimens form patients with long-segment BE. A Barrett's CK7/20 pattern was not observed in gastric cardia biopsy specimens (n = 13) or gastric resection specimens (n = 11) in patients with histological evidence of intestinal metaplasia. The sensitivity, specificity, and positive predictive value of a Barrett's CK7/20 pattern for a diagnosis of long-segment BE was 97%, 100%, and 100%, respectively. CK7 and 20 reactivity patterns can reliably identify the location of intestinal metaplasia in the esophagus and stomach using histological material from both routine endoscopic biopsy and surgical resection specimens.

Background & Aims: A previous study evaluating the morphological features of esophagi resected for endstage achalasia showed marked depletion of myenteric ganglion cells, widespread destruction of nerves, and variable chronic inflammation. The aim of this study was to evaluate the histological features in esophagomyotomy specimens from 11 patients with early achalasia, defined as minimal to moderate esophageal dilation without sigmoid deformity., Methods: The histological features of esophagomyotomy specimens from 11 patients with achalasia were analyzed and compared with the findings of control specimens obtained from 8 patients who underwent esophagectomy for intramucosal adenocarcinoma., Results: Control specimens had normal numbers of ganglion cells (0.70-0.91 ganglion cells per high-power field) and minimal inflammation. Three patients with vigorous achalasia had normal ganglion cell numbers (0.79-0.91 ganglion cells per high-power field) and at least mild myenteric inflammation without neural fibrosis. The remaining 8 patients had few or no ganglion cells (0-0.30 ganglion cells per high-power field) and at least mild myenteric inflammation and neural fibrosis. Ganglionitis was found in 2 cases. Ganglion cell number was inversely correlated with degree of myenteric neural fibrosis (P < 0.001)., Conclusions: Vigorous achalasia has pathological features that are distinct from classic achalasia. The earliest pathological changes consist of myenteric inflammation with injury to and subsequent loss of ganglion cells and injury to and fibrosis of myenteric nerves.

Background and Study Aims: Endoscopic ultrasonography (EUS) provides high-resolution images of the esophageal wall and adjacent structures. The purpose of this study was to evaluate the usefulness of EUS using the echoendoscope in the evaluation of patients with achalasia., Patients and Methods: Seventeen patients with achalasia underwent esophagogastroduodenoscopy (EGD), esophageal manometery, and EUS. The esophageal wall thickness was measured endosonographically in four quadrants at the gastroesophageal junction (GEJ) and at 1 cm intervals proximally. Of the 17 patients evaluated, five had a tortuous esophagus (Group A) and 12 had a relatively straight esophagus (Group B). Six patients without esophageal symptoms served as controls (Group C)., Results: There was no significant difference in the mean esophageal wall thickness measured at the GEJ between the groups (4.0 mm, 3.3 mm, and 2.9 mm for Groups A, B, and C, respectively). Esophageal wall thickness was significantly greater in Group A than Group C when measured 2, 3, and 4 cm above the GEJ (4.2 mm vs. 2.8 mm; 4.1 mm vs. 2.4 mm; 4.0 mm vs. 2.4 mm, respectively) (p < .05). When measured 2 cm above the GEJ, the esophageal wall in Group A patients was significantly thicker (4.2 mm) than in patients in either Group B (3.2 mm) or Group C (2.8 mm) (p < 0.05)., Conclusions: The appearance of esophageal wall thickening was common in patients with achalasia. Positioning of the echoendoscope in some patients with an irregularly-shaped, tortuous esophagus may result in tangential imaging and the production of artifacts simulating submucosal lesions. The production of such imaging artifacts suggests that caution must be exercise when EUS with the echoendoscope is used to evaluate patients with achalasia and a tortuous esophagus. Based on the present level of knowledge, EUS is not recommended in the routine evaluation of patients with achalasia.

Endosonography, which provides high-resolution images of the esophageal wall, could potentially detect carcinoma not visible endoscopically in patients with Barrett's esophagus and high-grade dysplasia. We studied the ability of endosonography to detect early esophageal carcinoma in 9 patients with Barrett's esophagus and high-grade dysplasia who were candidates for esophagectomy. Pre-operative endoscopy and biopsy revealed high-grade dysplasia without evidence of carcinoma in all patients. Pre-operative endosonographic evaluations were compared to the pathologic diagnoses of resected specimens. Post-operatively, 3 of the 9 patients were found to have intra-mucosal carcinoma. Endosonography identified a tumor in only 1 of these 3 patients and over-staged it as invasive carcinoma (T2, N1). In 2 of the 6 patients without intra-mucosal carcinoma, endosonography predicted invasive carcinoma (T2, N0). Endoscopy revealed mucosal nodularity in each of the 3 over-staged patients. We conclude that recommendation of the routine use of endosonography to determine the need for surgery in patients with Barrett's esophagus and high-grade dysplasia would be premature, because the current generation of echo-endoscopes does not reliably differentiate between benign and malignant wall thickening.

The role of surgery in patients with Barrett's esophagus and high-grade dysplasia is controversial. The aims of this study were to determine the prevalence of unsuspected early cancer and to evaluate surgical outcome in a cohort of patients with high-grade dysplasia. Records of all 16 patients who underwent esophagectomy for high-grade dysplasia from 1986 to 1991 were reviewed. All had preoperative endoscopy with no gross evidence of carcinoma, and none had a preoperative diagnosis of intramucosal or invasive carcinoma. Intramucosal carcinoma was found in six (38%) resection specimens. There were no cases of invasive carcinoma or lymph node metastases. One patient (6%) died 3 months postoperatively. The remaining patients are alive without evidence of recurrent cancer (range of follow-up, 2-68 months). Early postoperative complications occurred in seven patients (44%). Late complications occurred in 11 patients (73%). Anastomotic strictures accounted for seven of the 11 (64%) late complications. Complications were successfully managed conservatively in all but two patients. One required laryngectomy for chronic aspiration and another required a gastrojejunostomy for gastric outlet obstruction. Intramucosal carcinoma that had been unsuspected is frequently found in patients with Barrett's esophagus and high-grade dysplasia. Mortality associated with esophagectomy is low, and perioperative complications can usually be managed conservatively. Esophageal resection is indicated in appropriately selected patients with Barrett's esophagus and high-grade dysplasia.

Esophageal ultrasound allows the esophageal wall to be viewed as five discrete layers. Lymph nodes are easily identified, and their size, shape, margin, and internal structure can be assessed. This provides an alternative method of preoperative (clinical) evaluation of the primary tumor [T] and the regional lymph nodes [N] of patients with carcinoma of the esophagus. Esophageal ultrasound was attempted in the clinical staging of 28 patients with carcinoma of the esophagus. Six patients (21%) were not assessed because of the inability to pass the esophageal ultrasound probe through the malignant stricture. The staging system for carcinoma of the esophagus developed by the International Union Against Cancer and the American Joint Committee on Cancer was used. Twenty-two patients had the true T determined by pathologic review of the resected esophagus. Esophageal ultrasound correctly identified T in 13 patients (59% accuracy). In four patients (18%) the disease was overstaged by esophageal ultrasound; all these patients had early T1 tumors confined to the submucosa. In five patients (23%) the disease was understaged by esophageal ultrasound; all of these patients had advanced tumors (four T3 and one T4) that invaded beyond the esophageal wall. Seven of the nine incorrect esophageal ultrasound determinations were called T2 (three T1, three T3, one T4), which suggests that the borders of the muscularis propria require careful attention when evaluated by esophageal ultrasound. Twenty patients had the true N determined by pathologic review of the resected specimen. Esophageal ultrasound correctly identified N in 14 patients (70% accuracy). Three patients were falsely identified as having N1 disease and three were falsely identified as having N0 disease. The sensitivity, specificity, positive predictive value, and negative predictive value for N assessment by esophageal ultrasound were 70%. Esophageal ultrasound provides an alternative method of visualization of the esophageal wall and regional lymph nodes. Our early experience shows promise for esophageal ultrasound in the clinical staging of carcinoma of the esophagus.