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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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