The REAL (REctal Anastomotic Leak) score for prediction of anastomotic leak after rectal cancer surgery.

BACKGROUND: Anastomotic leak after rectal cancer surgery is a severe complication associated with poorer oncologic outcome and quality of life. Preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity to create a defunctioning stoma. OBJECTIVE: The purpose of this study was to identify and quantify the risk factors for anastomotic leak to minimize risk by either not restoring bowel continuity or protecting the anastomosis with a temporary diverting stoma. METHODS: Potentially relevant studies were identified from the following databases: PubMed, Embase and Cochrane Library. This meta-analysis included studies on transabdominal resection for rectal cancer that reported data about anastomotic leak. The risk for anastomotic leak after rectal cancer surgery was investigated. Preoperative, intraoperative, and postoperative factors were extracted and used to compare anastomotic leak rates. All variables demonstrating a p value < 0.1 in the univariate analysis were entered into a multivariate logistic regression model to determine the risk factors for anastomotic leak. RESULTS: Twenty-six centers provided individual data on 9735 patients. Selected preoperative covariates (time before surgery, age, gender, smoking, previous abdominal surgery, BMI, diabetes, ASA, hemoglobin level, TNM classification stage, anastomotic distance) were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. With a threshold value of the receiver operating characteristics (ROC) curve corresponding to 0.0791 in the training set, the area under the ROC curve (AUC) was 0.585 (p < 0.0001). Sensitivity and specificity of the model's probability > 0.0791 to identify anastomotic leak were 79.1% and 32.9%, respectively. Accuracy of the threshold value was confirmed in the validation set with 77.8% sensitivity and 35.2% specificity. CONCLUSIONS: We trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. The score is now available online ( http://www.real-score.org ).

Environmental enrichment mitigates the sex-specific effects of gestational inflammation on social engagement and the hypothalamic pituitary adrenal axis-feedback system.

Modest environmental enrichment (EE) is well recognized to protect and rescue the brain from the consequences of a variety of insults. Although animal models of maternal immune activation (MIA) are associated with several neurodevelopmental impairments in both the behavioral and cognitive functioning of offspring, the impact of EE in protecting or reversing these effects has not been fully evaluated. In the present study, female Sprague-Dawley rats were randomized into EE (pair-housed in a large multi-level cage with toys, tubes and ramps) or animal care control (ACC; pair-housed in standard cages) conditions. Each pair was bred, following assignment to their housing condition, and administered 100µg/kg of lipopolysaccharide (LPS) on gestational day 11. After birth, and until the end of the study, offspring were maintained in their respective housing conditions. EE protected against both the social and hypothalamic pituitary adrenal axis consequences of MIA in juvenile male rats, but surprisingly not against the spatial discrimination deficits or accompanying decrease in glutamate levels within the hippocampus (as measured via LCMS-MS). Based on these preliminary results, the mechanisms that underlie the sex-specific consequences that follow MIA appear to be dependent on environmental context. Together, this work highlights the importance of environmental complexity in the prevention of neurodevelopmental deficits following MIA.

Modeling realistic synaptic inputs of CA1 hippocampal pyramidal neurons and interneurons via Adaptive Generalized Leaky Integrate-and-Fire models.

Computational models of brain regions are crucial for understanding neuronal network dynamics and the emergence of cognitive functions. However, current supercomputing limitations hinder the implementation of large networks with millions of morphological and biophysical accurate neurons. Consequently, research has focused on simplified spiking neuron models, ranging from the computationally fast Leaky Integrate and Fire (LIF) linear models to more sophisticated non-linear implementations like Adaptive Exponential (AdEX) and Izhikevic models, through Generalized Leaky Integrate and Fire (GLIF) approaches. However, in almost all cases, these models are tuned (and can be validated) only under constant current injections and they may not, in general, also reproduce experimental findings under variable currents. This study introduces an Adaptive GLIF (A-GLIF) approach that addresses this limitation by incorporating a new set of update rules. The extended A-GLIF model successfully reproduces both constant and variable current inputs, and it was validated against the results obtained using a biophysical accurate model neuron. This enhancement provides researchers with a tool to optimize spiking neuron models using classic experimental traces under constant current injections, reliably predicting responses to synaptic inputs, which can be confidently used for large-scale network implementations.

Mathematical generation of data-driven hippocampal CA1 pyramidal neurons and interneurons copies via A-GLIF models for large-scale networks covering the experimental variability range.

Efficient and accurate large-scale networks are a fundamental tool in modeling brain areas, to advance our understanding of neuronal dynamics. However, their implementation faces two key issues: computational efficiency and heterogeneity. Computational efficiency is achieved using simplified neurons, whereas there are no practical solutions available to solve the problem of reproducing in a large-scale network the experimentally observed heterogeneity of the intrinsic properties of neurons. This is important, because the use of identical nodes in a network can generate artifacts which can hinder an adequate representation of the properties of a real network. To this aim, we introduce a mathematical procedure to generate an arbitrary large number of copies of simplified hippocampal CA1 pyramidal neurons and interneurons models, which exhibit the full range of firing dynamics observed in these cells - including adapting, non-adapting and bursting. For this purpose, we rely on a recently published adaptive generalized leaky integrate-and-fire (A-GLIF) modeling approach, leveraging on its ability to reproduce the rich set of electrophysiological behaviors of these types of neurons under a variety of different stimulation currents. The generation procedure is based on a perturbation of model's parameters related to the initial data, firing block, and internal dynamics, and suitably validated against experimental data to ensure that the firing dynamics of any given cell copy remains within the experimental range. A classification procedure confirmed that the firing behavior of most of the pyramidal/interneuron copies was consistent with the experimental data. This approach allows to obtain heterogeneous copies with mathematically controlled firing properties. A full set of heterogeneous neurons composing the CA1 region of a rat hippocampus (approximately 1.2 million neurons), are provided in a database freely available in the live paper section of the EBRAINS platform. By adapting the underlying A-GLIF framework, it will be possible to extend the numerical approach presented here to create, in a mathematically controlled manner, an arbitrarily large number of non-identical copies of cell populations with firing properties related to other brain areas.

The role of network connectivity on epileptiform activity.

A number of potentially important mechanisms have been identified as key players to generate epileptiform activity, such as genetic mutations, activity-dependent alteration of synaptic functions, and functional network reorganization at the macroscopic level. Here we study how network connectivity at cellular level can affect the onset of epileptiform activity, using computational model networks with different wiring properties. The model suggests that networks connected as in real brain circuits are more resistant to generate seizure-like activity. The results suggest new experimentally testable predictions on the cellular network connectivity in epileptic individuals, and highlight the importance of using the appropriate network connectivity to investigate epileptiform activity with computational models.

Preterm delivery and premature rupture of membranes after conization in 80 women. Preliminary data.

AIM: Cervical intraepithelial neoplasia is most frequently in young women in reproductive age. Cold knife conization, laser ablation, laser conization and large loop excision are conservative methods of treatment to remove the transformation zone and preserve the cervical function. Previous studies have shown conflicting results on the outcomes of pregnancy following these therapies that might increase the risk of preterm delivery. The purpose of this study was to evaluate the outcome of pregnancy after conization and its role as predictive risk factor. METHODS: A retrospective study was performed. The study group comprised 80 women who had a conization and that had a subsequent singleton pregnancy. Variables considered includes maternal excision date, surgery procedure, previous surgery treatments, time interval between excisional procedure and subsequent pregnancy; duration and week of pregnancy, mode of delivery, histological grading (no cervical intraepithelial neoplasia [CIN], CIN 1, CIN 2-3) and cone excised depth. RESULTS: In group study 45 women underwent loop electrosurgical excision procedure (LEEP) conization, 32 cold knife conization and 3 laser CO2. The authors found 11 cases of cone tissue depth<1 cm, and remaining one>1 cm. Eight preterm delivery have been reported to data: 5 between 28 and 34 weeks, 2 lower than 28 weeks and 1 between 34 and 37 weeks. CONCLUSION: In these preliminary data the percentage of preterm birth appears as 10% and in range 6-15% evaluated for women not submitted to excisional procedures.

Input-output relations in the entorhinal cortex-dentate-hippocampal system: evidence for a non-linear transfer of signals.

In the current study we analyzed the input-output relations in the entorhinal-dentate-hippocampal system, a major network involved in long-term memory. In anesthetized guinea pigs, the system was driven by activation of perforant path neurons in the entorhinal cortex (ENT), via presubicular fibers directly stimulated in the dorsal psalterium. Perforant path neuron discharge activated in parallel the dentate gyrus (DG) and hippocampal field CA2. Whereas the output from the DG activated hippocampal field CA3, the output from the sole field CA2 was sufficient for activation of field CA1. Signals from field CA3 operated in concert with CA2, likely contributing to discharge field CA1. These findings indicate the existence of two in parallel disynaptic systems: an ENT-CA2-CA1 and an ENT-DG-CA3 system. The convergence of the latter with the former gives origin the classical trisynaptic circuit, the ENT-DG-CA3-CA1 system. The input-output relations between the population excitatory postsynaptic potentials (pEPSP) evoked in the DG, CA3, CA2 and CA1 and the population spike (PS) evoked in the structure upstream (the input) were described by smooth sigmoid curves. In contrast, the input-output relations of the PS versus the pEPSP within each structure were described by steep sigmoid curves. The net input-output functions of the DG (ENT-DG system), field CA2 (ENT-CA2 system), field CA3 (ENT-DG-CA3 system) and field CA1 (ENT-CA2-CA1&ENT-DG-CA3-CA1 system) were described by sigmoid curves. While the DG and field CA2 exhibited steep sigmoids, fields CA3 and CA1 had less steep sigmoid functions. The present study demonstrates that all structures downstream to the ENT operate according to sigmoid input-output functions, characterized by specific parameters. These different behaviors may contribute to different memory processes. We additionally demonstrate that field CA1 can be activated by field CA2, independently from field CA3. This functional dissociation between CA3 and CA1 may subserve specific roles of each field in memory encoding/retrieval.

Morphofunctional alterations in ventral tegmental area dopamine neurons in acute and prolonged opiates withdrawal. A computational perspective.

Dopamine (DA) neurons of the ventral tegmental area (VTA) play a key role in the neurobiological basis of goal-directed behaviors and addiction. Morphine (MOR) withdrawal induces acute and long-term changes in the morphology and physiology of VTA DA cells, but the mechanisms underlying these modifications are poorly understood. Because of their predictive value, computational models are a powerful tool in neurobiological research, and are often used to gain further insights and deeper understanding on the molecular and physiological mechanisms underlying the development of various psychiatric disorders. Here we present a biophysical model of a DA VTA neuron based on 3D morphological reconstruction and electrophysiological data, showing how opiates withdrawal-driven morphological and electrophysiological changes could affect the firing rate and discharge pattern. The model findings suggest how and to what extent a change in the balance of GABA/GLU inputs can take into account the experimentally observed hypofunction of VTA DA neurons during acute and prolonged withdrawal, whereas morphological changes may play a role in the increased excitability of VTA DA cell to opiate administration observed during opiate withdrawal.

Tracing the trajectory of behavioral impairments and oxidative stress in an animal model of neonatal inflammation.

Exposure to early-life inflammation results in time-of-challenge-dependent changes in both brain and behavior. The consequences of this neural and behavioral reprogramming are most often reported in adulthood. However, the trajectory for the expression of these various changes is not well delineated, particularly between the juvenile and adult phases of development. Moreover, interventions to protect against these neurodevelopmental disruptions are rarely evaluated. Here, female Sprague-Dawley rats were housed in either environmental enrichment (EE) or standard care (SC) and their male and female offspring were administered 50 µg/kg i.p. of lipopolysaccharide (LPS) or pyrogen-free saline in a dual-administration neonatal protocol. All animals maintained their respective housing assignments from breeding until the end of the study. LPS exposure on postnatal days (P) 3 and 5 of life resulted in differential expression of emotional and cognitive disruptions and evidence of oxidative stress across development. Specifically, social behavior was reduced in neonatal-treated (n)LPS animals at adolescence (P40), but not adulthood (P70). In contrast, male nLPS rats exhibited intact spatial memory as adolescents which was impaired in later life. Moreover, these males had decreased prefrontal cortex levels of glutathione at P40, which was normalized in adult animals. Notably, EE appeared to offer some protection against the consequences of inflammation on juvenile social behavior and fully prevented reduced glutathione levels in the juvenile prefrontal cortex. Combined, these time-dependent effects provide evidence that early-life inflammation interacts with other developmental variables, specifically puberty and EE, in the expression (and prevention) of select behavioral and molecular programs.

Environmental enrichment models a naturalistic form of maternal separation and shapes the anxiety response patterns of offspring.

Environmental enrichment (EE) mimics positive life experiences by providing enhanced social and physical stimulation. Placement into EE following weaning, or in later life, confers beneficial outcomes on both emotional and cognitive processes. However, anxiety-like behavior is also reported, particularly in rats exposed to enhanced housing during early development. Notably, the quality of maternal behavior affects stress regulation and emotional stability in offspring, yet the impact of environmental context on maternal care has not been thoroughly evaluated, or are the influences of EE on their offspring understood. To investigate the role of EE on these factors we analyzed the details of mother-neonate interactions, and juvenile offspring performance on several anxiety measures. Additionally, we evaluated neurochemical differences (i.e. serotonin, corticosterone, GABA, glutamate) in prefrontal cortex and hippocampus as a function of EE, Communal Nesting (CN) and Standard Care (SC). Although EE dams spent significantly less time on the nest and had lower nursing frequencies compared to SC dams, there were no differences in maternal licking/grooming. In offspring, EE increased GLUR1 level and GABA concentrations in the prefrontal cortex of both juvenile male and female rats. A similar pattern for glutamate was only observed in males. Although EE offspring spent less time on the open arms of the elevated plus maze and had faster escape latencies in a light-dark test, there were no other indications of anxiety-like behavior on these measures or when engaged in social interaction with a conspecific. In the wild, rats live in complicated and variable environments. Consequently dams must leave their nest to defend and forage, limiting their duration of direct contact. EE exposure in early development may mimic this naturalistic maternal separation, shaping parental behavior and offspring resiliency to stressors.

Intranasal administration of glial-derived neurotrophic factor (GDNF) rapidly and significantly increases whole-brain GDNF level in rats.

Previous studies have shown that glial cell line-derived neurotrophic factor (GDNF) exerts significant neuroprotective effects on substantia nigra (SN) neurons in the rat 6-hydroxydopamine (6-OHDA) model of Parkinson's disease (PD). In this study we used enzyme-linked immunosorbent assay (ELISA) to determine GDNF brain levels and distribution to target regions (i.e. striatum and SN) following intranasal administration of GDNF at different time points after administration. Brain levels increased significantly within 1h following a single 50-µg dose of GDNF in a liposomal formulation, returning to baseline by 24h. In a second study, different doses of GDNF (10-150 µg) in phosphate-buffered saline (PBS) were studied at the 1-h time point. Dose-dependent increases in brain GDNF levels were observed with apparent saturation of uptake at doses above 100 µg. Liposomes delivered 10-fold more GDNF to brain than PBS despite yielding similar neuroprotective efficacy in the 6-OHDA model, suggesting incomplete release of GDNF from liposomes in tissue. In a third study, autoradiography was performed on brain sections taken 1h after intranasal (125)I-labeled GDNF. Radioactivity was detected throughout the brain along the rostral-to-caudal axis, indicating that nasally administered GDNF can reach target areas. Collectively, these results demonstrate that intranasal administration of GDNF in liposomes or PBS achieves significant increases in GDNF in target brain areas, supporting use of intranasal administration as a non-invasive means of delivering GDNF to the brain to protect dopamine neurons and arrest disease progression in PD.

Esophageal carcinoma with airway invasion. Evolution and choices of therapy.

In order to define the evolution of airway invasion by esophageal cancer, we reviewed 53 patients presenting with (group A) or without (group B) tracheoesophageal fistulae. Patients in group A were treated by esophageal bypass (4), esophageal diversion (4), expectant therapy (4), or esophageal prosthesis (1). The median survival was 4 months. Group B patients were treated by esophageal resection (18), esophageal bypass (4), or radiation therapy (13), depending on the extent of local disease. Bronchoscopy was a valuable tool for predicting resectability. Surgical resection, when possible, yielded better palliation. There were 4 long-term survivors in group B.

Pathophysiologic basis for operation on Zenker's diverticulum.

An increased resistance to bolus flow through the upper esophageal sphincter has in the past been considered the main cause of increased pharyngeal contraction and the subsequent development of Zenker's diverticulum (ZD). Our study was designed to elucidate the pathophysiologic characteristics of the swallowing mechanism and its possible role in the development of ZD. Fourteen patients with radiologically proved ZD and a matched control group of healthy volunteers with no gastrointestinal symptoms were investigated with esophageal manometry using the station pull-through technique. Although the mean amplitude of pharyngeal contraction was higher in the ZD group, there was no difference in the duration of contraction. The resting tone of the upper esophageal sphincter zone in patients with ZD was found to be lower than normal, but the closing pressure was higher and its duration longer. Though present in 2 patients, pharyngosphincteric incoordination was not the main feature in the ZD group. Sphincteroesophageal incoordination was noted in 9 patients, however. The mean amplitude of the upper esophageal contraction was higher and the duration longer in the ZD group. There was no upper esophageal peristalsis in 3 patients. An operation for the repair of ZD should therefore be undertaken only after careful interpretation of the manometric features of each patient.

Postoperative pain in neurosurgery: a pilot study in brain surgery.

The incidence, magnitude, and duration of acute pain experienced by neurosurgical patients after various brain operations are not precisely known, because of a lack of well-designed clinical and epidemiological studies. We assessed these important pain variables in 37 consecutive patients who underwent various brain neurosurgical procedures. Postoperative pain was more common than generally assumed (60%). In two-thirds of the patients with postoperative pain, the intensity was moderate to severe. Pain most frequently occurred within the first 48 hours after surgery, but a significant number of patients endured pain for longer periods. Pain was predominantly superficial (86%), suggesting somatic rather than visceral origin and possibly involving pericranial muscles and soft tissues. Subtemporal and suboccipital surgical routes yielded the highest incidence of postoperative pain. Age and sex were significantly associated with the onset of pain, with female and younger patients reporting higher percentages of postoperative pain. Psychological Minnesota Multiphasic Personality Inventory profiles of patients with and without pain significantly differed on the Hypochondriasis scale, with patients without pain scoring unexpectedly higher than patients with pain. It is possible that hypochondriasis serves as a defense mechanism against pain, at least in some patients. Results of this pilot study indicate that postoperative pain after brain surgery is an important, although neglected, clinical problem, that deserves greater attention by surgical teams, to provide better and more appropriate treatment.

Biomolecular-solvent stereodynamic coupling probed by deuteration.

Thermodynamic interpretation of experiments with isotopically perturbed solvent supports the view that solvent stereodynamics is directly relevant to thermodynamic stability of biomolecules. According with the current understanding of the structure of the aqueous solvent, in any stereodynamic configuration of the latter, connectivity pathways are identifiable for their topologic and order properties. Perturbing the solvent by isotopic substitution or, e.g., by addition of co-solvents, can therefore be viewed as reinforcing or otherwise perturbing these topologic structures. This microscopic model readily visualizes thermodynamic interpretation. In conclusion, the topologic stereodynamic structures of connectivity pathways in the solvent, as modified by interaction with solutes, acquire a specific thermodynamic and biological significance, and the problem of thermodynamic and functional stability of biomolecules is seen in its full pertinent phase space.

Early evaluation and therapy for caustic esophageal injury.

Forty-one patients with caustic ingestion were reviewed. Eighty-three percent were children, all of whom suffered accidental injury. Liquid drain cleaner was the agent in 57 percent and was responsible for all esophageal burns. Symptoms and physical findings were unreliable in predicting the extent of injury. Endoscopy was performed in most patients within 36 hours of ingestion and accurately estimated the risk of subsequent esophageal stricture formation. Steroid administration had no influence on the development of strictures. Esophageal strictures developed in 22 percent of the patients. One-third were successfully managed by periodic dilation, whereas the remaining two-thirds required esophagectomy and reconstruction. Early endoscopic evaluation was the best means of assessing the degree of injury after caustic ingestion. Routine steroid administration had no apparent clinical benefit.

A single-trocar technique for minimally-invasive surgery of the chest.

BACKGROUND: In thoracic surgery, the classic thoracoscope is used to perform simple maneuvers in the chest. We have devised a minimally invasive technique that requires only a single trocar. This technique is used in our department to diagnose and treat a wide range of thoracic pathologies. METHODS: Between October 1998 and August 1999, 37 patients underwent surgery prospectively for a thoracic disease through a single trocar. There were 19 men and 18 women with a mean age of 60 years (range, 40-85). The trocar was flexible or soft and had a diameter of 15-20 mm. A 2-cm skin incision was made in the planned intercostal space. The chest drain was always inserted under video control. RESULTS: The mean operative time was 53 +/- 5 min. One patient developed intraoperative bleeding that required intubation and a 5-cm mini-thoracotomy. In one patient with stage II empyema, it was necessary to insert another trocar. Chest tubes were removed after 77.7 +/- 7 h. Hospital stay was 4 +/- 1 days (range, 2-14). Histologic examination revealed malignant disease in 26 cases and benign disease in 11. Two patients (5.4%) developed wound infections. None of the patients had port site metastasis. There were no hospital deaths. CONCLUSION: Because of its simplicity, we recommend the use of this mini-invasive technique in place of the classic thoracoscope or video-mediastinoscope.

Clinical features and oesophageal motility in patients with tight fundoplication.

OBJECTIVE: Tight fundoplication is a well known complication of surgery for gastroesophageal reflux. We have noted, in clinical experience, that some patients operated for gastro-oesophageal reflux develop pharyngo-oesophageal dysphagia. This study was undertaken to elucidate, by comparing motility data in patients with and without tight fundoplication, the pathophysiologic characteristics of the swallowing mechanism and to clarify the cause of dysphagia in these patients. METHODS: Sixteen patients with postoperative persistent dysphagia following a fundoplication have been studied, of those 10 presented a lower oesophageal sphincter resting pressure above or equal to 30 mmHg (group A). Clinical work-up included a questionnaire, oendoscopy, manometry and barium meal or video-roentgenography. Oesophageal manometry was performed using a slow pull through technique while the stationary pull through technique was used for the pharyngo-oesophageal segment. The following parameters were evaluated: (a) amplitude of pharyngeal contraction; (b) upper oesophageal sphincter resting pressure; (c) amplitude of upper oesophageal sphincter contraction; (d) amplitude of oesophageal contraction; (e) lower oesophageal sphincter resting pressure. The results were compared to those of 21 patients who had a fundoplication with normal lower oesophageal sphincter pressure (group B). RESULTS: in group A there were three males and seven females, with a mean age of 51 years (ranging from 28 to 60 years). Previous operations were Nissen in two and Nissen Rossetti in eight patients. Three out of 10 patients of group A presented pharyngo-oesophageal dysphagia. Mean lower oesophageal sphincter 36 versus 21 mmHg and upper oesophageal sphincter 86 versus 42 mmHg resting pressure, pharyngeal 147 versus 76 mmHg and oesophageal amplitude, upper oesophageal contraction 251 versus 103 mmHg were significantly higher in patients of group A versus group B. An increased number of repetitive contractions was also found in group A. The presence of a strong correlation was demonstrated between the pharyngeal amplitude and the closing tone of the upper oesophageal sphincter (R2 0.742 and R2 0.739) in both groups. CONCLUSION: Tight fundoplication is, in our experience, always associated with total fundoplication. The appearance of pharyngo-oesophageal dysphagia in the postoperative period in patients operated on to correct gastroesophageal reflux using a total fundoplication, should not be under-estimated because it suggests an obstruction of the distal oesophagus.

Pharyngo-oesophageal dysphagia: surgery based on clinical and manometric data.

High or pharyngo-oesophageal dysphagia (PD) is defined as difficulty in initiating the act of swallowing within 1s. It involves the mechanisms controlling the tongue, pharynx and upper oesophageal sphincter (UOS) and is associated with a wide variety of local, neurologic and muscular disorders, and can also occur after surgery in the area and in response to gastro-oesophageal reflux (GOR). Our study aims at defining the criteria for surgery in PD and to evaluate the clinical results of such treatment. Twenty-three patients who underwent surgery were evaluated with pharyngo-oesophageal motility and ambulatory 24-hr pH-metry. The following parameters were measured: 1) pharyngeal contraction amplitude, 2) duration, 3) repetitive pharyngeal contractions, 4) UOS tone, 5) percentage of UOS relaxation, 6) duration of relaxation, 7) UOS closing pressure, 8) UOS closing duration, 9) co-ordination of UOS closing pressure and upper oesophageal (UO) contractions. Preoperative manometry showed a variety of abnormalities in several of the parameters, such as prolonged pharyngeal contraction ("spasm"), unco-ordinated pharyngeal contractions and UOS relaxation, low amplitude pharyngeal contractions, unco-ordinated UOS closing tone and UO contractions and hypotonic UO. Surgery was directed at the specific abnormality in each patient taking into consideration the presence or absence of GOR. Seventeen patients (74%) had excellent results. Three other patients (13%), who had improved swallowing but who continued to have GOR complicated by some oesophageal dysmotility, oesophagitis and an oesophageal web, underwent subsequent anti-reflux surgery with relief of symptoms. In conclusion, pharyngo-oesophageal motility measurement is mandatory in PD, especially when a diverticulum is absent. Cricopharyngeal myotomy with or without diverticulectomy as indicated produces excellent results. Associated oesophageal problems have to be dealt with appropriately.

The place of Belsey Mark IV fundoplication in the era of laparoscopic surgery.

OBJECTIVES: Laparoscopic fundoplication to correct or avoid gastroesophageal reflux decreased Belsey Mark IV fundoplication (BMIV) dramatically worldwide. The purpose of this paper was to determine the role of BMIV and its current indications. METHODS: We reviewed all patients who underwent fundoplication between April 1997 and December 2001. All patients underwent a complete work-up included barium meal, endoscopy, 24-h pH-metry and manometry preoperatively. RESULTS: Sixty-two consecutive fundoplications were performed. There were 23 males and 39 females. Forty-six patients were treated by laparoscopic approach (37 patients with total and nine patients with partial fundoplication). BMIV was preferred in 16 patients with the following indications: reoperations for failed oesophageal surgery (5), hiatal hernia fixed in the chest (4), epiphrenic oesophageal diverticula (3), diffuse oesophageal spam (2), hiatal hernia associated with bullous emphysema (1), leiomyoma of the oesophago-gastric junction (1). Excellent to good results were reported in 14 patients and poor in two. Follow-up was completed in all patients. CONCLUSIONS: BMIV remains a valid fundoplication although the current indications are now limited. The technique is to be considered an additional, but necessary, weapon for thoracic surgeons with interest in oesophageal disease.