Gastroesophageal reflux disease (GERD) is a chronic disease deteriorating patient's quality of life. With the advent of proton pump inhibitors, treatment failures have decreased considerably. However, surgical therapy offers the potential for cure in more than 90% of patients with GERD. Specific indications for antireflux surgery are: incomplete response to medical therapy, frequent recurrences despite the medical treatment, laryngopharyngeal, and/or respiratory symptoms, and complications of GERD, such as esophageal stricture, erosive esophagitis, esophageal ulcer, and/or Barrett's esophagus. The introduction of laparoscopic surgery in early ninties had a profound impact on many surgical fields, including the treatment of GERD. In this review, laparoscopic Nissen fundoplication is described and controversial topics, such as total vs. partial fundoplication, and the natural history of Barrett's esophagus after antireflux surgery are addressed.
Barrett Esophagus/surgery ; Fundoplication/methods ; Gastroesophageal Reflux/*surgery ; Humans ; Laparoscopy/methods ; Surgical Procedures, Minimally Invasive/methods

OBJECTIVETo establish animal models of reflux esophagitis in rats.

METHODSSeventy male Sprague Dawley rats aged 8 weeks were randomly divided into 4 groups: in Group A (n=20) esophagojejunostomy was performed to induce a gastro-jejuno-esophageal reflux; in Group B (n=20) esophagoduodenostomy was performed to induce a gastro-duodeno-esophageal reflux; in Group C (n=20) total gastrectomy plus esophagojejunostomy was performed to induce a jejuno-esophageal reflux; in Group D (n=10) only was performed sham operation (control).

RESULTAmong 70 rats, 6 died in Group A, 7 died in Group B, 6 died in Group C, and 72.9 %(51/70) animals were completed in the study. After 12 weeks the incidence of esophageal inflammation was 100.0%; in Groups A, B and C erosion occurred in 11/14 (78.6%), 10/13 (76.9%), 3/14 (21.4%) of animals, respectively; squamous dysplasia was in 10/14 (71.4%), 10/13 (76.9%), 5/14 (35.7%) of rats, respectively; Barrett's esophagus was in 6/14 (42.9%), 5/13 (38.5%), 1/14 (7.1%), respectively. One esophageal adenocarcinoma was found in Group A; no histological changes were observed in Group D.

CONCLUSIONThe animal models of reflux esophagitis can be induced by esophagojejunostomy, esophagoduodenostomy or total gastrectomy plus esophago-jejunostomy in rats; and the former two surgical modalities are better than the later.

Animals ; Barrett Esophagus ; Disease Models, Animal ; Esophagitis, Peptic ; classification ; Esophagus ; surgery ; Male ; Random Allocation ; Rats ; Rats, Sprague-Dawley

BACKGROUND/AIMS: The aim of this study was to evaluate clinicopathologic differences between Type II and Type III groups that were classified by Siewert in cardia cancer. METHODS: A hundred forty-one patients who were diagnosed as gastric cardia cancer and underwent surgery between January 1990 and December 2006 by single surgeon at Department of Surgery, Yonsei University College of Medicine were included in this study. The Kaplan-Meier method and log rank test were used for survival analysis. RESULTS: Barrett's adenocarcinoma was recognized in two patients so called type I. There were significant differences between type II and III in aspect of depth of invasion, Lauren's classification, and the number of retrieved lymph nodes in which cancer infiltrated. In type III, prognostic factors affecting survival were depth of invasion and nodal status in contrast to the no demonstrable prognostic factors existing in type II. However, there were no differences in recurrence and survival between two groups. CONCULSIONS: Several clinicopathologic differences exist between type II and III cardia cancer. In the future, further evaluation is needed regarding the classification and entities of the cardia cancer.
Adenocarcinoma/classification/mortality/*pathology ; Adolescent ; Adult ; Aged ; Aged, 80 and over ; Barrett Esophagus/pathology/surgery ; *Cardia ; Esophageal Neoplasms/classification/mortality/pathology ; Female ; Humans ; Kaplan-Meiers Estimate ; Lymphatic Metastasis ; Male ; Middle Aged ; Neoplasm Staging ; Prognosis ; Stomach Neoplasms/classification/mortality/*pathology ; Survival Analysis

Barrett's esophagus is a premalignant condition of esophageal adenocarcinoma. Inducible nitric oxide synthase (iNOS) is induced by cytokines and can generate locally high concentrations of nitric oxide (NO), whose metabolites can mediate genotoxicity and influence multistage carcinogenesis by causing DNA damage. Therefore, we evaluated the immunolocalization and expression of iNOS in surgically induced rat Barrett's esophagus. Esophagoduodenal anastomosis was performed in rats for inducing reflux of duodenal contents. Rats were killed at postoperative 10, 20, 30 and 40 weeks. We examined histologic changes and iNOS expression in esophagus by immunohistochemistry and reverse transcription-poly-merase chain reaction. Eighty six percent of experimental rats showed Barrett's esophagus above esophagoduodenal junction. iNOS immunoreactivity was clearly observed in the epithelial cells of Barrett's esophagus, predominantly at the apical surface of epithelial cells. Cytoplasmic staining was also seen only in atypical Barrett's esophagus. iNOS mRNA was detected only in the lower esophagus of experimental group. In conclusion, this study suggests that iNOS has some roles on Barrett's esophagus formation.
Anastomosis, Surgical ; Animals ; Barrett Esophagus/*enzymology/*surgery ; Cytoplasm/metabolism ; DNA Damage ; Disease Models, Animal ; Duodenum/*enzymology/surgery ; Esophagus/metabolism ; Immunohistochemistry ; Male ; Models, Anatomic ; Neoplasms, Experimental/pathology ; Nitric Oxide/metabolism ; Nitric-Oxide Synthase/*biosynthesis ; RNA/metabolism ; RNA, Messenger/metabolism ; Rats ; Rats, Sprague-Dawley ; Research Support, Non-U.S. Gov't ; Reverse Transcriptase Polymerase Chain Reaction ; Time Factors

OBJECTIVETo investigate the prognostic factors and to analyze the efficacy of chemotherapy and/or radiotherapy for Barrett's esophageal adenocarcinoma after radical surgical resection.

METHODSThe clinical data of 108 patients with adenocarcinoma Barrett's esophagus picking out from 783 esophageal adenocarcinoma patients surgically treated between June 1978 to June 2001 in the Shandong Provincial Hospital and Shandong Qianfoshan Hospital were analyzed retrospectively. 60Co gamma-irradiation or 6MVX-ray with conventional fraction were used for radiotherapy with a total volume dosage of 55-70 Gy. The chemotherapy was either FAM (iv infusion of 5-Fu 500 mg, d1-d5; ADM 50 mg d1; MMC 12 mg, d1) or CMF regimen (iv infusion of CTX 800 mg d1, d8; MTX 30 mg d1; 5-Fu 500 mg, d1-d5) for 4-6 cycles. The Kaplan-Meier amalysis was used to estimate the survival rate. Log rank test was used for comparison of the survival difference among different groups.

RESULTSIn this series, 76 of 92 patients who underwent radical surgical resection received postoperative radiotherapy alone, and 16 received radiotherapy plus chemotherapy. Twelve of the other 16 patients who underwent palliative surgical resection received chemotherapy plus radiotherapy, the remaining 4 patients died of operative complications during surgery. The overall 1-, 3- and 5-year survival rate of this series was 81.5%, 51.9% and 22.2%, respectively. In the radical resection group, it was 15.8% for the patients received radiotherapy alone versus 75.0% for those treated by chemotherapy plus radiotherapy. The 5-year survival rate was 33.3% for the patients without extra-esophageal infiltration and 33.3% for the patients without lymph node metastasis, respectively. However, it was only 9.1% for the patients with extra-esophageal infiltration and 14.3% for those with lymph node metastasis, respectively. For the patients who had palliative surgical resection, though they received chemotherapy plus radiotherapy postoperatively, none of them survived longer than 5-year. Statistically significant difference among these groups was demonstrated by Log rank test (P < 0.05).

CONCLUSIONChemotherapy plus radiotherapy after radical surgical resection may improve the survival of patients with adenocarcinoma in Barrett's esophagus adenocarcinoma patient. The pathological stage, extra-esophageal infiltration, lymph node metastasis and postoperative chemotherapy plus radiotherapy are important prognostic factors.

Adenocarcinoma ; pathology ; surgery ; therapy ; Adult ; Aged ; Antineoplastic Combined Chemotherapy Protocols ; therapeutic use ; Barrett Esophagus ; pathology ; surgery ; therapy ; Combined Modality Therapy ; Cyclophosphamide ; therapeutic use ; Doxorubicin ; therapeutic use ; Esophageal Neoplasms ; pathology ; surgery ; therapy ; Esophagectomy ; methods ; Female ; Fluorouracil ; therapeutic use ; Humans ; Lymphatic Metastasis ; Male ; Methotrexate ; therapeutic use ; Middle Aged ; Mitomycin ; therapeutic use ; Neoplasm Staging ; Postoperative Period ; Prognosis ; Radiotherapy, High-Energy ; methods ; Retrospective Studies ; Survival Analysis ; Treatment Outcome