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Background: As cystic neoplasms of the pancreas are discovered with advanced imaging techniques, pancreatic surgeons often struggle with identifying who is at risk of having or developing pancreatic cancer. We sought to review our experience with the surgical management of cystic neoplasms of the pancreas to determine pre-operative clinical indicators of malignancy or premalignant (i.e. mucinous) lesions., Methods: Between 1996 and 2007, 114 consecutive patients with cystic neoplasms of the pancreas underwent a pancreatectomy. Invasive adenocarcinoma was identified in 35 whereas 79 had benign lesions. Mucinous lesions were considered premalignant and consisted of 29 intraductal papillary mucinous neoplasms (IPMN) and 17 mucinous cystic neoplasms (MCN). The remaining 33 benign lesions were serous microcystic adenomas. Descriptive statistics were calculated and multivariate logistic regression was performed. Receiver-operating characteristic (ROC) curves were constructed for continuous variables and the area under the curves compared. Likelihood ratios were calculated from the combinations of predictors., Results: Patients with pancreatic cancer arising from a cystic neoplasm were older than those with benign cysts. Mucinous lesions with or without associated cancer were more likely to be symptomatic and present with elevated serum carbohydrate antigen (CA)19-9 levels. Cancers more commonly presented in the head of the pancreas and were associated with longer hospitalizations after resection. Using multivariate logistic regression, size and elevated CA19-9 were predictors of malignancy whereas male gender and size were predictors of mucinous lesions with or without malignancy. Size, however, was not an accurate test to determine premalignant or malignant lesions using area under the ROC curve analysis whereas CA19-9 performed the best regardless of gender or lesion location., Conclusions: Based upon our single institution experience with resection of cystic neoplasms of the pancreas, we advocate an aggressive surgical approach to any patient with a cystic neoplasm of the pancreas and associated elevated CA19-9.

Background: Loss of expression of fragile gene products, Fhit and Wwox, occurs in many cancer types, with loss exhibited early in the neoplastic process in some. Wwox has been understudied in pancreatobiliary cancers, especially in relation to other involved tumor suppressors. We have assessed the status of the Fhit and Wwox proteins encoded by DNA damage susceptible chromosome fragile sites encompassed by FHIT and WWOX tumor suppressor genes., Methods: Pancreatic, gallbladder and ampullary cancers, normal pancreas, chronic pancreatitis, and benign gallbladder specimens were stained for expression of Fhit, Fhit effector protein Fdxr, Wwox, and other tumor suppressors by immunohistochemistry, and comparisons were made between benign and malignant tissue. Correlations of expression among proteins and clinicopathologic features were sought using Spearman's rank order. Survival curves were created using the Kaplan-Meier method and compared by log-rank analysis. Predictors of survival were determined using multivariate Cox proportional hazards analysis., Results: Fhit and Wwox were ubiquitously expressed in benign samples and significantly and coordinately reduced in pancreatic, gallbladder, and ampullary cancers. In pancreatic cancers, Fdxr expression was positively correlated with Fhit and Wwox expression. Neither Fhit nor Wwox expression correlated with expression of other tumor suppressors or with clinicopathologic characteristics measured., Conclusion: Loss of Fhit and Wwox expression does not predict tumor progression or patient survival, suggesting that loss of expression of genes at the exquisitely replication stress sensitive chromosome fragile regions is an early event in the pathogenesis of cancers of the gallbladder, pancreas, and ampulla.

MicroRNAs (miRNAs or miRs) are small, noncoding RNAs (approximately 20-22 nucleotides) that have critical functions in cell proliferation, apoptosis, and differentiation. These evolutionarily conserved RNA sequences are the result of a complex sequence of processing steps, which can regulate the expression of tens, and even hundreds, of genes. Their regulatory effect is based upon the degree of complementarity between the mature miRNA and the 3' untranslated region region of the target mRNA resulting in either complete degradation or translational inhibition of the target mRNA. In vertebrates they are often tissue specific in their expression patterns and dysregulated in malignancies. Thus, miRNA profiling has been used to create signatures for many solid malignancies. These profiles have been used to not only classify tumors, but also to help predict survival and outcome. Herein, we review the role of miRNAs in the development and progression of solid tumors.

Background: Thiazolidinediones (TZDs) have been demonstrated to possess antitumor effects in breast cancer cells, although the mechanisms are not well established. We sought to better define TZDs' antitumor effects and molecular mechanisms to permit rational utilization of these agents., Materials and Methods: We studied the effects of TZDs on DNA synthesis (BrdU enzyme-linked immunosorbent assay), gene expression (microarray, quantitative reverse transcription-polymerase chain reaction, and immunoblot), serine phosphorylation and localization of beta-catenin (nuclear/cytoplasmic fractionation and immunoblot), transactivation activity of beta-catenin/T cell factor 4 (TCF4) (luciferase assay with wild-type and mutant TCF4 responsive element), and beta-catenin/TCF4 complex (immunoprecipitation) in human breast cancer cells MDA-MB-231 and T47D., Results: Troglitazone (TG) down-regulated DNA synthesis in MDA-MB-231 and T47D and decreased mRNA expression of the Wnt co-receptors frizzled-1 and low-density lipoprotein-related protein 6 (LRP6) as well as protein level of LRP6. TG also targets downstream Wnt signaling molecules in T47D cells. TG down-regulates p-beta-catenin (S33/S37/T41) and promotes translocation of beta-catenin into the nucleus. However, TG inhibits beta-catenin-mediated transactivation by down-regulating TCF4 protein levels, thereby inhibiting beta-catenin/TCF4 complex formation. Finally, we found that inhibition of Akt augments TG-mediated down-regulation of DNA synthesis and this result was accompanied with the decreased protein levels of Wnt signaling molecules: LRP6, beta-catenin, and TCF4., Conclusion: These results suggest that the Wnt/beta-catenin signaling pathway, which plays an important role in breast cancer pathogenesis, may be a target for TZD treatment. Moreover, a combination of TZDs and a specific Akt inhibitor may serve as a new approach to target Wnt/beta-catenin directly and via PI3K/Akt action on glycogen synthase-3beta.

The diagnosis of serous microcystic adenoma (SMA) is usually straightforward. For small biopsies and/or unusual variants, the differential diagnosis includes other pancreatic or metastatic neoplasms showing cystic or clear cell features. We evaluated immunostains for potential use in the diagnosis of SMA. Cases of SMA were identified from archival files. Tissue cores (2 per block) were arrayed to create a microarray of cores measuring 2mm each. Additionally, microarrays previously constructed from 56 pancreatic adenocarcinomas (PACs) and 64 pancreatic endocrine tumors (PENs) were studied. The microarrays were stained with calponin, chromogranin, CD10, alpha-inhibin, and monoclonal neuron-specific enolase (m-NSE). Subsequently, some were stained with MUC6, melan-A, D2-40, h-caldesmon, smooth muscle actin, and smooth muscle myosin. For SMAs, staining was seen with calponin (85.2%), alpha-inhibin (96.2%), and m-NSE (96.2%). Focal weak staining was seen with MUC6 (65%). All SMAs were negative with chromogranin, CD10, melan-A, D2-40, h-caldesmon, smooth muscle actin, and smooth muscle myosin. In contrast, calponin was negative in all PACs and PENs. Staining for alpha-inhibin was absent in PACs and present in 4.1% of PENs; whereas immunoreactivity for m-NSE was present in 26.8% of PACs and 73.7% of PENs. Chromogranin staining was present in 9.1% of PACs and 100% of PENs. An immunohistochemical profile of staining with calponin, alpha-inhibin, and m-NSE and absent staining with chromogranin supports the diagnosis of SMA, and distinguishes SMA from PAC and PEN. Calponin and alpha-inhibin are the most useful positive markers for SMA, and are negative in most entities in the differential diagnosis.

Background: Transarterial Chemoembolization (TACE) has been recognized as a successful way of managing symptomatic and/or progressive hepatic carcinoid metastases not amenable to surgical resection. Although it is a fairly safe procedure, it is not without its complications., Case Presentation: This is a case of a 53 year-old woman with a patent foramen ovale (PFO) and mild pulmonary hypertension who underwent TACE for progressive carcinoid liver metastases. She developed acute heart failure, due to a severe inflammatory response; this resulted in pneumatosis intestinalis due to non-occlusive mesenteric ischemia. We describe the successful non-operative management of her pneumatosis intestinalis and the role of a PFO in this patient's heart failure., Conclusion: TACE remains an effective and safe treatment for metastatic carcinoid not amenable to resection, this case illustrates the complexity of complications that can arise. A multi-disciplinary approach including ready access to advanced critical care facilities is recommended in managing such complex patients.

Hepatocellular carcinoma is rare, but increasing in prevalence in the United States. Recent studies have shown that sorafenib, a multikinase inhibitor, can reduce tumor progression in patients with this cancer. However, complete remission has not been observed. We report a case of a 78-year old patient with unresectable metastatic hepatocellular carcinoma who had a rapid and complete clinical response following therapy with sorafenib for six months. No evidence of disease recurrence has been noted for 6 months after discontinuation of therapy.

Background: Radiomicrosphere therapy (RT) utilizing yttrium-90 (90Y) microspheres has been shown to be an effective regional treatment for primary and secondary hepatic malignancies. We sought to determine a large academic institution's experience regarding the extent and frequency of gastrointestinal complications., Methods: Between 2004 and 2007, 27 patients underwent RT for primary or secondary hepatic malignancies. Charts were subsequently reviewed to determine the incidence and severity of GI ulceration., Results: Three patients presented with gastrointestinal bleeding and underwent upper endoscopy. Review of the pretreatment angiograms showed normal vascular anatomy in one patient, sclerosed hepatic vasculature in a patient who had undergone prior chemoembolization in a second, and an aberrant left hepatic artery in a third. None had undergone prophylactic gastroduodenal artery embolization. Endoscopic findings included erythema, mucosal erosions, and large gastric ulcers. Microspheres were visible on endoscopic biopsy. In two patients, gastric ulcers were persistent at the time of repeat endoscopy 1-4 months later despite proton pump inhibitor therapy. One elderly patient who refused surgical intervention died from recurrent hemorrhage., Conclusion: Gastrointestinal ulceration is a known yet rarely reported complication of 90Y microsphere embolization with potentially life-threatening consequences. Once diagnosed, refractory ulcers should be considered for aggressive surgical management.

Purpose: We sought to examine the synergistic antipancreatic cancer effect by simultaneously targeting hypoxic cancer cells with heat-shock protein 90 (HSP90) inhibitor and blockade of energy production., Experimental Design: The anticancer effects of an HSP90 inhibitor (geldanamycin) in pancreatic cells were investigated in hypoxia and normoxia. A hexokinase II inhibitor, 3-broma-pyruvate (3BrPA), was evaluated for selective glycolysis inhibition in hypoxia as a sensitizer of HSP90 inhibitor against pancreatic cancer. The HSP90 client protein degradation was monitored by Western blot. The synergistic antitumor effect of geldanamycin and 3BrPA was evaluated in a xenograft pancreatic cancer model and monitored by a noninvasive dynamic contrast-enhanced magnetic resonance imaging., Results: Hypoxia enhanced HIF-1alpha expression by 11-fold in pancreatic cancer cells, and HSP90 inhibitor exhibited a seven- to eightfold higher anticancer effect in hypoxia compared with normoxia via HSP90 client protein degradation. 3BrPA selectively inhibited glycolysis and sensitized geldanamycin against pancreatic cancer cells by 17- to 400-fold through HSP90 client protein degradation. The synergistic anticancer effect of reduced doses of geldanamycin and 3-BrPA was confirmed in xenograft models in vivo by more than 75% tumor growth inhibition., Conclusions: The combination of HSP90 inhibitors and glycolysis inhibitors provides preferential inhibition of cancer cells in hypoxia through HSP90 client protein degradation and selective glycolysis inhibition. This may provide a new therapeutic regimen to battle chemotherapy-resistant pancreatic cancers, by enhancing the synergistic therapeutic efficacy and reducing dose-limiting toxicity.

A number of hereditary syndromes have been found to be associated with pheochromocytoma development, but there is a paucity of data regarding secondary molecular events, such as downregulation of the p16INK4A/Cdkn2a gene (hereafter p16), contributing to pheochromocytoma tumorigenesis. Using tissue microarray and immunohistochemistry, we evaluated the expression of p16 in 31 pheochromocytoma tumor specimens. Our results showed that the p16 gene was expressed at low level or even not expressed in all but one specimens [30/31 (96.8%)], indicative of the prevalence of p16 downregulation in pheochromocytomas. In contrast, high expression of pl6 was observed in the majority of control "normal" specimens [5/7 (71.6%)]. To further investigate the molecular mechanisms underlying pl6 downregulation in pheochromocytomas, we used quantitative real-time PCR, methylation-specific PCR, and direct DNA sequencing to analyze these specimens for potential genetic alterations of the p16 gene. Deletions and aberrant CpG methylation of pl6 were identified in 9 (29.0%) and 11 (35.5%) specimens, respectively, while one specimen harbored a point mutation, Ala --> Pro at residue 20 of P16, and this mutation led to an eightfold decrease in the CDK4-inhibitory activity of P16. The overall frequency of pl6 genetic alterations is 67.7%. Taken together, our results demonstrate that reduced expression of pl6 is a common event in human pheochromocytomas, and the primary cause for such downregulation is inactivating genetic abnormalities in the p16 gene.

Aim: To report the clinicopathological features of patients with serous cystadenomas of the pancreas., Methods: Thirty-three cases of serous cystadenoma diagnosed between 1977 and 2006 were retrieved from the files of the Ohio State University Medical Center. Clinical data and microscopic slides were reviewed., Results: The patients included 27 women and 6 men with an age range of 38-83 (mean 64.3) years. The clinical presentation included 13 patients with abdominal pain and 8 patients with abdominal mass; 9 tumors were found incidentally. Abdominal CT scans in 25 patients were interpreted as suspicious for carcinoma in 8 (32%), suspicious for serous cystadenoma in 8, neoplasm not otherwise specified in 8, and suspicious for a pseudocyst in 1. Only 7 patients underwent a preoperative biopsy, and 5 of these were diagnosed as having a serous cystadenoma. All but 2 of the patients underwent surgical resection of the tumor. The serous cystadenomas varied in size from 1.0 to up to 13 cm in maximum dimension, and all but one had a multicystic appearance. Of the 33 serous cystadenomas, 20 (61%) were located in the pancreatic tail, 4 (12%) in the pancreatic body, 4 in the pancreatic body and tail, and 5 (15%) in the head of the pancreas. Follow-up in 17 patients (median 3 years, range from 1 month to 11 years) showed no recurrence of serous cystadenomas. One patient had von Hippel-Lindau syndrome, 4 patients had diabetes mellitus, 3 patients had metastatic cancer, and 2 patients had ovarian tumors., Conclusions: Serous cystadenoma is an uncommon neoplasm that can be confused with malignancy both clinically and radiologically; a correct diagnosis is important in order to provide an accurate prognosis., (Copyright 2008 S. Karger AG, Basel.)

In this case report, we describe an accessory spleen that presented as a mass in the tail of the pancreas and mimicked a neoplasm. Intrapancreatic accessory spleen have a relatively high prevalence and can be mistaken for tumors. We present a case of intrapancreatic accessory spleen in a 40-year-old man, which was discovered incidentally during a workup for an aortic dissection. Computerized axial tomography and magnetic resonance imaging scans demonstrated a hypervascular mass in the tail of the pancreas. The clinical and radiological differential diagnosis included pancreatic mucinous cystic neoplasm, pancreatic endocrine neoplasm, solid pseudopapillary tumor, ductal adenocarcinoma, and metastasis. After a distal pancreatectomy was completed, microscopic examination revealed heterotopic splenic tissue.

Peroxisome proliferator-activated receptor-gamma (PPARgamma) is a member of the nuclear hormone superfamily and has multiple endogenous and pharmacological ligands, including 15-deoxy-Delta (12,14)-prostaglandin J(2) and two thiazolidinediones (TZD), rosiglitazone and pioglitazone, which are used clinically to treat type-2 diabetes mellitus. PPARgamma agonists regulate development, cellular growth and metabolism in various tissues and have been documented to decrease cellular proliferation and to induce apoptosis of various tumour phenotypes, including breast cancer. However, the full spectrum of anti-tumour effects occurs only at suprapharmacological doses. In this study, we investigated the mechanism of rosiglitazone-induced anti-tumour effects of MDA-MB-231 human breast cancer cells, and used that information to predict rosiglitazone-induced sensitization of breast cancer cells to the effects of other compounds. We first confirmed that 100 microM rosiglitazone, but not lower doses, decreases MDA-MB-231 cell viability in vitro. We then used microarray gene expression analysis to determine early rosiglitazone-induced gene expression changes after 4-h exposure, which included 1298 genes that we grouped into functional categories. We selectively confirmed rosiglitazone-mediated effects on expression of key regulators of breast cancer proliferation and apoptosis, including p53, p21 and Bax. Finally, we used this information to predict that rosiglitazone would sensitize MDA-MB-231 cells to the anti-tumour effects of CH11, which trimerizes Fas, as well as tumour necrosis factor-alpha. Moreover, we used the confirmed array data to predict cooperative activity of rosiglitazone and R-roscovitine (CYC202), an inhibitor of multiple cyclin-dependent kinases. We conclude that microarray analysis can determine early TZD-modulated changes in gene expression that help to predict effective in vitro drug combinations.

Background: Real-time intraoperative image guidance has been successfully applied to malignancies of the head, neck and central nervous system. Few attempts have been made to apply this technology to gastrointestinal cancers. Our purpose was to determine if a computer-assisted navigation system could be accurately used at the time of abdominal exploration., Methods: Fourteen patients with resectable recurrent colorectal cancer underwent computer tomography (CT) imaging of the abdomen and pelvis. The CT images were uploaded to a StealthStation (Medtronic, Inc., Minneapolis, MN), a device that tracks the motion of a handheld probe in the operating field and displays its position, in real time, on the uploaded images. Various anatomic points were utilized to match, or register, the patient to the images in the navigation system. After four or more anatomic points were registered, the accuracy of the registration process was computed by the navigation system and reported as the global error., Results: A total of 23 different anatomic structures were used for registration. The median number of points used for registration per patient was 6.5 (range 5-9). The anatomic sites most commonly used were the anterior superior iliac spines, aortic bifurcation, sacral promontory, symphysis pubis, and iliac artery bifurcation. The median global error was 10.0 mm (range 6.7 mm-27.0 mm)., Conclusion: Computer-assisted navigation systems can be used to accurately deliver image guidance at the time of abdominal exploration. Future work will be directed at determining the value of this technology in the localization and resection of tumors.

Background: Osteonectin has been suggested to be important in the progression of pancreatic cancer but has not been correlated with survival. We determined the osteonectin expression and its influence on survival in patients with ampullary carcinoma., Methods: Tissue microarrays were constructed from the tumors of 56 patients with ampullary cancer undergoing pancreaticoduodenectomy. Immunohistochemical staining for osteonectin was undertaken and compared with staining in chronic pancreatitis (n = 13) and normal pancreas (n = 19). Survival curves were created by the Kaplan-Meier method and compared by log rank analysis. Median follow-up for all living patients with ampullary cancer was 69.6 months., Results: Osteonectin was significantly (P < .05, Fisher's exact test) overexpressed in the stroma of ampullary cancers (90%) relative to chronic pancreatitis (62%) and normal pancreas (0%). Tumors expressing osteonectin were more likely to have nodal metastases than those lacking osteonectin expression (48% vs. 0%, P = .06, Fisher's exact test) and showed decreased survival. Node-negative status, pylorus preservation at the time of pancreaticoduodenectomy, and lack of osteonectin expression were predictors of prolonged survival by multivariate analysis., Conclusions: Although the importance of tumor-stroma interactions in periampullary cancers is not fully understood, our data suggest that osteonectin is an integral stromal element in ampullary cancers, and its overexpression is associated with decreased survival.

Detection of serum markers for pancreatic cancer has been elusive. Although CA 19-9 is most commonly used, its sensitivity and specificity are modest. We used large-scale proteomics to identify potential serum markers for pancreatic cancer. Samples were analyzed using high-resolution two-dimensional gel electrophoresis to identify differentially expressed proteins in 32 normal and 30 pancreatic cancer patients. Up to 1,744 protein spots were resolved for each serum sample. Candidate proteins were identified using mass spectrometry. ANOVA was used to identify proteins that could discriminate cancer from normal sera. Serum fibrinogen level was also measured using enzymatic assay. Immunohistochemistry was used to detect fibrinogen in resected pancreatic cancers. One hundred fifty-four proteins were commonly overexpressed in all pancreatic cancers. Nine protein spots (four with identifications by mass spectrometry) could effectively separate cancer from normal controls using cross-validation. These proteins successfully discriminated all pancreatic cancer samples (30 of 30) and 94% of normal (30 of 32) samples. Prominent among these candidates was fibrinogen gamma, which was subsequently confirmed to be overexpressed in pancreatic cancer sera by enzymatic analysis (54.1 +/- 64.1 versus 0.0 +/- 0.0 mg/dL, P < 0.05) and tissue by immunohistochemistry (67% versus 29%, P < 0.05) relative to normal pancreas. Proteomic analysis combining two-dimensional gel electrophoresis and mass spectrometry successfully identified 154 potential serum markers for pancreatic cancer. Of these, fibrinogen gamma, a protein associated with the hypercoagulable state of pancreatic cancer, discriminated cancer from normal sera. Fibrinogen is a potential tumor marker in pancreatic cancer.

Background: We undertook this study to determine if clearance of a food bolus at preoperative esophagography predicts acceptable outcomes after laparoscopic Nissen fundoplication for patients with manometrically abnormal esophageal motility., Study Design: Patients with gastroesophageal reflux disease (GERD) or symptomatic hiatal hernia with evidence of esophageal dysmotility by stationary manometry underwent videoesophagography to document the ability of their esophagus to clear food boluses of varying consistencies. Sixty-six patients were identified who had manometric dysmotility yet were able to clear a food bolus at esophagography, and subsequently underwent laparoscopic Nissen fundoplication. These patients were compared with 100 randomly selected patients with normal motility who underwent laparoscopic Nissen fundoplication. Symptom reduction and satisfaction were assessed through followup. Patients with normal motility were compared with those with manometrically moderate and severe dysmotility., Results: Preoperative patient demographic data, symptoms, and symptom scores were similar among patients with normal motility and moderate or severe dysmotility. After fundoplication, symptom reduction was notable for all patients regardless of preoperative motility (p < 0.01, paired Student's t-test). There was no notable difference in postoperative symptom scores (p = NS, Kruskal-Wallis ANOVA) or in patient satisfaction (p = NS, chi-square analysis) among patients stratified by esophageal motility., Conclusions: Patients with esophageal dysmotility documented by manometry who are able to clear a food bolus at contrast esophagography, have functional results after laparoscopic Nissen fundoplication similar to patients with normal motility. Preoperative esophagography predicts successful outcomes after laparoscopic Nissen fundoplication for patients with manometric esophageal dysmotility.

Background: We have reported 1-year outcomes and antacid medication use in 100 patients undergoing laparoscropic Nissen fundoplication. As a follow-up study, we queried these same patients to determine whether their outcomes endured 4 years after fundoplication., Methods: One hundred patients undergoing laparoscopic Nissen fundoplication between 1992 and 1997 were asked, at 1 to 2 years and 4 to 6 years postoperatively, to grade their symptoms on a scale of 1 (mild) to 10 (severe). Patients were also queried as to the number/cost of antacid medications used before and after fundoplication., Results: Significant improvements were noted in symptoms of heartburn, postprandial emesis, gas/bloating, and dysphagia after fundoplication. Significant decreases in antacid medication use (97% vs 19%) and monthly costs (dollar 168 +/- dollar 91 vs dollar 30 +/- 54) were seen following fundoplication. The number of patients on antacid medications and the monthly costs of these medications (37% and dollar 53 +/- dollar 87, respectively) increased significantly from early to late follow-up, but were still significantly lower than those before surgery. Overall, 87% and 900% of patients were pleased with their outcome at early and late follow-up, respectively, and 93% and 92% of patients stated they would consider undergoing fundoplication again if necessary (P = NS)., Conclusion: Laparoscopic Nissen fundoplication results in a significant reduction in the symptoms of reflux and the use of antacid medications with a high degree of patient satisfaction. Although some patients return to antacid medications at late follow-up, they continue to have few symptoms and are pleased with their outcomes.

Background and Objectives: Minimally invasive surgical techniques are applicable to achalasia, but the optimum approach to intraoperative assessment of adequacy of myotomy remains unestablished. We set out to show that videoscopic Heller myotomy with concurrent endoscopy ensures adequacy of myotomy while limiting postoperative clinically apparent reflux., Methods: Seventy-eight consecutive patients with achalasia underwent videoscopic Heller myotomy with concomitant endoscopy between 1992 and 1998. Fundoplication was not routinely undertaken., Results: Preoperative symptoms consisted of dysphagia (100%), emesis/regurgitation (68%), heartburn (58%), and postprandial chest pain (49%). Following myotomy, significant improvement (P < 0.0001) was seen in dysphagia (43%), postprandial chest pain (13%), and emesis/regurgitation (9%) at a mean follow-up of 33+/-2.2 months. Mean reflux score (scale 0 to 5) improved from 3.7+/-0.3 to 1.5+/-0.2 (P < 0.0001). Improvement in symptoms was reported in 96% of patients. Fundoplication was used in 8 patients as part of hiatus reconstruction (n = 6) or repair of esophageal perforation (n = 2)., Conclusions: Intraoperative endoscopy during videoscopic Heller myotomy guides the extent and adequacy of myotomy. By utilizing a focused dissection with preservation of the natural antireflux mechanisms around the gastroesophageal junction and limiting the extent of myotomy along the cardia, postoperative reflux symptoms are minimized. We advocate concomitant endoscopy during Heller myotomy to guide myotomy and submit that routine fundoplication is clinically unnecessary.

Objectives: In the early 1990s, minimally invasive videoscopy was applied to numerous operations. After undertaking more than 50 "open" Heller myotomies, our experience with videoscopic Heller myotomy began in 1992. We sought to determine whether the outcome following videoscopic Heller myotomy is influenced by surgeon experience., Methods: Seventy-eight patients with severe dysphagia secondary to achalasia underwent videoscopic Heller myotomy between 1992 and 1998. Intraoperative endoscopy was utilized to ensure adequate myotomy in all patients. Patients were stratified into 3 groups: the first 25 patients (group I), the second 25 patients (group II), and the last 28 patients (group III). Clinical outcome was based on length of stay, incidence of intraoperative complications, conversion to an 'open' procedure, and postoperative symptoms., Results: Perioperative complications occurred in 20% of patients in group I compared with 8% and 12% in groups II and III, respectively (P = NS). Only 3 patients required conversion to an 'open' procedure, all in group I (P <0 .05). Symptomatic improvement was achieved in 80% of patients in group I, 100% in group II, and 96% in group III (P < 0.05). Significant reductions in conversions to open, length of stay, and postoperative symptoms were seen after 20 myotomies were undertaken., Conclusion: Outcome following videoscopic Heller myotomy, like other videoscopic operations, improves as surgeons progress along the videoscopic "learning curve." After approximately 20 videoscopic Heller myotomies, surgeons can expect fewer conversions to open procedures, shorter hospital stays, and better symptomatic relief.