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Aims: To study the prevalence, clinical characteristics and long-term outcome of oesophagitis in Chinese patients., Methods: Clinical and endoscopic data were collected prospectively from consecutive patients who underwent upper endoscopy between 1997 and 2001. Patients with endoscopic oesophagitis were graded according to the Los Angeles system and analysed according to their clinical presentation, endoscopic details, Helicobacter pylori status, non-steroidal anti-inflammatory drug history, co-morbidity and mortality., Results: A total of 22,628 upper endoscopies were performed in 16,606 patients. Of these, 631 (3.8%) had endoscopic oesophagitis, 14 had benign oesophageal stricture (0.08%) and 10 had Barrett's oesophagus (0.06%). Most patients (94%) had either Los Angeles grade A or grade B oesophagitis. Patients who died during follow-up had a significantly higher incidence of co-morbid illness (100% vs. 63%, P < 0.001). By Cox regression analysis, the presence of gastrointestinal bleeding (P = 0.008), advanced age (P = 0.004) and the use of Ryle's tube (P = 0.043) were identified to be independent factors associated with mortality., Conclusions: Complicated gastro-oesophageal reflux disease is uncommon in the Asian population. Advanced age, use of Ryle's tube and the presence of gastrointestinal bleeding are associated with a poor long-term outcome, which is a reflection of the severe underlying co-morbidity.

Background/purpose: The aim of this study was to determine the incidence and risk factors for esophageal foreign body obstruction (EFBO) after esophageal atresia/tracheoesophageal fistula (EA-TEF) repair., Methods: A Case-control chart review was conducted from 1987 to 1999., Results: EFBO occurred in 14 of 108 patients (13%) with EA-TEF. Mean follow-up was 31 months. Alimentary debris was the most common foreign body. Mean time between operation and EFBO was 25 months. EFBO recurred in 50%. Sixty-one percent of patients required endoscopic FB removal. Esophageal stenosis was present in 57% of EFBO patients, and 80% of stenoses presented initially with EFBO. The incidence of gastroesophageal reflux (GER; 50%), type C anomaly (100%), anastomotic leak (21%), major associated anomalies (50%), and encephalopathy (14%) were not significantly different between the EFBO group and the total EA-TEF population. There was no difference in the need for antireflux surgery (57%) between those with EFBO and GER and the total EA/TEF population with GER., Conclusions: Esophageal foreign body obstruction occurs in at least 13% of patients after EA-TEF repair. Because no reliable risk factors were identified that could predict foreign body obstruction, all families should be warned about this possibility during the first 5 years, particularly once the child begins eating solid foods., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Objective: To present incidences of the oesophageal atresia or stenosis and their maternal age distribution. To analyse maternal age as a possible risk factor for the defects studied., Design: Retrospective epidemiological study., Setting: Institute for Care of Mother and Child, Prague, Czech Republic., Methods: Retrospective epidemiological study of oesophageal atresia and stenosis using data from the population based register of congenital malformations in the Czech Republic over the 1961-2000 period. The main source of data for this paper is the database of congenital anomalies at the Institute for Care of Mother and Child in Prague (the 1961-1990 period) and the data analysed by the Institute of Health Information and Statistics (the 1987-2000 period)., Results: Out of the total number of 5,589,888 births in the Czech Republic in 1961-2000 period, 804 cases of oesophageal atresia and stenosis were registered. Mean incidence of oesophageal atresia and stenosis in the period under the study was 1.51 per 10,000 livebirths. In the 1991-2000 period an increase of incidences of this congenital anomaly was revealed in the Czech Republic. By application of the two-sided 95% CI, statistically significant correlation was found in women of 39 years of age and older., Conclusions: Statistically significant increase of risk (for age as a risk factor) was found in maternal age groups of 39 years of age and over.

Background: Laparoscopic fundoplication has become the standard for operative treatment of gastroesophageal reflux disease (GERD)., Methods: We reviewed our experience with 1,000 consecutive patients receiving laparoscopic fundoplication for GERD (n = 882) or paraesophageal hernia (n = 118) between October 1991 and July 1999. Patients with achalasia and failed fundoplication were excluded from analysis. All the patients were evaluated preoperatively by upper endoscopy, esophageal manometry, and barium swallow. After 1994, 24-h pH monitoring was performed selectively in patients with extraesophageal symptoms and/or those without erosive esophagitis. There were 490 men 510 women in this review. Their mean age was 49 years. Procedures performed were 360 degrees floppy fundoplication (n = 879), 360 degrees fundoplication without fundus mobilization (Rossetti) (n = 22), 270 degrees posterior fundoplication (n = 96), and anterior fundoplication (n = 2). Esophageal lengthening procedure (Collis gastroplasty) was performed in combination with fundoplication in 15 patients. In seven patients the treatment was converted to open fundoplication., Outcomes: The average length of hospitalization was 2.2 days, and 136 patients stayed longer than 2 days. Major complications occurred in 21 patients: esophageal perforation (n= 10), acute paraesophageal herniation (n = 4), splenic bleeding (n = 2), cardiac arrest (n = 1), pneumonia (n = 3), and testicular abscess (n = 1). Additional operations were required to manage the complications in 14 patients (70%): Four of these procedures were performed emergently, and 10 patients underwent reoperation between 6 h and 10 days. There were three deaths, all of which involved elderly patients with paraesophageal hernia. There were 35 late failures requiring reoperation for recurrence of GERD or development of new symptoms: The treatment of 32 patients was revised laparoscopically, and 4 patients required laparotomy. Beyond 1 year (median follow-up period, 27 months), 94% of the reviewed patients were satisfied with their surgical outcome.

Context: Severe gastroesophageal reflux disease (GERD) is a lifelong problem that can be complicated by peptic esophageal stricture and adenocarcinoma of the esophagus., Objective: To determine the long-term outcome of medical and surgical therapies for GERD., Design and Setting: Follow-up study conducted from October 1997 through October 1999 of a prospective randomized trial of medical and surgical antireflux treatments in patients with complicated GERD. Mean (median) duration of follow-up was 10.6 years (7.3 years) for medical patients and 9.1 years (6.3 years) for surgical patients., Participants: Two hundred thirty-nine (97%) of the original 247 study patients were found (79 were confirmed dead). Among the 160 survivors (157 men and 3 women; mean [SD] age, 67 [12] years), 129 (91 in the medical treatment group and 38 in the surgical treatment group) participated in the follow-up., Main Outcome Measures: Use of antireflux medication, Gastroesophageal Reflux Disease Activity Index (GRACI) scores, grade of esophagitis, frequency of treatment of esophageal stricture, frequency of subsequent antireflux operations, 36-item Short Form health survey (SF-36) scores, satisfaction with antireflux therapy, survival, and incidence of esophageal adenocarcinoma, compared between the medical antireflux therapy group and the fundoplication surgery group. Information on cause of death was obtained from autopsy results, hospital records, and death certificates., Results: Eighty-three (92%) of 90 medical patients and 23 (62%) of 37 surgical patients reported that they used antireflux medications regularly (P<.001). During a 1-week period after discontinuation of medication, mean (SD) GRACI symptom scores were significantly lower in the surgical treatment group (82.6 [17.5] vs 96.7 [21.4] in the medical treatment group; P =.003). However, no significant differences between the groups were found in grade of esophagitis, frequency of treatment of esophageal stricture and subsequent antireflux operations, SF-36 standardized physical and mental component scale scores, and overall satisfaction with antireflux therapy. Survival during a period of 140 months was decreased significantly in the surgical vs the medical treatment group (relative risk of death in the medical group, 1.57; 95% confidence interval, 1.01-2.46; P =.047), largely because of excess deaths from heart disease. Patients with Barrett esophagus at baseline developed esophageal adenocarcinomas at an annual rate of 0.4%, whereas these cancers developed in patients without Barrett esophagus at an annual rate of only 0.07%. There was no significant difference between groups in incidence of esophageal cancer., Conclusion: This study suggests that antireflux surgery should not be advised with the expectation that patients with GERD will no longer need to take antisecretory medications or that the procedure will prevent esophageal cancer among those with GERD and Barrett esophagus.

Objectives: The aim of this study was to compare the incidence and endoscopic management of esophageal stricture formation, significant ulcer bleeding, massive esophageal hematoma, and perforation resulting from endoscopic band ligation or sclerotherapy of esophageal varices., Methods: Consecutive esophagogastroduodenoscopies in which band ligation or sclerotherapy was performed for acute or obliterative therapy were entered into a computerized endoscopy database during a 7-yr period. Patients were excluded if they died within 72 h of treatment session from complications unrelated to the procedure. Sclerotherapy was performed using a 25-gauge needle with 1.5% sodium tetradecyl sulfate and banding was primarily performed with a Wilson-Cook 6 or 10 shooter. Complications were assessed at scheduled endoscopy and outpatient clinic visits, review of quality assurance data tallied on a monthly basis, and patient records., Results: Two hundred twenty-one cases of sclerotherapy were performed in 59 patients compared to 110 cases of band ligation in 52 patients. Five patients were excluded because of death within 72 h of the procedure. The incidence of complications from sclerotherapy:banding on a per patient basis included: esophageal stricture formation 25.6%:1.9%, ulcer bleed 25.4%:5.7%, esophageal perforation 2.2%:0%, and massive esophageal hematoma 1.6%:0%. A significant difference in complications between sclerotherapy and band ligation was noted for both stricture formation (p < 0.0005) and ulcer bleeding (p < 0.0001). The majority of ulcer bleeds required no therapeutic intervention, whereas stricture formation required multiple dilation sessions., Conclusions: Band ligation has a significantly lower incidence of stricture formation and ulcer bleeding compared to sclerotherapy. The majority of complications can be managed with endoscopic interventions.

Objective: The primary goal of this study was to investigate whether oral steroids would reduce the incidence of stricture formation after photodynamic therapy (PDT) in Barrett's patients. The effect of balloon window length, pretreatment of nodules, retreatment of skipped areas, and subsequent PDT on the incidence of strictures was also investigated. The ultimate goal of treatment was elimination of dysplasia, early cancer, and Barrett's mucosa., Methods: A total of 60 patients were injected with Photofrin (2 mg/kg). Patients were randomized to receive PDT (n = 30) or PDT and oral prednisone (n = 30). Two days later, 630 nm light (KTP/dye laser) was delivered using a 5- or 7-cm windowed balloon at a light dose of 200 or 175 J/cm. The majority of patients received 200 J/cm using a 7-cm balloon. Nodules were pretreated with a short diffuser at a dose of 50-75 J/cm. Additional light was delivered to skipped areas 2-3 days later. Endoscopies were conducted every 3-6 months to evaluate the response. Residual or recurrent Barrett's was treated using neodymium:aluminum-yttrium-garnet (Nd:YAG) laser (small areas) or was retreated with PDT., Results: The effect of steroids on the incidence of strictures was analyzed in patients receiving a single treatment with a light dose of 200 J/cm using a 7- cm balloon. There was no reduction in the incidence of strictures in patients receiving PDT and steroids (29%) compared to those receiving PDT alone (16%). Treatment using a 7-cm balloon caused more strictures (31%) than treatments using a 5-cm balloon (7%). Pretreatment of nodules or retreatment of skipped areas did not increase strictures. Patients receiving subsequent PDT had a higher incidence of strictures. Cancer was eliminated in all patients. High-grade dysplasia was eliminated in 41 of 43 patients (96%). Barrett's mucosa was totally eliminated in 25 of 60 patients (42%)., Conclusions: Oral prednisone after PDT did not reduce the incidence of strictures. Subsequent PDT and longer balloon window were associated with higher incidence of strictures. PDT followed by thermal ablation of small islands eliminated dysplasia, early cancer, and Barrett's mucosa.

Background: Circular staplers have reduced the incidence of anastomotic leaks in esophagovisceral anastomosis. However, the prevalence of stenosis is greater with staplers than with manual suturing. The aim of this study was to analyze potential risk factors for the onset of anastomotic stenoses and to evaluate their treatment and final outcome., Methods: Between 1990 and 1995, 187 patients underwent esophagectomy and esophagogastrostomy with anastomosis performed inside the chest using a circular stapler., Results: Twenty-three patients (12.3%) developed an anastomotic stenosis. The incidence of strictures was inversely related to the diameter of the stapler. Concomitant cardiovascular diseases; morphofunctional disorders of the tubulized stomach, such as those related to duodenogastric reflux; and neoadjuvant chemotherapy were also recognized as significant risk factors. Endoscopic dilatations proved safe and were effective in the treatment of most anastomotic stenoses., Conclusions: To reduce the risk of anastomotic stenosis after stapled intrathoracic esophagogastrostomy, adequate vascularization of the viscera being anastomized should be maintained, and it is mandatory to use the largest circular stapler suitable. Furthermore, it is essential to reduce the negative inflammation-inducing effects of duodenogastroesophageal reflux to a minimum. Endoscopic dilatations are safe and effective in curing the great majority of anastomotic stenoses.

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder. Despite its frequent occurrence, only a minority of patients seek medical attention, making it difficult to ascertain the true epidemiologic distribution of the disorder. A causal association between GERD and esophageal complications such as esophagitis, esophageal ulcer, and esophageal stricture is well accepted. Recent epidemiologic evidence suggests that GERD may likewise represent a risk factor for the development of supraesophageal conditions, such as asthma, chronic bronchitis, laryngitis, and even laryngeal cancer. Although epidemiologic associations do not establish a cause-and-effect relationship, they may indicate potential etiologic risk factors. Nevertheless, confirmation of the causal role of GERD in supraesophageal disorders awaits further investigation.

Objective: Esophageal strictures have been reported to complicate opportunistic esophageal infections in human immunodeficiency virus (HIV)-infected patients, although the etiology, prevalence, and incidence of strictures after these infections have not been studied., Methods: HIV-infected patients undergoing upper endoscopy for clinical indications over a 7.5-yr period were prospectively identified. The cause of esophageal ulceration was defined by previously proposed criteria. Endoscopic re-examination was performed in most patients after treatment, and long term clinical follow-up was obtained. An esophageal stricture was defined as circumferential luminal narrowing of > or = 30% at endoscopy and/or barium esophagography., Results: A total of 160 HIV-infected patients were identified with esophageal ulcer. Of these patients, 13 (8%; 95% CI 4-12%) developed esophageal strictures. Strictures were identified at the time of initial endoscopy in three patients (cytomegalovirus [CMV] in one patient and gastroesophageal reflux disease in two), and at the site of ulcer healing or persistence in the other patients (four, CMV; four, idiopathic; one, herpes simplex virus [HSV]; one, CMV/HSV). Long term follow-up did not identify any additional patients who developed an esophageal stricture., Conclusion: Esophageal strictures infrequently complicate ulcerative esophagitis caused by opportunistic infections in HIV-infected patients.

Background and Study Aims: Esophageal endoprosthesis placement is an established method of palliating inoperable esophageal malignancy. However, the prosthesis choice varies, with expandable metal stents recently gaining popularity. We present our experience of using an indigenously developed plastic prosthesis in 265 patients prospectively in the period April 1992 to May 1996., Patients and Methods: An indigenous endoprosthesis made of a medical grade, nontoxic, radiopaque plastic material was placed successfully in 259 patients after serial dilatation of the malignant stricture. Patients were followed up once every month for at least 6 months and also in between if they developed any significant symptoms. The results were analyzed prospectively with special emphasis on the cost of the therapy, technical success of placement, improvement of swallowing and occurrence of complications., Results: The technical success of placement was 97.7% (259/265 patients). The mean dysphagia score improved from 3.2 to 1.2; 212 patients (81.8%) could swallow semisolids whereas 47 patients (18.2%) could swallow liquids. Though 75 patients (28.3%) had an associated tracheoesophageal fistula and 29.8% had received prior radiotherapy/chemotherapy, immediate complications like perforation, respiratory distress or severe hemorrhage were encountered in only 4.3% of patients. Late complications occurred in 12.7% and 32.8% of the patients complained of mild post-procedure pain in the chest. The overall procedure-related mortality was 3.9%. The average cost of the prosthesis was only US$ 15 per patient., Conclusions: Placement of a plastic prosthesis is still a very effective and safe method for relief of malignancy-induced dysphagia. The associated complications can be significantly reduced by modifying the prosthesis material/design and adhering to a careful technique. The extremely low cost of the prosthesis and its safety profile makes this treatment highly cost-effective and widely applicable in developing countries such as India.

From 1990 to 1995, 187 patients underwent esophagectomy and esophagogastrostomy with the anastomosis performed inside the chest using a circular stapler. Twenty-three patients (12.3%) developed an anastomotic stricture. The incidence of anastomotic stricture was inversely related to the diameter of the stapler. Also concomitant cardiovascular diseases, morpho-functional disorders of the tubulized stomach (possible related to duodeno-gastric reflux) and neoadjuvant chemotherapy were recognized as significant risks factors. Endoscopic dilations were safe and effective in the treatment of anastomotic strictures.

Purpose: To evaluate long-term survivors of high-grade non-Hodgkin's lymphomas (NHLs) for late effects and to attempt to assess the relative contributions of the primary treatment modalities to these late effects., Patients and Methods: Of 103 young survivors followed up for 1 to 20 years, 74 patients were interviewed and underwent various investigations, and an additional 12 patients were interviewed only. Of the 86 patients, 65 had previously suffered from small non-cleaved-cell lymphoma, 16 from lymphoblastic lymphoma, and five from large-cell lymphoma., Results: Left ventricular dysfunction was identified in eight of 57 (14.0%) patients who had received doxorubicin (DOX) in doses greater than 200 mg/m2, of whom four were symptomatic and four were asymptomatic. A ninth patient required a pacemaker. Of the 86 patients, 23 (26.7%) reported pregnancies, 18 of whom had 30 children. Two of the 86 (2.3%) patients developed second cancers. Other major late effects included posttransfusion viral hepatitis, eight patients; CNS toxicity, two patients; endocrine impairment, 14 patients; vitamin B12 deficiency, two patients; esophageal stricture, one patient; urinary tract problems, two patients; and musculoskeletal defects, three patients. Major late effects occurred in 11 of 21 (52.4%) patients who had received radiation as well as chemotherapy, eight of 22 (36.4%) patients who had surgical resections as well as chemotherapy, and 17 of 74 (23.0%) patients who had received chemotherapy alone., Conclusion: The predominant major late effects observed were late cardiac toxicity related to DOX therapy and hepatitis C virus infection that presumably resulted from blood product transfusions administered before the introduction of screening for the hepatitis C virus. Fertility was not greatly impaired, and second malignancies were uncommon. No patient had clinically significant impairment of growth. Radiation appeared to increase the likelihood of late effects.

In 1992, the USA embargo on Cuba was tightened through the passage of the Cuban Democracy Act (CDA) that explicitly restricts food and medical supplies. The embargo has contributed to cause a number of public health problems in Cuba including: (1) an epidemic of more than 50,000 cases of optic and peripheral neuropathies in 1992-1993, resulting from dietary deficiency; (2) an epidemic of esophageal stenoses in toddlers who inadvertently drank liquid lye as a result of a soap shortage for which liquid lye was substituted; (3) an outbreak of Guillain-Barré syndrome in Havana, in June and July 1994, resulting from water contamination due to lack of chemicals for water treatment to eliminate Campylobacter sp.; (4) outbreaks of self-inflicted disease and injuries caused by rioting among Cubans detained at the US Naval base at Guantánamo Bay, and (5) a decline in medical practice standards and public health indicators in Cuba resulting from the enactment of the CDA, documented by the American Public Health Association in 1993 and confirmed in March 1997 by the American Association for World Health. Despite this evidence, the Cuban embargo remains a politically sensitive subject in the USA, resistant to public health concerns, as evidenced by the recent passage of the Helms-Burton Act. The public health effects of the CDA need to be reviewed with possible revocation or at least modification.

Background and Study Aims: Benign anastomotic stenosis (BAS) represents a frequent complication following esophagectomy and cervical esophagogastrostomy for cancer. This study was undertaken to evaluate through early postoperative esophagoscopy the morphologic change of the anastomosis which could be related to BAS development., Patients and Methods: Thirty-nine patients who underwent subtotal esophagectomy and cervical esophagogastrostomy were prospectively evaluated. The analyzed factors were: age; sex; the anastomotic size; the presence and number of endoscopically visible stitches; the presence and percentage of mucosal ulcerations involving the anastomotic suture line; the presence of anastomotic leak or dehiscence; the vascularization of the gastric tube; the patency of pylorus., Results: No complications related to the early esophagoscopy were observed. Twelve patients (30.7 %) developed a stenosis postoperatively. The univariate analysis demonstrated anastomotic leak (p < 0.006), more than one endoscopically visible stitch (p < 0.0003), and mucosal ulceration involving more than 50% of the anastomosis (p<0.00009) as factors significantly correlated with BAS development. However stepwise logistic regression extracted the presence of ulcerations involving more than 50% of the anastomosis as the most important independent factor in predicting BAS development (Odds Ratio = 9.03+/-5.5, p = 0.009). All patients who developed a BAS were treated with early pneumatic dilatations, with an 83.3% success rate after a mean of 3.6 sessions., Conclusions: Early postoperative esophagoscopy seems a safe and effective tool for the monitoring of the anastomosis healing after cervical esophagogastrostomy. The presence of extended mucosal ulcerations appeared as the most important factor in predicting BAS formation.

Aims: To study the epidemiology and natural history of gastro-oesophageal reflux disease (GORD)., Methods: Retrospective cohort study involving all 172 hospitals of the Department of Veterans Affairs. A total of 194,527 patients with GORD were followed between 1981 and 1994. Distribution of oesophagitis, oesophageal ulcer, oesophageal stricture, strictured hiatus hernia, hiatus hernia, and pyrosis by age, sex, and ethnicity were determined. The comorbid occurrence of various forms of GORD in identical patients was analysed by an age and race standardised morbidity ratio. The population of all hospitalised veterans was used for comparison., Results: Severe forms of GORD associated with oesophageal erosions, ulcers, or strictures, affected elderly, white, male patients more often than their corresponding opposite demographic group. All forms of GORD clustered in the same patient population; on average, any form of GORD was 10 times more likely to occur in a patient with another form of GORD than without. The highest morbidity ratio (22) was found in oesophageal ulcer and stricture. About one third of all patients with oesophageal erosions, ulcers, or strictures also had hiatus hernia; 46% of patients with hiatus hernia were diagnosed as having other forms of GORD. While one third of all oesophageal strictures appeared in patients without other forms of GORD diagnosed at any time, oesophageal ulcers were always associated with some other form of GORD. No clear cut progression in different forms of GORD was found., Conclusions: Older age, male sex, and white ethnicity are risk factors in the development of severe forms of GORD. The most severe grade of GORD is reached at the onset of the disease.

Background: The association of congenital stenosis of the distal esophagus (CES) in children with esophageal atresia/tracheoesophageal fistula complex (TEF) has been described but is thought to be rare. Most reports have been of individual or small numbers of cases., Objective: The objective of the study was to evaluate the incidence, clinical and radiographic features of CES associated with TEF, and to compare the clinical and radiographic features of CES with acquired anastomotic strictures in TEF patients., Materials and Methods: A retrospective review was undertaken of the records and radiographs of 225 infants with primary TEF repair over a 26-year period., Results: A total of 18 of 225 (8 %) cases of CES associated with TEF and 43 of 225 (19 %) cases of anastomotic strictures were identified. CES was typically a relatively long, smooth circumferential narrowing at the junction of the mid-esophagus and distal esophagus, with normal-caliber esophagus above and below; anastomotic strictures, in contrast, were focal. Diagnosis of CES was delayed in 10 cases and missed on one or more fluoroscopic studies in 14 children. Symptoms, including feeding and respiratory problems and foreign body impaction, were common in both CES and anastomotic strictures; repeated esophageal dilatations were usually necessary. Esophageal perforation complicated dilatation in 6 (33 %) young children with CES, but none of the children with anastomotic strictures (P < 0.001)., Conclusion: CES in combination with TEF is not rare and usually produces clinical symptoms. The diagnosis may be missed or delayed unless specifically evaluated surgically and radiologically. Esophageal dilatation in CES is potentially hazardous with a high risk of perforation, especially in young children.

Unlabelled: We reviewed the case histories of 743 children seen at our hospital from 1981 to 1990 for suspected ingestion of caustic substances. Mean patient age was 27 months; 85% of patients were less than 3 years old. The male-to-female ratio was about 2:1. About 53% of patients were from urban environments. All ingestions appear to have been accidental. Of the 743 children, 20% presented oesophageal burns (11.8% first-degree, 3.1% second-degree and 2.7% third-degree). Alkaline products were ingested about 11 times more frequently than acid products. The substance ingested was bleach in 73% of cases. The most dangerous substances were dishwasher liquids/powders (59% of ingestions led to oesophageal burn), caustic soda (55%) and drain cleaners (55%). The caustic product was not in its original container in 75% of cases. Most accidents (58%) took place in the home. We did not detect any reliable predictive relationship between the presence of symptoms and signs and of oesophageal burns. Of the 743 patients, 5% developed oesophageal stricture and 3% required oesophageal dilatation., Conclusion: The incidence of accidents caused by the ingestion of caustic substances can only be reduced by broad-based preventive strategies, including enforcement of safe manufacturing practices and public education programmes. Most importantly, the containers for caustic household products should be cheap, small and childproof.

Objective: To present our long-term results of the treatment of caustic-induced prepyloric obstruction, and to set out guidelines for the management of such patients., Design: Retrospective study., Setting: General hospital (medical centre), Taiwan., Subjects: 30 patients (8 male and 22 female, mean age 34 years, range 13-62) who developed prepyloric obstruction out of 271 treated for caustic injuries of the upper gastrointestinal tract., Interventions: Gastrojejunostomy (n = 24), antrectomy and Billroth I reconstruction (n = 4), and antrectomy and Billroth II reconstruction (n = 2). Four patients required second operations: oesophageal reconstruction for stricture (n = 3), and gastrojejunostomy for restenosis of Billroth I anastomosis (n = 1)., Main Outcome Measures: Morbidity and mortality., Results: No patient died postoperatively, and there were three complications--wound infection, internal bleeding, and stenosis of the Billroth I anastomosis. 21 patients were able to enjoy their normal diet postoperatively, 5 required periodic dilatation of oesophageal strictures, and 4 required further operations., Conclusions: Gastrojejunostomy gives good long term results as long as there is no oesophageal stricturing, and morbidity and mortality are low. The long term outcome is dependent on the degree of oesophageal involvement.

Esophageal stenosis caused by an intrinsic congenital deformity is uncommon in infants and children. The main forms of stenosis are congenital esophageal web congenital stricture caused by tracheobronchial remnants, and congenital idiopathic muscular hypertrophy. The authors report on two patients who were successfully treated and managed after being diagnosed as having upper esophageal stenosis. One patient underwent resection of the web and primary anastomosis of the esophagus and was discharged 6 days after surgery. After 1 year, this patient has had no symptoms of dysphagia or other postoperative difficulties. The second patient underwent balloon dilatation of the esophageal stricture and was discharged on the day of surgery; however, this patient required numerous repeat dilatations.

Over a ten-year period sixteen infants with isolated congenital tracheo-oesophageal fistulas (TOF) were treated. All infants were symptomatic from birth although the diagnosis was only established in the neonatal period in eleven cases. Tube oesophagography was the diagnostic investigation of choice. Bronchoscopic cannulation of the fistula greatly assisted division, which was achieved through a cervical incision in all cases. There were two early recurrent fistulas both of which closed spontaneously. Persistent oesophageal symptoms were common. Seven of the patients (43%) experienced dysphagia, three of whom developed oesophageal strictures requiring repeated dilation.

An apparent reduction in the rate of benign anastomotic stricture after stapled esophagogastrectomy prompted us to review the results obtained with different stapling devices since 1988. We present a retrospective review of 125 consecutive patients undergoing esophageal resection for malignancy with stapled intrathoracic anastomoses. Benign anastomotic stricture was deemed present when a patient required endoscopic dilatation to treat postoperative dysphagia. We found no difference in risk factors not related to stapler size (tumor histologic characteristics, adjuvant therapy) between patients with stricture and patients without stricture. Event-free survival was compared for different stapler diameters as well as for different stapler designs. We found that staplers of smaller diameter were associated with significantly more strictures (p < 0.005). In a comparison of different designs of 25 mm stapler, the newer CDH device (Ethicon Ltd., Edinburgh, United Kingdom) was associated with a similar stricture rate to that associated with other designs (ILP [Ethicon] and EEA [Autosuture Company Division, United States Surgical Corp., Norwalk, Conn.]). For a given stapler diameter, it appears that different stapler designs have no effect on stricture rate.

Objective: Oesophagectomies have a high morbidity rate, mainly related to pulmonary complications. The aim of this work was to assess whether the thoracoscopic approach could reduce this morbidity., Patients and Methods: We conducted a prospective study of the results of 26 attempts of esophagectomy using a right thoracoscopic approach. There were 17 males and 9 females having an average age of 47. The indication was a squamous cell carcinoma in 19 patients, an adenocarcinoma in 1 patient, a melanoma in 1 patient and a caustic stenosis in 5. The whole oesophagus was mobilized thoracoscopically, and the eosophagectomy was completed through the abdomen. The reconstruction was achieved using a gastric pull-through and a cervical anastomosis., Results: There were 5 failures for the following reasons: unresectable carcinoma (1 case), large tumour making a thoracoscopic dissection unsafe (1 case) and incomplete lung collapse making the exposure of the posterior mediastinum difficult (2 cases). The average time of the thoracoscopic procedure was 135 min. The post-operative course was uneventful in all but 5 patients who had a pulmonary complication: atelectasis (3 cases), right purulent pleural effusion (1 case), acute respiratory distress syndrome (1 case). The latter complication was lethal. Four out of 5 respiratory complications occurred in patients for whom the dissection was considered as difficult. Among the other complications, there were 5 anastomotic leakages and 3 laryngeal nerve palsy. The mortality rate was 3.8%., Conclusion: These initial results do not show a real benefit of the thoracoscopic approach for eosophageal dissection, especially for difficult oesophagectomies. Further evaluation of the technique is needed.

The optimal management of reflux-induced esophageal strictures that occur after esophagomytomy for achalasia is uncertain. This paper presents our experience with the nonsurgical treatment of postesophagomyotomy strictures in achalasia patients using endoscopic dilation and gastric acid suppression. Six patients with achalasia who had undergone prior esophagomyotomy subsequently developed recurrent dysphagia and were found to have an esophageal stricture. Esophagrams typically showed a markedly dilated esophagus with a narrowed, sharply angulated gastroesophageal junction. Esophageal manometry confirmed esophageal aperistalsis and, when measured, the LES pressure was < 5 mm Hg. Endoscopy showed esophageal inflammation and a fixed stricture at the gastroesophageal junction. Strictures were dilated under direct visualization using through-the-scope balloon dilators. Patients began gastric acid suppressive treatment at the same time. Five patients who remained symptomatic underwent repeat endoscopy, which demonstrated improvement in esophagitis. Dilation was then repeated with a larger balloon dilator. Over a mean follow-up period of 3.8 years, the average number of repeat dilations per patient was 3.6 (range: 0-12). All patients had symptomatic improvement and weight gain. No patient required surgery. We conclude that esophageal strictures after esophagomyotomy for achalasia can be safely treated using endoscopic dilation and gastric acid suppression, thus avoiding the need for reoperation.

Objectives: The clinical feasibility of self-expanding metal stents with respect to the technical success, complications, and reintervention rate should be tested., Methods: Five coated and 26 uncoated prototype Wallstents, especially designed for stenosis of the upper GI tract, were implanted in 23 patients. All patients with dysphagia suffered from inoperable tumor stenosis of the esophagus or the cardia. Stent implantation was performed under slight i.v. sedoanalgesia., Results: Technical success was achieved in all 31 implanted stents. Forty-eight hr after implantation, dysphagia was improved in 21/23 patients. Acute problems observed within 1 wk were stent migration (1 patient, uncoated stent), oblique position of the stent (3 patients), epigastric or retrosternal pain (9 patients), insufficient stent expansion (4 patients), and pouch formation at the upper rim of the stent (4 patients). An uncomplicated follow-up (median 66 days, range 10-139 days) was seen in 12 patients (52%). Major problems in the follow-up period were stent migration in three patients (three coated stents, two stent migrations in one patient) and stent obstruction by tumor ingrowth/overgrowth and/or food impaction in eight patients (35%). Most of these problems could be successfully resolved by implantation of a second stent or electrocoagulation of overgrowing tumor tissue. By the 1st of March, 1994, three patients were still alive with a follow-up period of 530 days (median range, 336-880 days); 20 patients were decreased with a follow-up period of 70 days (median range, 3-374 days)., Conclusions: Implantation of esophageal Wallstents is safe and has a low risk of acute complications and mortality for the patient. Early complications such as perforation and bleeding did not occur. Tumor ingrowth/overgrowth are the major reasons for the high reintervention rate in the follow-up period. Coated stents can resolve this problem, provided that stent migration can be avoided by improvement of the coating technology.

A case report of an intrathoracic application of tubed latissimus dorsi musculocutaneous flap as an island flap for one-stage reconstruction of an extensive and impassable stricture, following corrosive burns of the oropharynx and the cervical and upper half of the thoracic esophagus in a 1-year-old child, with follow-up results of 9 years is presented. Esophagoscopic and cineradiographic studies were carried out at regular intervals to monitor the growth and the patency of the neoesophagus. This was probably the youngest patient for whom the latissimus dorsi musculocutaneous flap has been used for an intrathoracic application. Also this may be the first reported case of the use of the latissimus dorsi flap for reconstruction of the thoracic esophagus.

Introduction and Objectives: Aortic vascular rings can produce compression and obstruction in the airway and/or esophagus early surgical treatment in the first days or months of life. The reported incidence range between 0.3-0.6% with an 0.5% in our series. The following is a retrospective analysis with clinical, radiological and angiocardiographic study of the patients operated on in our service with the diagnosis of aortic vascular ring focused on the surgical results., Methods: A total of 43 children with ages ranging between 21 days and 10 years (mean age 17 months) underwent surgical treatment for aortic vascular ring, during the period between january 68 and january 94. Clinically, 74% had stridor, 27.4% gastroesophageal reflux, 34% pulmonary infection, 14% respiratory insufficiency with mechanical ventilation, 12% heart failure, 9% dysphagia, 2% crisis of bronchospasm and 2% tracheomalacia that require tracheotomy prior to surgical correction. Diagnosis was made by esophagogram 86% of the cases. Aortography as the late diagnosis method or for election to surgical approach was made in 85% of the cases. In 42% were double aortic arch, 32% anomalous right subclavian artery and 25% right aortic arch with left ductal ligamentum., Results: Reoperation was performed in 4 cases. Two early (1 case for hemorrhage, 1 case for phrenic paralysis requiring diaphragmatic plication), and two late reoperations (1 aortopexy, 1 tracheal termino-terminal anastomosis) at 2 and 13 months respectively. Hospital mortality was 1 case (2%) with 1 additional late death (2%). Follow-up was performed in the remaining 39 cases with a mean of 11 years (ranging between 1 and 25 years. Thirty seven of 41 patients alive asymptomatic (90%)., Conclusions: Due to a low mortality rate (2.3%) not related with the age of the patient at the moment of the surgical procedure based in our experience, we conclude that it is very important to perform both, early diagnosis and surgical treatment in order to avoid the potential residual lesion on the airway caused by tracheo-broncho malacia, in order to avoid the deleterious effect on the results both at early and later follow-up.

Thirteen consecutive paediatric patients with acquired oesophageal obstruction were managed at the Paediatric Surgical Unit (PSU) of Muhimbili Medical Centre (MMC), Dar es Salaam, Tanzania, between January 1988 and December, 1992 inclusive. There were seven males and six females. The ages of onset ranged from the neonatal period to 6 years, with seven (54%) of them being within 2 years of age. Ten (77%) of the patients had corrosive strictures, caused by the ingestion of caustic soda 4, hair-plaiting chemicals 5, and kerosene one. Two of the remaining patients had non-corrosive strictures following measles in one and candidiasis in the other, while in the last case (a newborn), the obstruction was due to post-traumatic retropharyngeal haematoma from attempted infanticide. All but one of the patients were managed with oesophageal dilation, with or without a preliminary feeding gastrostomy. Six (50%) of the stricture cases died, all of them having had corrosive strictures. The main cause of mortality was complications of oesophageal dilatation.

This study was undertaken to determine the prevalence of vascular compression in manometric tracings and to determine whether these findings had any clinical significance. Vascular compression, defined as a localized area of elevated intraesophageal resting pressure > 4 mm Hg with superimposed cyclic pressure spikes with a frequency of 60-100/min, was noted in 55 of 241 consecutive tracings. The groups with and without vascular compression were similar with regard to mean age, sex, and prevalence of dysphagia. Radiographs were available for 29 of the 55 and showed compression in 18, but there was no relationship with the manometric findings, except for a trend towards finding a positive esophagogram with amplitudes > 16 mm Hg. Eleven tracings showed absent "relaxation" of this elevation of pressure in response to swallows, and five of six available esophagograms showed a corresponding area of compression. We conclude that manometric evidence of vascular compression is common and generally has no clear relationship with esophagographic findings or dysphagia. However, the combined findings of marked increases in pressure and absence of relaxation in response to swallows may indicate evidence for a vascular cause of dysphagia.

Ninety-three adult patients with benign esophageal stricture were randomized to receive balloon or bougie dilatation. Eighty-five patients were eligible for analysis and were followed prospectively for a year. Twenty-four patients required repeat dilatation within a year, but 50 patients completed a year's follow-up without further dilatation. The bougie group initially had a better symptomatic result, experiencing significantly less dysphagia at five months, although this difference had disappeared at one year. Eighteen patients in the balloon group required redilatation for symptoms compared with six in the bougie group. The bougie group had a significantly greater increase in their stricture diameter, and this was still present at one year after dilatation. There was no significant difference in safety or patient acceptability. Balloons are probably more costly to use than bougies. Bougie dilatation is to be preferred to balloon dilatation in adults except in special circumstances.

A total of 102 children less than 16 years of age admitted for caustic ingestion in the period 1976-1991 were registered. The annual incidence rate of hospitalization was 10.8:100,000 for the city of Aarhus, Denmark. Esophageal burns occurred with a frequency of 5.0:100,000 per year. Ninety-four percent of the children were less than 5 years old. For this age group, the incidence rates of admission and esophageal burns were 34.6:100,000 and 15.8:100,000, respectively. All ingestions were accidental. The incidence rates of esophageal burns in children 0-4 years old (p = 0.019) decreased significantly during the period studied. The cause of this decrease is not clear, but a change in the spectrum of household products and the gradual introduction of child-proof caps are possible explanations. To minimize the frequency of accidents, an information campaign directed specifically at parents of toddlers is recommended. Information material should stress that caustics should always be inaccessible to children and stored separately, and should never be decanted.

Despite the frequent occurrence of gastroesophageal reflux disease, until now only very few studies have dealt with the epidemiology of this common disorder. The Health Care Financing Administration complies annually 10 million records of all hospital discharges among Medicare beneficiaries distributed throughout the United States. The purpose of the present study was to take advantage of this large data set and analyze the demographic characteristics of patients discharged with esophagitis, esophageal ulcer, or esophageal stricture. The hospital discharge rates of all three diagnoses showed an age-related rise, the rise being most pronounced for esophageal stricture and, less significant, esophageal ulcer. The marked age dependency of esophageal stricture and ulcer may reflect the time necessary for complications to develop. While simple esophagitis affected women more frequently than men, significantly more men contracted its severe forms involving ulcers and strictures. All forms were more common in whites than blacks, and living in the southern parts of the United States was associated with an increased risk for esophagitis and strictures. The data suggest that besides varying exposure to environmental risk factors, differences in the pathophysiology among demographically stratified groups contribute to the occurrence of esophagitis.

Nine patients (mean age 64, range 51-83 years), with dysphagia due to incurable malignant obstruction of the esophagus were treated by the introduction of 10 self-expanding metal endoprostheses (Nitinol stents). All cases were technically and functionally successful. In one patient the stent did not expand completely; it had to be removed and a second introduced. There were no other complications from the stent implantation. During the period of observation of 136 +/- 86 days one stent (11%) was reobstructed by tumor growing into the stent. Two patients died after 60 and 119 days, both with open stents. Early experience with the Nitinol stent indicates that good palliation of malignant dysphagia can be achieved with a much lower complication rate than results from tube implantation. The design and application system of the stent is capable of further improvement.

A symptomatic lower esophageal ring generally responds to standard bougienage therapy. However, a subset of patients with a lower esophageal ring defy dilation therapy. We have evaluated the efficacy of electrocautery incision of "defiant" lower esophageal rings, the data of which forms the basis of this report. Seven of 75 patients with a lower esophageal ring failed to respond to conventional esophageal dilation. All seven patients underwent electrocautery incision of a "defiant" lower esophageal ring with alleviation of dysphagia. One patient had recurrence of dysphagia that occurred 6 months after initial electrocautery incision. No major complication occurred, although one patient had transient chest pain. Subsequently, all patients have remained without symptoms at a mean follow-up of 36 months. Electrocautery incision of "defiant" lower esophageal ring is efficacious, safe, and results in long-term relief of dysphagia.

Subtotal esophagectomy was attempted by right thoracoscopy on 13 patients, 10 having cancer and 3 long caustic stenosis. Thoracoscopy was converted into thoracotomy in 2 patients, owing to loss of selectivity in one-lung ventilation in 1 and injury to a right intercostal artery flush to the aorta in the other. One patient with cancer underwent an esophageal bypass operation only, owing to tumor invasion into the lung at exploratory thoracoscopy. The ten esophagectomies that could be performed in totality by thoracoscopy consisted of seven en bloc resections of the esophagus with extensive lymph node clearance in the posterior mediastinum, and three standard resections without any lymph node dissection. Postoperative complications included one death due to hepatic failure, two cases of acute pneumonitis, and one persistent chest wall discomfort at the trocar sites. Up to 51 lymph nodes were found in the resected specimens of the cancer patients. Six of the 7 cancer patients who were discharged from the hospital after esophagectomy completed by thoracoscopy were alive at 2 to 20 months of follow-up. Five of them were disease free. The study shows that esophageal resections as extensive as those carried out by thoracotomy can be performed by thoracoscopy. It suggests that prompt management of untoward injury to any mediastinal structure adjacent to the esophagus is less easy by thoracoscopy than by thoracotomy, and that classic complications of open thoracic surgery may occur after thoracoscopy as well.

Between 1987 and 1991, endoscopic balloon dilation was performed for esophageal strictures which developed after operation in 28 cases, after sclerotherapy in 9 cases, and after corrosive injury in 8 cases, for a total of 45 cases. The locations of stricture were upper third in 20 cases, mid-third in 2 cases, and lower third in 23 cases. The stricture appeared clinically 1 to 3 months after esophageal injury. Endoscopic follow-up interval was 1 week. A total of 136 dilations were done in these 45 patients with an average of 2.6 times/case (range, 1 to 8). The result of dilation was good in 9 cases, improved in 18 cases, slightly improved in 15 cases, with only 3 cases having no response. The follow-up period was 2 years on average (range, 0.5 to 4 years). The data suggest that endoscopic balloon dilation is a safe, effective, and easy method for the management of esophageal stricture caused by surgical anastomosis, sclerotherapy, and corrosive injury.

Three hundred patients underwent 1,177 esophageal dilations over a nine-year period. There were 164 men and 136 women. Mean age was 63 years. Etiology of stricture was peptic (160), Schatzki's ring (124), cancer (8), post-surgical (3), post-radiation (2), caustic ingestion (1), and esophageal web (2). Dilators used were Maloney red-rubber mercury weighted (78.1%), Savary wire-guided (15.2%), Eder-Puestow (6.3%) and Balloon (0.4%). Fluoroscopy was used in 98% of cases. One hundred and two of the 111 patients with peptic strictures observed for longer than six months had successful dilation. Forty-five of these patients (40.5%) required 54 redilations to maintain relief of dysphagia. Nine patients were refractory to dilation, two needing serial dilation and seven surgery. All Schatzki's rings were treated successfully. Ten of 82 patients followed for greater than six months needed redilation (12%). Morbidity was 0.2% with two complications occurring, an esophageal perforation and one case of hematemesis. There was no mortality.

The safety and long-term effectiveness of fluoroscopically guided balloon dilation for corrosive esophageal stricture was evaluated in 22 patients with a follow-up period of more than 1 year (range, 13-52 months). The average interval between corrosive agent ingestion and initial balloon dilation was 18 years (range, 2 months to 51 years). Balloons with a diameter of 5-8 mm were used in the initial attempt. The caliber of the balloon catheter was increased gradually over subsequent dilations, up to a diameter that allowed patients to swallow solid foods. Dilation of more than 17 mm in diameter was performed in five patients. Patients underwent one to five sessions. Esophageal rupture occurred in seven patients and was treated nonoperatively in five and surgically in two. With exclusion of these latter two, 11 of 20 could tolerate swallowing all kinds of food and nine could tolerate swallowing most foods. Balloon dilation in corrosive esophageal strictures is effective, but the high rupture rate indicates the need for extra caution.

The purpose of this study, making use of systematic records on computer over a period of 12 years, was to compare the prevalence and the demographic characteristics of patients with peptic stricture with those having a reflux esophagitis. As compared with 3880 cases of erosive and/or ulcerative esophagitis, the percentage of peptic stricture patients was 1.21%. The latter were on average nine years older and more frequently had a hiatus hernia. Ten patients with peptic stricture had had severe esophagitis previously recorded in our department. Thirty-four peptic stricture patients (72.3%) had at least one condition reported as possibly provocative of stricture. This study stresses the point that the incidence of peptic esophageal stricture is probably far lower than had been reported previously. Consequently, management of low-grade reflux esophagitis should be aimed primarily at relieving symptoms rather than healing esophageal lesions to prevent stricture.

Background and Objectives: The placement of plastic peroral endoprostheses frequently is done in the United States as a palliation for esophageal cancer. However, the combination of topical local anesthetics and sedatives, the most commonly used means to achieve anesthesia, can cause complications and often does not adequately suppress the gag reflex. The purpose of this study was to compare sedation requirements in patients receiving the standard topical local anesthetic versus patients receiving peroral pharyngeal plexus block., Methods: From December 1987 through April 1991, 11 patients underwent endoscopic esophageal stent placement. The first six patients received topical 10% lidocaine spray, the other five patients received pharyngeal plexus blocks. Supplemental sedation was given until the patient closed their eyes but were responsive to verbal stimuli. Completeness of block was evaluated by stimulating the posterior oropharynx. Total sedative requirements were recorded for each patient., Results: Patients receiving pharyngeal plexus block had profound anesthesia and suppression of the gag reflex, as determined by examination and the patient's tolerance of the procedure. Patients receiving only topical anesthesia and intravenous sedation tolerated the procedure poorly and required a greater amount of intravenous sedation than those in the blocked group (p less than 0.01). There were no anesthetic complications in patients receiving pharyngeal blocks., Conclusions: Our experience indicates that the endoscopic placement of esophageal endoprostheses is optimally performed with the aid of pharyngeal plexus block. This block provides profound anesthesia with minimal risk in debilitated, high-risk patients. The neuroanatomy of the oropharynx is also reviewed.

Open tube esophagoscopy is the mainstay of otolaryngic esophageal examination. Over the last 30 years flexible endoscopes have become popular and are challenging the open tube esophagoscope for use in otolaryngic practice. This study examines all open tube esophagoscopies performed on adult patients at the University of Pennsylvania over an 8-year period for the diagnosis and treatment of foreign bodies, strictures, functional disorders, and carcinoma. Open tube esophagoscopy is most useful for foreign body extraction, examination of the cervical esophagus, and dilation of pliable strictures. For most other indications flexible esophagoscopy provides improved visualization with lower morbidity. For patients with squamous cell carcinoma of the head and neck we found a 1.4% incidence of secondary esophageal malignancies and a 28% incidence of false-negative barium swallow studies. We recommend esophagoscopy for all patients with carcinoma of the upper aerodigestive tract. The otolaryngologist should be adept at both flexible and open tube esophagoscopy in order to allow optimal examination of and therapeutic intervention in the upper aerodigestive tract.

Of 199 neonates undergoing primary or delayed primary repair of esophageal atresia, 34 (17%) developed anastomotic leakage, 7 of which (3.5%) were major anastomotic disruptions. Infants with major leaks developed signs within 5 days and all required early reoperation, necessitating abandonment of the esophagus in 6. The remaining 27 were minor leaks demonstrated by water-soluble contrast studies and were successfully treated nonoperatively. Gastroesophageal reflux was unassociated with this complication but the use of braided silk sutures was associated with a significantly increased risk of anastomotic leakage when compared with polyglycolic acid (relative risk, 3.2) or polypropylene (relative risk, 2.6) sutures. Following anastomotic leakage there was a significantly increased risk (relative risk, 2.04) of subsequent esophageal stricture formation.

A variant of forming the permanent tubular gastro- and enterostoma brought out into the intercostal space is suggested. A created fistula is hermetical, safe, convenient in use.

Leakage from an oesophagogastric anastomosis has a high morbidity and mortality. Recent evidence suggests that mechanical tissue stapling devices can decrease the rate of anastomotic breakdown but at the expense of an increase in the occurrence of fibrotic strictures at the anastomosis site. This study examines the rate of leakage and stricture in hand sutured and stapled anastomoses. A retrospective study was made of 221 oesophagogastric anastomoses following resection for carcinoma between 1977 and 1986. There were 122 sutured and 99 stapled anastomoses. Leak occurred in 21 sutured (17.2%) and 7 stapled (7.1%), P less than 0.05. If the stapled anastomosis was completely satisfactory and required no reinforcing sutures, the breakdown rate was in fact only 3% (2/69), P less than 0.01. A stapled anastomosis which required reinforcement had a similar chance of breakdown as a sutured anastomosis (16.7%). There was little difference in the performance of registrars in training and consultants at hand-sewn anastomoses with leakage rates of 13.7% and 18%, respectively; P greater than 0.05. The registrars, however, did not improve with the use of the stapler with a leakage rate of 14.3% compared to the consultants' rate of 1.75%, P less than 0.05. Involvement of the limits of resection with tumour slightly favoured breakdown--15.5% compared to 11.6% if the limits were free from tumour, P greater than 0.05. The incidence of malignant strictures was similar in both groups but benign stricture was more common in the stapled group--13% (13/99) compared to 1.6% (2/122), P less than 0.01. The mechanical stapler brings uniformity to the anastomosis but cannot compensate for deficiencies in surgical technique.