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Achalasia, diffuse esophageal spasm, and nutcracker esophagus constitute the main primary esophageal motility disorders. During the past decade major progress has been made in understanding their pathophysiology and in the ability to establish a precise diagnosis. In addition, minimally invasive surgical intervention has radically changed the therapeutic approach, and thoracoscopic or laparoscopic myotomy is probably the best treatment for most patients., Achalasia, diffuse esophageal spasm, and nutcracker esophagus are the principal named primary esophageal motility disorders. They are characterized by esophageal dysmotility, which is responsible for the symptoms, in the absence [...]

BACKGROUND: Since the role of a hiatal hernia in the pathophysiology of gastroesophageal reflux disease (GERD) has not been fully elucidated, we studied the effects of hiatal hernias on the function of the lower esophageal sphincter (LES) and esophageal acid clearance. PATIENTS AND METHODS: Ninety-five consecutive patients with GERD diagnosed by 24-hour pH monitoring underwent upper gastrointestinal series (UGI), endoscopy, and esophageal manometry. Based on the presence (H+) or absence (H-) of a hiatal hernia on UGI series, they were divided into two groups: H+ (n = 51) and H- (n = 44). Then, using the size of the hiatal hernia, the H+ group was divided into three subgroups: I, H 5 cm (n = 6). RESULTS: Esophageal manometry showed that patients with larger hiatal hernias (groups II and III) had a weaker and shorter LES and less effective peristalsis compared to patients with a small or no hiatal hernia. Prolonged pH monitoring showed that patients with larger hiatal hernias were exposed to more refluxed acid and had more severely abnormal acid clearance. Endoscopy showed more severe esophagitis among patients with GERD and hiatal hernia compared with GERD patients without hiatal hernia, and the degree of esophagitis was proportionate to the size of the hernia. CONCLUSIONS: Among patients with proven GERD, those with a small hiatal hernia and those with no hiatal hernia had similar abnormalities of LES function and acid clearance. In patients with larger hiatal hernias, however, the LES was shorter and weaker, the amount of reflux was greater, and acid clearance was less efficient. Consequently, the degree of esophagitis was worse in the presence of a large hiatal hernia. Am J Surg. 1996;171:182-186.

This paper addresses the current status of General Surgery, the direction in which it is moving, and how to prepare for future changes. The paper points out that, since the predicted effects of new technology on the practice of General Surgery are more technical complexity, decreasing invasiveness, and fewer traditional operations, the consequences for the training of surgeons, the division of responsibilities among specialists, and the organization of surgical care will be substantial. In light of the current difficulty in dealing with the stresses within General Surgery, the paper discusses how changes in residency training and an increased use of Fellowships will enable the specialty to handle such disruptive changes in the future. Am J Surg. 1996;171:2-9.

We prospectively assessed the safety and efficacy of laparoscopic jejunostomy done by 11 surgeons in 8 medical centers using the T-fastener technique. in all, 23 men and 13 women aged 19 to 84 (mean, 59) years required enteral feeding, but could not undergo gastrostomy and had no contraindication to laparoscopy. Of these patients, 12 had head and neck cancer and 11 had neurologic swallowing dysfunction. The procedure took 25 to 180 minutes (mean, 75). Three (8%) early cases were converted to open jejunostomy because of accidental enterotomies caused by inappropriate techniques that were avoided in later cases. Minor technical problems, such as passing a needle through the back wall of the jejunum, occurred in 7 patients, but they were easily corrected and produced no complications. Feedings were routinely begun within 24 hours of the surgical procedure. All jejunostomy catheters functioned well. This is a safe and effective technique when done by experienced laparoscopic surgeons, and serious complications are rare., Jejunostomy is indicated in patients who have a functioning gut, but are unable to eat and in whom gastrostomy is contraindicated or not possible. We developed a new technique for [...]

We studied the impact of transhiatal esophagectomy on the cardiac and respiratory function of 44 consecutive patients. Preoperatively, 31 patients had associated medical problems (22 with cardiac disease, 31 with pulmonary disease). Mean forced expiratory volume in 1 second (FEV[.sub.1]) was 2.1 liters, but it was less than 1.2 liters in six patients. Postoperatively, mechanical ventilation was given for a mean of 49 hours. Of the six patients with FEV[.sub.1] less than 1.2 liters, five were ventilated for an average of 44 hours, and one was ventilated for 221 hours. Intraoperative hypotension, which averaged 8 minutes, was longer in patients with a history of cardiac disease (10 of 14 patients) and in those with a midesophageal tumor (9 of 14 patients). Atrial arrhythmias (14 patients) were more common in patients with a history of cardiac disease and were all successfully treated medically. Nine patients developed congestive heart failure, and they all recovered. Average hospital stay was 15 days. Transhiatal esophagectomy has a greater impact on pulmonary and cardiovascular physiology than previously believed, but the majority of complications can be treated successfully. Transhiatal esophagectomy can be performed safely in patients with poor respiratory function, who constitute about 10% of those who need esophageal resection., Surgical removal of the esophagus performed through the diaphragm avoids the complications involved in opening the chest cavity. However, this technique has a greater impact on respiratory and heart function than previously believed. A study was conducted on 44 patients who underwent transhiatal esophagectomy to determine the impact of surgery on heart and lung function. Thirty-seven patients underwent surgery because of esophageal cancer; seven patients had benign disease (esophageal perforation, narrowing or motility disorder). Prior to surgery, 31 patients had lung disease and 22 (of the 31) also had heart problems. Following surgery, all patients were treated in the intensive care unit; patients received an average of 49 hours of mechanical ventilation. Fourteen of the patients with a history of heart disease developed arrhythmias (abnormal heart rhythms); all were treated medically. Congestive heart failure developed in nine patients and all recovered. Five of the 44 patients died (11 percent); those who died were being treated for esophageal cancer. The average hospitalization for the survivors was 15 days. The data indicate that transhiatal esophagectomy can be performed safely on patients who have poor preoperative lung function; these patients make up about 10 percent of those needing esophagectomy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Painless jaundice suggests that the patient may have a tumor obstructing the bile duct. An ultrasound or computed tomographic scan is normally performed to locate the blockage; this is followed by a cholangiogram (a radiographic study that outlines the major bile ducts). The identification of a focal stenotic lesion usually leads to the diagnosis of cholangiocarcinoma (bile duct cancer); stenosis of the common hepatic (liver) duct often indicates Klatskin tumor (sclerosing tumor of the bile duct). Since biopsies are usually inconclusive, treatment of the patient is begun based on the results of the scans and cholangiogram alone. The accuracy and the implications of these assumptions have not been evaluated. To investigate this area, a comparison was made between the preoperative and the final diagnosis in 98 patients who were thought to have a Klatskin tumor prior to surgery. In 68 patients (69 percent) the final diagnosis was sclerosing cholangiocarcinoma of the bile duct, confirming the preoperative diagnosis. However, 30 patients (31 percent) had other diseases, including 5 cases of papillary duct cancer; 12 gallbladder cancers with invasion into the bile duct; and 5 metastatic cancers that had spread to the bile duct. Seven benign lesions that were initially misdiagnosed included two Mirizzi syndromes, three granulomas, and three cases of benign focal stenosis of unknown origin. These findings suggest that assuming a focal stenosis of the hepatic duct is a Klatskin tumor is not always correct. (Consumer Summary produced by Reliance Medical Information, Inc.)

Perforation of the esophagus, the muscular tube that conveys food from the mouth to the stomach, is life-threatening, and accurate diagnosis is essential. However, diagnosis is often delayed by as much as 24 hours, with grave consequences. To understand the reasons for such delay and to optimize treatment, the records of 69 patients (average age, 43) treated at one medical facility who suffered esophageal perforation over a 12-year period were reviewed. The injury was iatrogenic, i.e. due to physician error, in 33 patients (48 percent of the cases); due to external trauma in 23 (33 percent); and spontaneous (after vomiting) in 8 patients (12 percent). Foreign bodies and other causes accounted for the remaining seven percent. Patients commonly complained of chest pain and had fever, subcutaneous emphysema (air under the skin), and pneumothorax or pneumomediastinum (air abnormally present in chest cavities). Almost half the patients with iatrogenic injury had had a symptom-free interval of eight hours or more. Contrast esophagography (viewing the esophagus with X-ray after it has been filled with a contrast material) performed on 43 patients revealed the perforation in 40. While diagnosis was made within 24 hours in cases of trauma, the interval between injury and diagnosis exceeded 24 hours for 16 patients with iatrogenic injuries and in half of those with spontaneous perforations. Treatment was surgical in 59 patients, primarily by suture closure of the perforation. This method is desirable for patients in good health. Eight were treated nonoperatively, by antibiotics and total parenteral alimentation (delivery of nutrients intravenously). Seven patients died, yielding a mortality for patients with iatrogenic perforation of 12 percent, and for those with spontaneous perforations of 25 percent. Early diagnosis depends on aggressive use of esophagography and well-placed suspicion that esophageal perforation has occurred. Most such injuries will be best treated operatively, but the best strategy for a given patient must be individually determined. (Consumer Summary produced by Reliance Medical Information, Inc.)

Extracorporeal shock-wave lithotripsy (ESWL) uses a focused beam of sound waves that is transmitted across the skin to break apart stones which develop within ducts of the body. The technique has been used to treat more than 2,000 kidney stone patients throughout the world. The patient is placed in a water bath and the sound electrode is aligned with the stones. Pressures of between 500 and 2,000 times the pressure of the atmosphere (a little more than 15 lbs per square inch) are developed at the point of focus, i.e., at the stone. The current study is a preliminary report of the use of this device for the treatment of liver duct stones, which are located in sites which make them nontreatable by current surgical techniques (e.g., deep in the liver tissue ducts). The study was a multi-institutional trial organized by the manufacturer of the device and designed to demonstrate the efficacy and safety of the ESWL for use in the treatment of bile duct stones. Forty-two patients between 25 and 95 were entered into the trial. Stones were present in various sites of their biliary system and ranged in size from 6 mm to approximately 30 mm. No patients with single stones were included; the number of stones was between two and four. The 42 patients received a total of 57 ESWL treatments, each of which consisted of an average number of 1,924 shocks. Although the treatment time varied, it lasted an average of approximately 53 minutes. General anesthesia was used in a third of the cases and local anesthesia in the rest. Stone fragmentation occurred in approximately 95 percent of the cases. However, the fragments remained in approximately 60 percent of the cases 24 hours after the treatment. Some patients required added help in the removal of the fragments, which was provided by various means: catheters, endoscopes (small periscope-like instruments), washing of the bile delivery system, and surgery. At discharge, nearly three quarters of the patients were free of stones. ESWL proved successful when coupled with ancillary techniques for the removal of residual stone fragments in the treatment of bile stones that cannot be treated by conventional methods. The procedure produced no deaths in this group of extremely high-risk patients and was associated with acceptable morbidity.