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Background: Nissen fundoplication relieves symptoms of gastro-oesophageal reflux and effectively heals oesophagitis. During long-term follow-up some cases of recurrent reflux are seen. We investigated the possibility that long-term cure of gastro-oesophageal reflux after fundoplication is influenced by the surgeon's experience and focused interest, in line with results of surgery for rectal, gastric, and breast cancer. Methods: One hundred and five consecutive patients were evaluated a median of 77 months after open Nissen-Rossetti fundoplication for erosive oesophagitis. Follow-up included personal interviews and upper gastrointestinal endoscopy by an investigator not previously involved in the patients' treatment. The surgeons were classified as experienced (>10 of the operations in the series), less experienced (<10 operations), or trainees. Results: Of the most experienced surgeons' patients, 97% had no or at most mild reflux symptoms at follow-up, compared with 88% of the of less experienced surgeons' patients (P = 0.04). Healing of erosive oesophagitis was commoner when the operations were performed by experienced specialist surgeons (88% versus 72%; P = 0.04). The reoperation rate fell as the surgeons' experience increased, from 12% to 4%. Conclusions: Surgery for gastro-oesophageal reflux should be centralized to units specializing in the techniques and with sufficient annual numbers of operations to optimize results. This policy becomes especially advisable as laparoscopic surgery increases the numbers of treated patients. [ABSTRACT FROM AUTHOR]

Background: Malignant oesophageal obstruction with an advanced disease presents a difficult challenge. A new class of metal stents have been developed to overcome the limitations of existing treatment modalities., Methods: We present our first 58 patients, who have been treated with self-expandable metallic stents, using sedation anaesthesia, with fluoroscopic and endoscopic control. Both kinds of stents, covered and uncovered, were applied., Results: There was no procedure-related mortality. The immediate relief of dysphagia was 98%. All four oesophageal fistulas were successfully sealed with covered stents. Due to stent migration, tumour overgrowth, or ingrowth, twelve (21%) of the patients needed re-intervention. Restenting or laser therapies were used against recurrent dysphagia., Conclusion: The palliation of oesophageal malignant obstruction with metal stents is a rapid, effective, and relatively safe single treatment which can be employed as part of a multimodal treatment program.

Objective: There is no previous study concerning long term results of open Nissen fundoplication performed by general surgeons in a nonspecialized unit., Methods: Of 45 consecutive patients in a general provincial center, 39 were available for follow-up after a mean period of 78 months. All patients were interviewed using a standard questionnaire, and 35 of them consented to undergo endoscopy., Results: Of the patients, 85% had no or only mild reflux symptoms. The figures for dysphagia, flatulence, and bloating were 31%, 67%, and 46%, respectively. Endoscopy showed defective fundic wrap in 37% of the patients and erosive esophagitis in 29%. Five patients (13%) with recurrent esophagitis were referred for H2-blocker or omeprazole medication, and five others (13%) were scheduled for repeat antireflux surgery., Conclusions: The results were somewhat worse in regard to prevalence of defective fundic wrap and recurrent esophagitis than in other reports, which were from specialized units.

Objective: To evaluate the influence of antireflux surgery on gastric emptying., Design: Nonrandomized controlled trial 3 months before and after surgical intervention., Setting: Secondary and tertiary referral center., Patients and Control Subjects: Twenty consecutive patients (7 women, 13 men), mean age 49.2 years, with symptomatic, objectively confirmed gastroesophageal reflux disease and 10 healthy control subjects (3 women, 7 men), mean age 37.3 years., Intervention: Laparoscopic or open Nissen fundoplication (in 1 case Toupet 180 degrees posterior hemifundoplication)., Main Outcome Measures: Gastric emptying scintigraphy, using solid food, in control subjects and patients 3 months before and 3 months after the operation; time to halving of the maximal activity and the activity remaining at 60, 100, and 120 minutes., Results: Preoperative symptoms included pyrosis in 19 of 20 patients and regurgitation in 18. Three months postoperatively, 19 patients were symptom-free. The mean time to halving of the maximal activity decreased from 113 to 78 minutes (P = .001). Delayed gastric emptying was found postoperatively in 3 patients, compared with preoperative values, using activity at 60, 100, 120 minutes and the mean time to halving of the maximal activity as the variables. Compared with control subjects, gastric emptying was slower in patients preoperatively and faster postoperatively, but the difference was not statistically significant., Conclusion: Gastric emptying is enhanced after antireflux surgery, along with cessation of symptoms and healing of esophagitis.

Nissen fundoplication gives lasting relief from symptoms of gastro-oesophageal reflux and cures endoscopic oesophagitis effectively. The histological effect on the oesophageal mucosa is less clear. We studied the long-term histological effect of Nissen fundoplication on refractory gastro-oesophageal disease with erosive oesophagitis or Barrett's metaplasia in 33 patients with biopsy both before and after antireflux surgery. The median postoperative interval to re-examination was 80 (range 37-110) months. Symptoms of reflux were greatly relieved; 31 (94%) of the 33 patients had none or, at the most, mild symptoms. Endoscopic oesophagitis was healed in 26 (79%) of the cases. The histological appearance of the oesophageal mucosa had been abnormal in all the patients preoperatively, but at follow-up it was normal in 22 cases (67%): in 89% of the patients without objectively observed recurrent reflux and in 45% of those with recurrence. Both the pre- and postoperative severity of the histological changes correlated significantly with the endoscopic grade of oesophagitis (r=0.42, P=0.017 and r=0.837, P=0.0001, respectively), but not with the clinical reflux score. In conclusion, Nissen fundoplication resulted in histological healing in the great majority of patients with oesophagitis.

Background: Open or laparoscopic surgery for gastroesophageal reflux disease gives longterm freedom from symptoms in 83-100% of cases but has a certain percentage of complications. This study was undertaken to evaluate the early and late complication rates after primary or repeat antireflux operations., Study Design: The records of all patients who underwent surgery for gastroesophageal reflux disease during a 32-year period at a university teaching hospital were reviewed retrospectively. Records for 793 adults (448 men and 345 women) aged 16-85 years (mean, 51) were retrieved for calculation of complication rates and statistical analysis., Results: A total of 827 operations were performed: 793 primary and 41 for recurrent disease (2 patients were each reoperated on twice). There were 49 laparoscopic operations. Only two patients died (mortality, 0.3%), both after open operation. Morbidity was 24% after open surgery and 14% after laparoscopic operation. The total (early and late) complication rate was higher after reoperations than that after open or laparoscopic procedures. The overall complication rate in the open operations was similar in the first and the third decade of the study, namely, 24.6% and 26.1%, respectively., Conclusions: Surgical treatment of gastroesophageal reflux disease carries very low mortality when performed in a specialized unit. The main causes of morbidity after open operation are infectious complications. The incidence of complications is substantially lower after laparoscopic surgery than after open operation. Reoperation is seldom required, but it carries higher morbidity than the primary operations.

Objective: The purpose of the study was to evaluate the long-term symptomatic and endoscopic outcome in gastroesophageal reflux disease with erosive esophagitis, comparing conservative with operative management., Methods: The study comprised 105 of 120 patients consecutively referred for severe reflux symptoms to the gastroenterologic outpatient department of a teaching hospital, where erosive esophagitis was confirmed endoscopically. If conservative management (modified lifestyle and medication) failed to relieve symptoms and heal the esophagitis, antireflux surgery (Nissen fundoplication) was undertaken. Follow-up (median, 10.9 years) evaluation of all patients included comprehensive, standardized interviews; self-scoring of symptoms at the time of referral and currently; and observations at endoscopy., Results: Nissen fundoplication was performed on 37 of the 105 patients. At follow-up of these 37 patients, (31) 84% had no or only occasional mild heartburn, (33) 89% were free from erosive esophagitis, and (2) 5% were taking H2 antagonists or omeprazole. The corresponding figures in the 68 patients with only conservative treatment were (36) 53%, (31) 45%, and (14) 21%. The mean change in symptom score between referral time and follow-up was 5.7 in the surgically treated group and 1.7 in the nonsurgically treated group. Fifteen new cases of Barrett's metaplasia were found at follow-up., Conclusions: In gastroesophageal reflux disease with erosive esophagitis, surgical treatment gave results subjectively and objectively superior to those from conservative management.

Objective: To elucidate the long-term course of conservatively managed gastroesophageal reflux disease without H2-antagonists or omeprazole., Design: Clinical trial, uncontrolled., Setting: Gastroenterological outpatient department of a teaching hospital., Patients: Sixty of 87 patients consecutively referred for severe gastroesophageal reflux symptoms and with objectively proven pathological reflux., Measurements: Esophagoscopy, esophagography, cinecardiography of cardiac region, standard reflux test, and confirmatory Bernstein-Baker test. Follow-up included a standardized interview, esophagoscopy with biopsy, and 24-h pH monitoring., Results: At follow-up 17-22 yr after referral, symptoms were less than at the time of referral in 36 of the 50 nonoperated patients (six now symptom-free), were unchanged in five, and were worse in nine patients. Medication for reflux symptoms was no longer used by 34 of the nonoperated patients. The prevalence of erosive esophagitis fell from 40% at referral to 27% at follow-up endoscopy; 42% of the studied patients had pathological 24-h pH, and the endoscopies revealed six new cases of Barrett's metaplasia. Of the 41 nonoperated patients examined with both endoscopy and 24-h pH, 27 (66%) had erosive esophagitis and/or pathological pH values. Of the 10 operated patients, all had fewer symptoms at follow-up than they had at referral (nine were symptom-free). The prevalence of erosive esophagitis fell from 60% at referral to 10% at follow-up. One of the 10 patients had pathological 24-h pH at follow-up. Neither the presence of esophagitis or hiatal hernia nor the severity of symptoms at the time of referral predicted the course of the disease of the conservatively treated patients., Conclusions: The severity of the symptoms declines in the long term, but pathological reflux persists in most of the conservatively treated patients. Thus, the reflux itself is not self-limiting, and therapy should be designed with this in mind.

Background: Tuberculous involvement of the esophagus has been extremely rare during the past 40 years. It will be, however, more frequently encountered in the future, as the number of immunocompromised patients is growing. This condition is usually secondary to infection in other thoracic sites, such as lungs, larynx, or mediastinum. The diagnosis is difficult if the suspicion of tuberculosis is not raised. Dysphagia and cough after ingestion of fluids and food are common symptoms without any other specific signs in these patients. Diagnosis is based on combination of esophagography, esophagoscopy, bronchoscopy, and computed tomographic scan., Methods: We present 3 patients with tuberculous fistulas of the esophagus. Two of our 3 patients were treated successfully with the combination of operation and antituberculous chemotherapy. Fistulas were resected and closed directly. Suture lines were secured with pedicled pleural flaps., Results: Both patients who underwent operation recovered without complications. One patient died without definitive diagnosis and treatment., Conclusions: Treatment of tuberculous fistulas consists of operation and antituberculous chemotherapy, although antituberculous medication alone has been suggested to be effective if the diagnosis is early. However, operation is usually necessary to establish the correct diagnosis. Therefore, we believe that if the cause of the esophageal fistula cannot be verified, thoracotomy should be performed. If the fistula is left untreated the consequences are usually fatal.

We explored the function of the intestine's mucosal barrier to foreign antigen entry in Crohn's disease. Macroscopically and microscopically uninvolved areas of the small intestines of patients with Crohn's disease were examined. We studied 27 endoscopic biopsy samples from 17 patients with Crohn's disease and 14 samples from nine controls. The absorption and degradation of horseradish peroxidase (molecular weight 40,000 Da) were studied in Ussing chambers. The absorption of intact horseradish peroxidase was significantly increased in patients with moderate or severe Crohn's disease: 271 (95% confidence interval 119-616) ng/hr/cm2, but not in those with slight disease activity: 42 (18-98), compared with controls: 45 (32-64); F = 10.90, P = 0.0002. The transport rates of degraded horseradish peroxidase were comparable in the Crohn's disease samples and controls. Our results indicate that enhanced absorption of macromolecules is associated with clinical activation of Crohn's disease, and impairment of the mucosal barrier function is a secondary phenomenon in Crohn's disease.

Objective: To assess the effect on postoperative dysphagia and oesophageal transit of fundal mobilisation during Nissen-Rossetti fundoplication., Design: Prospective, randomised study., Setting: University Hospital, Finland., Subjects: 20 consecutive patients with confirmed gastro-oesophageal reflux who were referred for antireflux surgery., Interventions: Fundoplication with either conventional Nissen-Rossetti procedure or an otherwise identical technique incorporating total fundal mobilisation (n = 10 in each group)., Main Outcome Measures: Recurrent or persistent symptoms of dysphagia, and the oesophageal transit time of a liquid bolus labelled with radioactive nuclide., Results: In both groups excellent relief of heartburn and regurgitation was achieved (only 2 patients in each group reported occasional symptoms), one patient had oesophagitis, and the pH returned to the normal range. The incidence of dysphagia was similar in both groups by 6 months postoperatively, but there was significant, though transient, impairment of oesophageal transit after findal mobilisation (p = 0.03)., Conclusions: Fundal mobilisation did not seem to confer any advantage as fas as the incidence of postoperative dysphagia was concerned. On the contrary, it was associated with transient disturbance in the oesophageal transit time of a liquid bolus. Longer follow up is needed to show if this impairment is of any clinical relevance.

The effects of fundic mobilization in Nissen fundoplication on belching ability, abdominal gas volume, bloating and flatus were assessed in a prospective, randomized study of 25 patients with refractory gastro-oesophageal reflux disease. Reflux was cured regardless of fundic mobilization. Subjective ability to belch was restored to preoperative in 73% of the patients with fundic mobilization, compared to 50% without. About 10% in both groups totally lost their ability to belch. Disturbance from flatus increased postoperatively slightly in both groups, but from bloating it remained the same or even diminished. The residual intra-abdominal radioactivity (median (interquartile range)) after provoked belching was preoperatively 8.9% (4.4-12.0) with and 13.2% (6.8-15.2) without fundic mobilization, compared to 36.7% (31.1-40.9) of the controls (P < 0.05). After fundoplication this residual activity was normalized in both study groups. Disturbance from postoperative bloating or flatus were not related to the ability of belching. Preoperatively symptomatic patients tended to have more complaints postoperatively. In conclusion, fundic mobilization restored belching ability slightly more effectively without compromising antireflux efficacy, but there did not seem to be any advantage regarding flatus or bloating.

Symptoms suggestive of gastro-oesophageal reflux disease are very common. The aim of the study was to assess the prevalence of these symptoms and factors influencing them in an unselected adult population. A questionnaire was mailed to a random sample of 2500 people aged > or = 20 years. The questions concerned heartburn, regurgitation, dysphagia, chest and upper abdominal pain, as well as medication and medical consultations for these symptoms. Of the 1700 (68%) responders, 9% had experienced heartburn on the day of response and 15%, 21% and 27% during the preceding week, month and year, respectively. The corresponding figures for regurgitation were 5, 15, 29 and 45%. During the past year 43% of the study group had had no such symptoms. Age, overweight, pregnancy and cigarette smoking significantly influenced the prevalence of symptoms. Using daily heartburn and/or regurgitation as dominant indicators 10.3% (95% CI 12-11.7) of the responders had gastro-oesophageal reflux disease. Medication (most commonly antacids) was used by only 16% of the symptomatic people, and only 5.5% had sought medical advice for symptoms during the past year. Thus, despite commonness of symptoms suggestive of gastro-oesophageal reflux disease only a minority of the individuals suffering from such symptoms use medication or have medical consultation.

Heller's myotomy for esophageal achalasia was performed on 64 patients in the 24 yr up to 1988. After follow-up averaging 13 yr, 46 patients were reexamined with endoscopy, biopsy, and manometry. Barrett's metaplasia of the distal esophagus was found in four patients 6, 13, 20, and 23 yr after the myotomy. These four also underwent ambulatory 24-h pH monitoring. They had the lowest distal esophageal sphincter pressures (1-5 mm Hg), and all four had symptoms of gastroesophageal reflux and pathologic pH values (< 4 in the distal esophagus for 32-62% of the total recording time). Because of heightened risk for the development of Barrett's metaplasia following cardiomyotomy for esophageal achalasia, with increased liability to carcinoma of the esophagus, regular endoscopic surveillance of these patients is advisable.

Ninety patients with esophageal perforations were operated on at our institutions between 1970 and 1992. Thirty-four of them were seen after delayed diagnosis (> 24 hours) with mediastinal sepsis caused by perforation of the thoracic esophagus. There were 18 patients with spontaneous ruptures, 11 with instrumental perforations (including one caused during laparotomy), and 3 perforations caused by foreign bodies. One patient had perforation of an esophageal ulcer into the pericardium and another had perforation of an esophageal diverticulum into the mediastinum. Nineteen patients underwent primary repair of the perforation with cleansing and drainage of the mediastinum and the pleural cavity. The remaining 15 had primary extirpation of the thoracic esophagus, irrigation of the mediastinum with antibiotics, cervical esophagostomy, gastrostomy, and drainage of the mediastinum and pleural cavity. Nineteen of the 34 patients survived (hospital mortality 44%). Of patients with primary repair, only six survived (in-hospital mortality 68%), whereas only two patients treated with esophagectomy died (in-hospital mortality 13%). The difference was highly significant (p = 0.001). The most common cause of death was multiorgan failure resulting from sepsis. Postoperative complications developed in four patients treated with primary repair (two sepsis, one empyema, and one anuria) and in seven patients treated with esophagectomy (two empyema, two sepsis, one pneumonia, one mediastinal abscess, and one brain abscess). After healing of the mediastinitis, the esophagogastric continuity was reconstructed with colon in 11 patients and stomach in two patients. In the management of delayed esophageal perforation with mediastinal sepsis, esophagectomy is superior to primary repair alone, which often leads to mediastinal leakage, continued sepsis, and death.

Reoperation after a failed antireflux procedure is a surgical challenge. Many operative techniques have been proposed, but reports on systematic follow-up with endoscopy and esophageal function tests are few. The purpose of the present study was to evaluate the results of repeated fundoplication in cases of recurrent reflux, including assessment of esophageal function. Of the 18 cases of repeat fundoplication performed for recurrent reflux during 1970-1991 at Tampere University Hospital, 15 were evaluated a median of 18 (range 5-152) months after reoperation. Follow-up studies included endoscopy in all and esophageal function tests (esophageal 24-hour pH recording, manometry, and radionuclide transit) in 14 cases. All the patients had defective fundic wrap before reoperation, whereas at follow-up 12 of the 15 wraps were intact. Reflux symptoms were diminished in all 15. Six patients (40%), however, had objective recurrence of reflux (esophagitis or pathologic pH recording). Three of the recurrences were due to slipped fundic wrap, but the others were probably caused by impaired esophageal function. By repeat fundoplication the wrap could be repaired as reliably as in primary operation. Symptomatic outcome and objective results were reasonable. The results were, however, not as good as after primary operation, which was due to more impaired esophageal motility caused by prolonged reflux or repeated surgery (or both).

Modified Heller's myotomy for achalasia of the esophagus was performed via a left thoracotomy in 34 cases (group A) and via an upper midline abdominal incision in 30 (group B). There were no perioperative deaths. Complications arose in ten cases. After follow-up averaging 13 years (range 3-24 years) 4% of the group A patients reported dysphagia for solids, but none for liquids, and in group B the corresponding figures were 52% and 26%. Reflux symptoms were present in 30% of the group A and 60% of the group B cases, and the respective incidence of microscopic esophagitis was 30% and 43%. There were three esophageal strictures, all in group B, and three cases of Barrett's epithelium, all in group A. Because of the high incidence of esophagitis and its complications following esophagomyotomy for achalasia, yearly endoscopy with biopsy and brush cytology is recommended. When myotomy is performed, an antireflux operation should be added.

Thirty-six patients, subjected to colon interposition for benign esophageal disease or carcinoma of the esophagus or gastric cardia, were studied by endoscopy for signs of mucosal disease in the interposed colon. Five months to 15 yr (mean 57 months) after the operation, endoscopic finding of the interposed colon was macroscopically normal in 28 patients. Signs of inflammation, including hyperemia or hyperemia and friability, were observed in seven patients. Histologic specimens obtained at endoscopy were examined microscopically, and the findings were compared with those seen in the preoperative graft. In two patients, chronic inflammatory changes were observed in the graft mucosa, consisting of mononuclear cell infiltration of the lamina propria accompanied by crypt dilatation and deformation. In one of these patients, the inflammation was in the proximal third of the graft, and it was also seen at the endoscopy. In the remaining 34 patients, the graft mucosa was microscopically comparable to normal. The alterations were unexpectedly few and mild considering the marked change in the location and function of the colonic segment.

We present a clinicopathological and flow cytometric evaluation of eight primary small cell carcinomas of the esophagus representing 1.5% of all esophageal malignancies diagnosed during a 22-year period (1965-1987) in the Tampere University Central Hospital. The mean age of the patients (four male and four female) was 67 years (range 55-75 years). Five cases had distant metastases at the time of diagnosis. Three patients were treated by esophageal resection, one by laser vaporisation, and four by chemotherapy. The median survival time was 4 months (range 9 days to 8 months). A complete local response to chemotherapy in serial esophagogramms was detected in one patient. All four patients given chemotherapy survived longer than those treated with esophageal resection only. Four (67%) of the six carcinomas analyzed by DNA flow cytometry contained DNA-aneuploid stemlines. The median S-phase fraction of these small cell carcinomas was high (16.3%), reflecting rapid cell proliferation rate, which may be related to their responsiveness to chemotherapy.

Fifteen cases of carcinoma of the esophagus associated with a history of lye ingestion are presented. They compromised 3% of the total patients treated for esophageal carcinoma in 1964-1986. The mean age of the ten women and five men was 57 years and the average time from corrosion injury to diagnosis of carcinoma was 58 years in the men and 47 years in the women. Most of the patients had accidentally swallowed liquid lye at 2-3 years of age. All 15 tumors were squamous cell carcinoma, and 11 were located at the level of the tracheal bifurcation. Esophageal resection was possible in ten cases. The survival rate in the total series was 40% at 1 year and 13% at 5 years. Because of the high carcinoma risk, patients with corrosion injury to the esophagus should be kept under surveillance that includes regularly repeated esophagoscopy, cytologic study of washings and biopsy at least when the time from the injury exceeds 20 years.

The results in 90 patients with osteoarthritis of the hip, treated by intertrochanteric osteotomy fixed with an AO blade plate, were analyzed 1-5 years after operation. The operation was performed without displacement of osteotomy, the aim being to produce bony union in the original position using the AO compression technique. With one exception, all osteotomies fused, but dislocation exceeding 0.5 cm resulted in four cases. The operation brought about relief from night pain in 88% of the patients and relief from weight-bearing pain in 41%. Abduction and adduction were the only movements that improved. The results were the same 1-2 and 4-5 years after the operation. Complications were rare, and the use of the compression method enabled the patients to get on by themselves the day after operation. This method is particularly well suited for young patients.

Pancreatic resection for acute necrotising pancreatitis was followed by abscess of the remnant in 14 out of 83 cases. Not even extensive pancreatic resection could prevent pancreatic remnant infection. The 14 cases of abscess are reviewed. Seven were fatal. Enterocutaneous fistula, commonly accompanied by sepsis and major bleeding, was identified in five patients, four of whom died.

Replacement of the esophagus for benign disease requires familiarity with the long-term results of various esophageal substitutes. In the present study, 60 esophageal reconstructions for benign disease using colonic interposition have been presented. The operations were performed mainly without thoracotomy, using both antiperistaltic and isoperistaltic colonic segments. There were no differences in swallowing ability between patients with antiperistaltic and patients with isoperistaltic interpositions. Regurgitation symptoms, however, seemed to be somewhat more common and more difficult in patients with antiperistaltic colonic transpositions. Endoscopic signs of colitis were common, but they did not correlate with regurgitation symptoms. Bacterial cultures from the transplanted colon mainly revealed the usual mouth organisms. Candida albicans was frequently found in the fungal samples. There were no differences in the results between patients with follow-up periods of more and less than 2 years. The clinical results were good or fair in a great majority of the patients.

Enterogastric reflux was studied using the scintigraphic method in 20 patients with colonic interposition for benign esophageal disease. The state of the transplanted colonic mucosa was evaluated by endoscopy. In 16 patients, reflux of the duodenal contents into the stomach could be seen. In eight, reflux of the duodenal contents into the interposed colon could be demonstrated. There were no differences in the occurrence of reflux into the colonic graft between the isoperistaltic and antiperistaltic interpositions. In three patients, signs of colitis on the mucosa on the lower part of the graft were observed by endoscopy. Each of these patients had a reflux of the duodenal contents into the colonic graft. In monitoring the 24 hour pH of these three patients, one patient had marked acid reflux. Alkaline reflux was not observed. It is concluded that enterogastric reflux is frequent in patients with colonic interposition. Its role in the development of lower colonic graft colitis changes is discussed.

A case of corrosion and necrosis of the esophagus and stomach after ingestion of fluid containing copper sulfate, ethylene glycol and methanol is presented. Esophagectomy and gastrectomy were performed in a primary stage. Four months later reconstruction was carried out, using a right-sided isoperistaltic segment of colon. The mechanism of caustic chemical ingestion injuries and their treatment are discussed.

Colon interposition was carried out in 12 patients with oesophageal carcinoma and on 38 patients with benign oesophageal disease an average of 71 months before the radiographic examination. Various ischaemic changes including "jejunization", loss of haustration and stricture formation were observed in 15 cases. In 12 patients one or several diverticula were seen in the colon graft. Reflux was observed in 17 cases in supine position. Double contrast technique in the examination of interposed colon is recommended.

Fifty patients reoperated for failed Nissen fundoplication are presented; 29 patients (group 2) were operated between 1983 and 1988 while 21 patients (group 1) were operated before 1983. In group 1, the "slipped Nissen" had been the most frequent cause of reoperation (48%). In group 2, the most frequent causes for the unsuccessful operation were: (1) partial or total disruption of the fundic wrap (62%), (2) slipping of the fundoplication, giving rise to the telescope phenomenon (21%), and (3) creation of a fundoplication which was too low (10%). Refundoplication was performed in cases where the dissection of the previously formed fundic wrap was possible (42/50 = 84%). In group 1, three patients were treated by resection of the cardia, one by an Angelchik prosthesis and one by a distal gastric resection with Roux-en-Y diversion. In group 2, fundectomy was performed in one patient; in another, an Angelchik device was inserted, and in a third patient, fundoplication and proximal gastric vagotomy were performed. The results were excellent or good in 66% of patients in group 1 and in 76% of group 2. Operative mortality was 2% and morbidity, 4%. In conclusion, repeat fundoplication is recommended when reestablishment of the fundic region anatomy is possible during dissection. The operation can usually be performed through an abdominal route. Meticulous preoperative evaluation of the patients including 24-hour pH measurement and manometry is necessary. Good results of refundoplication should be expected in 66%-76% of patients with recurrent disease.

The stomach is the organ most used for restoring esophageal continuity after esophageal resection for malignancy. In the present series, we report our experience over a 20-year period (1965 through 1984) with an alternative method, colon interposition. Two hundred forty-eight patients (124 men and 124 women) underwent colon interposition. Seventy-one percent (175) of the tumors were squamous cell carcinomas, and 23% (58) were adenocarcinomas in the gastric cardia and lower esophagus. The left colon was the substitute of first choice and was used in 54% of the patients. Of the interpositions, 59% were antiperistaltic. Esophagectomy without thoracotomy was the method in 146 patients. The operative mortality was 16% (40 patients), and 3% (8 patients) sustained colon graft necrosis. Leakage in the upper anastomosis occurred in 4% (10). No dysphagia was experienced by 85%, 80%, and 76% of the patients during reexaminations 3, 6, and 12 months, respectively, after operation. The 1-year and 5-year survival for patients with squamous cell carcinoma was 40% and 10%, respectively, and for patients with adenocarcinoma, 50% and 12%, respectively. The data from this study suggest that colon interposition offers a good alternative for long-term relief of dysphagia in patients with carcinoma of the esophagus. The rate of complications is acceptable.