Esophageal hypermotility: cause or effect?

Nutcracker esophagus (NE), Jackhammer esophagus (JHE), distal esophageal spasm (DES), and hypertensive lower esophageal sphincter (HTLES) are defined by esophageal manometric findings. Some patients with these esophageal motility disorders also have abnormal gastroesophageal reflux. It is unclear to what extent these patients' symptoms are caused by the motility disorder, the acid reflux, or both. The aim of this study was to determine the effectiveness of laparoscopic Nissen fundoplication (LNF) on esophageal motility disorders, gastroesophageal reflux, and patient symptoms. Between 2007 and 2013, we performed high-resolution esophageal manometry on 3400 patients, and 221 patients were found to have a spastic esophageal motility disorder. The medical records of these patients were reviewed to determine the manometric abnormality, presence of gastroesophageal symptoms, and amount of esophageal acid exposure. In those patients that underwent LNF, we compared pre- and postoperative esophageal motility, gastroesophageal symptom severity, and esophageal acid exposure. Of the 221 patients with spastic motility disorders, 77 had NE, 2 had JHE, 30 had DES, and 112 had HTLES. The most frequently reported primary and secondary symptoms among all patients were: heartburn and/or regurgitation, 69.2%; respiratory, 39.8%; dysphagia, 35.7%; and chest pain, 22.6%. Of the 221 patients, 192 underwent 24-hour pH monitoring, and 103 demonstrated abnormal distal esophageal acid exposure. Abnormal 24-hour pH monitoring was detected in 62% of patients with heartburn and regurgitation, 49% of patients with respiratory symptoms, 36.8 % of patients with dysphagia, and 32.6% of patients with chest pain. Sixty-six of the 103 patients with abnormal 24-hour pH monitoring underwent LNF. Thirty-eight (13NE, 2JHE, 6 DES, and 17 HTLES) of these 66 patients had a minimum of 6-month postoperative follow-up that included clinical evaluation, esophageal manometry, and 24-hour pH monitoring. Postoperatively, all 38 patients had normal distal esophageal acid exposure. Of these 38 patients, symptoms resolved in 28 and improved in 10. Of six patients (one with NE, two JHE, and three with HTLES) that underwent postoperative esophageal manometry, five exhibited normal motility. Typical reflux symptoms are common among patients with esophageal hypermotility disorders. Abnormal 24-hour pH monitoring is present in the majority of patients with who report typical reflux symptoms and almost half of patients who report respiratory symptoms. Conversely, the majority of patients who report dysphagia or chest pain have normal distal esophageal acid exposure. Based on a small number of patients in this study, it also appears that motility disorders often improve after LNF. LNF is associated with resolution or improvement in reflux related symptoms and esophageal motility parameters in patients exhibiting abnormal esophageal acid exposure. This suggests that patient symptoms are due to abnormal acid exposure and not the motility disorder.

Synopsis of investigations into proposed theories on the etiology of achalasia.

The current state of research into the etiology of achalasia only allows for speculation. To date, several studies have been performed investigating genetic, immune, and infectious disease mechanisms; however, none of these have been conclusive. Further research into this topic is warranted given the severity of the disease, and it may be possible that all of these mechanisms are involved in the pathophysiology of the disease.

Outcomes of laparoscopic-assisted transhiatal esophagectomy for adenocarcinoma of the esophagus and esophago-gastric junction.

Esophagectomy is associated with substantial morbidity and mortality, yet it is the only modality that offers the possibility of cure for esophageal and gastroesophageal junction (E-GEJ) adenocarcinoma. Several minimally invasive techniques have been developed to decrease the morbidity of the operation, but to date, the results have not led to its wide adoption in part due to their complexity. We developed a technique of laparoscopic-assisted transhiatal esophagectomy (LA-THE) with the idea of preserving some of the advantages of the minimally invasive approach while eliminating the degree of complexity and the time required to complete the operation solely using laparoscopy. The course of all patients who underwent LA-THE for E-GEJ adenocarcinoma at the University of Washington Medical Center was determined by analysis of all hospital records to determine perioperative variables, complications, and survival. Patients were also given a follow-up survey in order to assess long-term health-related quality of life (Gastrointestinal Quality of Life Index or GIQLI). Seventy-two patients underwent LA-THE between 1995 and 2007. Median age was 64 years (range, 42-83 years), and the median body mass index was 28 (range 17-35). Twenty-eight tumors (39%) were categorized as Siewert I, 41 (57%) as Siewert II, and 3 (4%) as Siewert III. Median operative time was 299min (range, 212-700min). All the resections were R-0. The median number of lymph nodes harvested was 11 (range, 2-32). Using the Dindo-Clavien classification of surgical complication, we had a total of 48 postoperative complications in 37 patients: 26 (53%) grade I, 20 (41%) grade II, 1 (2%) grade IIIb, 1 (2%) grade IVb, and 1 (2%) grade V complications. Median length of hospital stay was 9 days (range, 7-58 days). One patient (1.4%) died within 30 days. Overall, 3- and 5-year survival (calculated Kaplan-Meier) was 68% and 63%, respectively. Forty-nine patients (90% of those still alive) answered the GIQLI survey. Median follow-up was 26 months (range, 6-144 months). The mean GIQLI score was 108 (range, 74-138) from a maximum possible value of 144. Our study shows that LA-THE is feasible, safe, and effective in the treatment of adenocarcinoma of the esophagus and GEJ and should probably be considered an alternative to open esophagectomy and other minimally invasive techniques in the treatment of this disease.

Prevalence of respiratory symptoms in patients with achalasia.

Achalasia is a primary esophageal motor disorder that results in poor clearance of the esophagus. Although an esophagus filled with debris and undigested food should put these patients at risk for aspiration, the frequency with which the latter occurs has never been documented. In this study, we sought to determine the incidence of respiratory symptoms and complaints in patients with achalasia. A comprehensive symptom questionnaire was administered to 110 patients with achalasia presenting to the Swallowing Center at the University of Washington between 1994 and 2008 as part of their preoperative work-up. Questionnaires were analyzed for the frequency of respiratory complaints in addition to the more typical symptoms of dysphagia, regurgitation, and chest pain. Twenty-two achalasia patients with respiratory symptoms who had also undergone Heller myotomy and completed a post-op follow-up questionnaire were analyzed as a subset. Ninety-five patients (86%) complained of at least daily dysphagia. Fifty-one patients (40%) reported the occurrence of at least one respiratory symptom daily, including cough in 41 patients (37%), aspiration (the sensation of inhaling regurgitated esophagogastric material) in 34 patients (31%), hoarseness in 23 patients (21%), wheezing in 17 patients (15%), shortness of breath in 11 patients (10%), and sore throat in 13 patients (12%). Neither age nor gender differed between those with and those without respiratory symptoms. In the subset of patients with respiratory symptoms who had undergone Heller myotomy, respiratory symptoms improved in the majority after the procedure. Patients with achalasia experience respiratory symptoms with much greater frequency than the approximately 10% that was previously believed. Awareness of this association may be important in the workup and ultimate treatment of patients with this uncommon esophageal disorder.

Does combined multichannel intraluminal esophageal impedance and manometry predict postoperative dysphagia after laparoscopic Nissen fundoplication?

Laparoscopic Nissen fundoplication (LNF) is an effective treatment for gastroesophageal reflux disease; however, some patients develop dysphagia postoperatively. Manometry is used to evaluate disorders of peristalsis, but has not been proven useful to identify which patients may be at risk for postoperative dysphagia. Multichannel intraluminal impedance (MII) evaluates the effective clearance of a swallowed bolus through the esophagus. We hypothesized that MII combined with manometry may detect those patients most at risk of developing dysphagia after LNF. Between March 2003 and January 2007, 74 patients who agreed to participate in this study were prospectively enrolled. All patients completed a preoperative symptom questionnaire, MII/manometry, and 24-h pH monitoring. All patients underwent LNF. Symptom questionnaires were administered postoperatively at a median of 18 months (range: 6-46 months), and we defined dysphagia (both preoperatively and postoperatively) as occurring more than once a month with a severity >or=4 (0-10 Symptom Severity Index). Thirty-two patients (43%) reported preoperative dysphagia, but there was no significant difference in pH monitoring, lower esophageal sphincter pressure/relaxation, peristalsis, liquid or viscous bolus transit (MII), or bolus transit time (MII) between patients with and without preoperative dysphagia. In those patients reporting preoperative dysphagia, the severity of dysphagia improved significantly from 6.8 +/- 2 to 2.6 +/- 3.4 (P < 0.001) after LNF. Thirteen (17%) patients reported dysphagia postoperatively, 10 of whom (75%) reported some degree of preoperative dysphagia. The presence of postoperative dysphagia was significantly more common in patients with preoperative dysphagia (P= 0.01). Patients with postoperative dysphagia had similar lower esophageal sphincter pressure and relaxation, peristalsis, and esophageal clearance to those without dysphagia. Neither MII nor manometry predicts dysphagia in patients with gastroesophageal reflux disease or its occurrence after LNF. The presence of dysphagia preoperatively is the only predictor of dysphagia after LNF.

Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia.

BACKGROUND: The standard Heller myotomy (SM) for achalasia extends 1 to 2 cm on to the stomach. The authors perform an extended myotomy (EM) (>3 cm) with the goal of reducing postoperative dysphagia. This study examines the long-term efficacy and durability of EM compared with SM. METHODS: Patients with achalasia who underwent a laparoscopic Heller myotomy were identified from a prospective database that includes symptom evaluation and results of esophageal functional studies. From September 1994 to August 1998, the authors performed SM with Dor fundoplication, and from September 1998 through 2003, they performed EM with Toupet fundoplication. In 2001, they performed a telephone survey of all available patients. This was repeated in 2005 for the EM group. The survey included scales of symptom frequency (0 [never], 1 [once per month], 2 [once per week], 3 [once per day], 4 [more than once per day]) and severity (0 [no symptoms] to 10 [symptoms equal to preoperative state]) as well as the need to undergo postoperative intervention for dysphagia. RESULTS: For this study, 52 patients underwent SM with Dor fundoplication (median follow-up period, 46 +/- 24 months), and 63 patients underwent EM with Toupet fundoplication (median follow-up period, 45 +/- 17 months. Postoperative dysphagia severity was significantly better in the EM group (4.8 +/- 2.3 vs 3.1 +/- 2.6; p < 0.005). There was no significant difference in postoperative heartburn frequency, esophageal acid exposure, or lower esophageal sphincter pressure. In the SM group, 9 patients (17%) required reintervention for dysphagia: 14 endoscopic interventions for 5 patients (10%) and reoperation for 4 patients. Three patients (5%) in the EM group required reintervention for dysphagia: one endoscopic intervention each and no reoperations (p < 0.05). A total of 30 patients in the EM group were contacted in both 2001 (median follow-up period, 19 +/- 11 months) and 2005 (median follow-up period, 63 +/- 10 months). There was no significant change over time in dysphagia severity (2.6 +/- 1.9 vs 3.7 +/- 2.0; p = 0.19). CONCLUSIONS: For the treatment of achalasia, EM with Toupet fundoplication provides excellent durable dysphagia relief that is superior to SM with Dor fundoplication.

Long-term outcomes of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD)-related airway disorder.

UNLABELLED: A strong link exists between gastroesophageal reflux disease (GERD) and airway diseases. Surgical therapy has been recommended as it is more effective than medical therapy in the short-term, but there is little data on the effectiveness of surgery long-term. We analyzed the long-term response of GERD-related airway disease after laparoscopic anti-reflux surgery (LARS). METHODS: In 2004, we contacted 128 patients with airway symptoms and GERD who underwent laparoscopic antireflux surgery (LARS) between 12/1993 and 12/ 2002. At median follow-up of 53 months (19-110 mo) we studied the effects on symptoms, esophageal acid exposure, and medication use and we analyzed the data to determine predictors of successful resolution of airway symptoms. RESULTS: Cough, hoarseness, wheezing, sore throat, and dyspnea improved in 65-75% of patients. Heartburn improved in 91% (105/116) of patients and regurgitation in 92% (90/98). The response rate for airway symptoms was the same in patients with and without heartburn. Almost every patient took proton pump inhibitors (PPIs) preoperatively (99%, 127/128) and 61% (n = 78) were taking double or triple dose. Postoperatively, 33% (n = 45) of patients were using daily antiacid therapy but no one was on double dose. The only factor that predicted a successful surgical outcome was the presence of abnormal reflux in the pharynx as determined by 24-hour pharyngeal pH monitoring. One hundred eleven (87%) patients rated their results as excellent (n = 78, 57%) or good (n = 33, 24%). CONCLUSION: LARS provides an effective and durable barrier to reflux, and in so doing improves GERD-related airway symptoms in approximately 70% of patients and improves typical GERD symptoms in approximately 90% of patients. Pharyngeal pH monitoring identifies those patients more likely to benefit from LARS, but better diagnostic tools are needed to improve the response of airway symptoms to that of typical esophageal symptoms.

Medium- and long-term outcome of laparoscopic redo fundoplication.

BACKGROUND: For a small subset of patients, laparoscopic fundoplication fails, typically resulting in recurrent reflux or severe dysphagia. Although redo fundoplications can be performed laparoscopically, few studies have examined their long-term efficacy. METHODS: Using a prospectively maintained database, the authors identified and contacted 41 patients who had undergone redo laparoscopic fundoplications at the University of Washington between 1996 and 2001. The median follow-up period was 50 months (range, 20-95 months). Current symptoms were compared with those acquired and entered into the authors' database preoperatively. Patients also were asked to return for esophageal manometry and pH testing. RESULTS: All redo fundoplications were performed laparoscopically. There were no conversions. The most common indication for redo fundoplication was recurrent reflux. The most common anatomic abnormality was a herniated wrap. Heartburn improved in 61%, regurgitation in 69%, and dysphagia in 74% of the patients. Complete resolution of these symptoms was achieved, respectively, in 45%, 41% and 38% of these same patients. Overall, 68% of the patients rated the success of the procedure as either "excellent" or "good," and 78% said they were happy they chose to have it. For those who underwent reoperation for gastroesophageal reflux disease, distal esophageal acid exposure according to 24-h pH monitoring decreased after redo fundoplication from 15.7% +/- 18.1% to 3.4% +/- 3.6% (p = 0.041). CONCLUSION: Although not as successful as primary fundoplication, a majority of patients can expect durable improvement in their symptoms with a laparoscopic redo fundoplication.

Barrett's ulcer of the esophagus. Previously unrecognized cause of acquired esophagorespiratory fistula.

Acquired fistulas between the esophagus and tracheobronchial tree are usually associated with malignancy of the esophagus, lung, or trachea. Less commonly, fistulas result from trauma or inflammation involving these structures. Untreated fistulas of any cause lead to fatal complications of aspiration. Although the prognosis in cases of malignant fistula is poor, the recognition and surgical management of nonmalignant fistulas may result in cure. An acquired esophagobronchial fistula resulting from a Barrett's ulcer of the esophagus, a previously unreported cause, is described, and the differential diagnosis and treatment of nonmalignant esophagorespiratory fistulas are discussed.

Technique, indications, and clinical use of 24 hour esophageal pH monitoring.

The technique of 24 hour esophageal pH monitoring (24 hour pH test) is described. Experience with the 24 hour pH test in 393 patients with suspected esophageal disease has shown the clinical usefulness of the test in objectively determining the presence of gastroesophageal reflux. The test was effective in evaluating atypical symptoms of gastroesophageal reflux such as respiratory symptoms and chest pain and, in children, failure to thrive and recurrent pneumonia. The 24 hour pH test was particularly useful in evaluating patients who were referred with other abdominal or thoracic disease and had, in addition, symptoms suggestive of gastroesophageal reflux on history. The test helped to unsnarl the cause of recurrent symptoms after an esophageal myotomy for achalasia or an antireflux procedure. Of 179 patients with typical symptoms of gastroesophageal reflux, 27% had normal 24 hour test results and were subsequently diagnosed as having another cause for their symptoms. Of 146 patients who had normal findings on esophagoscopy, 54% were shown to have abnormal gastroesophageal reflux on 24 hour pH monitoring, indicating lack of sensitivity of endoscopy to detect reflux. In addition, the 24 hour pH test identified patterns of abnormal reflux and indicated those patients most at risk for development of stricture. The test is well tolerated by the patients, simple to use, and dependable when performed and read as described. The clinical use of the 24 hour pH test brings objectivity to the evaluation of exophageal disease that has hitherto not been available.

Gallbladder filling and response to cholecystokinin are not affected by vagotomy.

We studied the effects of vagotomy on gallbladder (GB) motility in prairie dogs and humans with infusion cholescintigraphy. Twelve male prairie dogs were anesthetized and given an intravenous infusion of 120 microCi of diethyl-HIDA for 150 minutes. Images were acquired every 10 minutes. Then cholecystokinin (CCK)-8, 1.5 micrograms/kg, was given as a bolus, and images were acquired for another 30 minutes. We repeated the studies giving 300 micrograms/kg of atropine 20 minutes before administration of CCK-8. All animals underwent truncal vagotomy, and the studies were repeated 1 and 3 months later. The GB filled in a stepwise fashion; partitioning of bile varied from one 10-minute period to the next and averaged 20% +/- 2%/80% +/- 3% during the 150-minute period. Episodic partial GB emptying (ejection fraction 19% +/- 2%; intervals of 70 +/- 5 minutes) occurred during this phase. GB filling and partitioning of bile were unchanged after vagotomy. GB ejection fraction in response to CCK-8 was 69% +/- 6% in controls, 74% +/- 5% after atropine, 78% +/- 8% 4 weeks after vagotomy, and 66% +/- 6% 3 months after vagotomy. Sixteen human subjects were studied after parietal cell vagotomy (six patients) or truncal vagotomy and drainage (10 patients). GB filling average 2.5% +/- 2% per minute in patients who underwent truncal vagotomy and 3% +/- 1% per minute in patients who underwent parietal cell vagotomy. GB emptying in response to CCK-33 (0.02 U/kg/min) was 74% +/- 7% in patients who underwent truncal vagotomy and 82% +/- 4% in patients who underwent parietal cell vagotomy. Thus neither GB filling nor GB emptying in response to CCK was altered by cholinergic blockade or vagotomy.

Gastroesophageal reflux and pulmonary aspiration: incidence, functional abnormality, and results of surgical therapy.

The incidence of aspiration, the causative esophageal pathophysiology, and the results of surgical therapy were evaluated in 100 patients with abnormal gastroesophageal reflux documented by 24-hour esophageal pH monitoring. Based on historical evidence, 48 patients were suspected to be aspirators. Eight patients had documented episodes of aspiration (drop on esophagela pH, followed by acid taste in mouth and onset of cough or wheezing spell) during the monitoring period. Nine patients were considered to be potential aspirators because they presented oral acid regurgitation without development of pulmonary symptoms. In five patients a primary respiratory disorder (PRD) induced gastroesophageal reflux. The remaining 78 patients had abnormal reflux without aspiartion or regurgitation. Aspirators had a 75% incidence of esophageal motor abnormality on manometry, and the clearance of refluxed acid was significantly delayed in the supine position. A history of heartburn and endoscopic evidence of esophagitis were present in only half of the patients who were documented aspirators. Potential aspirators were spared from aspiration by rapid esophageal clearance of refluxed acid unaffected by changes in body position. Patients with a PRD had higher distal esophageal segment (DES) pressure and normal esophageal motility with minimal esophagitis. Nonaspirators significantly improved their clearance while in the supine position, emphasizing the protective effect of esophageal peristalsis against aspiration. An antireflux procedure in five aspirators raised the DES pressure significantly and returned the reflux status to normal by 24-hour pH-monitoring standards. The incidence of aspiration appears to be less than that suspected by history and is due to a motor disorder that interferes with the ability of the esophagus to clear reflex acid. Abnormal pulmonary symptoms can induce or result from gastroesophageal reflux and, when the latter occurs, an antireflex procedure stops both reflux and aspiration.

The treatment of achalasia. A current perspective.

We analyzed the course of 79 adult patients treated for achalasia between 1977 and 1988. Sixty-six patients (84%) had pneumatic dilatation as the primary therapy. Fifty-three patients (80%) had immediate improvement in swallowing. Three patients required immediate redilatation, 2 developed pulmonary aspiration, and 8 (12%) suffered esophageal perforation. Esophageal perforation was treated by closure plus Heller's myotomy in 3 patients, closure only in 3, chest tube in 1, and antibiotics and nasogastric suction in 1. At 4 years' follow-up, 50% of patients who had dilatation remained asymptomatic, 30% had symptoms of gastroesophageal reflux, and 20% had persistent dysphagia. Eight Heller myotomies were performed, with excellent results in 7 and 1 postoperative death from respiratory failure. Seven additional patients with disabling esophageal symptoms after multiple operations for achalasia were ultimately treated by esophagectomy (n = 5), hemigastrectomy and Roux-en-Y gastrojejunostomy (n = 1), and repeated myotomy (n = 1). All recovered and are able to eat solid food. Thus, our experience indicates that pneumatic dilatation remains unperfected (ie, the line between undertreatment and overtreatment is finer than generally recognized), and unless improvements can be made, the role for surgery may need to be reexpanded.

Abdominal abscess. A surgical strategy.

To reassess the role of laparotomy and extraserosal drainage in the treatment of patients with abdominal abscess, we analyzed the course of 79 patients who underwent 97 operations to treat 120 abdominal abscesses during a five-year period. In 66 clinical episodes the abscess was drained by the most direct approach. Sepsis resolved with a single operation In 80% of these patients, five patients (8%) required a second operation for drainage for an abscess, and eight patients (12%) died. In 31 clinical episodes, the abscess was drained by a laparotomy. Sepsis resolved with a single operation in 61% of these patients, seven patients (21%) had a second abscess, six patients (19%) required a second operation to drain a metachronous abscess, and six patients (19%) died. When the location or number of abscesses was diagnosed incorrectly, the success rate of therapy fell substantially. Since most abdominal abscesses can now be accurately diagnosed preoperatively, most abscesses should be drained by a direct approach. Exploratory laparotomy is indicated when preoperative localization is unsuccessful, when sepsis has not resolved after other methods of drainage, or when the patient has a concomitant abdominal condition that must be treated surgically.

Peritoneovenous shunt for refractory ascites: operative complications and long-term results.

We studied the clinical course of 35 patients with refractory ascites who underwent 51 peritoneovenous shunts. Nine of them had hepatorenal syndrome (HRS). Operative complications included shunt malfunction, shunt infection, ascitic leak, fluid overload, and disseminated intravascular coagulation. Two of the patients without HRS died postoperatively. The survival rate in this group was 67% at one year and 43% at two years. Ascites was completely controlled in 83% of the survivors at two months and 50% at two years. Neither survival nor shunt patency were predictable. The shunt reversed HRS in three patients, but failed to do so in the other six. Late complications included shunt malfunction and infection. During the first two years of follow-up, five patients bled from esophageal varices. Liver failure was the sole cause of late death. Peritoneovenous shunt should be reserved for patients with truly refractory ascites, for whom it provides excellent palliation.

Gastric emptying and small bowel transit of solid food after pylorus-preserving pancreaticoduodenectomy.

We examined the gastric emptying and small bowel transit of solid food in ten patients one to 45 months after pylorus-preserving pancreaticoduodenectomy. Gastric emptying and small bowel transit were measured by computer analysis of data from a scintillation camera using technetium Tc 99m-tagged chicken liver mixed with beef stew and were compared with the results in five control subjects. The nutritional status of the patients was also evaluated. Gastric emptying was normal in six patients, rapid in three patients, and delayed in one patient. Small bowel transit was normal in two patients, rapid in seven patients, and delayed in one patient. Most of the patients were asymptomatic, ate three meals a day, and gained weight after the operation. These findings show that after pylorus-preserving pancreaticoduodenectomy, most patients consume a regular diet and achieve an excellent nutritional status. Gastric emptying is normal, not slowed. Small bowel transit is faster than normal but is without clinical sequelae.

Management and outcome of complications after laparoscopic antireflux operations.

HYPOTHESIS: Perioperative complications of laparoscopic antireflux operations are infrequent and treatable and do not cause permanent disability. DESIGN: Retrospective review of all patients with laparoscopic antireflux operations for the management and outcome of all complications. SETTING: University medical center. PATIENTS: All 538 patients who underwent operation from January 20, 1993, through December 28, 1999. MAIN OUTCOME MEASURES: Complications were defined as any major or minor deviation from the standard postoperative clinical pathway. Minor complications did not require invasive treatment and were not expected to result in permanent disability. Major complications required invasive treatment or could result in permanent disability. The frequency of complications was also stratified into those that occurred during primary antireflux procedures and those that occurred during reoperations for previously failed procedures. RESULTS: Ninety-two complications occurred in 538 operations (17.1%). Sixty-eight patients (12.6%) experienced minor complications. Postoperative ileus was the most common complication (n = 37 [6.9%]), followed by pneumothorax (n = 13 [2.4%]) and urinary retention (n = 10 [1.9%]). Major complications were present in only 24 patients (4.5%) and occurred significantly more frequently after reoperations. Of these, dysphagia was the most frequent complication observed (n = 11 [2.0%]), followed by perforated viscus (n = 4 [0.7%]). Two patients (0.4%) died. All but 4 major complications resulted in full recovery. CONCLUSIONS: Major complications in laparoscopic antireflux surgery are rare, their treatment is straightforward, and permanent disability is uncommon. Complications occur twice as often during reoperations, highlighting the difficulty in performing these procedures. Although primary laparoscopic antireflux operations are performed by many general surgeons routinely, reoperations should be performed by a team experienced in laparoscopic esophageal surgery.

An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy.

We examined the course of 51 consecutive patients who underwent pancreaticoduodenectomies between 1979 and 1987. Fifteen patients (30%) had a traditional pancreaticoduodenectomy and 36 (70%) had a pylorus-preserving procedure. Operative blood loss, resumption of oral intake, and time to discharge from the hospital were not different for the two operations. One patient (2%) died of complications of the operation, and 14 patients (27%) had nonlethal intra-abdominal complications. Two patients required reoperation: 1 had a hemoperitoneum and 1 had a breakdown of a choledochoenterostomy. Of the patients undergoing pancreaticoduodenectomy for cancer, 26 (74%) of 35 survived 1 year, 9 (47%) of 19 survived 3 years, and 3 (33%) of 10 patients survived 5 or more years postoperatively. Our data showed that (1) on a service where a large number of these operations is performed, the mortality rate of patients who have undergone a pancreaticoduodenectomy is substantially lower than in the past and that (2) the main reasons for these improved results are greater experience of a few surgeons who perform the procedure regularly and the availability of computed tomographic scans and skilled interventional radiologists, which allows postoperative infection and pancreatic fistulas to be controlled. Although pancreaticoduodenectomy is only palliative in most patients with cancer, it provides the best palliation and the only chance of cure, and the procedure can be recommended when performed in tertiary care centers that possess these elements of success.

Comparison of medical and minimally invasive surgical therapy for primary esophageal motility disorders.

OBJECTIVE: To compare medical with minimally invasive surgical therapy in the treatment of primary esophageal motility disorders. DESIGN: Prospective study. SETTING: University-based tertiary care center. PATIENTS: Eighty-nine patients (46 men and 43 women) with either achalasia or nutcracker esophagus and diffuse esophageal spasm (DES). Choice of treatment was based not on randomization but on the preference of the referring physician, the patient's choice, and/or the patient's eligibility to access the University of California, San Francisco, for treatment. INTERVENTIONS: Nineteen patients with achalasia and 30 patients with nutcracker esophagus and DES were treated with dilatations and/or medications. Thirty patients with achalasia and 10 with nutcracker esophagus and DES underwent a thoracoscopic myotomy. MAIN OUTCOME MEASURES: Dysphagia, pain, and overall quality of life. RESULTS: In the surgical group, 80% of the patients with nutcracker esophagus and DES and 87% of the patients with achalasia had good or excellent results. In contrast, in the medical group, 26% of the patients with nutcracker esophagus and DES and 26% of the patients with achalasia had good or excellent results. CONCLUSIONS: Surgery by minimally invasive techniques offers a better chance than does medical therapy or dilatation of rendering the patient with achalasia, nutcracker esophagus, and DES asymptomatic.

Esophageal perforation.

Sixty-nine patients with perforation of the esophagus were treated at the University of California, San Francisco, from 1977 to 1988. The perforation was iatrogenic in 33 (48%) of the patients, spontaneous in 8 (12%), and a result of external trauma in 23 (33%). Clinical findings included chest pain in 36 (52%) of 69 patients, subcutaneous emphysema in 22 (32%) of 59 patients, and pneumomediastinum in 21 (36%) of 59 patients. Esophagograms demonstrated the perforation in 40 (93%) of 43 patients. Treatment delays of more than 24 hours occurred in about half of spontaneous and iatrogenic perforations, but when the perforation was due to external trauma, treatment was delayed infrequently. Operative therapy in 59 (86%) of the patients included primary closure in 44 patients, drainage alone in 9 patients, and Celestin tube placement in 1 patient. Four patients with benign strictures had esophagectomy, and 4 patients with achalasia had Heller myotomy in addition to closure of the perforation. Eight (12%) of the patients were treated nonoperatively. For thoracic perforations, nonoperative treatment was reserved for patients who were diagnosed late but who had minimal evidence of sepsis. Seven (10%) of the patients died. Factors that influenced outcome included cause of perforation, anatomic location, and patient age. Our study shows that a high index of suspicion, aggressive use of esophagography, and individualized treatment are necessary for the best results when treating esophageal perforation.