Radical esophagectomy.
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Deglutition Disorders↗
Biomedical subjects
N K Altorki
Publications and source records attributed to N K Altorki.
High-grade dysplasia in the columnar-lined esophagus.
Abnormal columnar lining of the esophagus is a well-recognized premalignant condition. The management of patients with high-grade dysplasia without evidence of carcinoma remains controversial. Esophagectomy is proposed by some investigators, whereas others favor follow-up endoscopy and biopsy until microinvasive malignancy is documented. We reviewed our experience with nine patients referred with high-grade dysplasia on endoscopic biopsies without evidence of carcinoma. Eight patients had the columnar lining extending orad from the cardia, and one patient had heterotopic columnar epithelium in the cervical esophagus. All were white men ranging in age from 19 to 76 years (median: 47 years). Eight patients underwent esophagectomy with colon interposition. A sleeve resection of the cervical esophagus was done in one patient. Multifocal carcinoma was found in three patients, all of whom had severe dysplastic changes throughout the columnar lining. The patient with heterotopic columnar epithelium had microinvasive carcinoma. All four patients with carcinoma had negative nodes and are long-term survivors. No carcinoma was found in the resected specimens of the remaining five patients. High-grade dysplasia is an important marker of malignancy in patients with a columnar-lined esophagus. Esophagectomy is indicated in suitable candidates since carcinoma was found in 45% of our patients.
Adult↗
Adenocarcinoma in Barrett's esophagus.
Adenocarcinoma arising in association with the columnar-lined esophagus is now recognized with increasing frequency. The incidence of malignant degeneration in Barrett's esophagus, its etiology, and pathogenesis are all issues of ongoing debate. The role of gastroesophageal reflux in driving the malignant change remains unproven. Surgical resection is the treatment of choice; however, prognosis is generally poor. Surveillance of patients with non-malignant Barrett's esophagus permits detection of early lesions where resection results in excellent long-term survival.
Adenocarcinoma↗
Indications for esophagectomy in nonmalignant Barrett's esophagus: a 10-year experience.
Between 1978 and 1988, 88 patients were referred for the surgical treatment of nonmalignant Barrett's esophagus. Nineteen patients required esophageal resection. Male/female ratio was 13:6; age range was 13 to 84 years (mean age, 49.8 years; median age, 40 years). Preoperative studies demonstrated strictures in 11 patients and ulcers in 7. Penetrating Barrett's ulcer resistant to treatment was the indication for resection in 5 patients. Ulcers penetrated to the pericardium (1 patient), pulmonary vein (1), lung (1), and mediastinum (2). Other indications for resection included undilatable strictures (2), previous operations (4), high-grade dysplasia (3), parietal cells lining the esophagus (1), patient's refusal of long-term surveillance (2), and the inability to exclude adenocarcinoma preoperatively (2). Reconstruction was achieved by colon interposition (15) or esophagogastrostomy (4), with one postoperative death. Mean follow-up was 41 months and was 100% complete. Of the 18 patients, 3 have occasional regurgitation but none have any dysphagia or weight loss. Esophageal resection is indicated in a select group of patients with Barrett's esophagus. Absolute indications include a deep penetrating ulcer confirmed intraoperatively, high-grade dysplasia, strong suspicion of cancer, and multiple previous operations. Relative indications include strictures not responding to dilation and young patients refusing long-term surveillance.
Adolescent↗
Simultaneous pulmonary and renal malignancy.
Simultaneous primary malignancy of the lung and kidney has been rarely recognized during life. Three patients with synchronous primary pulmonary and renal cancer are described. The pulmonary tumors were asymptomatic and were discovered on plain chest roentgenography. The renal tumors, also asymptomatic, were incidentally discovered on CT, performed for staging. Although one patient was treated with interleukin-2 for a presumed solitary pulmonary metastasis from renal carcinoma, in all three patients, both the kidney and lung tumors were eventually removed either concurrently or sequentially. Prior autopsy case series are reviewed. In the elderly, synchronous asymptomatic pulmonary and renal malignancy is not surprising, and it should be approached as a distinct clinical problem. With the use of chest roentgenography for screening high risk populations and CT for staging, simultaneous primary pulmonary and renal malignancy will probably be recognized increasingly.
Adenocarcinoma↗
En bloc esophagectomy: the first 100 patients.
Between 1969 and 1984, 251 patients with carcinoma of the esophagus were evaluated. One hundred and eleven patients underwent en bloc esophagectomy. The technique of operation is described. Hospital mortality was 11% (12/111). Complications occurred in 49 patients. There have been no recurrences of cancer more than 3 years after operation. Absolute survival at 5 years is 55%, 29%, 15%, and 8% for W1N0, W1N1, W2N0, and W1/W2N2, respectively. En-bloc resection could be accomplished for esophageal carcinoma with an acceptable mortality and morbidity. The operation is potentially curative in a small subset of patients with unfavorable prognostic factors.
Adult↗
Pathophysiology of gastroesophageal reflux.
The factors controlling competence of the gastroesophageal junction have been carefully analyzed over the last decade. Although the presence of an anatomic sphincter guarding the lower esophagus has not been confirmed in humans, a manometrically defined high-pressure zone is present in the lower esophagus. The magnitude of sphincter pressure correlates well with the incidence of pathologic gastroesophageal reflux. Another important determinant of cardial competence is the length of intra-abdominal esophagus. The interaction of length and pressure in maintaining competence is demonstrated by several clinical and experimental studies. Twenty percent of refluxors have normal components of cardial competence. Several physical factors, namely components of Laplace's law, may govern control of reflux especially after antireflux repairs. The occurrence of esophagitis as a complication of gastroesophageal reflux is determined by the ability of the esophageal body to rid itself of an acid load as well as by factors that delay gastric emptying.
Animals↗
Epidemiology and molecular biology of Barrett's adenocarcinoma.
In the United States, the incidence of esophageal adenocarcinoma has risen faster than any other malignancy in recent years, and now represents the most common histologic type of esophageal cancer observed in major institutions. The precise etiology of this malignancy, and the epidermiologic variables responsible for its dramatically rising incidence, remains obscure. Elucidation of the molecular biology of malignant transformation in Barrett's esophagus may improve the management of patients with advanced esophageal adenocarcinomas. Furthermore, appreciation of the molecular events associated with esophageal adenocarcinomas. Furthermore, appreciation of the molecular events associated with esophageal adenocarcinogenesis may facilitate early detection of occult carcinomas, and enable therapeutic interventions designed to prevent these otherwise highly lethal neoplasms.
Adenocarcinoma↗
Squamous cell carcinoma of the esophagus: therapeutic dilemma.
Seventy-five patients with squamous cell carcinoma of the esophagus were evaluated over a 5-year period. Most of the patients had advanced-stage cancer when first seen. Only 50% were surgically explored, and 33% underwent resection. Operative mortality was 8%. Despite the immediate and durable palliation provided by surgical resection, survival rates were poor. Early diagnosis and aggressive surgical resection are the main hopes for improved long-term results.
Adult↗
CT-guided transthoracic needle biopsy of small solitary pulmonary nodules.
The use of CT guidance in performing transthoracic needle biopsy is well established. We evaluated its accuracy in the diagnosis of small solitary nodules and found it to be highly accurate regardless of size or location. While specific benign diagnoses were uncommon, additional confidence in a benign diagnosis can be gained by careful analysis of needle tip location using strict CT criteria.
Biopsy, Needle↗