Gerd Kanzler

Life expectancy and cancer risk in patients with Barrett’s esophagus: a prospective controlled investigation

BACKGROUND It has been suggested that patients with Barretts esophagus have a substantially increased risk of esophageal and possibly extra-esophageal cancers. We compared the incidence of cancer and the survival rates of patients with Barretts esophagus with those observed in patients with achalasia, with Schatzkis ring, and in the general population. PATIENTS AND METHODS From 1980 through 1994, 60 consecutive patients with newly diagnosed long-segment Barretts esophagus without dysplasia were seen in a single gastroenterology consultation office and followed until the Fall of 1999. Cancer incidence and survival rates were compared with age- and sex-matched patients with symptomatic Schatzkis ring (n = 60) and achalasia (n = 60). Survival data were also compared with those of the German population. RESULTS During a mean (+/-SD) observation period of 10 +/- 5 years, 2 patients with Barretts esophagus (3%; 95% confidence interval [CI]: 0% to 11%) developed esophageal cancer, and 9 (15%; 95% CI: 7% to 27%) developed extra-esophageal cancers. These data differed only slightly from those of patients with Schatzkis ring (esophageal cancer: n = 1, 2%; 95% CI: 0% to 9%; extra-esophageal cancers: n = 9, 15%; 95% CI: 7%-27%) and achalasia (no esophageal cancers, extra-esophageal cancers: n = 3, 5%; 95% CI: 1% to 4%). Estimated 10-year survival was similar in patients with Barretts esophagus (83%), patients with symptomatic Schatzkis ring (80%), patients with achalasia (87%), and in the general population (82%). CONCLUSIONS The cancer risk in patients with Barretts esophagus has been overestimated. If patients with nondysplastic epithelium are followed, the risk of esophageal cancer is about 1 per 300 patient-years.

Anorectal function and morphology in patients with sporadic proctalgia fugax

PURPOSE: The pathophysiology of sporadic proctalgia fugax remains unknown. This study investigates whether patients with this syndrome exhibit alterations in anal function and morphology. METHODS: Eighteen patients with sporadic proctalgia fugax and 18 sex-matched and age-matched healthy controls were studied. Manometric studies investigated anal resting and squeeze pressures, the rectoanal inhibitory reflex, rectal compliance, and smooth muscle response to edrophonium chloride administration. External and internal sphincter thickness was measured endosonographically. RESULTS: Patients had slightly higher (P=0.0291) anal resting pressures (65.5±11.4 mmHg) than controls (56±9.9 mmHg). However, anal squeeze pressure, sphincter relaxation during rectal distention, and rectal compliance were similar in both groups, and no alterations were detected in external and internal anal sphincter thickness. Edrophonium chloride administration was followed by sharp postrelaxation contractions in two patients, whereas anal function remained unaltered in controls. Acute episodes of proctalgia, which occurred in two patients while under study, were associated with a rise in anal resting tone and an increase in slow wave amplitude. CONCLUSIONS: In the resting state, patients with proctalgia fugax have normal anorectal function and morphology. However, they may exhibit a motor abnormality of the anal smooth muscle during an acute attack.

Single dilation of symptomatic Schatzki rings : a prospective evaluation of its effectiveness

This study investigates the effect of a single dilation on the morphology of the lower esophageal ring and on the clinical course of symptomatic patients. Thirty-three patients were studied prospectively for a mean period of 24.3±19.2 months. Passage of a large bougie (46–58 F) resulted in a rupture of the ring in each instance and its mean diameter increased from 11.4±3.6 to 17.2±4.1 mm. No complications occurred, and all patients were symptom-free at the first follow-up examination four weeks after dilation. However, late symptomatic recurrences were frequent. After one year, the estimated proportion of patients remaining free of symptoms was 68%, after two years 35%, and after five years 11%. Repeated treatments were performed with similar ease and effectiveness; again, no complications were encountered. Neither the initial ring size nor the presence or absence of esophagitis determined the likelihood of symptomatic recurrences. It is concluded that single dilations of symtomatic lower esophageal rings are safe, easily performed, and well tolerated. Long-term cure of episodic dysphagia is rare, but recurrences can be successfully treated by repeated dilations.

Colonoscopy without premedication versus barium enema: a comparison of patient discomfort

BACKGROUND Colonoscopy is considered a painful procedure requiring routine intravenous sedation. We investigated whether unsedated colonoscopy causes more discomfort than barium enema. METHODS Procedure-related discomfort was determined in 100 consecutive patients undergoing colonoscopy without premedication and in an equal number of patients referred for sigmoidoscopy and barium enema. All patients underwent such examinations for the first time and had no history of previous bowel surgery. During colonoscopy, sedation was offered if significant pain or discomfort occurred. RESULTS In patients without stenosis and with satisfactory preparation, the completion rate of colonoscopy was 95%. Five percent of all patients undergoing endoscopy required sedation. On an analog scale ranging from 1 to 9, patients undergoing colonoscopy and barium enema reported similar ratings for procedure related discomfort (3.2 +/- 1.7 and 3.1 +/- 1.9) and for discomfort caused by bowel preparation (3.2 +/- 2.1 and 3.1 +/- 1.8). Eighty-seven percent of all patients undergoing colonoscopy stated that they would prefer no premedication in the event of repeated examinations. CONCLUSIONS Colonoscopy with sedation on demand does not cause more discomfort than barium enema and will be accepted by the vast majority of patients undergoing this procedure.

Same-day versus separate-day sigmoidoscopy and double contrast barium enema: a randomized controlled study

A randomized controlled study was carried out in 400 patients to investigate whether same-day sigmoidoscopy impairs the quality of a double contrast barium enema. There was no difference with regard to spasm, fluid, and air retention as well as barium coat in patients undergoing both procedures during the same day or on different days. The overall quality of the radiographic films received similar ratings in a blind appraisal by an outside radiologist. In contrast, the performance of sigmoidoscopy was facilitated by the more thorough bowel cleansing for same-day procedures. It is concluded that same-day sigmoidoscopy and double contrast barium enema diminishes the cost and patient discomfort for colonic investigation without impairing its quality, provided that CO2 instead of air is used during the endoscopic study.