Endoscopic Diagnosis and Treatment of Mucosal Lesions of the Esophagus

Surgical Endoscopy

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Endoscopic Diagnosis and Treatment of Mucosal lesions of the Esophagus

Wayne H. Schwesinger, M.D. *

Lesions of the esophageal mucosa are ideally suited for examination by fiberoptic endoscopy because they are readily accessible and can easily be sampled for specific histologic or microbiologic investigation with the available biopsy forceps, electrocoagulation snares, and cytologic brushes. Because endoscopy is both accurate and safe, it is indicated early in the evaluation of all patients with dysphagia and in selected patients with persistent heartburn. Its role in the work-up of noncardiac chest pain and motility disorders is not as axiomatic, and it probably should be relegated to those situations in which fluoroscopic or manometric studies are nondiagnostic. 25 Whether complementary barium radiographs are always necessary prior to esophagoscopy is a contentious issue that continues to receive attention. Early studies showing a diagnostic advantage for endoscopy, although interesting, were consistently flawed by uncontrolled bias and other types of dubious design. 62 Nonetheless, a recent prospective blinded comparison also indicated that endoscopic methods are more sensitive and specific than radiographic techniques when used in the upper gastrointestinal tract. 28 This advantage is offset somewhat by the higher cost of endoscopy and by the fact that radiographic errors are usually noncritical and related to subtle abnormalities such as esophagitis but not to cancer. 26 Endoscopy also has exceptional potential for therapeutic applications. A variety of endoscopic techniques are now available that provide localized therapy for many esophageal lesions. These therapeutic procedures can be performed under direct vision with patients only lightly sedated, an approach that, in selected instances, obviates anesthesia and surgery. In general terms, those mucosal disorders responsible for the majority of endoscopic interventions are of inflammatory or neoplastic origin. Fa*Professor, Department of Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas Illustrations in this article are reproduced in color by courtesy of Claxo, Inc.

Surgical Clinics of North America-Vol. 69, No.6, December 1989

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miliarity with the principal lesions in each of these categories is important in planning appropriate management strategies. INFECTIOUS ESOPHAGITIS Endoscopy has assumed a role of growing importance in immunocompromised patients because esophagitis caused by opportunistic organisms is frequently found in this setting. The actual prevalence of this problem is not known, but it should be suspected in any high-risk patient with odynophagia, dysphagia, or dull chest pain. Rapid and precise diagnosis is essential, because specific antifungal and antiviral therapy may ameliorate the symptoms and control morbidity. The diagnosis may be suggested by the demonstration of relatively specific lesions on air-contrast radiography, but histologic confirmation requires endoscopic sampling. 34 Candida Esophagitis Candida esophagitis is occasionally associated with diabetes and advanced age but is most often seen in patients with impaired immune function. Candidiasis is now the most common cause of odynophagia or dysphagia in patients with acquired immune deficiency syndrome (AIDS).58 When related to AIDS, it frequently occurs together with oral candidiasis (thrush). This unique association permits specific antifungal therapy to be initiated without endoscopic studies if a patient has both documented thrush and esophageal symptoms. 96 Endoscopy is indicated if the condition fails to respond to appropriate treatment or if other pathology is suspected. The typical endoscopic picture is one of multiple whitish plaques surrounded by an erythematous mucosa and localized to the distal esophagus (Fig. 1). Shallow ulcers and nodularity may also be present. Brushings from the plaques will show typical fungal spores and non septate pseudohyphae. Biopsy specimens are not as useful, as the picture often is histologically indistinguishable from that of reflux esophagitis. 56 Similarly, culture results are generally not interpretable because of oropharyngeal contamination. Esophageal candidiasis in patients without AIDS generally responds to treatment with nystatin or ketoconazole. However, in AIDS patients, amphotericin or progressively higher doses of ketoconazole often are required. Even when symptoms respond to standard antifungal therapy, endoscopic evidence of infection may persist for months. 97 Herpes Simplex Esophagitis Herpes simplex esophagitis occurs predominantly in patients with immune incompetence or systemic malignancies but may also be seen in apparently normal individuals. 38 Odynophagia is the most prominent symptom and is often accompanied by dysphagia and fever.2 Rarely, patients present with severe esophageal bleeding. 77 Herpetic esophagitis progresses through three stages: vesicle formation; development of shallow, wellcircumscribed ulcers; and finally tissue necrosis. Radiographic findings may be nonspecific or may consist of discrete, superficial ulcers on a normal mucosal background. Endoscopic features

r

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typically reflect the clinical stage of the disease. The putative diagnosis is confirmed by brushings or biopsies of the ulcer margins, which demonstrate multinucleated giant cells and intranuclear inclusion bodies within epithelial cells. 59 Viral cultures are also important, because they may be positive even when the histologic picture is non diagnostic. Herpetic lesions may heal spontaneously in patients with competent immune systems, but acyclovir has been found to be necessary for the treatment of most AIDS patients. 2 Cytomegalovirus Infection Cytomegalovirus infection involves the stomach and intestine predominantly, but esophageal lesions are being reported with increased frequency in association with AIDS. Commonly, the patient with cytomegalovirus esophagitis has widespread systemic infection with the same organism. 64 The clinical, endoscopic, and radiographic pictures are similar to those seen with herpes esophagitis except that vesicles are not formed. 5 In established cytomegalovirus esophagitis, large superficial erosions with serpiginous, nonraised borders are characteristically seen on endoscopy. Both intranuclear and intracytoplasmic inclusions are found in cytologic or biopsy specimens taken from the central portion of ulcer craters. Viral cultures provide a definitive diagnosis. No effective treatment has yet been established for symptomatic disease. Preliminary studies with an experimental antiviral agent, ganciclovir, have demonstrated clinical and virologic efficacy in the majority of patients with cytomegalovirus infections. 19

ESOPHAGEAL INJURY The mucosa of the esophagus is repeatedly exposed to a variety of potentially injurious substances. Tissue reaction may range from mild inflammation to full-thickness damage involving the underlying submucosa and muscle. Early endoscopic assessment will help not only to establish the correct diagnosis but also to estimate the degree of damage and the risk of serious sequelae. It may also serve specific therapeutic and monitoring functions. Ingestion of Foreign Bodies Foreign body ingestions may result in mucosal erosions and lacerations or in perforation of the esophagus. Although many objects pass without sequelae, more than 40 per cent of patients presenting to the emergency room after swallowing a foreign body require endoscopic removal of the object. 86 Fiberoptic endoscopy has assumed a preeminent role in the management of this problem because it is cost-effective and safe. 100 The timing for endoscopy is best determined by the location of the foreign body. When it is lodged in the cricopharyngeal area or in the body of the esophagus, early removal is advisable, and general anesthesia is commonly required to assure maintenance of an airway during the procedure. If the foreign body has passed into the stomach, a period of

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Figure 1. Candidiasis of the distal esophagus.

B

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c Figure 2. Reflux esophagitis and its complications. A, Grade II reflux. B, Benign stricture with guidewire in place. C, After stricture dilatation to 34 F.

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Figure 4. Esophageal webs and rings. A, Schatzki's ring at gastroesophageal junction. B, Midesophageal web.

Color reproduction courtesy of Glaxo, Inc.

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c Figure 5. Barrett's esophagus. A, Island of columnar-lined esophagus. B, Circumferential involvement. C, Focus of invasive adenocarcinoma.

Figure 6. Squamous papilloma in distal esophagus.

Figure 7. Squamous cell cancer at midesophagus.

Figure 8. Retroflexed view of esophageal adenocarcinoma.

Color reproduction courtesy of Claxo, Inc.

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observation is warranted, as 80 per cent of these objects will continue their migration through the digestive tract uneventfully. 83 Esophageal injury most commonly occurs secondary to the swallowing of sharp objects such as bone fragments, pins, toothpicks, and dental prostheses. Safe extraction requires the grasping and positioning of the object so that the pointed end is trailing. In some instances, the use of an overtube may provide additional protection for the proximal esophagus. In other cases, such as with open safety pins, it may be advisable to push the object into the stomach for repositioning. An endoscopic hood can be used to cover the point as the object is pulled back through the esophagus. 95 Meat impaction is a relatively common problem in adults. It may require urgent management when the meat bolus is lodged in the cricopharyngeal region because of the risk of respiratory compromise. When the impaction occurs in the distal esophagus, the meat can usually be pushed into the stomach by applying lateral force with the endoscope. 100 Use of meat tenderizer has been advised but should be avoided because of the local mucosal erosion that develops.40 After extraction of impacted meat, the esophagus should be carefully inspected, because underlying esophageal pathology is present in the majority of cases. 101 A contemporary hazard requiring urgent endoscopic attention is the ingestion of miniature disk batteries. When these devices lodge in the esophagus, serious corrosive damage can develop within hours. 53 It is therefore important that esophageal disk batteries be promptly extricated. This is most easily accomplished with an intraluminal balloon catheter. Batteries that have already passed into the stomach can be managed conservatively, but radiologic observation for splitting of the battery should continue until the battery is expelled, because the mercury released can reach hazardous levels. Caustic Injury Caustic injury of the esophagus occurs most commonly as a result of the ingestion of a variety of household corrosives such as acid, bleach, ammonia, or lye. In this country, the number of such cases has decreased substantially since federal legislation was passed in the 1970s to reduce the allowable concentration of hazardous household products. Nonetheless, esophageal damage is still noted in at least 30 per cent of patients who have a history of caustic ingestion. 69 The severity of the induced lesions ranges from superficial burns to total necrosis and is related to the nature of the swallowed caustic as well as to its volume and concentration. Endoscopic inspection is the most direct and accurate method for assessing the degree of esophageal damage and thus helps in planning the management of patients and assures early discharge for those without injury. Contrast studies do not significantly contribute to the evaluation and are likely to underestimate the severity of involvement. 31 However, a barium swallow is helpful in determining whether perforation has occurred in the high-risk patient. Esophagoscopy should be performed regardless of whether oral burns are present. To avoid additional injury to damaged esophageal mucosa, a

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small-caliber panendoscope should be used, and care should be taken to advance only to the most proximal level of major burn. 94 If areas of necrosis are seen without evidence of perforation, the examination should be repeated within 48 hours. The finding of severe ulceration and impending perforation mandates prompt operative intervention. Fortunately, the majority of patients will heal fully and can then be followed at regular intervals with either contrast studies or endoscopy. Strictures develop in 22 to 40 per cent of patients, and periodic dilatation under direct vision may maintain satisfactory patency in as many as one third of these cases. 31 , 87 The majority of patients with long, dense areas of fibrosis ultimately require operative therapy. Medication-Induced Injuries Medication-induced injuries have been reported with increasing frequency over the past decade. Even so, the true incidence of this problem probably is still underestimated, because its manifestations may be easily confused with those from symptomatic reflux disease. More than 26 different types of medication have been implicated as causes of mucosal damage. 54 Both mucosal ulceration and stricture formation may develop from prolonged exposure to certain capsules or tablets. Interestingly, in a recent radiographic study of swallowed barium tablets, 58 per cent of subjects retained the tablets in the esophagus for longer than 5 minutes. 3o Factors such as advanced age and esophageal abnormalities can further increase the retention time of ingested capsules. The intense toxicity of certain medications is also important in the pathogenesis of this lesion. Those medications most often associated with mucosal damage include emepronium bromide, tetracycline and its derivatives, potassium chloride, qUinidine, ferrous sulfate, and acetylsalicylic acid. 14 It is important to distinguish drug-induced esophageal injury from reflux disease, because antireflux therapy plays no significant role in the management of these iatrogenic esophageal lesions. The endoscopic findings may be particularly helpful if ulcers or strictures are found in the midesophagus, a level of pathology not normally seen in reflux. In one study, proximal strictures accounted for 6 of 11 cases of tablet-induced lesions. 13 Tablets also lodge in the distal esophagus and may cause strictures that are easily confused with those from reflux disease. In this circumstance, the addition of a 24-hour pH monitoring study is helpful, as a normal study in a patient with a history of medication usage suggests an etiologic role for the medication. Treatment with dilation of strictures and withdrawal of the responsible substance results in eventual resolution of symptoms in most patients. 13

GASTROESOPHAGEAL REFLUX DISEASE The regurgitation of gastroduodenal contents into the distal esophagus occurs transiently in many normal individuals without producing symptoms

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or causing pathologyY However, in others, a spectrum of clinical abnormalities results. The severity of the mucosal lesions depends on multiple factors, including the concentration of the refluxed acid and the duration of epithelial exposure. Thus, patients with more complicated esophagitis have greater acid reflux and longer bathing of the mucosa, especially nocturnally. 80 Because esophagoscopy is a morphologic study, it provides only indirect information about reflux by identifYing and quantifying any secondary mucosal changes. Endoscopic examination is particularly helpful in patients with more advanced and complicated reflux disease; it remains relatively insensitive in patients with only low-grade disease. For this reason, functional studies such as esophageal manometry, gastroesophageal scintiscanning, or 24-hour pH monitoring have become increasingly important adjuncts in the management of selected reflux patients. 35 Reflux Esophagitis Reflux esophagitis is usually diagnosed clinically on the basis of its typical presentation with heartburn and regurgitation. Most patients with these symptoms will respond to simple therapeutic measures and will require no special diagnostic studies. However, when symptoms are severe, or if they fail to respond to conservative treatment, further diagnostic evaluation, including endoscopy, will become necessary. 79 Endoscopic inspection combined with biopsy is the only testing modality by which mucosal damage from reflux can be objectively assessed, but these methods are still far from precise. Based on visual signs alone, the severity of the esophagitis can be estimated; a simplified staging system is depicted in Table 1. Unfortunately, as many as 40 per cent of patients with symptoms of esophagitis have no macroscopic evidence of mucosal pathology.8 This lack of correlation appears to result from the inherent difficulty of distinguishing mild or grade I esophageal inflammation from normal mucosa endoscopically. Notably, the common finding of erythel)la in the distal esophagus is not diagnostic for esophagitis, as it also is seen frequently in normal individuals.102 Granularity and friability in the distal esophagus is a more helpful endoscopic sign of early esophagitis. 6. 51 Advanced mucosal lesions Table 1. Endoscopic Staging of Esophagitis GRADE

VISUAL CHARACTERISTICS

I (mild)

Erythematous, friable mucosa Irregularity of Z line

II (moderate)

Scattered linear erosions SuperfiCial ulcers Granular mucosa

III (severe)

Confluent erosions with cobblestoning Deep, punched-out ulcers Diffusely hemorrhagic mucosa Fibrous strictures Barrett's (columnar-lined) esophagus

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include shallow erosions and exudates ansmg at the gastroesophageal junction, discrete ulcers, diffuse hemorrhagic mucosa, and esophageal strictures (Fig. 2A). Even endoscopic biopsies are frequently not diagnostic, especially in mild to moderate reflux disease, because the histologic picture is difficult to interpret. A number of histologic criteria have been recommended. Deep specimens obtained by suction biopsy may demonstrate an increased length of the stromal papillae in the lamina propria as well as hyperplasia of the basal-cell layer. It has been speculated that these findings represent an adaptive response to chronic mucosal erosion and repair.49 However, they often show marked variation within individual patients and are even observed in individuals without reflux when biopsies are obtained from within 2.5 cm of the gastroesophageal junction. 85 Superficial specimens obtained by forceps biopsy demonstrate a significant inflammatory-cell response in many patients with symptomatic reflux disease. Infiltration of the epithelium and the lamina propria by neutrophils and eosinophils is, in fact, a relatively specific, although insensitive, indicator of reflux esophagitis, being found in 40 to 60 per cent of patients with moderate to severe disease. 7, 88, 103 Lymphocyte, histiocyte, and plasma cell infiltrates do not appear to correlate with the diagnosis of esophagitis at any stage. Because of these diagnostic ambiguities, the role of endoscopy in the diagnosis of esophagitis may be somewhat limited unless symptoms are severe or other secondary affects of reflux have occurred. Esophageal Strictures Esophageal strictures represent the most common serious complication of gastroesophageal reflux disease. Fiberoptic endoscopy plays a clear and indispensable role in their diagnosis and treatment. Peptic strictures usually develop in the distal esophagus proximal to the esophagogastric junction, but occasionally they are seen in the middle esophagus in association with extensive Barrett's metaplasia. Rarely, benign strictures occur in the cervical esophagus in patients who have severe nocturnal reflux with resultant pooling of acid in the cricopharyngeal region. 46 Esophagoscopy should be performed in all patients with strictures, whether the lesions have been demonstrated on contrast studies or are suspected on the basis of progressive dysphagia. The principal diagnostic objectives of endoscopy are to document the presence of the stricture and to characterize the degree of esophageal involvement. It is also essential to differentiate benign strictures from malignant lesions. This can best be accomplished by the combined use of four to eight pinch biopsies of the strictured area and brush or aspiration cytology specimens obtained from the intraluminal surface. 42 Symptomatic benign strictures can be treated in the short term with dilatation, Relief is obtained if a final luminal diameter of at least 13 mm (40 Fr) is achieved. Indirect bougienage using mercury-filled dilators of progressively larger diameter (Hurst; Maloney) is successful in relieving dysphagia in 75 to 85 per cent of treated patients with strictures. 57, 71, 75 Serious complications such as bleeding and aspiration are unusual. Perfo-

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ration has been reported in 0.25 per cent of 23,000 dilatations in one collected series. 61 With some of the more extensive strictures, endoscopically directed dilatation is gaining acceptance (Fig. 2B and C). Several dilating systems are available, including the pressure-regulated balloon dilator, which is passed and inflated under direct vision, and graduated tapered polyvinyl dilators, which are passed over spring-tip guidewires that have been positioned endoscopically (Fig. 3). Theoretically, balloon dilators should be better because they exert only radial dilating pressure, whereas bougies exert both longitudinal and radial force. 43 However, a recent controlled study has suggested that balloon dilatation with current equipment is no safer and is probably less effective in reducing dysphagia and maintaining stricture patency. 23 The role of dilatation as primary therapy in the long-term management of benign esophageal strictures is a matter of controversy. In several reported series, operative therapy was ultimately used in only 15 per cent of patients with strictures. 33 Nonetheless, dilatation represents only a

Figure 3. Esophageal dilators and stents. From the top: large and small metal, olive-tip dilators (Eder-Puestow; Olympus, Inc.), a balloon dilator (Rigiflex; Microvasive, Inc.), a tapered polyvinyl dilator with spring-tip guidewire (American Dilatation System; Bard, Inc.), and medium and large silicone rubber stents with flared ends (Atkinson Prosthesis; Olympus, Inc.).

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temporizing palliative approach in most patients and may actually worsen the primary disease in some. 72 Strictures have been noted to recur more than 50 per cent of the time after the first dilatation, and additional dilatations are required after the first recurrence in approximately 90 per cent of cases. 39 Furthermore, continued reflux and repeat dilatations can ultimately lead to transmural changes in the esophageal wall and eventual loss of normal motility; subsequent surgery may become much more difficult. 47 Although rigorous medical treatment appears to reduce the frequency of recurrences, this approach alone is incapable of completely reversing the underlying anatomic or functional abnormalities that contribute to reflux. Accordingly, it would appear that antireflux surgery should be considered for most patients with recurrent strictures except those who have a prohibitive operative risk. 10, 90 Controlled studies to document the validity of either this approach or repetitive dilatation alone are not available. Various webs and rings may also require dilatation, but their relation to reflux disease remains obscure. Schatzki's ring is a relatively common, presumably acquired, diaphragm-like narrowing that is found at the squamocolumnar junction and is almost always associated with a hiatus hernia. 41 Patients commonly present with episodic dysphagia and frequently, but not invariably, have a history of symptomatic reflux. Schatzki's ring is best seen on barium swallow and is sometimes overlooked at initial endoscopy (Fig. 4). Dilatation will provide long-term relief and can be achieved by passage of the endoscope through the ring or by dilating bougies or balloons. 3 Electrosurgical incision has been advised for difficult or recurrent rings. 76 Barrett's Esophagus Barrett's esophagus is a complication of prolonged gastroesophageal reflux. A portion of the squamous epithelium in the distal esophagus is replaced by one or more types of columnar epithelium. The condition has been observed in as many as 10 to 12 per cent of patients undergoing endoscopy for reflux disease and often is accompanied by only relatively mild symptomatology. 22, 104 The correct diagnosis is of special concern because of the common association of Barrett's esophagus with proximal strictures and deep ulcers and because it has a unique predisposition to the development of adenocarcinoma. Barrett's esophagus can be recognized easily through the endoscope except in children and in patients with erosive esophagitis. The typical velvet-red columnar mucosa extends circumferentially or in linear streaks in an orad direction beginning from the proximal gastric folds (Fig. 5A and B). Macroscopic identification may be facilitated by the application of Lugol's solution or toluidine blue, but these special studies probably are only rarely necessary. 17, 21 Biopsies are mandatory for definitive diagnosis and should histologically confirm the presence of cardiac, fundic, or specialized intestinal columnar epithelium in the tubular esophagus. 82 As with other manifestations of gastroesophageal reflux disease, the management of Barrett's esophagus initially is directed toward the medical control of esophageal reflux. Such an approach is often successful in relieving the symptoms of esophagitis and in improving the strictures and ulcers that

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accompany Barrett's esophagus. However, long-term medical therapy does not appear to induce regression of the metaplastic columnar mucosa. 15 AntireHux surgery is best reserved for patients in whom symptoms are intractable or in whom complications cannot be controlled effectively by aggressive medical measures. Whether antireHux surgery is more likely to result in regression is still problematic. Early but limited endoscopic studies reported regression in as many as 40 per cent of cases. 16 More recent investigations demonstrate no significant change in the metaplastic mucosa. In fact, some patients treated with antireHux procedures have developed adenocarcinoma years after surgery. 1. 93 The association of Barrett's esophagus with adenocarcinoma is well known (Fig. 5C). At the time of their initial diagnosis, 9 to 26 per cent of patients with Barrett's esophagus already have evidence of invasive adenocarcinoma and are thus candidates for esophagectomy.67, 74 Barrett's patients without malignancy should undergo regular surveillance because the risk of developing carcinomatous changes is estimated to be 40- to 60-fold that of the general population. 81 , 92 Surveillance should include at least annual endoscopy to collect cytologic specimens and to obtain four-quadrant biopsies at 2- to 3-cm intervals in all areas of columnar-lined esophagus. Demonstration of high-grade dysplasia in these specimens is currently the most reliable morphologic marker for either the presence of carcinoma or its imminent development. 78 The preferred treatment for patients with confirmed high-grade dysplasia is controversial, but in most centers with experienced esophageal surgeons, esophagectomy is the most appropriate course. 91

BENIGN EPITHELIAL GROWTHS The distal esophagus is the most likely site for benign mucosal growths. The frequent association of these growths with esophageal reHux suggests that mucosal injury may be one of the important pathogenetic factors. Glycogenic Acanthosis Glycogenic acanthosis presents endoscopically as a raised whitish plaque lining the folds of the distal esophagus. This relatively common growth has been incorrectly labeled leukoplakia in the past, but the presence of abundant cytoplasmic glycogen in hyperplastic epithelial cells identifies it as a specific and unrelated lesion with no premalignant potential. 9 The mucosal plaques of glycogenic acanthosis may be confused with candidiasis except for their lack of surrounding erythema and the absence of typical fungi on smear. Squamous Papillomas Squamous papillomas are uncommon neoplasms that usually are asymptomatic and have a wart-like, pale appearance with a sessile configuration (Fig. 6). They generally are small and may be single or multiple. Management by snare resection is effective, but the lesions occasionally recur. 98

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Polyps Polyps are rare adenomatous growths that can become large and symptomatic. Because they often arise in the cervical region and may develop a substantial pedicle, they have a potential for laryngeal obstruction. Removal can be accomplished either with a polypectomy snare or by operative esophagotomy.73 CANCER OF THE ESOPHAGUS . Diagnosis and Staging Although fiberoptic endoscopy clearly facilitates the earlier diagnosis of mucosal lesions in the esophagus, it has produced no significant improvement in the dismal survival statistics for carcinoma. This is explained by the advanced stage esophageal tumors have reached when patients first present for evaluation. In the majority, dysphagia is the initial complaint and does not become evident until the esophageal lumen is reduced to a critical diameter below 12 mm. Squamous-cell cancer accounts for 90 per cent of malignancies of the esophagus. No premalignant squamous lesion has yet been identified, although a pattern of chronic esophagitis with dysplasia has recently been implicated as the precursor lesion in one high-risk population in Huixian County, China. 44 Cancers of the esophagus may have any of several macroscopic appearances on endoscopy. Most commonly, they are circumferential and fungating, but they may also be ulcerative, polypoid, or infiltrative with a gross appearance simulating a benign stricture (Fig. 7). Guided biopsies obtained from the margins of obvious lesions are likely to provide the correct histologic diagnosis, particularly when multiple biopsies are taken. However, errors may be made in those patients with dense strictures or extensive necrosis. Brush cytology under direct vision significantly increases the yield of diagnostic endoscopy. Moreover, a recently described technique for endoscopic fine-needle aspiration appears to improve the positive yield to nearly 100 per cent and is probably best used in dealing with infiltrative tumors. 55 After the diagnosis of cancer is established, clinical diagnostic staging proceeds using available laboratory, radiologic, and surgical data. Endoscopic ultrasonography is a relatively new method by which the extent of local cancer invasion can be assessed. In one limited study in which a sonographic probe was attached to an endoscope tip, an overall accuracy of 89 per cent was reported for the detection of regional lymph-node metastasis or extraluminal spread. 48 However, full intubation and thorough sonographic mapping was possible in only half the candidates because of obstruction caused by the tumor. A smaller ultrasound probe that can be passed through the biopsy channel of the fiberoptic endoscope may allow a more extensive examination with better tissue-plane orientation. 89 For the present, these devices are experimental, but they hold the promise of substantially improving noninvasive staging methods.

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Treatment and Palliation

Although accurate staging is fundamental to the selection of an appropriate therapeutic regimen for esophageal cancer, cure is still unlikely, and palliation becomes a more realistic goal in most patients. Optimum palliation is provided by esophageal resection, but only 14 to 40 per cent of tumors are resectable when discovered. 24. 99 Furthermore, palliative operations are associated with a mortality rate of8 to 28 per cent as well as with appreciable morbidity.ll,12 Radiotherapy alone or in combination with chemotherapy has demonstrated benefit in some patients with squamous cancer. However, the inherent side effects and the disruption of the patient's remaining life are limiting factors. More controlled trials will be necessary before the role of these nonoperative methods is clearly defined. Endoscopic palliation continues to evolve. The two methods currently used are esophageal intubation and tumor ablation. Palliative intubation usually requires prior dilatation of the tumor over a guidewire placed under direct vision. A variety of tubes and devices are available. The cannulation of unusually difficult stenoses may be further aided by the use of fluoroscopy and steerable angiographic catheters.66 A special cuffed tube can be used in patients with tracheoesophageal fistulas. 60 Tube placement results in some improvement of swallowing in 80 to 90 per cent of obstructed patients, but symptom relapse is common. 20 The procedure-related mortality rate has been reported to be 4 to 8 per cent, and the short-term management of successfully positioned tubes may be complicated by migration, obstruction, or erosion into adjacent structures. 18,36 Laser photoablation of esophageal tumors has been reported with increasing frequency, The beam from the neodymium:yttrium-aluminumgarnet (Nd:YAG) laser is transmitted by a quartz probe placed through the biopsy channel of the endoscope. With brief bursts of the high-energy laser, sufficient local heat is produced to coagulate, necrose, or vaporize exposed tissue with relatively precise anatomic control. Relief of dysphagia has been achieved in 80 to 95 per cent of patients treated in this way.32, 68 When patient performance status has been measured, a sometimes dramatic improvement in the quality of remaining life has been demonstrated. 29, 84 Because of tumor regrowth or the inability to ablate the tumor adequately in a single session, repeat treatments may be necessary in as many as half the patients. The procedure-related mortality rate in large series is reported not to exceed 1 per cent, while the most serious complications, perforation or fistulization, can be seen in as many as 4 per cent of subjects. 29 Complications are more likely when laser photoablation is used in tissue fields that have been irradiated previously or in those having simultaneous instrumentation. The risk of serious tissue injury can be minimized by carefully controlling the total laser energy and by using special caution when treating tumors associated with long strictures or severe angulation. In some instances, the success of laser ablation has been augmented by adjunctive procedures such as prosthetic tube placement or irradiation with intracavitary 192iridium.4, 37 Although these procedures may be helpful in some patients, confirmation of their overall effectiveness awaits further study. Similarly, experience is still limited with endoscopic photodynamic

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therapy, which uses hematoporphyrin derivative to sensitize malignant tissue to the later application of light. Preliminary data suggest that photodynamic therapy may achieve near-total control of symptoms in some advanced lesions and may be capable of eradicating superficial esophageal cancer. 63, 70 The disadvantages of endoscopic lasers include their high cost and limited accessibility. The search for new ablative methods that would circumvent these problems has prompted modification of the bipolar electrocoagulation (BICAP) probe for use with esophageal tumors. Current models consist of a series of olive-shaped circumferential or 180-degree electrodes ranging in diameter from 6 to 15 mm. The probe is passed through the tumor over a . guidewire. Ablative effects may be observed with an endoscope positioned parallel to the BlCAP shaft. Typically, coagulation results in eventual tissue necrosis to a depth of 2 to 4 mm. In one early multicenter study, dysphagia and lumen size improved significantly, but serious hemorrhage or fistulization occurred in 4 of 20 patients treated. A subsequent controlled comparison of the palliative values of Nd:YAG laser and the BlCAP probe suggested nearly equivalent results, with 86 per cent improvement in oral intake in both groups.50 However, the development of a fistula in one BICAP-treated patient underscores the risk of circumferential coagulation in tumors that are characteristically eccentric in configuration. Better definition of the morphology and depth of tumors by either magnetic resonance imaging or endoscopic ultrasound may provide a greater margin of safety for BICAP treatment in the future. Adenocarcinoma of the Esophagus Adenocarcinoma accounts for 10 per cent of all primary mucosal malignancies in the esophagus and is associated with Barrett's metaplasia in nearly two thirds of these cases. 45 As noted previously, this unique association mandates regular surveillance of patients with Barrett's esophagus (Fig. 8). In those patients presenting with adenocarcinoma or developing a malignancy during surveillance of Barrett's esophagus, the approaches to staging as well as to surgical and endoscopic management aJ;"e the same as those used for squamous carcinoma. However, conventional chemotherapy and radiotherapy continue to be largely ineffective in the treatment of esophageal adenocarcinoma.

SUMMARY The rapid evolution of fiberoptic endoscopes over the past three decades has greatly enhanced our understanding of esophageal diseases and has stimulated significant improvements in their management. With the early endoscopic diagnosis of infectious and inflammatory lesions, specific medical or surgical treatment can be initiated promptly and the results monitored easily. Although the diagnosis of malignant lesions is still commonly delayed because of the absence of early symptoms, surveillance of Barrett's esophagus offers the hope of more definitive management in

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these patients. Endoscopy has assumed an increasingly important therapeutic role in patients with inoperable cancer because it provides access for new ablative techniques or the placement of palliative prosthetic devices. Continuing advances in the use of endoscopic ultrasound, the delivery of photodynamic therapy, and the adjunctive application of intraluminal irradiation promise to further broaden the scope of fiberoptic intervention.

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