ObjectiveTo evaluate the rate of duodenogastroesophageal reflux in patients with columnar lined esophagus compared with patients with gastroesophageal reflux disease without columnar lined esophagus, and to analyze whether it is related to the presence of specialized columnar epithelium in the metaplastic segment.
Forty-eight patients with achalasia of the cardia were treated by Heller's myotomy with a posterior fundoplication of approximately 270 degrees, suturing the gastric fundus to the edges of the myotomy. The mean(s.d.) postoperative follow-up period was 5.4(2.8) years. The clinical results were good to excellent in 44 cases (92 per cent) and fair in four cases (8 per cent) (two with residual dysphagia and two with gastrooesophageal reflux). Barium studies showed a decrease in oesophageal diameter and disappearance of distal narrowing but normal oesophageal emptying did not occur. Postoperative manometric studies (29 patients) revealed a significant decrease in lower oesophageal sphincter pressure and a significant increase in the length of the infradiaphragmatic segment. In the oesophageal body a recovery of peristaltic waves in the proximal third was seen in ten of the patients (34 per cent). Twenty-four-hour pH monitoring showed pathological reflux in only three of 25 patients studied, and one of these was asymptomatic. This technique is effective, improving oesophageal symptoms and controlling long-term reflux.
These results show that there are no differences between the two types of treatment with respect to preventing BE from progressing to dysplasia and adenocarcinoma. However, successful antireflux surgery proved to be more efficient than medical treatment in this sense, perhaps because it completely controls acid and biliopancreatic reflux to the esophagus.
Two cases are presented of benign stenosis of the cardia secondary to fibrosis following antireflux surgery in which the patients developed a motor alteration in the esophageal body similar to that of achalasia of the cardia. There was a complete absence of contractions in one patient, which had developed over a long period of time, and a vigorous pattern in the other patient, which had evolved over a short period. In both cases, after surgical treatment of the stenosis, normal motility in the esophageal body returned.
Regular endoscopic surveillance is recommended for patients with Barrett's esophagus to detect dysplasia and to diagnose carcinoma while it is in an early and possibly treatable stage. However, there are numerous unknown aspects regarding the natural history of dysplasia in this disease, and there is still a need for more accurate markers of risk of a malignant change. The aim of this study was to investigate the usefulness of DNA flow cytometry in Barrett's esophagus to define subgroups of patients showing similar histologic findings but with a different malignancy potential. Routinely formalin-fixed and paraffin-embedded tissues of 43 patients with Barrett's esophagus were processed for flow cytometric measurements (ploidy, proliferative index) and the results were compared with the histologic evolution observed in these patients. Only in the group of patients with "indefinite" dysplasia did we find statistically significant differences between the samples from patients with and without progression to more severe lesions (mean proliferative index of stable patients: 5.2% versus 8.3% in patients with progression, p = 0.001, Student's t-test). The presence in the flow cytometric analysis of a DNA aneuploid cell line is closely related to the presence of severe histologic alterations (i.e., high-grade dysplasia: p < 0.001, Fisher's exact test). Our results suggest that this procedure is at least capable of distinguishing between a real, although incipient, neoplastic process and morphologic changes of a reactive or reparative type. The increment in the tissue proliferative index could be an indicator of an early genomic instability which, with time, will develop into lesions with a more altered DNA content: aneuploidy.
Objective.—To determine the usefulness of p53 immunostaining in identifying the subgroup of patients with Barrett esophagus who may be at increased risk of developing adenocarcinoma of the esophagus.
Materials and Methods.—Tissue samples of 41 patients with Barrett esophagus and available sequential histologic data were processed for p53 immunostaining. Results from each patient were compared over time, and the results of a subset of patients were compared with each other.
Results.—We observed a significant correlation between the percentage of samples with p53 expression and the severity of dysplasia. Moreover, in a subset of patients with mild dysplasia (cases classified as showing indefinite dysplasia), we observed a statistically significant difference in the percentage of p53-positive samples between the group that progressed to more severe dysplasia and the group that did not progress.
Conclusion.—Our results suggest that this procedure, which is technically simple, economical, and quick, could play a role in the evaluation and follow-up of patients with Barrett esophagus.
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