Esophagus resection

A 63-year-old hjrpertensive woman, who had a carcinoma of the distal esophagus resected 19 months earlier, developed chronic diarrhea. Clostridium difficile toxin was identified in her stools and the diarrhea resolved after treatment with metronidazole. Enalapril was added to her antihypertensive treatment, and 3 months later the diarrhea recurred. Stool examination was negative and there was no Clostridium difficile toxin. Her condition worsened and she lost 5 kg in weight She had marked eosinophiha (2.4 x 10 /1), and a small bowel biopsy showed mild chronic inflammation and edema, partial villous atrophy, and large clusters of eosinophils in the lamina propria with some focal infiltration of the epithelium. She stopped taking enalapril and her diarrhea promptly abated and the eosinophil count fell to 0.5 X 10 /1 at 3 weeks and 0.1 x 10 /1 at 2 months. 

Although the primary treatment for cancers of the esophagus for many years had been surgical resection, the optimal surgery remains controversial. One approach uses transhiatal esophagectomy with anastamosis of the stomach to the cervical esophagus,... 

Clark PI, Medical Research Council. Randomized Trial of Surgery with or without Pre-Operative Chemotherapy in Resectable Cancer of the Esophagus. Ann Oncol 2000 11 4. 

Stewart JR, Hoff SJ, Johnson DH, et al. Improved survival with neoadjuvant therapy and resection for adenocarcinoma of the esophagus. Ann Surg 1993 218(4) 571—576. 

Esophageal adenocarcinomas do not appear to be as responsive [171]. Ajani et al. [172] have studies neoadjuvant EAP (VP-16, doxorubicin, and cisplatin) for patients with adenocarcinomas of the distal esophagus and gastroesophageal junction and observed a 42% response rate 78% of treated patients underwent curative resection and overall median survival was 23 months. 

Radiotherapy alone (without chemotherapy or surgery) is the treatment of choice for stage I and II patients who refuse surgery or who are considered high surgical risks because of concomitant illness or restrictive pulmonary reserve. It is also used when the tumor is unresectable because of fixation to a major blood vessel, the trachea, or the esophagus. Of those patients, the 2- and 5-year survival rates appear to be highest for patients whose tumors would otherwise be considered resectable. 

Osugi H, Takemura M, Morimura K, et al. Clinicopathologic and immunohistochemical features of surgically resected small cell carcinoma of the esophagus. Oncol Rep. 2002 9 1245-1249. 

Figure 9. Balloon applicators for light distribution in hollow cavities (a) brain tumor cavity irradiation post-resection, (b) with centered diffusing fiber for treatment of the esophagus the balloon is collapsed for passage through the endoscope instrument channel (courtesy Drs M. Panjepour and G. Overholt, Knoxville, USA).

Figure 16. Detection of photosensitizer fluorescence in vivo, (a) fluorescence spectrum of ALA-PpIX fluorescence at different points in the esophagus within Barrett s (BE) and normal squamous epithelium (SE) at 3 h after 10 mg kg ALA orally (courtesy Dr N. Marcon, Toronto, Canada), (b) fluorescence camera imaging the photosensitizer distribution in tissue during brain tumor PDT, (c) fluorescence in the resection bed at the end of radical brain tumor resection at 24 h after 2 mg kg" Photofrin (courtesy Dr P. Muller, Toronto, Canada).

Ell, C. et al.. Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett s esophagus. Gastroenterology, 118, 670-677, 2000. 

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