squeezing and straining. In active proctologic Crohn's disease these dynamic changes of the anal sphincter were less pronounced than in normal subjects. This study could be useful in predicting and diagnosing anal incontinence. LIONELLO GANDOLFI
Bologna, Italy
A prospective study of esophageal squamous cell carcinoma in achalasia MEIJSSEN MA, TILANUS
HW,
VAN BLANKENSTEIN M,
ETAL.
Gut 1992;33:155-8
The authors of this article from The Netherlands set out to establish the true incidence of esophageal carcinoma in patients with achalasia and the efficacy of endoscopic surveillance. One hundred and ninety-five consecutive patients (90 men and 105 women) diagnosed with achalasia between 1973 and 1988 were followed prospectively. The diagnosis of achalasia was confirmed by contrast radiology, endoscopy, and esophageal manometry. All patients underwent serial pneumatic dilation with review at 3 months and years 1, 2, 4, 7, and 10 (or greater). Follow-up included a barium swallow, esophageal manometry, and EGD with biopsy. If esophageal carcinoma was detected, staging was carried out. The incidence of squamous cell carcinoma (SeC) of the esophagus in the study group was compared with the expected incidence in age- and sex-matched controls, using the subject-years method. Follow-up after pneumatic dilation totaled 874 person years. The mean age at the time of diagnosis of achalasia was 52 years. Twenty-seven patients died over the course of the study, one from stage IV sec of the esophagus. This patient refused routine examinations after 1 year; carcinoma was identified 3 years later. Two of the remaining patients developed sec of the esophagus (stage I and IIa, respectively), resulting in an incidence of 3/874 person years or 3,4/ 1000 patients per year. The mean age at the time of diagnosis of squamous cell carcinoma was 68 years (range, 37 to 89 years). A mean of 17 years separated the onset of dysphagia and the diagnosis of carcinoma. The mean interval between the diagnosis of achalasia (as distinct from the onset of symptoms) and detection of esophageal carcinoma was 5.7 years (range, 4 to 8 years). Tumor was located in the middle third of the esophagus in all three patients, although it extended to the distal esophagus in one. The expected incidence of sec of the esophagus in an age- and sex-matched population in the Netherlands was 0.104/1000 patients per year, resulting in a relative risk for development of squamous cell carcinoma of the esophagus in patients with achalasia of 33 (p < 0.001). Based on these findings, the authors conclude that there is substantially increased risk for the development of esophageal carcinoma in patients with long-standing 738
achalasia and recommend endoscopic screening every 2 to 3 years. However, the authors also caution that their conclusions are based on data from only three patients who developed cancer and suggest that largescale studies are needed to accurately determine the efficacy and optimal frequency of endoscopic screening in patients with achalasia. 'This article represents a commendable effort to identify the true incidence of malignancy complicating achalasia of the esophagus. However, some questions and problems arise. First, the authors fail to state whether or not the study and control populations were screened for potentially confounding variables, such as cigarette smoking and alcohol use. Second, the incidence of esophageal malignancy in the control group could have been underestimated as these patients were subjected to less vigorous screening than the study population. Third, were biopsies directed at mucosal abnormalities only, or were random biopsies obtained? Of the 195 achalasia study patients, did the 192 who reportedly did not develop malignancy have random biopsies during surveillance endoscopy? Finally, why were patients subjected to serial contrast radiology and esophageal manometry when the study was designed to establish the efficacy of endoscopic surveillance for malignancy in achalasia? This study appears to demonstrate an increased incidence of SCC of the esophagus in patients with long-standing achalasia over that of the general population of The Netherlands. The relative risk of 33 is impressive and appears to justify selective screening for this high risk group. Three questions are relevant to screening for any disease. First, does early detection improve survival? As cited in the excellent 1984 review article by Lightdale and Winawer (Semin Oncol 1984;11:101-12), large-scale studies of esophageal cancer in China (Endoscopy 1982;14:157-61) suggest that early detection may indeed improve survival. Using cytology obtained by blind abrasive balloon technique and subsequent endoscopic biopsy, the accuracy of esophageal cancer detection in asymptomatic individuals in a high incidence province of China was estimated as 80%, although the denominator is unclear. Of particular interest, 75% of the cancers detected were "early" lesions. Second, how severe is the disease itself? The 5-year survival of patients with symptomatic esophageal carcinoma has been estimated at 10%. The cure rate following surgery in early carcinoma patients in the Chinese study was reportedly 90%, a remarkable improvement suggesting that early detection of this disease benefits survival. The apparent long lead time adds weight to the case for screening. The Chinese study suggests that cytology can detect early, non-, or minimally invasive esophageal carcinoma and that the biologic rate of progression of these tumors is slow, in the order of 3 to 4 years from localized to advanced disease. This would suggest, as in the study from The Netherlands, that periodic screening with intervals of 1 to 2 years will allow detection of most esophageal carcinomas at an early, potentially curable stage. Finally, how good is the screening test itself? Endoscopy with brush cytology and biopsy has the highest sensitivity and specificity of all of the available screening tests for esophageal cancer, although blind abrasive cytology may be comparable for early carcinomas. However, endoscopy is preferable for screening as positive blind cytology still necessitates endoGASTROINTESTINAL ENDOSCOPY
scopic confirmation. The Chinese esophageal cancer screening project results suggest that as many as 20% of patients with early esophageal cancer will have normal-appearing mucosa at endoscopy. Therefore, "blind" cytologic brushing and biopsy should be performed at endoscopy even if the esophagus appears to be grossly normal. How should gastroenterologists proceed? This article confirms the observation that patients with achalasia are a small but high risk subgroup for the development of esophageal carcinoma and suggests that they may benefit from routine surveillance. However, as the authors clearly state, a larger prospective trial with longer follow-up is required to establish the efficacy and cost effectiveness of endoscopic screening as a way to reduce morbidity and mortality from esophageal carcinoma in patients with achalasia. The short interval (mean 5.7 years) between the diagnosis of achalasia and onset of malignancy in the three patients reported, and the impressive relative risk (33), suggest that screening will be rewarded earlier and more often in achalasia than in most other chronic gastrointestinal disorders. JANE
E.
ONKEN
JOHN BAILLIE
Durham, North Carolina
John P. Papp, MD
Book Reviews
Grand Rapids, Michigan
Double Contrast Gastrointestinal Radiology, Second Edition by I. Laufer, M. S. Levine W. B. Saunders, Philadelphia, 1992, 720 pp., 788 illustrations, $125.00 The second edition of Igor Laufer's Double Contrast Gastrointestinal Radiology is a superb book. Dr. Marc Levine, also from the University of Pennsylvania Hospital, has joined Dr. Laufer as a co-author. The principles of technique and interpretation of barium radiography are clearly written. Major pathologic entities of the esophagus, stomach, small bowel, and colon are discussed and superbly illustrated. The second edition also includes new diseases such as those associated with HIV infection and a new chapter on evaluation of the pharynx. The quality of the text and radiographs in this publication are beyond comparison. Double contrast gastrointestinal radiology is a classic and should be considered essential reading for any physician who performs or interprets barium studies of the gastrointestinal tract. Stephen W. Trenkner, MD Minneapolis, Minnesota
The Stomach edited by Sven Gustavsson, DeVinder Kumar, David Y. Graham Churchill Livingstone, New York, 1992,444 pp., $125.00 VOLUME 38, NO.6, 1992
The Stomach has 36 contributing authors and 18 chapters. It is intended to provide comprehensive coverage of the stomach, which it does exceedingly well. It carefully covers such topics as gastric mucosal anatomy, neurology of the stomach, gastric physiology and gastric pathophysiology, signs and symptoms of upper gastrointestinal disease, and numerous disease states of the stomach. Medical and surgical approaches to pathological states affecting the stomach are discussed in depth. Numerous references are given at the end of each chapter. Each chapter is succinctly written and up to date. Particularly excellent are those chapters dealing with physiology and pathophysiology. This book would make an excellent addition to one's library as a reference source. It would be useful to . medical students, residents, gastroenterology fellows, and clinical practitioners. It provides a source where one can look to answer any question one might have regarding the stomach. Its easily readable print and format makes the book enjoyable to read, as well as most informative. It is a welcome addition to our reference libraries. The book is a credit to its editors and authors.
Gastrointestinal Emergencies edited by M. B. Taylor Williams & Wilkins, Baltimore, 1992, 615 pp., $105.00 This multi-authored book is a very comprehensive text covering all aspects of gastrointestinal diseases. Most of the 58 chapters expand well beyond the title theme of Gastrointestinal Emergencies and provide complete reviews of current pathophysiology, clinical presentation, and therapy of a large number of gastrointestinal problems. The text is organized in an organ system fashion starting with the esophagus and ending with the large intestine. Included are multiple chapters on liver, biliary tract, and pancreatic disease. Particularly well covered are the problems of gastrointestinal bleeding (7 chapters) and infectious problems (10 chapters). In addition to the traditional gastrointestinal topics, the editors have included several unusual topics such as foreign bodies of the esophagus and colon, typhlitis, and radiation exposure in pregnancy. Particularly useful for endoscopists are five chapters reviewing complications of gastrointestinal procedures. This text is very useful for quick reference because the topic-oriented chapters and extensive index allow rapid location of pertinent information on specific problems. Each chapter is well referenced (over 100 references per chapter) if more indepth information is desired. Several times, the same problem is discussed in different chapters which is a plus for reference use, 739
Bologna, Italy
A prospective study of esophageal squamous cell carcinoma in achalasia MEIJSSEN MA, TILANUS
HW,
VAN BLANKENSTEIN M,
ETAL.
Gut 1992;33:155-8
The authors of this article from The Netherlands set out to establish the true incidence of esophageal carcinoma in patients with achalasia and the efficacy of endoscopic surveillance. One hundred and ninety-five consecutive patients (90 men and 105 women) diagnosed with achalasia between 1973 and 1988 were followed prospectively. The diagnosis of achalasia was confirmed by contrast radiology, endoscopy, and esophageal manometry. All patients underwent serial pneumatic dilation with review at 3 months and years 1, 2, 4, 7, and 10 (or greater). Follow-up included a barium swallow, esophageal manometry, and EGD with biopsy. If esophageal carcinoma was detected, staging was carried out. The incidence of squamous cell carcinoma (SeC) of the esophagus in the study group was compared with the expected incidence in age- and sex-matched controls, using the subject-years method. Follow-up after pneumatic dilation totaled 874 person years. The mean age at the time of diagnosis of achalasia was 52 years. Twenty-seven patients died over the course of the study, one from stage IV sec of the esophagus. This patient refused routine examinations after 1 year; carcinoma was identified 3 years later. Two of the remaining patients developed sec of the esophagus (stage I and IIa, respectively), resulting in an incidence of 3/874 person years or 3,4/ 1000 patients per year. The mean age at the time of diagnosis of squamous cell carcinoma was 68 years (range, 37 to 89 years). A mean of 17 years separated the onset of dysphagia and the diagnosis of carcinoma. The mean interval between the diagnosis of achalasia (as distinct from the onset of symptoms) and detection of esophageal carcinoma was 5.7 years (range, 4 to 8 years). Tumor was located in the middle third of the esophagus in all three patients, although it extended to the distal esophagus in one. The expected incidence of sec of the esophagus in an age- and sex-matched population in the Netherlands was 0.104/1000 patients per year, resulting in a relative risk for development of squamous cell carcinoma of the esophagus in patients with achalasia of 33 (p < 0.001). Based on these findings, the authors conclude that there is substantially increased risk for the development of esophageal carcinoma in patients with long-standing 738
achalasia and recommend endoscopic screening every 2 to 3 years. However, the authors also caution that their conclusions are based on data from only three patients who developed cancer and suggest that largescale studies are needed to accurately determine the efficacy and optimal frequency of endoscopic screening in patients with achalasia. 'This article represents a commendable effort to identify the true incidence of malignancy complicating achalasia of the esophagus. However, some questions and problems arise. First, the authors fail to state whether or not the study and control populations were screened for potentially confounding variables, such as cigarette smoking and alcohol use. Second, the incidence of esophageal malignancy in the control group could have been underestimated as these patients were subjected to less vigorous screening than the study population. Third, were biopsies directed at mucosal abnormalities only, or were random biopsies obtained? Of the 195 achalasia study patients, did the 192 who reportedly did not develop malignancy have random biopsies during surveillance endoscopy? Finally, why were patients subjected to serial contrast radiology and esophageal manometry when the study was designed to establish the efficacy of endoscopic surveillance for malignancy in achalasia? This study appears to demonstrate an increased incidence of SCC of the esophagus in patients with long-standing achalasia over that of the general population of The Netherlands. The relative risk of 33 is impressive and appears to justify selective screening for this high risk group. Three questions are relevant to screening for any disease. First, does early detection improve survival? As cited in the excellent 1984 review article by Lightdale and Winawer (Semin Oncol 1984;11:101-12), large-scale studies of esophageal cancer in China (Endoscopy 1982;14:157-61) suggest that early detection may indeed improve survival. Using cytology obtained by blind abrasive balloon technique and subsequent endoscopic biopsy, the accuracy of esophageal cancer detection in asymptomatic individuals in a high incidence province of China was estimated as 80%, although the denominator is unclear. Of particular interest, 75% of the cancers detected were "early" lesions. Second, how severe is the disease itself? The 5-year survival of patients with symptomatic esophageal carcinoma has been estimated at 10%. The cure rate following surgery in early carcinoma patients in the Chinese study was reportedly 90%, a remarkable improvement suggesting that early detection of this disease benefits survival. The apparent long lead time adds weight to the case for screening. The Chinese study suggests that cytology can detect early, non-, or minimally invasive esophageal carcinoma and that the biologic rate of progression of these tumors is slow, in the order of 3 to 4 years from localized to advanced disease. This would suggest, as in the study from The Netherlands, that periodic screening with intervals of 1 to 2 years will allow detection of most esophageal carcinomas at an early, potentially curable stage. Finally, how good is the screening test itself? Endoscopy with brush cytology and biopsy has the highest sensitivity and specificity of all of the available screening tests for esophageal cancer, although blind abrasive cytology may be comparable for early carcinomas. However, endoscopy is preferable for screening as positive blind cytology still necessitates endoGASTROINTESTINAL ENDOSCOPY
scopic confirmation. The Chinese esophageal cancer screening project results suggest that as many as 20% of patients with early esophageal cancer will have normal-appearing mucosa at endoscopy. Therefore, "blind" cytologic brushing and biopsy should be performed at endoscopy even if the esophagus appears to be grossly normal. How should gastroenterologists proceed? This article confirms the observation that patients with achalasia are a small but high risk subgroup for the development of esophageal carcinoma and suggests that they may benefit from routine surveillance. However, as the authors clearly state, a larger prospective trial with longer follow-up is required to establish the efficacy and cost effectiveness of endoscopic screening as a way to reduce morbidity and mortality from esophageal carcinoma in patients with achalasia. The short interval (mean 5.7 years) between the diagnosis of achalasia and onset of malignancy in the three patients reported, and the impressive relative risk (33), suggest that screening will be rewarded earlier and more often in achalasia than in most other chronic gastrointestinal disorders. JANE
E.
ONKEN
JOHN BAILLIE
Durham, North Carolina
John P. Papp, MD
Book Reviews
Grand Rapids, Michigan
Double Contrast Gastrointestinal Radiology, Second Edition by I. Laufer, M. S. Levine W. B. Saunders, Philadelphia, 1992, 720 pp., 788 illustrations, $125.00 The second edition of Igor Laufer's Double Contrast Gastrointestinal Radiology is a superb book. Dr. Marc Levine, also from the University of Pennsylvania Hospital, has joined Dr. Laufer as a co-author. The principles of technique and interpretation of barium radiography are clearly written. Major pathologic entities of the esophagus, stomach, small bowel, and colon are discussed and superbly illustrated. The second edition also includes new diseases such as those associated with HIV infection and a new chapter on evaluation of the pharynx. The quality of the text and radiographs in this publication are beyond comparison. Double contrast gastrointestinal radiology is a classic and should be considered essential reading for any physician who performs or interprets barium studies of the gastrointestinal tract. Stephen W. Trenkner, MD Minneapolis, Minnesota
The Stomach edited by Sven Gustavsson, DeVinder Kumar, David Y. Graham Churchill Livingstone, New York, 1992,444 pp., $125.00 VOLUME 38, NO.6, 1992
The Stomach has 36 contributing authors and 18 chapters. It is intended to provide comprehensive coverage of the stomach, which it does exceedingly well. It carefully covers such topics as gastric mucosal anatomy, neurology of the stomach, gastric physiology and gastric pathophysiology, signs and symptoms of upper gastrointestinal disease, and numerous disease states of the stomach. Medical and surgical approaches to pathological states affecting the stomach are discussed in depth. Numerous references are given at the end of each chapter. Each chapter is succinctly written and up to date. Particularly excellent are those chapters dealing with physiology and pathophysiology. This book would make an excellent addition to one's library as a reference source. It would be useful to . medical students, residents, gastroenterology fellows, and clinical practitioners. It provides a source where one can look to answer any question one might have regarding the stomach. Its easily readable print and format makes the book enjoyable to read, as well as most informative. It is a welcome addition to our reference libraries. The book is a credit to its editors and authors.
Gastrointestinal Emergencies edited by M. B. Taylor Williams & Wilkins, Baltimore, 1992, 615 pp., $105.00 This multi-authored book is a very comprehensive text covering all aspects of gastrointestinal diseases. Most of the 58 chapters expand well beyond the title theme of Gastrointestinal Emergencies and provide complete reviews of current pathophysiology, clinical presentation, and therapy of a large number of gastrointestinal problems. The text is organized in an organ system fashion starting with the esophagus and ending with the large intestine. Included are multiple chapters on liver, biliary tract, and pancreatic disease. Particularly well covered are the problems of gastrointestinal bleeding (7 chapters) and infectious problems (10 chapters). In addition to the traditional gastrointestinal topics, the editors have included several unusual topics such as foreign bodies of the esophagus and colon, typhlitis, and radiation exposure in pregnancy. Particularly useful for endoscopists are five chapters reviewing complications of gastrointestinal procedures. This text is very useful for quick reference because the topic-oriented chapters and extensive index allow rapid location of pertinent information on specific problems. Each chapter is well referenced (over 100 references per chapter) if more indepth information is desired. Several times, the same problem is discussed in different chapters which is a plus for reference use, 739
