Cricopharyngeal myotomy for neurogenic oropharyngeal dysphagia.

BACKGROUND: Forty patients (18 women, 22 men) with incapacitating oropharyngeal dysphagia of neurologic origin underwent cricopharyngeal myotomy. The subjective and objective response to myotomy was analyzed retrospectively with a mean postoperative follow-up of 48 months (range 1 to 255 months). RESULTS: Radiologic evidence of functional obstruction caused by incoordination and incomplete relaxation of the upper esophageal sphincter was significantly reduced. Manometric recordings of resting and closing pressures of the upper esophageal sphincter were also significantly altered by the myotomy. Resting pressures decreased from 65 to 18 mm Hg and closing pressures dropped from 69 to 22 mm Hg. The relaxation time and poor coordination at the level of the upper esophageal sphincter, observed in the preoperative period, persisted after the operation. Radionuclide emptying studies in which a single liquid bolus was used showed persistent hypopharyngeal stasis with a 20% retention of radioactive material at 120 seconds. Subjectively, 33 patients initially had frequent aspiration episodes. Twenty became free of symptoms after myotomy (p < 0.01) and in six others the symptoms were improved. Overall, seven patients claimed to be free of symptoms of dysphagia and no longer had pharyngo-oral or pharyngonasal regurgitations and aspirations after their operation. Twenty-three other patients had improvement in symptoms. Ten patients reported no change in symptoms. All of them either were unable to swallow voluntarily or had dysarthria when assessed before the operation. One retropharyngeal hematoma is the only postoperative complication recorded. The operative mortality was 2.5% (1/40). CONCLUSIONS: Cricopharyngeal myotomy palliates neurogenic oropharyngeal dysphagia in patients with intact oral-phase deglutition.

A new approach to tumour marker assessment by perioperative determination in breast and colorectal cancer.

Preoperative serum tumour markers are currently classified as positive or negative according to a predetermined cut-off point. In the present study we examined the dynamic variation of marker levels after radical surgery of breast and colorectal cancer. CEA and CA15.3 were measured in 93 patients with breast cancer, CEA and CA19.9 in 97 patients with colorectal carcinoma before and 30 days after radical surgery. Any variation higher than 3-fold the analytical coefficient of variation of the assay was considered significant. In patients with negative preoperative marker levels a significant decrease was noted after surgery in 15.6% of cases for CEA and 27.8% for CA15.3 in breast cancer and in 46.8% for CEA and 25.7% for CA19.9 in colorectal cancer. Using both cut-off-based and dynamic criteria, we found an overall positivity rate of 19.6% for CEA and 33.3% for CA15.3 in breast cancer; 60.0% for CEA and 37.1% for CA19.9 in colorectal cancer. From the present findings we conclude that the dynamic study of perioperative variations of tumour markers is a sensitive method additional to cut-off-based criteria for the assessment of the phenotypic expression of the marker by the tumour.

Primary treatment of esophageal achalasia. Long-term results of myotomy and Dor fundoplication.

From 1976 to 1989, 206 patients referred for primary treatment of esophageal achalasia underwent transabdominal Heller's myotomy and anterior fundoplication according to the Dor technique. In the majority of the patients, the cardia was not mobilized, and the myotomy was extended in length for about 10 cm (8 cm on the esophagus and 2 cm on the stomach). There was no operative mortality. Two patients (0.9%) required reoperation due to bleeding from the myotomy site in one and leakage from the gastrotomy site in the other. One hundred ninety-three patients entered the follow-up study and were followed up from 12 to 144 months (median, 64.5 months). Five patients died during the follow-up of unrelated diseases, and in one patient, an esophageal cancer infiltrating the trachea was discovered 26 months after the operation. Clinical results were excellent or good in 93.8% of the patients, and fair in 2.6%. Disabling dysphagia recurred in seven patients (3.6%), six of whom required pneumatic dilation for relief and one patient who underwent reoperation because of a paraesophageal hiatal hernia. Postoperative roentgenographic studies showed a significant reduction in the mean value of the maximal esophageal diameter. Esophageal manometry showed a significant reduction of lower esophageal sphincter pressure and length over preoperative values. Twenty-four-hour esophageal pH monitoring showed an abnormal acid exposure in seven (8.6%) of 81 patients tested. Of these patients, one had erosive esophagitis on endoscopy. Esophageal transit scintigraphy, performed in 11 patients, showed a significant improvement of transit time in the erect position compared with preoperative values. We concluded that transabdominal esophagomyotomy combined with Dor fundoplication is a safe, effective, and durable procedure in the treatment of esophageal achalasia.

Epidermal growth-factor receptor and erbb2 protein in colorectal tissue - comparison between cancer and normal mucosa.

Epidermal growth factor receptor (EGFr) and p185neu protein were measured in 55 samples of carcinoma and 55 of normal colorectal mucosa from the same patient, using a ligand binding assay and an ELISA method respectively. The binding characteristics of EGFr were similar in cancer and normal tissue. The concentrations of both EGFr and p185 showed gaussian distribution and were not significantly different between normal and cancer tissue, although a trend toward higher levels of EGFr in normal mucosa was found. Moreover, no significative variations were found in the ratios between cancer and normal tissue after desaturation of the EGFr. No correlations were found between EGFr and p185 and the main clinopathological parameters.

Tumor-associated trypsin inhibitor (TATI) in primary esophageal carcinoma.

Esophageal carcinoma has a catastrophic clinical course with a very low 5 year survival rate of 5%. A circulating tumor marker with good specificity and sensitivity would be useful in the management strategy of the disease. So far, no tumor marker effective in esophageal carcinoma has been identified. Preliminary reports suggest satisfactory positivity rates of tumor-associated trypsin inhibitor (TATI) in esophageal carcinoma. We measured TATI levels in 71 patients with primary squamous cell esophageal carcinoma as well as in 30 tissue samples from both carcinoma and normal esophageal mucosa. Detectable TATI levels were not found in tumor tissue samples. The marker showed significantly higher serum levels in patients than in controls, with an overall positivity rate of 28%. TATI levels were significantly lower in patients with a high number of tumor-positive lymph nodes. No relationship was found between TATI and several other clinical and pathological parameters. High TATI levels correlated with a lower probability of overall survival as well as in cases without clinical evidence of lymph node metastases. TATI did not show any relationship with CEA, TPA, ferritin or SCC. The results of the present study suggest that TATI shows a satisfactory positivity rate in esophageal carcinoma, and TATI levels are related to local disease spread and prognosis.

Substrate availability other than glucose in the brain during euglycemia and insulin-induced hypoglycemia in dogs.

Alternative substrates other than glucose could be used by the brain. In this study we hypothesized that lactate and ketone bodies can provide a significant portion of oxidative brain substrates in insulin-dependent diabetes mellitus (IDDM). Six control (C) and six insulin-treated streptozotocin diabetic (IDDM) dogs were studied during euglycemia (EU) and acute insulin induced hypoglycemia (HYPO). During EU for similar plasma glucose concentration (5.5 +/- 0.4 v 5.2 +/- 0.2 mmol/L in IDDM dogs showed a higher baseline lactate concentration (1.5 +/- 0.25 v 0.74 +/- 0.10 mmol/L; P less than .05). The ketone body concentrations were also increased in IDDM dogs but this increase was not statistically significant. The brain glucose uptake was 6.9 +/- 0.6 mumol/kg/min in C and 5.4 +/- 0.7 in IDDM. Lactate was released by the brain both in IDDM dogs (11.36 +/- 1.8 mumol/kg/min) and in C dogs (3.87 +/- 0.9; P less than .05). The brain ketones rate of disappearance (Rd) was 0.3 +/- 0.05 mumol/kg/min in IDDM dogs and 0.19 +/- 0.08 in C dogs. During HYPO the glucose uptake across the brain was 2.88 +/- 0.7 mumol/kg/min in IDDM and 3.12 +/- 0.5 in C dogs. We observed an overall brain lactate release (3.21 +/- 1.7 mol/kg/min) in C dogs and a net uptake (13.44 +/- 1.1; P less than .01) in IDDM (P less than .01). The brain ketones Rd was 0.1 +/- 0.2 mumol/kg/min in IDDM and 0.1 +/- 0.1 in C dogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Tumor markers in squamous cell carcinoma of esophagus: immunometric assay in cytosol and membrane fraction.

Carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), ferritin, and the monoclonal antibody-detected tumor-associated antigens CA19.9 and CA50 were measured by radioimmunoassay in tissue fractions of carcinoma and normal esophageal mucosa from 59 patients with untreated primary squamous cell carcinoma of the esophagus. Tumor markers were measured in cytosol (118 samples) and in a membrane-enriched fraction (32 samples). CEA, TPA and ferritin were detected in almost all the cytosol samples evaluated, CA19.9 and CA50 in 66% and 50% of cases respectively. Ferritin was significantly higher in carcinoma than in normal mucosa. The cytosol concentrations of CEA, TPA, CA19.9 and CA50 were not significantly different in carcinoma and normal tissue. Concentrations of CEA, CA19.9 and CA50 in the membrane fraction tended to be higher in normal tissue than in carcinoma, whereas the cytosol-to-membrane ratio was significantly higher in carcinoma. For CEA, CA19.9 and CA50, the phenotypic pattern of the malignant transformation seems to involve a different intracellular distribution rather than a quantitative change. No correlations were found between tissue and serum concentrations of the tumor markers, the former being related to the phenotypic characteristics of the tumor, the latter to the tumor burden.

[Use of a latissimus dorsi myocutaneous flap in locally advanced breast cancer]. / L'uso del lembo miocutaneo di gran dorsale nel carcinoma mammario localmente avanzato.

Locally advanced breast cancer has a poor prognosis. Skin infiltration, ulceration and invasion of the chest wall, in the absence of distant metastases, worsen dramatically the quality of life. The Authors report 4 cases of one time wide resection and reconstruction using a pedicled myocutaneous flap of latissimus dorsi. This technique allowed good and rapid palliation of local symptoms.

Tumor markers in serum of patients with primary squamous cell carcinoma of the esophagus.

Serum levels of several tumor markers were studied in 96 patients with untreated primary squamous cell carcinoma of the esophagus. Three markers specific for digestive tract malignancies--CEA, CA19.9 and CA50--and two non organ specific indicators of malignancy--ferritin and TPA--were evaluated. Positivity rates of CA19.9 and CA50 were very low (4.4% and 8.6% respectively); the markers were therefore considered ineffective in the disease. CEA, TPA and ferritin showed a fair positivity rate (27.1%, 28.1%, 33.7% respectively); CEA and TPA were directly related to clinical stage, CEA levels being significantly higher in stage IV than in stage III cases (p = 0.016). TPA preoperatory levels were also directly related to a lower survival probability (p = 0.004). CEA showed significantly lower levels in tumors of lower than in those of middle (p = 0.03) and upper esophagus (p = 0.004). TPA showed a similar behaviour with lower levels in tumors of lower than of middle esophagus (p = 0.03). These findings could be due to a bulky metabolism of tumor markers drained via portail vein in the liver. From our data the following conclusions may be drawn: 1) CEA and TPA may be useful in the staging of esophageal cancer as an ancillary tool to assess the extent of the disease; 2) tumor location is an important variable when evaluating blood levels of tumor markers in patients with esophageal cancer.

[Esophageal lesions caused by oral drugs. Epidemiology, physiopathologic bases, prospectives of prevention]. / Lesioni esofagee da farmaci per uso orale. Epidemiologia, basi fisiopatologiche, prospettive di prevenzione.

Esophageal injuries caused by oral medications have recently been recognized as a iatrogenic entity. This pathogenesis is due to the retention in the esophagus of drugs with caustic properties. The main predisposing factor is the practice of taking oral drugs with a small quantity of water of and/or in a recumbent position. Elderly subjects and patients with pre-existing esophageal disorders are at higher risk, so that fluid formulations or different routes of drug administration are strongly recommended. A more widespread education to the correct use of drugs and a better drug formulation are necessary for effective prevention.

[Presentation of a new instrument for the prolonged monitoring (24 hrs.) of endoesophageal pH, based on microprocessor technologies]. / Presentazione di un nuovo strumento per il monitoraggio prolungato (24 ore) del pH endoesofageo, basato su tecnologie a microprocessori.

Prolonged monitoring of oesophageal pH is the most sensitive test for GOR. An ideal instrument for this test should be simple, reliable and inexpensive. It should enable the patient to live a normal life, even at home, allows rapid analysis of the data, and monitors other parameters at the same time (intragastric pH). An instrument with these features has been devised at Padua University Surgical Clinic. It uses NSC 800 microprocessor technology and has a 32 K C-MOS memory. The examination can be programmed (patient code, date, start and end times, sampling duration and time). Postural changes are automatically recorded. Subjective symptoms are signalled by the patient through an alphanumeric keyboard. ROM software at the end of the test is employed for automatic processing according to Johnson and De Meester's parameters. Proxima is also made for a serial output to a larger-capacity computer and an analogue output compatible with a Beckman paper printer.

Functional evaluation of distal esophagus and lower esophageal sphincter after esophagogastric devascularization, esophageal transection and antireflux procedure for bleeding esophageal varices.

Distal esophageal function and LES competence were evaluated in 21 patients by means of esophageal manometry and standard pHmetry after Sujura mod. operation for bleeding esophageal varices. This operation involves complete devascularization of 10-12 cm. of distal esophagus, disruption of anatomic anti-reflux mechanism, excision of nearly one cm. of muscular tissue at lower esophageal sphincter level. Intraoperative manometry was performed in 8 patients and demonstrated a significant shortening of high pressure zone, while lower esophageal sphincter pressure did not show significant variations. Postoperatively gastroesophageal reflux at pHmetry was not observed (five patients had pathological reflux preoperatively). No significant variations of resting lower esophageal sphincter pressure and no peristaltic alterations were observed. In conclusion despite the marked anatomic alterations related to this procedure, sphincter dynamics and distal esophageal function remain nearly normal.

Esophagogastric anastomotic leakage.

Anastomotic leakage of esophagogastric anastomoses can be prevented by administering adequate preoperative nutritional support and by employing mechanical circular staplers. In a series of 299 intrathoracic anastomoses, 35 leakages were observed, 11 of which gave asymptomatic radiological findings. In a series of 46 cervical anastomoses, nine leakages were observed. In the majority of cases conservative treatment was adopted. This is based upon external drainage of septic collections, gastric emptying, antibiotics and intensive nutritional care. The mortality rate in cases of anastomotic fistulas was 1.74% (6 patients) in the patients with esophagogastric anastomoses.