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Evidence on the long-term outcome of laparoscopic Heller-Dor surgery is limited. The aim of this study was to assess the long-term outcome of achalasic patients after surgery, particularly in relation to the radiologic preoperative stage of the disease.Sixty-eight patients with achalasia were assessed clinically and by esophageal radiology, manometry, and 24-hour ambulatory esophageal pH monitoring before and at 3 months, 1, 1 to 3, 3 to 5, and 5 to 8 years after a laparoscopic Heller-Dor procedure.At 1 year after surgery the symptom score was significantly lower than the preoperative score (P.001), and a satisfactory clinical outcome was seen in more than 90% of the patients with stage I, II, and III disease at the preoperative radiologic assessment. Only 50% of stage IV patients reported satisfactory results. An adequate opening of the lower esophageal sphincter (LES) and LES resting pressure of less than 8 mm Hg was achieved in all patients, and esophageal emptying was accelerated significantly (P.001). At the consecutive follow-up evaluation (1-8 y), a satisfactory outcome was maintained in all stage I, II, and III responders. Stage IV patients with initially unsatisfactory results reported a worsening of symptoms (P.02). Patients with pseudodiverticulum had a higher symptom score (P.01). LES opening and resting pressure remained at levels of the 1-year follow-up evaluation. Esophageal emptying remained satisfactory in stage I, II, and III responders, but deteriorated in stage IV nonresponders and in 6 of the 10 patients with a pseudodiverticulum.A satisfactory outcome of the laparoscopic Heller-Dor procedure in stage I, II, and III achalasic patients seems to last. Stage IV nonresponders tend to deteriorate over time. The development of pseudodiverticulum is associated with an increased symptom score.

It has been proposed that partial fundoplication is associated with less incidence of postoperative dysphagia and consequently is more suitable for patients with gastroesophageal reflux disease (GERD) and impaired esophageal body motility. The aim of this study was to assess whether outcomes of Toupet fundoplication (TF) are better than those of Nissen-Rossetti fundoplication (NF) in patients with GERD and low-amplitude esophageal peristalsis.Thirty-three consecutive patients with proved GERD and amplitude of peristalsis at 5 cm proximal to lower esophageal sphincter (LES) less than 30 mmHg were randomly allocated to undergo either TF (19 patients: 11 men, 8 women; mean age: 61.7 +/- 8.7 SD years) or NF (14 patients: 7 men, 7 women; mean age: 59.2 +/- 11.5 years), both by the laparoscopic approach. Pre- and postoperative assessment included clinical questionnaires, esophageal radiology, esophageal transit time study, endoscopy, stationary manometry, and 24-hour ambulatory esophageal pH testing.Duration of operation was significantly prolonged in the TF arm (TF: 90 +/- 12 minutes versus NF: 67 +/- 15 minutes; p0.001). At 3 months postoperatively, the incidences of dysphagia (grades I, II, III) and gas-bloat syndrome were higher after NF than after TF (NF: 57% versus TF: 16%; p0.01 and NF: 50% versus TF: 21%; p = 0.02, respectively), but decreased to the same level in both groups at the 1-year followup (NF: 14% versus TF: 16% and NF: 21% versus TF: 16%, respectively). At 3 months postoperatively, patients with NF presented with significantly increased LES pressure than those with TF (p = 0.02), although LES pressure significantly increased after surgery in both groups, as compared with preoperative values. Amplitude of esophageal peristalsis at 5 cm proximal to LES increased postoperatively to the same extent in both groups (TF, preoperatively: 21 +/- 6 mmHg versus postoperatively: 39 +/- 12 mmHg; p0.001, and NF, preoperatively: 20 +/- 8 mmHg versus postoperatively: 38 +/- 12 mmHg; p0.001). Reflux was abolished in all patients of both groups.Both TF and NF efficiently control reflux in patients with GERD and low amplitude of esophageal peristalsis. Early in the postoperative period, TF is associated with fewer functional symptoms, although at 1 year after surgery those symptoms are reported at similar frequencies after either procedure.

The effect of total (Nissen) and anterior partial fundoplication (APF) for the surgical treatment of gastroesophageal reflux disease (GERD) on the motor behavior of the esophagogastric axis has not been fully assessed. The purpose of this study was to assess any alterations in lower esophageal sphincter (LES) and gastric fundus motor parameters in GERD patients after Nissen or APF fundoplication.Twenty four patients with documented GERD underwent either laparoscopic Nissen fundoplication (n = 12) or laparoscopic APF (n = 12). Preoperative and postoperative stationary esophageal manometry included assessment of LES resting and postdeglutition relaxation pressures, intragastric pressure, and LES transient relaxations in the left lateral and upright positions and after gastric distension.Both types of fundoplication resulted in significant increases in LES resting (P0.001) and postdeglutition relaxation pressure (P0.001) in both positions and after gastric distention. Intragastric pressure increased only after Nissen fundoplication in the postgastric distention state (P = 0.01). Transient LES relaxations were equally abolished after both procedures. All postoperative changes were to a similar level after either procedure with the exception of intragastric pressure after gastric distention, which was significantly higher after total than after partial fundoplication (P = 0.04).Both procedures equally increase LES resting and postdeglutition relaxation pressures and abolish transient LES relaxations at all states. The significantly higher intragastric pressure at the postgastric distention state after Nissen fundoplication could possibly explain the higher incidence of epigastric fullness and discomfort after this type of antireflux surgery.

Persistence of dyspeptic symptoms after cholecystectomy or choledochoduodenostomy is common. There is -evidence that at least some of these symptoms may be attributed to duodenogastric reflux (DGR). The aim of the study was to quantify DGR before and after cholecystectomy, with or without choledochoduodenostomy, and endoscopic sphincterotomy for common bile duct stones, and to assess the effect of erythromycin on the increased DGR.Forty-seven patients before and after cholecystectomy, 26 after cholecystectomy and choledochoduodenostomy and nine after sphincterotomy had postprandial (300 mL of fresh milk, 4% fat) duodenogastric reflux measured by 99mTc-hepatic imino diacetic acid scintigraphy. Patients with a DGR index (DGRi)20% were considered as having pathological DGR that justifies symptoms, and their DGRi was reassessed after administration of 200 mg of erythromycin intravenously.Twenty-seven patients before cholecystectomy (57%) showed a normal DGRi7%. In five cases DGRi was greater than 20%. After cholecystectomy, duodenogastric refluxes increased, so that only 16 patients (32%) showed a normal DGRi, while a DGRi20% was observed in 10 cases. Only eight patients after cholecystectomy and choledochoduodenostomy (23%) presented with a DGRi within the normal range. The remaining 18 had a DGRi7%. Five of them exhibited a DGRi20%. Of the nine patients with sphincterotomy, three showed a DGRi20%. Erythromycin almost completely normalized DGRi in all 18 patients with pathological DGR (P0.0001).Duodenogastric reflux is common after biliary surgery, including endoscopic sphincterotomy. Erythromycin appears to decrease duodenogastric reflux to normal levels.

There are conflicting data concerning the effect of gastroesophageal reflux disease (GERD) on esophageal motor function.Duration of GERD might affect severity of symptoms, grade of esophageal mucosal injury, and esophageal motor behavior.Retrospective study of a defined cohort.Two referral centers, one of them academic, for esophageal gastrointestinal motility disorders.One hundred forty-seven patients with documented GERD.Symptoms, grade of mucosal injury on esophagoscopy, esophageal manometry, ambulatory esophageal pH monitoring, and esophagogram.Patients with GERD had significantly decreased lower esophageal sphincter resting pressure (P =.02), lower amplitude of esophageal peristalsis at all levels of measurement (P.001), and more delayed esophageal transit (P =.007) compared with control subjects. Patients with dysphagia, severe esophagitis, and Barrett esophagus presented with a longer history of the disease, significantly worse esophageal motor function (P.01), and more prolonged esophageal transit than patients without the above features of the disease. Impairment of esophageal peristalsis and lower esophageal sphincter resting pressure were significantly inversely related to the duration of the disease (P.001). Also, delay of esophageal transit was significantly related to the duration of the disease (P =.002) and inversely related to the amplitude of esophageal peristalsis (P.001). Unlike the manometric variables, the extent of reflux, as assessed by ambulatory 24-hour esophageal pH monitoring, was not related to the duration of the disease.A long history of GERD is more commonly associated with presence of dysphagia, delayed esophageal transit, severe esophagitis, presence of Barrett esophagus, and impaired esophageal motility.

Background: Although stationary manometry commonly reveals esophageal body motility disorders in patients with gastroesophageal reflux disease (GERD), esophageal function cannot be fully and precisely assessed during normal daily activities by this investigatory modality. Aim: To compare the results of 24-hour ambulatory manometry with those of stationary manometry and to determine the specificity and accuracy of the former to detect motility disorders in patients with GERD. Patients and Methods: 15 patients with documented GERD were included in the study. Clinical assessment, upper alimentary endoscopy and stationary manometry as well as 24-hour ambulatory manometry with concomitant 24-hour monitoring of the esophageal pH were performed in each patient. Results: 24-hour ambulatory manometry revealed a significant number of dropped or interrupted esophageal contractions in patients who were found to have only complete peristalsis on stationary manometry. Furthermore, in certain patients, ambulatory manometry detected an increased incidence of dropped or interrupted contractions as compared to those recorded during stationary manometry. Ineffective contractions, suggestive of poor esophageal motility, although absent on stationary manometry, were detected in a large number of patients during a 24-hour period of recording. Also, the amplitude of esophageal contractions was clearly overestimated when evaluated by stationary manometry. Conclusions: 24-hour ambulatory esophageal manometry reveals esophageal motor abnormalities to a greater extent than those demonstrated at stationary manometry, in patients with GERD. This might be of significance in designing the treatment and predicting possible outcome.

Background/Aims: Although pancreatic trauma, isolated or not, is uncommon, it carries significant morbidity and mortality because of the delay in recognition and consequent treatment. Methods: The current knowledge of pancreatic injury, concerning the incidence, mechanism of induction, diagnosis, treatment, complications and outcome, is herein presented based on a literature review and our limited experience. Results: The diagnosis of pancreatic trauma entails a high index of suspicion because neither clinical nor laboratory evaluation provide pathognomonic elements. Patients with penetrating injuries are usually evaluated during laparotomy, while those with a blunt trauma can be managed conservatively, provided they are in a stable condition, there is no pancreatic duct involvement and care is intensive. At laparotomy, minor pancreatic injuries are best managed by drainage. Distal pancreatectomy is best suited for distal pancreatic trauma with ductal involvement. For severe trauma, Roux-en-Y pancreaticojejunostomy, pancreaticogastrostomy, duodenal diversion operations and Whipple’s procedure are all indicated according to the preoperative evaluation and intraoperative findings. Independent of the procedure to be performed, drainage is mandatory. Conclusion: Because pancreatic injury is rare, most general surgeons lack experience and ability to deal with such injured patients. Therefore, an experienced and skilled surgeon should govern the management of pancreatic trauma in order to minimize the incidence of morbidity and mortality.

Subtotal colectomy with ileosigmoid or ileorectal anastomosis is one of the standard procedures for obstructed tumours of the left colon. The lower the level of the anastomosis, the greater the number of bowel motions per day. The aim of the present study was to assess whether an ileal pouch-rectal anastomosis is associated with fewer bowel motions per day.In four patients with obstructed carcinoma of the rectosigmoid junction and upper rectum, a total colectomy with removal of the upper rectum for adequate tumour clearance was used, followed by construction of a 10 cm ileal J-pouch that was subsequently anastomosed to the distal rectal stump.Postoperative recovery was uneventful in all patients. At 3 months postoperatively, anorectal manometry showed anal resting and squeeze pressures at lower normal limits and a neorectal capacity ranging from 160 to 310 mL. One year postoperatively, all patients experienced one to three normal bowel motions daily and no episodes of incontinence.Total colectomy with ileal J-pouch-rectal anastomosis is a reasonable operative alternative in cases with obstructed tumours of the rectosigmoid junction, which necessitate removal of the upper rectum.

It has been documented that Crohn's disease affects anorectal function when anorectal manifestations of the disease are present. The aim of this study was to investigate whether the presence of histologic lesions in rectal biopsy affected anorectal motility in patients with Crohn's disease but no evidence of macroscopic anorectal involvement.Forty-one patients with documented Crohn's disease were included in the study. Twenty-one of them had no endoscopic or histologic lesions in the rectum, and 20 patients had a positive histology for Crohn's disease on rectal biopsy, with or without macroscopic or endoscopic involvement of the anorectum. All patients underwent a standard anorectal manometry, with an eight-channel, water-perfused catheter.Patients with positive rectal biopsy but no evidence of endoscopic rectal involvement had lower anal resting and squeeze pressures (76 +/- 16 standard deviation vs. 86 +/- 19 standard deviation P = 0.002; 152 +/- 56 standard deviation vs. 192 +/- 52 standard deviation P0.001, respectively), and a lower sphincter and high-pressure zone length (2.8 +/- 0.8 standard deviation vs. 3.2 +/- 0.8 standard deviation P = 0.006; 1.7 +/- 0.6 standard deviation vs. 2 +/- 0.6 standard deviation P = 0.005, respectively) compared with patients with negative rectal histology. Also, slow and ultra slow wave amplitude and ultra slow wave frequency were significantly lower (10 +/- 6 standard deviation vs. 13 +/- 7 standard deviation P = 0.04; 17 +/- 16 standard deviation vs. 34 +/- 24 SD P = 0.004; 0.9 +/- 0.8 standard deviation vs. 1.3 +/- 0.6 standard deviation P = 0.05, respectively), rectal sensation more affected, and rectal compliance significantly reduced (7.4 +/- 1 standard deviation vs. 11.1 +/- 2.2 standard deviation P0.001) in the former group of patients. Simultaneous presence of endoscopic and histologic lesions in the rectum was associated with further impairment of the anorectal function.Microscopic presence alone of Crohn's disease in the rectum appears to induce anorectal motility disorders. The synchronous presence of endoscopic rectal and macroscopic anal involvement is associated with further deterioration of anorectal function.

RATIONALE AND OBJECTIVES The purpose of the study was to determine the effect of orally administered cisapride on gallbladder emptying in healthy subjects during fasting and postprandial states. MATERIALS AND METHODS Gallbladder emptying was assessed by means of ultrasonography in 10 healthy male subjects (age range, 25-33 years; mean age, 28.6 years +/- 3.2 [standard deviation]) under four randomly applied conditions: (a) after oral intake of a placebo tablet, (b) after oral intake of 10 mg of cisapride during fasting, (c) after oral intake of a placebo tablet followed 30 minutes later by ingestion of 300 mL of fresh whole milk (postprandial emptying), and (d) after oral intake of 10 mg of cisapride followed 30 minutes later by ingestion of 300 mL of milk. RESULTS Cisapride given during the fasting state induced gallbladder contraction by 44.1% +/- 12.6 (standard deviation) of its initial volume. Gallbladder emptying started after 19.4 minutes +/- 12.6 and reached its peak 51 minutes +/- 5.7 later. The ejection fraction after administration of only cisapride was significantly less than that after placebo and milk ingestion (44.1% +/- 12.6 vs 60.6% +/- 8.5, P < .0002). Oral administration of cisapride 30 minutes before milk consumption induced gallbladder emptying, which started approximately 10 minutes before milk ingestion. The ejection fraction after administration of cisapride with milk was significantly greater than that after consumption of placebo and milk (67.1% +/- 8.8 vs 60.6% +/- 8.5, P < .02). CONCLUSION Oral cisapride induces contraction of the gallbladder during the fasting state and enhances postprandial gallbladder emptying.

RATIONALE AND OBJECTIVES Reports on the effect of the ovulatory cycle on gallbladder motility are inconsistent. The authors investigated the gallbladder motor function at both phases of the menstrual cycle in humans. METHODS Seventeen young, healthy, nulliparous women participated in the study. Gallbladder fasting volume and postprandial emptying were measured twice in each subject using real-time ultrasonography: one at the follicular (12th-13th day) and another at the luteal (21st-22nd day) phases. From the emptying curves, the duration of the lag phase and the ejection fraction of emptying were calculated. RESULTS Fasting volume was significantly greater (P = 0.025) at the luteal (14.8 +/- 8 mL standard deviation [SD]) than at the follicular (11.2 +/- 4.7 mL SD) phase. Although the lag phase duration was longer (P = 0.009) at the follicular (5.2 +/- 6.4 SD minutes) than the luteal (1.6 +/- 3.6 minutes SD) phase, the ejection fraction was significantly greater at the latter one (follicular phase: 62 +/- 13.2% SD; luteal phase: 73.4 +/- 14% SD; P = 0.0085). CONCLUSIONS Female sex hormones seem to biologically affect the gallbladder motor function.

Fasting gallbladder volume and fasting gallbladder roundness index (ratio of anteroposterior diameter to gallbladder length) were estimated by ultrasonography in 182 normal subjects and 43 patients with gallstones and correlated to body size indices. In 20 of the normal subjects, gallbladder emptying was assessed and correlated to gallbladder roundness index. Gallstone patients had a larger fasting gallbladder volume as compared to normals (42 +/- 10 vs 22 +/- 7 (SD) ml, p0.001). Gallbladder fasting volume was found to be significantly related to roundness index (p0.001) and body surface area (p0.0001) in normals, but not in patients with cholelithiasis. Subjects with a roundness index0.3 showed a less-complete gallbladder emptying as compared to those with a roundness index0.3 (p0.01). It is concluded that increased body size, but not obesity alone, is associated with an increased gallbladder fasting volume, and that a rounder gallbladder tends to empty less completely.

In 28 controls and 142 patients subjected to a variety of antiulcer procedures, the enterogastric reflux (EGR) was quantitated by 99mTc-HIDA scintigraphy and expressed as the EGR index on 229 different occasions. The EGR index was calculated according to two different formulas: one based on the maximal radioactivity over the gastric area as a percentage value of the total abdominal activity (EGR-Im) and the other based on the relative maximal radioactivity over the gastric area as a percentage value of the relative hepatobiliary activity (EGR-It). There was a significant positive correlation of values between the two methods (P less than 0.0001). In patients with an EGR-Im greater than 20% or EGR-It greater than 57% and postgastric surgery symptoms some of the symptoms were attributed to EGR, an antireflux procedure is expected to relieve those symptoms. Sixteen of these patients underwent Roux-en-Y gastrectomy and their preoperative symptoms were relieved.

A series of 155 cases of hepatic hydatid disease, occurring in 121 patients, were operated on at the Naval and Veterans Hospital of Athens. Ultrasonography and computerized axial tomography provided the preoperative diagnosis in 89 and 93 percent of the cases respectively in recent years. Thirty one percent of the cases presented with complications, the commonest of these being infection of the cyst (10 percent) and rupture of the cyst into the bile ducts (17 percent). Total cystectomy was performed in three cases and removal of the endocyst with its content in the remaining 152. The remaining cavity was either externally drained (57 cases), or filled with omentum (omentoplasty — 95 cases). External fistula and infection of the residual cavity occurred in 32 and 56 percent after simple drainage and in 4 and 2 percent respectively after omentoplasty. Differences are statistically significant (p < 0.001). Hospitalization was also significantly longer after drainage than after omentoplasty (p < 0.01). Obstructive jaundice after intrabiliary rupture of the cyst was more successfully managed after additional choledochoduodenostomy than after simple drainage of the common bile duct. Intrapericoneal recurrence of hydatid disease occurred in two cases. The conclusion of the present study is, that ultrasonography and computerized axial tomography provide an acceptable rate in the diagnosis and that omentoplasty offers a very low complication rate in the management of hydatid cystic disease of the liver.

Laparoscopic Heller myotomy with anterior hemifundoplication is the surgical procedure of choice for the treatment of esophageal achalasia. Specific factors, eg, severity of esophageal body deformity, might affect postoperative outcome.Prospective case-control study.Academic referral center for gastrointestinal tract motility disorders.Twenty-nine patients with esophageal achalasia who underwent 1 to 3 sessions of failed pneumatic dilation each.Laparoscopic Heller myotomy with anterior (Dor) hemifundoplication.Preoperative and postoperative symptomatic evaluation, esophagoscopy, esophagography, stationary and ambulatory esophageal manometry, and pH monitoring.Three patients had stage I disease, 10 had stage II, 12 had stage III, and 4 had stage IV at preoperative radiologic examination. At surgery, there were no conversions to open procedures, and 2 mucosal perforations were immediately identified and sutured. Good or excellent results were seen in 26 patients. All patients with stage I or II disease had excellent functional results. Of patients with stage III disease, results were excellent in 7, good in 4, and bad in 1. Of patients with stage IV disease, 2 had good results and 2 had bad results. After surgery, lower esophageal sphincter pressure was reduced significantly (from 46.1 +/- 12.1 to 5.4 +/- 1.8 mm Hg; P.001), as was esophageal diameter (from 61 +/- 17 to 35 +/- 19 mm; P.001) (data are given as mean +/- SD). However, an excellent result occurred only in patients with a postoperative esophageal diameter less than 40 mm.Functional outcome of laparoscopic Heller-Dor procedure for achalasia is related to the preoperative stage of the disease on the esophagogram and to the extent of reduction in esophageal width after surgery.

Background Roux-en-Y reconstruction is sometimes associated with symptoms that suggest food stasis, as a result of dysmotility of either the gastric remnant and/or the efferent jejunal limb. Objective To study the possible effect of intravenous erythromycin lactobionate on gastric emptying of solids in patients who have undergone a Roux-en-Y procedure. Patients Twenty-four patients with a Roux-en-Y procedure participated in the study. Ten of them had undergone truncal vagotomy with pyloroplasty; the remaining 14 had undergone a Billroth II subtotal gastrectomy as the initial antiulcer procedure. Sixteen healthy subjects served as controls. Methods All healthy subjects and patients underwent assessment of gastric emptying of a standard radiolabeled solid meal after administration of placebo or 200 mg of erythromycin lactobionate intravenously. Scanning was done with a gamma camera, and emptying curves were constructed. From these curves the half-time of gastric emptying was calculated. Results Patients with severe symptoms of gastric stasis had a significantly longer half-time than did patients with mild or no symptoms (P=.002). Patients with a Billroth II subtotal gastrectomy as the initial antiulcer procedure had a significantly worse grade of symptoms (P=.01) and a significantly prolonged half-time (P=.02) compared with patients with a truncal vagotomy with pyloroplasty as the initial antiulcer procedure. Erythromycin significantly reduced the half-time in the controls (P Conclusion Erythromycin could be a useful prokinetic drug in patients with Roux stasis syndrome.

One hundred and twenty-seven male patients were subjected to antiulcer surgery for duodenal ulcer resistant to H2-receptor antagonist treatment. Fifty-four (group A) had been on conservativ

Fourteen guinea pigs were given prednisolone daily for 20 days and 11 for 40 days. Another 20 formed the two control groups. Short-term prednisolone treatment significantly increased serum gastrin levels and antral G-cell population as compared to the control group. The same parameters significantly decreased following 40 days of prednisolone treatment as compared to the group of short-term prednisolone treatment. Forty days of prednisolone treatment significantly increased antral D-cell population as compared to the control and short-term prednisolone treatment groups. It is concluded that hypergastrinaemia and antral G-cell hyperplasia following corticosteroid administration is temporary and is accompanied by antral D-cell hyperplasia.

Twelve patients, who previously had surgery for peptic ulcer, underwent a Roux-en-Y procedure for the treatment of a combination of severe symptoms. The original operation was truncal vagotomy with py