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PubMed2001

A prospective evaluation of dietary status and symptoms after near-total esophagectomy without gastric emptying procedure.

BACKGROUND: After esophagectomy, the stomach is the most commonly utilized reconstructive conduit. There remains debate among surgeons regarding the requirements for pyloroplasty/pyloromyotomy following reconstruction. We present a series of patients having undergone near total esophagectomy and reconstruction with gastric tube without gastric emptying procedure to analyze critically these patients' ability to reestablish a subjectively acceptable and nutritionally adequate eating pattern without significant side effects of early satiety, dumping, or diarrhea. METHODS: Between 1991 and 1998, 48 patients underwent esophagectomy utilizing this technique and were available for long-term follow-up and nutritional assessment. Patient weights were recorded at 2 weeks, 6 months, and 1 year and a telephone interview conducted at a mean of 36 months postoperatively for the evaluation of eating patterns and symptoms. A subgroup of these patients (32 of 48) completed a 3-day dietary record that was assessed by a certified nutritionist. This patient group included 10 patients (21%) who had received perioperative chemoradiotherapy. RESULTS: Dietary intake was characterized as normal or minimally limited in 41 patients (85%). Those who had received perioperative chemoradiotherapy needed no significant increased time to return to a normal dietary baseline (6.1 versus 5.9 months). Mean weight loss prior to surgery was 3 kg. Weight loss continued for the first 6 months (mean 10 kg); however, 63% were able to gain weight from 6 months to 1 year following surgery (mean 3 kg). Most patients were overweight prior to operation (mean 115% of ideal body weight) and achieved a new postoperative baseline (mean 104% of ideal body weight) at 1 year. Patients demonstrated a mean daily caloric intake of 2,179 kilocalories per day, which was 98% of recommended according to their ideal body weight. Postoperative symptoms of short-term nausea (19%), occasional dysphagia with certain foods (38%), mild increased stool frequency (15%), and occasional regurgitation (25%) were noted. CONCLUSIONS: Near-total esophagectomy with verticalized gastric tube without a gastric emptying procedure is well tolerated and allows a return to subjectively acceptable and nutritionally appropriate dietary eating pattern without significant associated side effects.

Adult↗

PubMed2001

Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy.

BACKGROUND: Benign tracheo-neo-esophageal fistulas after esophagectomy are rare and treatment can be challenging. They can result from perioperative tracheal injury or various postoperative complications. METHODS: Charts of 6 patients with a benign tracheoneo-esophageal fistula after subtotal esophagectomy treated in this institution between July 1993 and August 1999 were analyzed. RESULTS: Three men and 3 women (median age 61 years) developed a fistula after subtotal esophagectomy. Symptoms varied from mild swallowing difficulties to aspiration pneumonia and mediastinitis. Two patients with mild symptoms were treated conservatively. In 1 patient a long fistula was partly excised through the neck. In 3 patients the gastric tube was excluded or excised, with surgical closure of the tracheal defect. The alimentary tract was reconstructed by colonic interposition. There were no major complications. After a median follow-up of 1.6 years, all fistulas were closed. All patients were capable of sufficient oral intake. CONCLUSIONS: A benign tracheo-neo-esophageal fistula after esophagectomy is a rare, but serious complication. Site and size of the fistula, together with the severity of symptoms, should dictate management.

Aged↗

PubMed2001

Impact of hospital volume on clinical and economic outcomes for esophagectomy.

BACKGROUND: Several complex surgical procedures had a reduction in mortality when they were performed at high volume centers. We hypothesized esophagectomy procedures for cancer performed at high volume hospitals in the state of Massachusetts would show a similar relationship. METHODS: Data were obtained from the Massachusetts Health Data Consortium on discharge information for all acute care hospitals in Massachusetts regardless of payer from 1992 to 2000. The influence of hospital volume was related to days in the intensive care unit, length of stay, discharge disposition, hospital mortality, and total cost. Hospitals were stratified to low volume hospitals (< 6 cases per year) and high volume hospitals (> 6 cases per year). RESULTS: One thousand one hundred ninety-three patients underwent esophagectomy during this 8-year study period in Massachusetts. Three high volume hospitals performed 56.5% of all resections (674 of 1,193). Sixty-one low volume hospitals performed 43.5% of the resections (519 of 1,193) with an average volume of only 1 case of esophagectomy per year. High volume hospitals were associated with a 2-day decrease in median length of stay (p < 0.001), a 3-day reduction in median intensive care unit stay (p < 0.001), an increased rate of home discharges (as opposed to rehabilitation hospitals) (p < 0.001), and a 3.7-fold decrease in hospital mortality (9.2% vs 2.5%; p < 0.001). The odds ratio of death at a low volume hospital was 4.3 (95% confidence interval, 2.3 to 7.7; p < 0.001). The median cost was $755 dollars greater at high volume hospitals (p = not significant). CONCLUSIONS: Hospitals that perform a high volume of esophagectomies have better results with early clinical outcomes and marked reductions in mortality compared with low volume hospitals.

Aged↗

PubMed2001

Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma.

BACKGROUND: Several techniques for esophageal resection have been reported. This study examines the morbidity, mortality, and early survival of patients after transthoracic esophagectomy for esophageal carcinoma using current staging techniques and neoadjuvant therapy. The technique includes right thoracotomy, laparotomy, and cervical esophagogastrostomy (total thoracic esophagectomy) with radical mediastinal and abdominal lymph node dissection. METHODS: Three hundred forty-two patients had surgery for esophageal carcinoma between 1989 and 2000 at our institution. Two hundred fifty consecutive patients had esophagectomy using this technique. Kaplan-Meier curves and univariate and multivariate analyses were performed by postsurgical pathologic stage. RESULTS: Median age was 62.7 years (31 to 86 years). Fifty-nine were female. Eighty-one percent (202) had induction chemotherapy (all patients with clinical T3/4 or N1). Early postoperative complications included recurrent laryngeal nerve injury (14% [35]), chylothorax (9%, [22]), and leak (8%, [19]). Median length of stay was 13 days (5 to 330 days). In-hospital or 30-day mortality was 3.6% (9). Overall survival at 3 years was 44%; median survival was 25 months, and 3-year survival by posttreatment pathologic stage was: stage 0 (complete response) (n = 60), 56%; stage I (n = 32), 65%; stage IIA (n = 67), 41%; stage IIB (n = 30), 46%; and stage III (n = 49), 17%. Mean follow-up was 24 months (SEM 1.6, 0 to 138 months). Five patients with tumor in situ, 6 patients with stage IV disease, and 1 patient who could not be staged (12 pts) were excluded from survival and multivariate calculations. In univariate and different models of multivariate analysis, age more than 65 years, posttreatment T3, and nodal involvement were predictive of poor survival. For univariate analysis, p = 0.002, p = 0.004, p = 0.02, respectively; for multivariate analysis, p = 0.001, p = 0.003, p = 0.02, respectively. CONCLUSIONS: Total thoracic esophagectomy with node dissection for esophageal cancer appears to have acceptable morbidity and mortality with encouraging survival results in the setting of neoadjuvant therapy. Patients who show complete response after induction chemoradiotherapy appear to have improved long-term survival.

Abdomen↗

PubMed2002

Pulmonary complications after esophagectomy.

BACKGROUND: Pulmonary complications are common in patients who have undergone esophagectomy. There are no good predictive variables for these complications. In addition, the role that preoperative treatment with chemotherapy and radiation may play in postoperative complications remains unclear. METHODS: We performed a retrospective review of all patients who underwent esophagectomy by a single surgeon at our institution over a 6-year period. Data were analyzed for a correlation between patient risk factors and pulmonary complications, including mortality, prolonged mechanical ventilation, and hospital length of stay. RESULTS: Complete data were available on 61 patients. Nearly all patients had some pulmonary abnormality (eg, pleural effusion), although most of these were clinically insignificant. Pneumonia was the most common clinically important complication, and 19.7% of patients required prolonged ventilatory support. Significant risk factors identified included impaired pulmonary function, especially for patients with forced expiratory volume in 1 second (FEV1) less than 65% of predicted, preoperative chemoradiotherapy, and age. CONCLUSIONS: Impaired lung function is a significant risk factor for pulmonary complications after esophagectomy. Patients with FEV1 less than 65% of predicted appear to be at greatest risk. There also seems to be an associated risk of preoperative chemoradiotherapy for pulmonary complications after esophagectomy.

Adenocarcinoma↗

PubMed2003

Outcomes after esophagectomy: a ten-year prospective cohort.

BACKGROUND: The Department of Veterans Affairs National Surgical Quality Improvement Program is a unique resource to prospectively analyze surgical outcomes from a cross-section of surgical services nationally. We used this database to assess risk factors for morbidity and mortality after esophagectomy in Veterans Affairs Medical Centers from 1991 to 2001. METHODS: A total of 1,777 patients underwent an esophagectomy at 109 Veterans Affairs hospitals with complete in-hospital and 30-day outcomes recorded. Bivariate and multivariable analyses were completed. RESULTS: Thirty-day mortality was 9.8% (174/1,777) and the incidence of one or more of 20 predefined complications was 49.5% (880/1,777). The most frequent postoperative complications were pneumonia in 21% (380/1,777), respiratory failure in 16% (288/1,777), and ventilator support more than 48 hours in 22% (387/1,777). Preoperative predictors of mortality based on multivariable analysis included neoadjuvant therapy, blood urea nitrogen level of more than 40 mg/dL, alkaline phosphatase level of more than 125 U/L, diabetes mellitus, alcohol abuse, decreased functional status, ascites, and increasing age. Preoperative factors impacting morbidity were increasing age, dyspnea, diabetes mellitus, chronic obstructive pulmonary disease, alkaline phosphatase level of more than 125 U/L, lower serum albumin concentration, increased complexity score, and decreased functional status. Intraoperative risk factors for mortality included the need for transfusion; intraoperative risk factors for morbidity included the need for transfusion and longer operative time. CONCLUSIONS: These data constitute the largest prospective outcomes cohort in the literature and document a near 50% morbidity rate and 10% mortality rate after esophagectomy. Data from this study can be used to better stratify patients before esophagectomy.

Age Factors↗

PubMed1997

One-stage esophagectomy and in situ colon interposition for esophageal replacement in children.

PURPOSE: Esophageal replacement has been achieved using stomach, gastric tube, small intestine, and colon in various positions and in single or multiple stages. Long-term functional results are of prime importance in children with benign disease. The aim of this study is to present the immediate and long-term results of one-stage esophagectomy and in situ colon interposition esophageal replacement in children. METHODS: Seven children have undergone one-stage esophagectomy and in situ colon interposition esophageal replacement for stricture secondary to caustic ingestion (n = 4), battery ingestion (n = 2), and epidermolysis bullosa (n = 1). TECHNIQUE: Via thoracoabdominal and cervical incisions, the transverse colon, isolated on the left colic artery, is pulled through the esophageal hiatus and normal esophageal bed into the neck at the time of simultaneous esophagectomy. The stomach is partially wrapped around the colon as an antireflux procedure and a pyloroplasty are performed. RESULTS: There was no immediate postoperative morbidity or mortality. All patients were discharged taking a soft diet by mouth. There were no anastomotic leaks or strictures, and functional swallowing is excellent. Contrast studies show no dilation of the colon in the chest. Growth and development have been normal up to 7 years postoperatively. CONCLUSION: The one-stage esophagectomy and in situ colon interposition is an excellent technique for esophageal replacement in children. Continued evaluation of this technique will be necessary to confirm these preliminary results.

Child, Preschool↗

PubMed1999

Esophagectomy with gastric reconstruction for achalasia.

PURPOSE: Achalasia is a degenerative esophageal disorder that may result in esophageal failure necessitating resection for restoration of gastrointestinal function. This study evaluates a protocol of esophageal resection and gastric reconstruction for end-stage achalasia. METHODS: Hospital records, radiographic studies, and resection specimens of patients undergoing esophagectomy and gastric reconstruction were reviewed. Patient outcome was defined by an evaluation of symptoms (early satiety, dysphagia, regurgitation, and reflux), dietary restrictions, and ability to maintain or gain weight. Preoperative, operative, and postoperative variables and pathologic features in the resection specimens were analyzed to determine predictors of outcome. RESULTS: In a 10-year period, 32 patients underwent esophagectomy with gastric reconstruction for achalasia; 30 (94%) underwent elective surgery and 2 (6%), emergency surgery. No postoperative deaths occurred. Of 29 patients completing telephone interviews, 24 (83%) had no or mild dysphagia; 21 (72%), no or mild regurgitation; 20 (69%), no or mild reflux; and 19 (66%), no or mild early satiety. Twenty-four (83%) patients had no or minimal dietary restrictions; 26 (90%) had no or minimal social dietary restrictions. Postoperative weight was not different from preoperative weight. Of 30 patients, 26 (87%) felt better after esophagectomy and 25 (83%) would have the operation again. There were few predictors of outcome. Younger patients were more likely to have dysphagia ( P =.03). CONCLUSIONS: Esophagectomy with gastric reconstruction relieves preoperative dysphasia and regurgitation in the majority of patients. Dietary function and weight maintenance are excellent, attesting to the durability of the procedure in patients with end-stage achalasia.

Adult↗

PubMed1997

Serial changes in contribution of substrates to energy expenditure after transthoracic esophagectomy for cancer.

This study was designed to examine the metabolic response of patients following transthoracic esophagectomy for carcinoma of the esophagus during the administration of total parenteral nutrition. Thirty-five patients underwent a right thoracotomy and transthoracic esophagectomy with nodal dissection in the neck, mediastinum, and abdomen. The resting energy expenditure (REE) was measured preoperatively, and on the 1st, 3rd, 5th, and 7th postoperative days (PODs) using indirect calorimetry. The REE was significantly higher following transthoracic esophagectomy on PODs 1, 3, 5, and 7 than preoperatively. The caloric contribution of fat was significantly less on 3rd, 5th, and 7th PODs than on the 1st POD. In contrast, carbohydrate oxidation increased significantly on the 3rd, 5th, and 7th PODs compared to that of the 1st POD. These results may help optimize the nutritional support regimen for post-esophagectomy patients.

Adult↗

PubMed2002

Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma.

STUDY OBJECTIVE: To investigate whether intraoperative fluid management contributes to postoperative respiratory disturbances in esophagectomy for carcinoma. DESIGN: Retrospective study. SETTING: Operating room and postanesthetic care unit of the cancer center. PATIENTS: From 1997 to 2000, 112 ASA physical status I, II, and III patients with primary carcinoma of the esophagus undergoing transthoracic esophagectomy. INTERVENTIONS AND MEASUREMENTS: As of 1998, we altered fluid management during esophagectomy to save intraoperative fluid administration. Then, we investigated postoperative respiratory disturbances after esophagectomy in the period from 1998 to 2000 (late period) compared with the period from 1997 to 1998 (early period). We also investigated the relationship between perioperative risk factors and postoperative respiratory disturbances. The need for frequent (>10) bronchoscopic suctioning of sputum during postoperative period, the need for tracheostomy, and failure in the removal of endotracheal tube (ETT) (extubation) on the first postoperative day (1 POD) were investigated for respiratory disturbances after surgery. MAIN RESULTS: Intraoperative volume balance decreased more so in the late period compared with early period (p < 0.0,001). The need for tracheostomy, bronchoscopic suctioning, and extubation failure on 1 POD were more frequent in the early period than in the late period (p = 0.0083, p = 0.0319, and p = 0.0024, respectively). The hospital recovery period after surgery was shortened during the late period (p = 0.032). Intraoperative volume balance affected the need for tracheostomy and frequent bronchoscopy postoperatively. CONCLUSIONS: Careful intraoperative fluid administration may decrease postoperative respiratory disturbances.

Adult↗

PubMed2002

Intravenous hydration versus naso-jejunal enteral feeding after esophagectomy: a randomised study.

OBJECTIVE: Patients undergoing esophagectomy are typically nutritionally depleted and cannot establish oral feeding for up to a week after surgery. We have investigated the routine use of enteral feeding via a naso-jejunal tube. METHODS: Forty consecutive patients undergoing a transthoracic esophagectomy for cancer were randomised to receive enteral feeding or intravenous crystalloid fluids after surgery. Nutritional indices were obtained prior to surgery and on the 7th post-operative day. RESULTS: There were no post-operative deaths. Non-fatal complications occurred in 10 patients, without difference in morbidity between the two groups. Lean body mass did not change in either group over the study period. No differences in any other parameters were identified between the two groups. CONCLUSION: Enteral feeding via a naso-jejunal tube is safe and well tolerated after esophagectomy. It is a simple method of providing nutritional support prior to the re-introduction of oral feeding. However it provides no measurable benefit over intravenous hydration only for patients undergoing routine esophagectomy.

Adult↗

PubMed2002

High-grade dysplasia in Barrett's esophagus. The case for esophagectomy.

The main principles for optimal management of HGD arising in Barrett's esophagus are that unequivocal diagnosis of HGD is a prerequisite for making the decision of any kind of treatment. HGD must be resected because of the presence of neoplastic cells in the lamina propria in 40% of patients. No reliable endoscopic or endosonographic feature exists that allows accurate prediction of the existence of neoplastic cells within the lamina propria of a patient having HGD in endoscopic biopsy material. Prompt decision to remove an HGD lesion as soon as unequivocal histologic diagnosis has been settled prevents the development of extraesophageal neoplastic spread. Esophagectomy is preferable to endoscopic mucosal excision because approximately 20% of patients who have HGD in preoperative biopsy material carry neoplastic cells beyond the muscularis mucosae. Esophagectomy can be limited to the removal of the esophageal tube without extended lymphadenectomy because 96% of patients who have HGD in endoscopic biopsy samples have a neoplastic process confined to the esophageal wall. Esophageal resection must encompass all the Barrett's area because of the risk for the further development of a second cancer in the metaplastic remnant. Vagus-sparing esophagectomy with colon interposition or elevation of the antrally innervated stomach up to the neck is preferable to conventional esophagectomy with gastric pull up because the former procedure maintains gastric function intact, whereas the latter exposes patients to the risk for the long-term development of reflux esophagitis and even of metaplastic transformation of the proximal esophageal remnant. Subtle details in the understanding of a given patient's clinical course may be critical for making the decision of the most relevant mode of therapy; therefore, patients who have HGD should be treated in dedicated centers, the experience of which offers the best chances of uneventful recovery if the surgical option is retained.

Barrett Esophagus↗

PubMed2002

Technique and role of minimally invasive esophagectomy for premalignant and malignant diseases of the esophagus.

Esophagectomy remains the standard of care in most centers for patients with resectable esophageal cancer. The choice of incision and conduit has remained the subject of much discussion. Open surgical approaches include the Ivor Lewis, transhiatal, left thoracoabdominal, three-hole, and left thoracoabdominal with left neck anastomosis. These techniques will be covered in the article by. Regardless of the approach, esophagectomy has been associated with considerable morbidity and mortality. Although modern anesthetic and surgical care has reduced the risks of esophagectomy, the incidence of major or minor complications is still approximately 70% to 80%, and the hospital mortality rate is 4% to 7% at experienced centers. In the hopes of reducing perioperative morbidity, minimally invasive techniques have been increasingly applied to esophageal surgery. Experience with laparoscopic antireflux surgery has allowed us to perform more and more complex surgery on the stomach and esophagus and, in 1995, surgeons began to report their experiences with minimally invasive esophagectomy using various techniques.

Esophageal Diseases↗

PubMed2001

Interleukin-6 production in lung tissue after transthoracic esophagectomy.

BACKGROUND: The mechanisms of the reported high increase in interleukin-6 (IL-6) levels after esophagectomy are unclear. We investigated the influence of an intrathoracic procedure, esophagectomy, on IL-6 production in lung tissue. STUDY DESIGN: Fourteen paired lung tissue samples were obtained from patients before and after they underwent transthoracic esophagectomy for esophageal cancer. IL-6 levels in the lung were measured with enzyme-linked immunosorbent assay, and IL-6 mRNA expression was determined with real-time quantitative reverse transcription-polymerase chain reaction. Immunohistochemical staining was used to localize IL-6, and circulating levels were also measured. RESULTS: IL-6 protein and mRNA were significantly increased in lung tissue after this intrathoracic procedure (p < 0.05). Peak levels of plasma IL-6 after surgery were correlated with IL-6 levels in lung tissues obtained after the procedure (p < 0.05). Immunohistochemical staining revealed IL-6 production from alveolar and bronchial epithelial cells but not from alveolar macrophages. CONCLUSIONS: Transthoracic esophagectomy causes an increase in IL-6 production from airway epithelial cells, secondary to increased expression of IL-6 mRNA. Local response of lung tissue may be one source of increased serum IL-6 after this procedure.

Aged↗

PubMed2005

Thoracic epidural analgesia or intravenous morphine analgesia after thoracoabdominal esophagectomy: a prospective follow-up of 201 patients.

OBJECTIVE: Thoracoabdominal esophagectomy is a major surgical procedure that carries significant postoperative morbidity and mortality. Because the choice of analgesic technique may influence outcome, the impact of thoracic epidural or intravenous analgesia was investigated after esophagectomy. DESIGN: Prospective observational study during January 1996 until January 2002. SETTING: University hospital. PARTICIPANTS: All patients undergoing thoracoabdominal esophagectomy during the 6-year period. INTERVENTIONS: Patients were prospectively monitored during a 6-year period. Duration of surgery, intraoperative blood loss, fluid administration, postoperative intubation time, intensive care unit (ICU) stay, pain relief and related side effects, postoperative complications, hospital stay, and in-hospital and long-term mortality were compared in relation with the analgesic technique. MEASUREMENTS AND MAIN RESULT: Thoracic epidural analgesia with bupivacaine/morphine was used in 166 patients, and intravenous morphine analgesia was used in 35 patients. Postoperative intubation time and ICU stay were similar in both groups. Patients with epidural analgesia experienced less pain. Sedation, respiratory depression, hallucinations, and confusion were more common in the intravenous morphine group. Postoperative weight did not differ between the groups, despite fluid replacement that was higher in the epidural group during the first 24 hours. The in-hospital mortality rate was 0.5%. CONCLUSIONS: No differences in morbidity/mortality rates depending on analgesic treatment were observed in patients undergoing thoracoabdominal esophagectomy. Thoracic epidural analgesia provided better pain relief with fewer opioid-related side effects than intravenous morphine analgesia. However, postoperative epidural analgesia was associated with more technical difficulties.

Abdomen↗

PubMed2004

Quality of life after esophagectomy.

Esophagectomy is associated with high complication rates and consequent mortality. The 5-year survival for esophageal cancer is also discouraging with rates of 6 to 33% after surgery. Nonsurgical series of selected patients have shown similar survival. Therefore, quality of life may be a better assessment of patient outcomes than survival. At present few reports have address quality of life in patients after esophagectomy, particularly in those patients who succumb quickly to recurrent cancer. This article investigates the determinants of quality of life after esophagectomy and reviews the use of quality of life measures in comparative trials. Quality of life measures may become valuable tools in the selection of patients for esophagectomy.

Esophagectomy↗

PubMed2000

Thoracoscopic and laparoscopic esophagectomy.

Esophagectomy is both complex and challenging, and it may be associated with significant morbidity and mortality. With improvements in instrumentation and increasing experience with laparoscopic and thoracoscopic techniques, minimally invasive approaches to esophagectomy are being explored to determine feasibility, results, and potential advantages. Most of this experience has been with case studies or small series, with many surgeons using thoracoscopy in combination with standard laparotomy. Many of the patients have been carefully selected for these procedures because they have small tumors or high-grade dysplasia. Our technique for esophagectomy has evolved from a laparoscopic transhiatal approach to a combined laparoscopic and thoracoscopic approach. Our experience with this procedure has increased, and now we offer this approach to the majority of patients with resectable cancers. We review our operative technique and the results of surgery in our first 50 patients who underwent minimally invasive esophagectomy for cancer or high-grade dysplasia.

Adult↗

PubMed2001

Squamous mucosal alterations in esophagectomy specimens from patients with end-stage achalasia.

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 (</=18 years) from patients with no known esophageal disease. A representative block was immunostained for p53 (DO7), CD3, and CD20. p53 immunoreactivity was graded as follows: 0 = no staining; 1+ = rare basal cell staining; 2+ = extensive basal cell staining; 3+ = suprabasilar staining. Intraepithelial lymphocyte counts were performed by counting five high power fields (HPF) and calculating an average/HPF. Ages of achalasia patients at esophagectomy ranged from 21 to 78 years (mean 56 years), including 20 men and 15 women. Disease duration ranged from 1 to 44 years (mean 17 years). In all cases the squamous mucosa from achalasia patients was markedly hyperplastic with papillomatosis and basal cell hyperplasia. p53 staining in the squamous mucosa from achalasia patients was significantly more common than in controls (32 of 35 [91%] vs 1 of 17 [6%]; p <0.05). In all achalasia cases CD3+ cells far outnumbered CD20+ cells. There was a significantly greater number of CD3+ cells in achalasia cases (range 32-239/HPF; mean 107/HPF) compared with controls (range 0.8-12/HPF; mean 6/HPF) (p <0.05). In conclusion, the squamous mucosa in esophagectomy specimens from patients with end-stage achalasia shows significant alterations including marked squamous hyperplasia, an increased frequency of p53 immunoreactivity, and increased numbers of CD3+ cells when compared with controls. These changes may be related to the increased risk of squamous cell carcinoma in these patients.

Adolescent↗