Long-term effects of myotomy and partial fundoplication for esophageal achalasia.

Controversy persists in the surgical approach to treat esophageal achalasia. This investigation reports the long-term effects of esophageal myotomy and partial fundoplication in treating this disorder. From 1984 to 1998, 32 patients with achalasia underwent myotomy and partial fundoplication (Belsey Mark IV) using a left thoracotomy. The median follow up is 7.2 years. Assessments include clinical evaluation, esophagogram, radionuclide transit, manometry, 24-h pH, and endoscopy. There is no complication and no mortality. Preoperative assessment was compared with that in 0-3, 3-7, and 7-16 postoperative years. Clinically, the prevalence of dysphagia was decreased from 100% to 6%, 12%, and 13%, respectively (P < 0.001). Heartburn remains unchanged (P > 0.25). On radiology, the prevalence of barium stasis was decreased from 97% to 44%, 48%, and 47%, respectively (P=0.001), whereas a pseudo-diverticulum was observed in two-thirds of patients after operation (P=0.001). Percent radionuclide stasis at 2 min was measured as 70%, 17%, 20%, and 20%, respectively (P=0.001). Manometrically, lower esophageal sphincter (LES) gradient was decreased from 29 to 10, 9, and 9 mmHg, respectively (P=0.001). LES relaxation was improved from 41% preoperatively to 100% postoperatively at each postoperative period (P < 0.001). An abnormal acid exposure was observed in four patients after the operation. Endoscopy documented mucosal damage in three patients (P > 0.25). In conclusion, on long-term follow up, myotomy and partial fundoplication for achalasia relieve obstructive symptoms and improve esophageal emptying, and reduce LES gradient and improve LES relaxation. Acid reflux is recorded in 13% of patients and esophageal mucosal damage is identified in 11% of the patient population. A longer myotomy not covered by the fundoplication results in pseudodiverticulum formation and increased esophageal retention.

Clips versus suture technique: is there a difference?

INTRODUCTION: Coronary artery bypass grafting (CABG) is one of the most common procedures performed today, and wound complications are a major source of morbidity and cost. OBJECTIVE: To determine whether there is any difference in wound outcome (including cost in a Canadian context) between a subcuticular suture technique and skin stapling technique for closure of sternal and leg incisions in CABG patients. PATIENTS AND METHODS: One hundred and sixty-two patients undergoing CABG were prospectively, randomly placed to have their sternal and leg incisions closed with either a subcuticular suture technique or with a skin clip. Data were obtained through chart review, in-hospital assessments and follow-up visits. Nonblinded assessments were made regarding wound leakage, inflammation, infection, necrosis, swelling, dehiscence and cosmesis. Each of the parameters was graded on a scale from 1 to 4. The cost was evaluated in Canadian dollars. RESULTS: There were trends toward increased rates of in-hospital sternal (P=0.09) and leg (P=0.17) incision inflammation when the wounds were closed with skin clips. There was a significantly greater (P=0.05) rate of sternal wound infection with clips, as well as a tendency (P=0.15) toward a greater rate of mediastinitis at follow-up assessment. Cosmetic outcome was similar for both groups. The cost incurred was significantly greater when skin clips were used for closure. There was a greater than threefold difference, which translates to a greater than $10,000 difference over one year. CONCLUSIONS: Closure with a subcuticular technique achieves better outcomes than the use of skin clips. When factoring in the increased cost incurred by using clips, as well as other intangible factors such as surgical skill acquisition, subcuticular suture closure appears to be a favourable method of wound closure in CABG patients compared with the use of skin stapling techniques.

Results of the Collis-Nissen gastroplasty in patients with Barrett's esophagus.

BACKGROUND: Barrett's esophagus (BE) is an advanced stage of gastroesophageal reflux disease. Medical treatment and standard antireflux operations show a high failure rate. An elongated gastroplasty, wrapped by a total fundoplication should provide a tension-free repair with adequate protection against reflux. The aim of this study is to review the operative effects of a Collis-Nissen gastroplasty to treat reflux in Barrett's esophagus. METHODS: From January 1989 to December 1997, 45 patients with BE (38 men, 7 women) aged 53.5 years, underwent a Collis-Nissen gastroplasty. Mean follow-up is 35.9 months (range, 6 to 110 months). Pre- and postoperative evaluations included symptom assessment, esophagogram, endoscopy, manometry, 24-hour pH study, and esophageal emptying scintigrams. RESULTS: There were no operative deaths. All reflux symptoms were controlled. Acid reflux was significantly reduced (percent time exposure decreased from 10% to 1%) and lower esophageal sphincter (LES) pressure were restored to normal (LES gradient increased from 4 mm Hg to 11 mm Hg). LES incomplete relaxation was noted in 50% of patients postoperatively. Endoscopically, mucosal damage from reflux healed but the columnar mucosa with intestinal metaplasia persisted. CONCLUSIONS: The Collis-Nissen gastroplasty, in patients with BE, controls reflux disease, its symptoms, and the mucosal damage associated with this condition. It restores the LES gradient but increases the resistance to bolus transit. There is no regression of the abnormal mucosa despite reflux control.

Successful repair of aortoesophageal fistula secondary to traumatic pseudoaneurysm.

There have previously been only rare reported survivors of an aortoesophageal fistula resulting from a traumatic pseudoaneurysm. We report a case of a young man with a dramatic presentation who was successfully managed by immediate operative repair. A prosthetic graft was sewn within the sac of the aneurysm, with the aneurysm wall being used to protect the graft, and the esophagus was resected. Staged reconstruction of the esophagus was subsequently performed successfully. The patient is now alive and well 2 1/2 years later.

Bronchial carcinoid--twenty years' experience defines a selective surgical approach.

BACKGROUND: The purpose of this study was to look at the clinical behavior of bronchial carcinoids and clarify a surgical approach. METHODS: Eighty-four patients resected for bronchial carcinoids were retrospectively reviewed for clinicopathologic variables, surgical management, and outcome. Tumors were considered "typical" or "atypical" based on histologic features. "Conservative" surgery signified lung parenchyma-sparing procedures. Survival analysis was performed using standard statistical methods. RESULTS: Most patients presented with an abnormal routine chest x-ray. One patient had the carcinoid syndrome. Computed tomography scan reliably predicted lymph node status and bronchoscopic biopsy diagnosed carcinoids with 70% success. Fifteen "conservative" procedures were performed. Fifteen percent of patients had atypical carcinoids, 12% presented with lymph node metastases, and 6 patients had tumorlets associated with the primary tumor. Overall survival rates were 93% and 82% at 5 and 10 years, respectively. Significantly decreased disease-free survival was found with atypical histology (p < 0.0001) and the presence of tumorlets (p = 0.02); lymph node involvement strongly tended toward poorer outcome. CONCLUSIONS: Bronchial carcinoids have a definite malignant potential predicted by atypical histology, presence of tumorlets, and lymph node involvement. These features can be identified with routine bronchoscopic biopsy, computed tomography scanning, and intraoperative assessment including frozen section. In the select group of patients without negative features, strong consideration should be given to performing a conservative resection.