Cricopharyngeal myotomy.

Cricopharyngeal myotomy has been used in the treatment of pharyngoesophageal diverticulum and various neurogenic, myogenic and myoneurogenic disorders. An appreciable number of patients with pseudobulbar palsy due to cerebrovascular accidents and patients with idiopathic hypertrophy of the cricopharyngeal muscle will greatly benefit from this procedure. This paper describes the indications for, and results of, 20 consecutive cricopharyngeal myotomies carried out with or without diverticulectomy. All 20 patients experienced cervical esophageal dysphagia and 55% had substantial weight loss. The most valuable investigation is roentgenography of the pharynx and esophagus, which will confirm megapharynx, hypopharyngeal stasis, weak or absent pharyngeal contractions and regurgitation. Hypertrophic cricopharyngeal muscle was demonstrated in 9 of the 20 patients. The diagnostic value of endoscopy and esophageal manometry is limited. The results were considered excellent in all patients with pharyngoesophageal diverticulum and idiopathic hypertrophy of the cricopharyngeal muscle. Marked symptomatic and objective improvement was achieved in patients with cerebrovascular accidents, vagal injuries and amyotrophic lateral sclerosis. However, the result was poor in patients with myoneurogenic disorders.

Right paraduodenal hernia.

Right paraduodenal hernias are uncommon. Approximately 50 cases have been reported and 2 more are reported in this paper. The diagnosis of internal hernia should be considered in all patients with abdominal cramps and intermittent small bowel obstruction. The most valuable investigation is roentgenography of the small intestine after barium ingestion; this usually shows a clumping of the intestine, as in a bag, with incomplete rotation of the cecum and ascending colon. Duodenal hernias should be treated surgically even if they are asymptomatic, because they may cause potentially lethal complications such as obstruction. gangrene or bowel perforation.

Intraoperative common duct pressure and flow measurements.

Operative cholangiography is still the most accurate and available method for assessing the presence or absence of stones in the common duct. However, 30 to 40 percent of stones will still be overlooked with cholangiography. To reduce the incidence of overlooked common duct stones we recommended that pressure and flow measurements be obtained before cholangiography. When pressures are high or high normal and flows low, the duct should be explored even in the presence of a normal cholangiogram. Under these circumstances, the incidence of false-positive pressure flow studies is less than 5 percent even in inexperienced hands.

Cholecystectomy with and without drainage.

The authors studied the effect of intraoperative drainage, presence of postoperative pyrexia, influence of appendectomy, chest complications and wound infection in 200 patients who had undergone routine uncomplicated cholecystectomy. One hundred patients in whom no drain was inserted were matched with 100 patients whose cholecystectomies, performed during the same period, included placement of a drain. There were 10 males and 90 females in each group; the mean age was 40.5 years in the undrained group and 40.4 years in the drained group. There was a significantly (P less than 0.05) higher frequency of chest complications, longer hospital stay and pronounced postoperative pyrexia (P less than 0.003) in the group with drainage. The rate of wound infection was substantially increased in both groups by adding appendectomy to the procedure, particularly if drains were not used. It is evident that the routine placement of a drain in an uncomplicated cholecystectomy is unnecessary and may even be harmful.