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Abstracts
ENDOSCOPY AROUND THE WORLDEditor for Abstracts, Charles J. Lightdale, MD
Endoscopic evaluation of dysphagia in twohundred and nir-ety-three patients with benigndisease
WEBB WA JONES LSurg Gynecol Obstet 158:152-156, 1984
The authors report their results using barium radiog-
THE EDITOR
The risk of gastric carcinoma after surgicaltreatment for benign ulcer disease. Apopulation-based study in Olmsted County,Minnesota
SCHAFER LW, LARSON DE, MELTON LJ III, HIGGINS
JA, ILSTRUP DM
N Engl J Med 309:1210-1213, 1983To determine the long-term risk of gastric cancer inbenign peptic ulcer disease, the authors studied 338residents of Olmsted County, Minnesota, who had
GASTROINTESTINAL ENDOSCOPY
raphy, endoscopy, and peroral esophageal dilationwith bougies in 293 patients with benign, nonemergentesophageal disease, who presented to a surgical clinicin Alabama. Patients with malignant lesions of theesophagus and cardia of the stomach, foreign bodies,and cricopharyngeal diverticula were deleted from thestudy. Detailed experience with these patients showedthe most common cause of dysphagia to be pepticstricture, accounting for 65.5% of patients. The otherdiagnoses in descending order of frequency were postoperative stricture in 6.1 %, esophageal web in 4.8%,Schatzki's ring in 3.8%, achalasia in 3.4%, cricopharyngeal dysfunction in 3.0%, esophagitis in 2.4%, extrinsic compression in 1.4%, and caustic stricture in0.3%. In 9.2% of patients, no cause for dysphagiacould be determined. The authors concluded that truedysphagia (occurring within 10 seconds of swallowing)should always be investigated through a careful history, physical examination, barium study, and endoscopy, with manometry reserved for those not diagnosed by these initial studies.
This is an interesting experience, verifying the utility offiberoptic endoscopy in the evaluation of dysphagia. Theauthors employ the excellent ckIssification of dysphagia usedby Boyce. Abnormalities are divided into those of transfer(e.g., myasthenia gravis), transit (e.g., achaUIsia), and obstruction (e.g., stricture). They prefer barium studies prior toendoscopy to know whether a high stricture or diverticulumis present that would increase the risk of endoscopy, and alsoto evaluate gastric and duodenal emptying. I think mostendoscopists would feel more comfortable with a prior bariumstudy in patients with dysphagia, and a case for doing cinestudies initially in these patients can be made. This mighthelp decrease the 9.2% of undiagnosed cases that probablyhave early or subtle motility abnormalities. The authors'experience with esophageal webs was fascinating, accountingfor a much higher percentage of cases (4.8%) than I wouldhave expected and accounting for their only complication. Theuse of endoscopic balloon dilation in tight strictures and webswill see increasing use for immediate treatment and may addsome safety. Finally, in taking a history for solid food dysphagia, I have always asked about meat and rye bread orFrench bread. At the authors' suggestion, I will remember tospecifically ask about corn bread when I see a patient fromAlabama and environs.
Panel of Reviewers
Jeffrey L. PonskyPaul RozenRobert A. SanowskiFrancis J. TedescoAsgeir TheodorsGary WeissmanChristopher B. Williams
Peter B. CoUonDavid B. FalkensteinHarald HenningRichard H. HuntSeibi KobayashiH. Juergen Nord
REFERENCES1. Lee SM, Mosenthal WT, Weismann RE. Tumorous heterotopic
gastric mucosa in the small intestine. Arch Surg 1970;100:61992.
2. Doberneck RC, Deane WM, Antoine JE. Ectopic gastric mucosain the ileum: a cause of intussusception. J Ped Surg 1976;11:99100.
3. Briggs FL, Moore JP. Heterotopic gastric mucosa of the smallbowel with perforated ulcer. Am Surg 1979;45:413-7.
4. Blundell CR, Kanun CS, Earnest DL. Biliary obstruction byheterotopic gastric mucosa at the ampulla of Vater. Am JGastroenteroI1982;77:111.
According to Lee et al.,t as of 1970, only 16 cases ofectopic gastric mucosa had been reported, and most of thesehad been in the jejunum. Four cases were identified atnecropsy. Ten cases had symptoms of intermittent obstruction hypothesized to be secondary to intermittent intussusception related to the ectopic gastric mucosa.
Since 1970, several more cases have appeared. Dobernecket al.2 reported a case in which an 8-year-old boy presentedwith an ileocolic intussusception. The leading edge was a 2cm area of ectopic gastric mucosa. Briggs and Moore3 reported a 15-year-old boy who had perforated an ileal ulcerwhich had formed secondary to gastric secretions from a 17mm focus of gastric mucosa in the ileum. Recently, Blundellet al.' reported an 83-year-old man with obstructive jaundicesecondary to biliary obstruction at the ampulla of Vaterfrom heterotopic gastric mucosa.
Our two cases each presented with symptoms suggestiveof peptic ulcer disease and a mass in the duodenum. Ectopicgastric mucosa unassociated with other anomalies is rare.
Charles A. Jungreis, MDMatthew McKinley, MD
North Shore University Hospital
Manhasset, New York
surgical treatment for benign peptic ulcer disease inthe 25-year period of 1935-1959 and had no evidenceof gastric cancer for 5 years after that surgery. Thepatients were subsequently followed for over 5635person-years of observation. The risk of developmentof a gastric cancer in this group was compared withthat expected on the basis of gastric cancer incidencerates for the local population. Carcinomas in the gastric remnant developed in only two of these patients,as compared with an expected 2.6 primary gastriccarcinomas (relative risk, 0.8; 95% confidence interval,0.1 to 2.7). The authors conclude that there is noindication for endoscopic surveillance in asymptomatic patients with previous gastric surgery for benignpeptic ulcer disease.
This report is supported by another survey from Denmark(Br J Surg 1983; 70: 552-554) where 1000 patients werefollowed after Billroth II surgery for duodenal ulcer. In thisstudy, only after 15 years was the gastric cancer risk slightlyincreased over expected. The overall follow-up was imperfect,however, and the European gastric cancer incidence in general is higher than that in the United States. Many clinicianscontinue to encounter patients with gastric cancer developingin a Billroth II pouch. In addition, there is laboratory datashowing gastric cancer developing in mice at a much higherincidence after Billroth II type surgery (Hepato-Gastroenterol1981;28:34-37). In another recent report (Gastrointest Endosc 1984;30:71-73) an emphasis was placed on identifyingsubgroups with premalignant mucosal changes such as intestinal metaplasia, dysplasia, and frank adenomas. Followingthese patients endoscopically would offer some hope of detecting a gastric cancer at an early resectable stage. A recommendation to screen patients initially at 10 to 15 years afterpartial gastric resection with endoscopy, multiple biopsies,and cytology seems reasonable at our current level of knowledge. Subsequent examinations at 5-year intervals wouldseem prudent, with annual or biannual studies in thoseidentified as having premalignant changes. Other subgroupsat risk may emerge from such studies to better define surveillance recommendations (Surg Gynecol Obstet 1983;157:431433). The most comforting thought for me is that, while thereare probably thousands ofpatients currently at some increasedrisk, the incidence of gastric resection for peptic ulcer diseaseseems to be markedly decreasing, no doubt due at least in partto the development and widespread use of HTblockers.
THE EDITOR
Patterns of recurrence of rectal cancer afterpotentially curative surgery
RICH T, GUNDERSON LL, LEW R, GALDIBINI JJ,COHEN AM, DONALDSON G
Cancer 52:1317-1329,1983The results of surgical treatment alone for 142 casesof carcinoma of the rectum and rectosigmoid from theMassachusetts General Hospital were reviewed. Theincidence of local failure as any component of failurewas found to be strongly dependent on the pathologicstage, and for Dukes' A it was 8.0% (three of 39);
VOLUME 3D, NO.5, 1984
Dukes' B, 31 % (18 of 59); and Dukes' C, 50% (22 of44). The incidence of local failure for tumors withoutlymph node metastases was 17% with only microscopic extension through the wall (modified AstlerColler Stage MAC-B3). Similarly, in tumors with positive lymph nodes, there was a 36% incidence of localfailur~ for tumors confined to the wall or with onlymicrosc<?pic extension through the wall (MAC-C11C2m), compared to a 67% incidence for tumors withadherence or involvement of adjacent organs (MACC3). Other predictors of local recurrence were thetumor location, grade, number of lymph nodes, andblood vessel invasion. Five-year survival for Dukes' Awas 77% (30 of 39); Dukes' B, 44% (26 of 59); andDukes' C, 23% (10 of 44).
Cancer of the colon and rectum is the second most commoncause of cancer-related death in both sexes in the UnitedStates. Secondary prevention by the early detection of asymptomatic early malignancy and the removal of adenomatouspolyps may improve survival. In the meantime, radiation andchemotherapy are used in the attempt to improve postresection survival. This paper aims at identifying the patients atrisk for local recurrence, and also the sites. Local recurrenceoccurred in 24 patients and also in a further 19 patientshaving both local and distant failure. Only six asymptomaticpatients were found to have an abnormality on routine sigmoidoscopic or x-ray examination. Only three patients had asuture line recurrence. Local control declined significantly asthe depth of penetration into and beyond the bowel wallincreased. The results of this study clearly point out thelimitations of endoscopic postoperative follow-up of rectalcancer.
PAUL ROZEN, MDTel-Aviv, Israel
Book Reviews
Gastrointestinal Endoscopy. Technique andInterpretation
by Angelo E. DagradiIgaku-Shoin, New York, 1983,234 pp., $45.00
There is nothing more valuable to the student ofendoscopy than the experience a master of techniquescan relate, and so it is with this author and hisnarrative. One must be impressed with the practicalnature of the author's effort for readers of this smallvolume. He concisely chronicles the evolution of endoscopy from Schindler to the modern fiberoptic instruments and in nine additional chapters covers thebasics of diagnostic and therapeutic endoscopy.
There are excellent descriptions of the techniquesof upper endoscopy, ERCP, and colonoscopy includingthose caveats regarding indications, contraindications,
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