information about these unanswered questions. As clini-cians, we must continue to obtain a careful history to lookfor potential risk factors in women who are being seen forchronic anal-rectal complaints. This present study does sup-port the concern that risk factors may have occurred fartherin the past than we may have thought.
Timothy R. Koch, M.D.Division of Gastroenterology and Hepatology
Digestive Disease CenterMedical College of Wisconsin
1. Donnelly VS, OHerlihy C, Campbell DM, OConnell PR.Postpartum fecal incontinence is more common in women withirritable bowel syndrome. Dis Colon Rectum 1998;41:5859.
2. Fynes M, Donnelly VS, OConnell PR, OHerlihy C. Cesareandelivery and anal sphincter injury. Obstet Gynecol 1998;92:496500.
3. Corby H, Donnelly VS, OHerlihy C, OConnell PR. Anal canalpressures are low in women with postpartum anal fissure. Br JSurg 1997;84:868.
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Literature Around the WorldHeitmiller RF., et al.Prophylactic Esophagectomy in Barretts Esophagus With High-grade DysplasiaLangenbecks Arch Surg 2003;388:837.
ABSTRACTThis is an interesting review of the experience of thesurgical group at Johns Hopkins University with esoph-agectomy for patients with Barretts esophagus with highgrade dysplasia. There were a total of 60 patients reportedin this review who underwent resection between 1982 and2001. All of these patients did not have endoscopicallyidentifiable cancer. The article reviewed the surgical prin-cipals for treatment of high grade dysplasia, which in-cluded the need for histological review of the high gradedysplasia before embarking on any therapy. The authorsfavored using trans-hiatal esophagectomy because it ac-cessed N1 lymph nodes and guaranteed the ability of thesurgeon to achieve a comfortable margin of squamous
mucosa above the columnar Barretts epithelium, and thecervical anastomosis decreased the chance of possibleleaks. The study reported that this approach was taken in82% of their patients. The author compared their expe-rience with Barretts esophagus between 1982 and 1994with 30 patients with their experience from 1994 to 2001in another 30 patients. The patients had similar gender,ethnicity, and ages. Interestingly, the mortality rate in thefirst 30 patients was 3.3%, but in the most recent periodno patients died from the operation. Some of this im-provement in mortality seemed to be due to the initiationof a step-wise approach to managing these patients. An-other finding was that the incidence of endoscopicallyoccult cancers decreased from 43% in the earlier periodto 16.7% in the most recently treated groups. The studyconcluded that surgical therapy was an option in the manage-ment of Barretts esophagus, but that recent studies had dem-onstrated that the risk of cancer progression may have beenoverestimated and that endoscopic surveillance should also beconsidered. (Am J Gastroenterol 2003;98:27992800. 2003 by Am. Coll. of Gastroenterology)
The importance of this study for gastroenterologists is thatit helps to place into perspective the role of surgery forBarretts esophagus with high grade dysplasia. Althoughmortality rates of 520% are often quoted for esophagec-tomy, these reports include large numbers of patients withknown adenocarcinoma that are invasive and can be difficultto resect because of transmural invasion and adhesion toadjacent structures. In addition, the patients with knowncarcinoma generally have dysphagia at presentation withconcomitant malnutrition. These surgeons are able to dem-onstrate that esophagectomy can be performed with verylow mortality rates in patients with Barretts esophagus.However, complications occurred in more than one quarterof the patients across the 2-decade experience. Although theauthors did not elaborate on the type of complications in thisreport, others have found that these complications can bequite severe and include anastomotic leaks, anastomoticstrictures, aspiration, formation of empyema, lymphangio-mas, and pleural effusions. It is clear that the operation isstill a major procedure, as the authors postoperative ap-proach involves intensive care unit observation for all pa-tients, overnight endotracheal intubation, a feeding jejunos-tomy, and the implementation of a special postesophagectomy diet (generally liquids only). Their resultsactually help to promote the argument that endoscopic ther-apies are a more viable option because the number of occultadenocarcinomas found in the resected specimens was de-creased by almost 50% in the more recent time period. Thismay be due to the initiation of more standardized protocolsfor surveillance biopsies in Barretts esophagus with highgrade dysplasia or to the development of better endoscopic
2799AJG December, 2003 World Literature Review