Surveillance after colorectal cancer: The final word?

Correlation of endoanal sonography with cross-sectional anatomy of the anal sphincter

Abstract Background: Anal endosonography has become an important imaging method in the diagnosis of anorectal disorders. However, little information exists as to whether anal endosonography reliably defines pelvic floor structures. The aim of this study was to correlate endoanal sonography with cross-sectional anatomy and histology. Methods: Endosonographic tomograms were obtained from 9 human cadavers before fixation and cross-sectioning at identical levels. Muscular layers were defined by visual inspection, histology, immunohistology, and morphometry using three-dimensional sphincter reconstructions. Results: Endosonography visualized only two muscular layers, whereas anatomic sections al…

Subtotal esophageal resection in motility disorders of the esophagus.

<i>Background:</i> Esophagectomy for motility disorders is performed infrequently. It is indicated after failed medical therapy, pneumatic dilation, non-resecting surgical and redo procedures. Patient selection in this group is challenging and the operative risk has to be weighted carefully against the poor quality of life with persistent or recurrent dysphagia. <i>Patients and Methods:</i> Between September 1985 and April 2004, subtotal esophageal resections for advanced esophageal motility disorders of the esophagus not responding to previous therapy were carried out in 8 patients (6 females, 2 males). The median age of these patients was 59.5 (43–78) years. Six pa…

Effects of pneumatic dilation and myotomy on esophageal function and morphology in patients with achalasia.

Only two treatment modalities–pneumatic dilation and Heller myotomy–promise long-term relief from dysphagia and regurgitation in patients with achalasia. The objective of this study was to determine whether both options differ in their effects on esophageal function, morphology, and improvement in symptoms. Eighty-nine patients diagnosed with achalasia between January 1980 and December 2002 at a single center were enrolled in this study. Sixty-four patients underwent pneumatic dilation and 25 Heller myotomy in combination with an anterior semifundoplication (Dor procedure). Clinical evaluation (Eckardt-Score), esophageal manometry, and barium swallow were performed before and within 6 mont…

Pseudoachalasia: a case series and analysis of the literature.

Pseudoachalasia frequently cannot be distinguished from idiopathic achalasia by manometry, radiologic examination or endoscopy. Mechanisms proposed to explain the clinical features of pseudoachalasia include a circumferential mechanical obstruction of the distal esophagus or a malignant infiltration of inhibitory neurons within the myenteric plexus.Between January 1980 and December 2002, the clinical features of 5 patients with pseudoachalasia and 174 patients with primary achalasia, diagnosed in a single center, were compared. A literature analysis of the etiology of pseudoachalasia for the time period 1968 to December 2002 was performed. The search concentrated on the databases and online…

D-penicillamine in Wilson's disease presenting as acute liver failure with hemolysis.

Wilson's disease in a young woman presenting with an acute course is described. The clinical manifestations were fulminant hepatic failure associated with marked intravascular hemolysis. Immediate D-penicillamine and high-dose steroid therapy did not influence the course of the disease. Necropsy revealed an increased hepatic copper content and cirrhosis with extensive necrosis of the liver.

Achalasie oder Pseudoachalasie? Fallstricke der Diagnostik und Therapieentscheidung

History Patient 1 (female, aged 55 years) had for some time complained of morning nausea. She reported symptoms of reflux with regurgitation of food for two-and-a-half years and also dysphagia with retrosternal bolus obstruction for the last eighteen months. Patient 2 (male, aged 84 years) complained of restrosternal dysphagia with each intake of food for one year, weight loss of 12 kg and occasional regurgitation of food. Investigations The general condition of patient 1 was only slightly impaired but that of patient 2 markedly reduced. Routine laboratory tests were unremarkable in both. Barium meal in patient 1 revealed fixed narrowing in the region of the esophageal hiatus. The inferior …

Does endoscopic follow-up improve the outcome of patients with benign gastric ulcers and gastric cancer?

This study investigated whether an endoscopic surveillance program for patients with "benign" gastric ulcers and gastric cancer leads to early detection of neoplasms and improves survival. The clinical course of all patients diagnosed between 1977 and 1986 as having either gastric ulcers or gastric cancer was followed for a minimum of 3 years. Of 597 patients with initially benign gastric ulcers, 452 (76%) returned for the recommended endoscopic follow-up examinations. In eight patients (1.8%), repeated biopsies disclosed malignant neoplasms; four of these patients (0.9%) had become asymptomatic. Survival curves were nearly identical in patients who complied and those who did not. Of 241 pa…

Clinical Presentation and Complications of Achalasia

Patients with achalasia often present with atypical symptoms. If these occur in the context of "normal" morphological findings, the diagnosis may be delayed for several years. However, a careful interview and the use of modern methods that concentrate on pathophysiologic aspects always allow an early diagnosis and the initiation of therapy that affects most but rarely all symptoms. Finally, regardless of whether this therapy remains partially or totally effective, patients require some follow-up since serious and late complications may occur.

16 Jahre Myotomie und Semifundoplikatio nach Dor bei Achalasie — Die Langzeitergebnisse

Die Behandlung der Achalasie besteht in der Beseitigung der Schluckbeschwerden durch die Schwachung des unteren osophagussphinkter bei gleichzeitiger Vermeidung einer Reflux-symptomatik. Wenige Studien zu Langzeitergebnissen operativer Behandlung liegen vor. Ziel der Studie war die Erfassung der Langzeitergebnisse nach abdomineller Myotomie und Semifundoplicatio nach Dor bei Achalasie fur ein seit 1985 prospektiv erfasstes Krankengut. Patienten und Methode: 71 Patienten, 22 Manner und 49 Frauen, im Alter von 16 bis 78 Jahren wurden seit 1985 durch den selben Operateur behandelt. Die Anamnesedauer lag bei 3,5 Jahren im Median. Bereits behandelt durch Dilatation waren 66% und durch Operation …

Langzeitergebnisse nach Heller-Myotomie mit anteriorer Semifundoplikatio bei Achalasie

INTRODUCTION The positive success rate of cardiomyotomy in the treatment of achalasia has recently - especially in young patients - resulted in a primary operative treatment concept. Few studies of long-term effects of myotomy concerning the removal of dysphagia and the development of gastroesophageal reflux have been submitted. PATIENTS AND METHODS In the period between September 1985 and March 2003, an open, transabdominal Heller-myotomy combined with a Dor-semifundoplication was carried out in 93 patients with achalasia. 77 patients were followed for more than 6 months postoperatively (median follow-up: 70 months). The procedure was prospectively observed, and patients were questioned co…

Treatment of Ulcerative Colitis with Olsalazine and Sulphasalazine: Efficacy and Side-Effects

The effects of olsalazine were studied mainly in patients with ulcerative colitis who were intolerant to sulphasalazine, and for relapse prevention. A crossover design with sulphasalazine, 3 g/day, and olsalazine, 1.5 g/day, was applied to compare the side-effects of each drug and to evaluate their therapeutic efficacy. A total of 41 patients with mild or moderately severe left-sided colitis or proctitis were assigned to a randomized treatment schedule. Olsalazine and sulphasalazine were similar in their therapeutic efficacy. Twelve patients complained of adverse effects while on sulphasalazine and 4 patients during olsalazine treatment (p less than 0.05). It is concluded that olsalazine is…

5-Aminosalicylsäure-assoziierte Pankreatitis

Acute pancreatitis with severe belt-like upper abdominal pain developed within 1-4 weeks of starting medication in three patients (29-year-old man with ulcerative colitis; 43-year-old woman and 22-year-old woman with Crohn's disease) treated, for the first time, with 5-aminosalicylic acid (mesalazine), 500 mg three times daily. Concentrations of lipase initially were 545, 1182 and 3000 U/l, and of amylase 243, 449 and 129 U/l, respectively. Symptoms receded within a few hours after the drug had been discontinued, enzyme levels returning to normal in the course of the next 2-3 weeks. On repeating the drug in two of the patients, in lower dosage, the pancreatitis recurred within a few days. T…

Long-term results of conventional myotomy in patients with achalasia: a prospective 20-year analysis.

Myotomy has proved to be an efficient primary therapy in patients with achalasia, especially in younger patients (<40 years of age). The results of laparoscopic myotomy cannot be finally assessed, on account of the shorter postoperative follow-up. Thus, there are considerable data regarding intermediate-term outcomes after laparoscopic myotomy. The aim of our study was a 20-year analysis of the conventional cardiomyotomy as the underlying basis assessing the results of minimal-invasive surgery. Within 20 years (September 1985 through September 2005), 161 operations for achalasia were performed in our clinic. Enrolled in this study were 108 patients with a conventional, transabdominal myotom…

Persistierende und rezidivierende Schluckstörung nach Operation bei Achalasie — Ursache und Behandlung

Die operative Therapie bei Achalasie fuhrt zu lang andauernder Beschwerdefreiheit. Selten persistieren die Beschwerden oder es treten im Verlauf erneute schwere Schluckstorungen auf. Ziel vorliegender Untersuchung war die Erfassung der Ursache und Therapie des Rezidivs sowie die Darstellung der Ergebnisse nach einer erneuten Operation. Patienten und Methode: Unter 83 Patienten mit Achalasie wurden 11 seit 1985 wegen persistierender oder erneuter Schluckbeschwerden wiederholt operiert. Die Patienten im Alter zwischen 19 und 77 Jahren waren bereits durch Kardiomyotomie behandelt. Die Anamnesedauer lag zwischen 12 Monaten und 42 Jahren. Vor der Zweitoperation litten alle Erkrankten unter Dysph…

Histological abnormalities in patients with multiple esophageal webs

Two cases of multiple esophageal webs are presented. Histological evaluation of multiple esophageal biopsies revealed marked basal cell hyperplasia along the whole length of the esophagus. In one case these mucosal alterations remained unchanged during several years of follow-up.

Is biofeedback therapy an effective treatment for patients with constipation?

Bacteremia after proctoscopy and hemorrhoidal injection sclerotherapy

The incidence of bacteremia following proctoscopy and hemorrhoidal injection sclerotherapy was studied in 50 outpatients undergoing both procedures. Bacteremia was found in 2 per cent of the subjects after proctoscopy and in 8 per cent after sclerotherapy. None of the subjects developed symptoms of septicemia following the procedure. It is concluded that antibiotic prophylaxis should be used before sclerotherapy in patients with valvular heart disease or compromised host defense.

Reversible esophageal motor dysfunction in botulism

Two cases of botulism with autonomic and neuromuscular system involvement are presented. In both patients, dryness of the mouth and difficulties in swallowing were predominant symptoms. Esophageal manometry revealed a marked decrease in peristaltic amplitude, which was most pronounced in the upper third of the esophagus. These functional abnormalities returned to normal following recovery from the acute disease.

Reduction of Interstitial Cells of Cajal (ICC) Associated With Neuronal Nitric Oxide Synthase (n-NOS) in Patients With Achalasia

The etiology of achalasia is still unknown. The current theories of chronic inflammation leading to autoimmune response with destruction and loss of the inhibitory myenteric ganglion cells enlighten its pathogenesis in a limited way only. Interstitial cells of Cajal (ICC) have been shown to be involved in nitrergic neurotransmission of the lower esophageal sphincter (LES).To investigate the significance of ICC and neuronal nitric oxide synthase (n-NOS) in esophageal wall tissue of patients undergoing surgery for achalasia.In 53 patients with a median age of 45 (6-78) yr undergoing surgery for achalasia, the immunoreactivity of ICC (CD117/c-kit) and n-NOS was assessed. In 42 patients, biopsi…

Anorectal function and morphology in patients with sporadic proctalgia fugax

PURPOSE: The pathophysiology of sporadic proctalgia fugax remains unknown. This study investigates whether patients with this syndrome exhibit alterations in anal function and morphology. METHODS: Eighteen patients with sporadic proctalgia fugax and 18 sex-matched and age-matched healthy controls were studied. Manometric studies investigated anal resting and squeeze pressures, the rectoanal inhibitory reflex, rectal compliance, and smooth muscle response to edrophonium chloride administration. External and internal sphincter thickness was measured endosonographically. RESULTS: Patients had slightly higher (P=0.0291) anal resting pressures (65.5±11.4 mmHg) than controls (56±9.9 mmHg). Howeve…

Sekundäre Achalasie bei niedrigmalignem Non-Hodgkin-Lymphom und Leiomyomatose der Kardia

A 28-year-old man had been dysphagic for 9 months with a weight loss of 4 kg. A preliminary diagnosis of primary achalasia was made on the basis of typical radiological and manometric findings. Despite balloon dilatation of the cardia the symptoms did not improve and further diagnostic tests were performed. Ultrasound demonstrated a 4 cm tumour below the cardia. But its type and possible malignancy remained uncertain even at laparotomy. But as a malignant tumour was suspected a gastrectomy and omentectomy with removal of the local and regional lymph nodes were performed. After this the symptoms regressed and postoperative food intake was without problem. Histological examination of the surg…

Spectrum of histopathologic findings in patients with achalasia reflects different etiologies

Background:  The etiology of achalasia is still unknown. The aim of the present study was to illucidate its underlying pathologies and their chronology by investigation of esophageal specimens in patients undergoing surgery (esophageal resection or myotomy) for achalasia. Methods:  In 17 patients with achalasia, histopathologic examinations of the esophageal wall focussing on the myenteric plexus were performed. Preoperative diagnosis was based on clinical evaluation, esophagogastroscopy, barium esophagogram in all, and esophageal manometry in eight patients. The median age at the time of surgery was 54 years (range: 14–78 years). In eight cases, the complete esophageal, body and in nine ca…

Follow-up of patients with colonic polyps containing severe atypia and invasive carcinoma. Compliance, recurrence, and survival

Between January 1975 and December 1984 1769 polyps were endoscopically removed from 1219 patients. Eight percent of these patients had polyps containing severe atypia and 5.0% had polyps containing invasive cancer. A close postoperative surveillance program was followed by only a few patients, but compliance improved with longer follow-up intervals. Metachronous polyps were observed with similar frequency in patients with benign polyps (34.8%) and those with polyps containing severe atypia (23.8%) or cancer (41.7%). Patients in whom malignant polyps were endoscopically removed had a 5-year survival rate of 84.3% that did not differ from that of patients' whose polyps contained severe atypia…

Gastroesophageal Reflux and Bleeding Esophageal Varices

The incidence of gastroesophageal reflux was evaluated with the use of a pH probe in 12 patients with cirrhosis and recent variceal hemorrhage and in 15 healthy control subjects. Short episodes of reflux occurred in 42% of the patients and in 47% of the controls. During an observation period of 1 hr, the cumulative duration of reflux was similar in patients (2.5 ± 1.3 min) and controls (3.1 ± 1.4 min). Mean lower esophageal sphincter pressures were normal in both groups but did not show a significant correlation with the duration of reflux. These data support previous observations that gastroesophageal reflux does not appear to be a contributing factor in the development of variceal hemorrh…

Dolichomegaösophagus bei Achalasie

HISTORY AND CLINICAL FINDINGS A 78-year-old woman suffered from achalasia since 63 years with a progressive decompensation over the last year. 53 years ago, treatment with the Stark Dilator and 24 years ago, pneumatic dilation had been carried out. Currently, the patient presented with dysphagia for liquid and solid food, with permanent retrosternal pain and regurgitation for every meal, leading to a weight loss of 10 kg. INVESTIGATIONS The barium esophagogram showed a marked dilation of the esophagus with retinated secretions and food. The cardia had a maximum width of 15 mm. On endoscopy, reflux esophagitis and an insufficient lower esophageal sphincter were evident. TREATMENT AND COURSE …

Image cytometric DNA analysis of mucosal biopsies in patients with primary achalasia.

(P < 0.0001), and 9c- (P = 0.0001) exceeding rate with progredient DNA alterations in the respective order. CONCLUSION: The finding that DNA aneuploidy was identifi ed by image cytometry in esophageal specimens of patients with achalasia, which may be due to specifi c chromosomal alterations presenting as precancerous lesions in 27% of patients, leads us to conclude that image cytometry represents a valuable screening tool. Abstract AIM: To determine DNA aneuploidy in mucosal biopsies of achalasia patients for subsequent rapid diagnosis. METHODS: Biopsies from the middle third of the esophagus were obtained in 15 patients with achalasia. Immunohistochemical staining was carried out with mon…

Persistent and recurrent achalasia after Heller myotomy: analysis of different patterns and long-term results of reoperation.

Hypothesis Two groups of patients with inadequate therapeutic success after surgical treatment for achalasia can be identified, patients with type 1 recurrence (early recurrence after technical failure of myotomy or a scarring process requiring remyotomy) and patients with type 2 recurrence (late recurrence with irreversible progression of the disease and development of megaesophagus requiring esophagectomy). Design Prospective study. Setting University-based tertiary care center. Patients One hundred sixty-three patients undergoing surgery for achalasia during 20.3 years. Interventions Conventional remyotomy for type 1 recurrence (group 1) and esophagectomy (transhiatal or transthoracic) f…