Does the participation of a surgical trainee adversely impact patient outcomes? A study of major pancreatic resections in California

BACKGROUND

Some patients have concerns regarding the impact of surgical trainees on the quality of care that they receive in teaching hospitals. No population-based data exist that describe outcomes of surgical procedures in teaching and nonteaching hospitals; however, institutional data suggest that teaching hospitals provide high-quality care. We hypothesized that the presence of a general surgery residency program (GSRP) is associated with superior outcomes for pancreatic resection, a complex surgical procedure.

METHODS

A retrospective, population-based, risk-adjusted analysis of 5696 patients who underwent major pancreatic resection compares the outcomes of patients treated at hospitals with a GSRP (GSRP+) and those hospitals without a GSRP (GSRP-).

RESULTS

GSRP+ hospitals had a lower operative mortality rate (8.3% vs 11.0%; P <. 001), a lower percentage of patients discharged to another acute care hospital or skilled nursing facility (6.5% vs 13.0%; P <.001), and a longer length of stay compared with GSRP- hospitals (22.1 +/- 0.4 days vs 19.6 +/- 0.3 days; P <.001). The observed difference in hospital mortality rates was not significant after an adjustment was made for patient mix and hospital volume (9.7% vs 10.0%). However, superior outcomes were found in the university teaching hospitals, as compared with the affiliated teaching and the nonteaching hospitals (5.3% [P <.001] vs 11.4% vs 11.0%; risk adjusted, 8.0% [P <.05] vs 10.9% vs 10.0%).

CONCLUSIONS

The presence of surgical trainees does not have an adverse impact on the quality of care for One complex procedure, pancreatectomy, and is associated with superior operative mortality rate in university teaching hospitals.

Laparoscopic splenectomy

Splenectomy is a powerful tool for treatment of hematologic disease, with 70% to 90% of patients achieving long-term improvement. In recent years laparoscopic splenectomy has gained acceptance as a viable alternative to open splenectomy. This review summarizes the indications for laparoscopic splenectomy, the operative techniques, and the most recent results. Laparoscopic splenectomy is evolving and may become the standard operative method for the treatment of the problem spleen.

Percutaneous management of abscess and fistula following pancreaticoduodenectomy

PURPOSE

To evaluate the efficacy of percutaneous drainage of fluid collections following pancreaticoduodenectomy (Whipple's procedure).

METHODS

We performed a retrospective review of 19 patients referred to our service with fluid collections following pancreaticoduodenectomy. The presence of associated enteric or biliary fistulas, the route(s) of access for image-guided drainage, the incidence of positive bacterial cultures, and the duration and success of percutaneous management were recorded.

RESULTS

Fistulous communication to the jejunum in the region of the pancreatico-jejunal anastomosis was demonstrable in all 19 patients by gentle contrast injection into drainage tubes. Three patients had concurrent biliary fistulas. In 18 of 19 patients, fluid samples yielded positive bacterial cultures. Successful percutaneous evacuation of fluid was achieved in 17 of 19 patients (89%). The mean duration of drainage was 31 days.

CONCLUSION

Percutaneous drainage of abscess following pancreaticoduodenectomy is effective in virtually all patients despite the coexistence of enteric and biliary fistulas.

The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma

BACKGROUND

Volume-outcome relations have been established for several complex therapies. However, few studies have examined volume-outcome relations for high-risk procedures in general surgery, such as hepatectomy for hepatocellular carcinoma (HCC).

OBJECTIVE

To evaluate the relation between hospital volume and outcome for patients undergoing hepatectomy for HCC.

DESIGN

Retrospective cohort study.

SETTING

All acute-care hospitals in California.

PATIENTS

Hospital discharge data were analyzed for each patient in California who underwent major hepatic resection for HCC from January 1, 1990, through December 31, 1994. Hospitals were grouped according to number of hepatectomies performed at each center during the 5-year study.

MAIN OUTCOME MEASURES

Outcome measures included operative mortality and length of hospital stay. Regression analyses were used to adjust for differences in patient mix.

RESULTS

Five hundred seven patients underwent hepatectomy for HCC during the study. Hepatic resections were performed in 138 hospitals, with an overall in-hospital mortality rate of 14.8%. Three quarters of patients were treated at hospitals that average 3 or fewer hepatic resections for HCC per year. These low-volume providers represent 97.1% of all hospitals treating patients with HCC statewide. Significant reductions in risk-adjusted operative mortality rates (22.7%-9.4%; P = .002, multiple logistic regression) and risk-adjusted length of stay (14.3-11.3 days; P = .03, multiple linear regression) were observed as hospital volume increased.

CONCLUSIONS

Low operative mortality and length of stay were associated with high-volume centers. These data support regionalization of high-risk procedures in general surgery, such as hepatectomy for HCC.

Hepatocyte growth factor stimulates fetal gastric epithelial cell growth in vitro

BACKGROUND

The growth and development of the fetal gastrointestinal tract is likely mediated, in part, by peptide growth factors. We compared the mitogenic effects of graded doses of hepatocyte growth factor (HGF) to epidermal growth factor (EGF), transforming growth factor-alpha (TGF-alpha), and insulin-like growth factor-1 (IGF-1) on fetal rabbit gastric epithelial cells.

MATERIALS AND METHODS

Fetal rabbit gastric epithelial cells were purified by mechanical dissociation and selected culture and grown in short-term (24 h) and long-term (12 days) culture. Stimulation of fetal gastric epithelial cell growth in response to individual peptide growth factors was measured by [3H]thymidine incorporation and cell counting.

RESULTS

In short-term culture, HGF stimulated [3H]thymidine incorporation in a dose-dependent manner from a threshold at 10 pM to a maximum at 100 pM. For EGF and TGF-alpha, maximal stimulation occurred at 100 pM. For HGF, maximal [3H]thymidine incorporation was 3.6 +/- 0.7 times basal. For EGF and TGF-alpha, maximal [3H]thymidine incorporation was 4.3 +/- 0.4, and 3.6 +/- 0.4 times basal, respectively. For IGF-1, maximal [3H]thymidine incorporation was only 70% of the maximal effect observed for the other growth factors tested. Rabbit amniotic fluid increased [3H]thymidine uptake in a dose-dependent manner. In long-term culture, purification to greater than 90% epithelial cells was attained after 12 days treatment. For HGF, EGF, TGF-alpha, and 20% rabbit amniotic fluid, significant increases in cell number above control (P < 0.05) were observed at 1 nM concentrations. None of these individual factors, however, increased cell growth as significantly as that of 10% fetal bovine serum.

CONCLUSIONS

Our results suggest that: (1) HGF stimulates [3H]thymidine uptake and cell proliferation in fetal rabbit gastric epithelial cells in vitro, and (2) HGF's mitogenic effect on fetal rabbit gastric epithelial cell growth is comparable to that observed for EGF and TGF-alpha, but superior to the effect observed for IGF-1.

Laparoscopic repair of paraesophageal hiatal hernias

BACKGROUND

Regardless of symptoms, paraesophageal hiatal hernias should be repaired in order to prevent complications. This study reports the University of California San Francisco experience with laparoscopic repair of paraesophageal hiatal hernias, emphasizing the technical steps essential for good results.

PATIENTS AND METHODS

From May 1993 to September 1997, 55 patients, 27 women and 28 men, with a mean age of 67 years (range, 35-102 years) underwent laparoscopic repair of paraesophageal hernias at the University of California San Francisco. Symptoms, which had been present an average of 85 months before surgery, consisted mainly of pain (55%), heartburn (52%), dysphagia (45%), and regurgitation (41%). Of the four patients who presented with acute illness, two had gastric obstruction, one had severe dyspnea, and one had gastric bleeding. Endoscopy demonstrated esophagitis in 25 (69%) of 36 patients, and 24-hour pH-monitoring demonstrated acid reflux in 22 (67%) of 33 patients. Manometry detected severely impaired distal esophageal peristalsis in 17 (52%) of 33 patients. The preferred operation consisted of reduction of the hernia, excision of the sack and the gastric fat pad, closure of the enlarged hiatus without mesh, and construction of a fundoplication anchored by sutures within the abdomen.

RESULTS

Of the 55 patients, the operations of 49 were completed laparoscopically using the following reconstructions: Guarner (270-degree) fundoplication (30 patients); Nissen fundoplication (10 patients); and gastropexy (9 patients). Five (9%) operations were converted to laparotomies. The average operating time was 219 minutes; the average blood loss was less than 25 mL; resumption of an unrestricted diet, 27 hours; and mean hospital stay, 58 hours. Intraoperative technical complications occurred in five (9%) patients. One patient died during surgery from a sudden pulmonary embolus. Two (4%) patients required a second operation for recurrent paraesophageal hernias.

CONCLUSIONS

Laparoscopic repair of paraesophageal hiatal hernias is safe and effective, but the operation is difficult and good results hinge on details of the operative technique and the surgeon's experience. In this series, the crus could always be closed securely without using mesh. We realized early that a fundoplication should be a routine step, because it corrects reflux and is the best method to secure the gastroesophageal junction in the abdomen.

Changing management of gallstone disease during pregnancy

BACKGROUND

Symptomatic gallstones may be problematic during pregnancy. The advisability of laparoscopic cholecystectomy (LC) is uncertain. The objective of this study is to define the natural history of gallstone disease during pregnancy and evaluate the safety of LC during pregnancy.

METHODS

Review of medical records of all pregnant patients with gallstone disease at the University of California, San Francisco, from 1980 to 1996.

RESULTS

Of approximately 29,750 deliveries, 47 (0.16%) patients were treated for gallstone disease, including biliary colic in 33, acute cholecystitis in 12, and pancreatitis in two. Conservative treatment was attempted in all patients but failed in 17 (36%) cases. Two patients required combined preterm Cesarean-section cholecystectomy and 10 required surgery in the early postpartum period for persistent symptoms. Seventeen patients required cholecystectomy during pregnancy for biliary colic (10), acute cholecystitis (six), and pancreatitis (one). Three patients were treated with open cholecystectomy. Fourteen patients underwent LC at a mean gestational age of 18.6 weeks, mean OR time of 74 min, and mean length of stay of 1.2 days. Hasson cannulation was utilized in 11 patients. Reduced-pressure pneumoperitoneum (6-10 mmHg) was used in seven patients. Prophylactic tocolytics were used in seven patients, with transient postoperative preterm labor observed in one. There were no open conversions, preterm deliveries, fetal loss, teratogenicity, or maternal morbidity.

CONCLUSIONS

In past years, symptomatic gallstones during pregnancy were managed conservatively or with open cholecystectomy. LC is a feasible and safe method for treating severely symptomatic patients.

Importance of preoperative and postoperative pH monitoring in patients with esophageal achalasia

Gastroesophageal reflux (GER) can develop in patients with esophageal achalasia either before treatment or following pneumatic dilatation or Heller myotomy. In this study we assessed the value of pre- and postoperative pH monitoring in identifying GER in patients with esophageal achalasia. Ambulatory pH monitoring was performed preoperatively in 40 patients with achalasia (18 untreated patients and 22 patients after pneumatic dilatation), 27 (68%) of whom complained of heartburn in addition to dysphagia (group A), and postoperatively in 18 of 51 patients who underwent a thoracoscopic (n=30) or laparoscopic (n=21) Heller myotomy (group B). The DeMeester reflux score was abnormal in 14 patients in group A, 13 of whom had been treated previously by pneumatic dilatation. Two types of pH tracings were seen: (1) GER in eight patients (7 of whom had undergone dilatation) and (2) pseudo-GER in six patients (all 6 of whom had undergone dilatation). Therefore 7 (32%) of 22 patients had abnormal GER after pneumatic dilatation. Postoperatively (group B) seven patients had abnormal GER (6 after thoracoscopic and 1 after laparoscopic myotomy). Six of the seven patients were asymptomatic. These findings show that (1) approximately one third of patients treated by pneumatic dilatation had GER; (2) symptoms were an unreliable index of the presence of abnormal GER, so pH monitoring must be performed in order to make this diagnosis; and (3) the preoperative detection of GER in patients with achalasia is important because it influences the choice of operation.

Comparison of laparoscopic total and partial fundoplication for gastroesophageal reflux

Approximately 25% of patients with gastroesophageal reflux severe enough to be considered for surgical treatment have dysfunction of esophageal peristalsis in addition to dysfunction of the lower esophageal sphincter. A standard total (i.e., Nissen) fundoplication in these patients may be followed by dysphagia, so many experts recommend a partial fundoplication as an alternative. The goal of this study was to compare the clinical results and changes in esophageal function following laparoscopic total and partial fundoplication. Ninety-three patients with gastroesophageal reflux disease had laparoscopic antireflux operations. Total fundoplication was performed in 50 patients with normal esophageal peristalsis. Partial fundoplication was chosen for 43 patients with severe abnormalities of esophageal peristalsis. The same percentage of patients has resolution of heartburn (93%) and regurgitation (97%) after partial as compared to total fundoplication. Dysphagia developed in four patients (8%) after total fundoplication (one patient required dilatation) and in no patients after partial fundoplication. Both operations produced similar changes in lower esophageal sphincter function, but only partial fundoplication was associated with improvement in esophageal dysfunction. Esophageal acid exposure became normal in 92% of patients after total and in 91% of patients after partial fundoplication. Partial fundoplication improves lower esophageal sphincter pressure and esophageal body function and, in patients with abnormal esophageal peristalsis, it corrects reflux without producing dysphagia. Partial and total fundoplication are both indicated in patients with gastroesophageal reflux disease, and the choice of which procedure to use should be based on each patient"s specific esophageal motor function abnormalities.

Prognostic factors in pancreatic carcinoma

Pancreatic cancer is a relatively common malignancy. Its gravity is underscored by the low overall cure rates. A number of clinical, pathologic, and molecular factors have been identified that predict survival of patients with this neoplasm. These factors are reviewed and analyzed.

Partial fundoplication for gastroesophageal reflux

BACKGROUND

About 20% of patients with gastroesophageal reflux disease (GERD) have severely impaired esophageal peristalsis in addition to an incompetent lower esophageal sphincter. In these patients a total fundoplication corrects the abnormal reflux, but it is often associated with postoperative dysphagia and gas bloat syndrome. We studied the efficacy of partial fundoplication in such patients.

METHODS

A partial fundoplication (240 degrees -270 degrees ) was performed laparoscopically in 26 patients (11 men, 15 women; mean age 50.5 years) with GERD (mean DeMeester score: 92 +/- 16) in whom manometry demonstrated severely abnormal esophageal peristalsis.

RESULTS

All operations were completed laparoscopically and the patients were dicharged an average of 39 h after surgery. The preoperative symptoms resolved or improved in all patients, and no patient developed dysphagia or gas bloat syndrome. Postoperative pH monitoring showed complete or nearly complete resolution of the abnormal reflux in every patient.

CONCLUSIONS

Partial fundoplication is an excellent treatment for patients with GERD and weak peristalsis, for it corrects the abnormal reflux and avoids postoperative dysphagia.

Laparoscopic splenectomy. The emerging standard

BACKGROUND

The purpose of this study was to evaluate the outcome of patients undergoing laparoscopic splenectomy (LS) at the University of California, San Francisco.

METHODS

The medical records of the initial 52 unselected patients undergoing LS were reviewed and compared to 28 concurrently treated open splenectomy patients (OS).

RESULTS

Patients did not differ with regard to age, gender, body, or splenic weights. The operative time was longer in the LS patients (mean 196 vs 156 min), but the length of stay and duration of ileus were shorter in the LS group. For adult patients admitted exclusively for splenectomy, operative times did not differ between LS and OS and total hospital cost was less in the LS group (mean $8, 939 vs $14,022). Six patients required conversion to OS, four occurring in the first 11 patients treated (overall conversion rate of 11%). Three patients died from complications related to their underlying disease. Two other major complications occurred. Complication rates and transfusion requirements did not differ between OS and LS patients.

CONCLUSIONS

Laparoscopic splenectomy is a safe and effective alternative to open splenectomy for treatment of hematologic diseases in patients of all ages.

Hospital volume influences outcome in patients undergoing pancreatic resection for cancer

Surgical resection is the only possibly curative treatment of malignant pancreatic neoplasms, but major pancreatic resection for cancer is associated with high rates of morbidity and mortality. The objective of this study was to determine the relation between hospital volume and outcome in patients undergoing pancreatic resection for malignancy in California. Data were obtained from reports submitted to the Office of Statewide Health Planning and Development by all California hospitals from 1990 through 1994. Patient abstracts were analyzed for each of 1,705 patients who underwent major pancreatic resection for malignancy. Of the 298 reporting hospitals, 88% treated fewer than 2 patients per year; these low-volume centers treated the majority of patients. High-volume providers had significantly decreased operative mortality, complication-associated mortality, patient resource use, and total charges and were more likely than low-volume centers to discharge patients to home. These differences were not accounted for by patient mix. This study supports the concept of regionalizing high risk procedures in general surgery, such as major pancreatic resection for cancer.

Minimally invasive surgery for gastroesophageal reflux disease

BACKGROUND

The goal of this study was to determine if the outcome of antireflux surgery can be improved by: (1) conducting a careful preoperative workup to characterize gastroesophageal reflux disease (GERD) in the individual patient; and (2) tailoring the operation to the results of the preoperative function tests.

PATIENTS AND METHODS

Sixty-eight patients had operations for GERD by minimally invasive techniques.

RESULTS

A Rossetti fundoplication was performed in 22 patients. Sixty-eight percent became asymptomatic. Twenty-seven percent developed dysphagia or gas bloat. Thirty-five patients had a Nissen fundoplication. Ninety-one percent are asymptomatic. Eleven patients with severe abnormalities of esophageal peristalsis underwent a Guarner fundoplication with relief of symptoms in 82% of patients. No patients in the Nissen or Guarner group developed postoperative persistent dysphagia or gas bloat. A pyloromyotomy was performed in 3 patients because of severe delayed gastric emptying.

CONCLUSIONS

Minimally invasive surgery for GERD gives good-to-excellent results even in patients with abnormal esophageal body function, provided that the operation is tailored to the individual patient based on the results of the preoperative function tests.

Neuroendocrine disorders of the gut

The regulation of gastrointestinal function is known to involve elements of the enteric nervous system. Processes such as secretion, motility, blood flow, and immune function are all influenced by a complex network of neurons whose cell bodies lie in the gut. These neurons use a wide spectrum of substances as neurotransmitters, although the majority use peptides once thought to function only as gut hormones. It has been increasingly recognized that abnormalities of this neuroendocrine regulatory system underlie many gastrointestinal disorders. The most obvious are states of peptide excess found in patients with gut endocrine tumors such as carcinoid, gastrinoma, and somatostatinoma. Conversely, other disorders appear to be related to deficiency states. Examples include both achalasia and Hirschsprung's disease (congenital megacolon), where the loss of inhibitory neural action leads to abnormalities of peristalsis and sphincter function. Evidence for abnormal neuroendocrine regulation leading to disease states is increasing for many other gastrointestinal disorders.

Mechanisms of gastric acid secretion in the fetal rabbit

BACKGROUND

The parietal cell specific protein H+/K(+)-adenosine triphosphatase H+/K(+)-ATPase) is responsible for gastric acid secretion in adult mammals; however, its ontogeny and role in fetal acid secretion are unknown. The purpose of this study was twofold: (1) to determine the ontogeny of gastric acid secretion and parietal cell H+/K(+)-ATPase expression in the fetal rabbit and (2) to determine the role of H+K(+)-ATPase in fetal acid secretion.

METHODS

For the ontogeny studies 88 fetuses from nine time-mated rabbits were studied at successive gestational ages. Gastric fluid and amniotic fluid pH were measured, and total gastric acid was determined by titration. Gastric microsomal protein was analyzed by Western blot analysis for H+/K(+)-ATPase expression by using a monoclonal antibody to the 94 kd alpha-catalytic subunit. To determine the role of H+/K(+)-ATPase in fetal acid secretion, 37 fetuses at day 26 from four time-mated rabbits were treated with (1) omeprazole (20 mg/kg) injection into the amniotic sac (n = 13), (2) carrier injection (n = 12), or (3) no injection (n = 12). Fetal gastric pH and titratable acid were measured at day 28.

RESULTS

Amniotic fluid pH was neutral (7.44 to 7.64) throughout the third trimester. Gastric fluid pH was neutral (7.42 to 7.51) until day 25, when it decreased to 7.16 +/- 0.23 (p < 0.05) and subsequently fell to 5.37 +/- 0.05 by day 30. Titratable gastric acid (micromoles) increased from 0 at day 20 to 54.7 +/- 5.4 by day 30. By use of Western blot analysis and immunohistochemistry, gastric microsomal H+/K(+)-ATPase expression was absent from days 20 through 25 of gestation and first detectable at day 26, with qualitative increases to term. Omeprazole significantly inhibited pH (5.45 +/- 0.13 in controls, 5.56 +/- 0.12 with carrier injection, and 6.01 +/- 0.10 with omeprazole injection; p < 0.05).

CONCLUSIONS

These data suggest that (1) gastric acid acid secretion begins at day 25 of gestation and increases to term, (2) gastric microsomal H+/K(+)-ATPase expression is first detectable at day 26 of gestation, and (3) omeprazole inhibits, but does not abolish, gastric acid secretion in the fetal rabbit. We conclude that gastric acid secretion is present before birth in the fetal rabbit and is mediated, in part, by omeprazole-sensitive H+/K(+)-ATPase.

Laparoscopic splenectomy. The initial experience at University of California, San Francisco

OBJECTIVE

To evaluate the outcomes of patients undergoing laparoscopic splenectomy (LS) at a single institution.

DESIGN

Case control.

SETTING

University teaching hospital.

PATIENTS

The medical records of the initial 25 consecutive patients who underwent LS at a single institution were reviewed. For comparison, a control group of 25 patients undergoing open splenectomy (OS) matched for age, diagnosis, and splenic weight were also reviewed.

MAIN OUTCOME MEASURES

Data regarding operative time, blood loss, pathologic findings, complications, postoperative hospital stay, ileus duration, preoperative and postoperative hematocrit and platelet counts, blood and platelet transfusions, and hospital costs were collected.

RESULTS

Twenty-five patients underwent attempted LS. Four procedures (16%) were converted to OS. Operative time averaged 3.3 +/- 0.2 hours for LS and 2.6 +/- 0.1 hours for OS (P = .001). In the LS group, a regular diet was tolerated 2.1 +/- 0.3 days after surgery (P < .001), and mean postoperative hospital stay was 5.1 +/- 0.6 days (P = .037), compared with 4.3 +/- 0.3 and 6.7 +/- 0.5 days, respectively, in the OS group. No differences were observed in blood loss, complication rate, transfusion requirement, or hospital cost.

CONCLUSIONS

Compared with OS, LS requires more operative time, is comparable in blood loss, transfusion requirement, complication rate, and cost, and appears to be superior in terms of return of bowel function and hospital stay.

Hepatocyte growth factor induces gastric H+/K(+)-ATPase expression

The processes regulating the development of the fetal gastrointestinal tract are largely unknown, but are likely dependent, in part, on peptide growth factors. The purpose of this study was to determine the contribution of hepatocyte growth factor (HGF) to the development of the fetal gastric epithelium, with particular reference to the parietal cell. Fifty-six fetal rabbits from 18 time-mated pregnant New Zealand White rabbit does were divided into four groups at Day 23 of gestation (term is 31 days): (1) unoperated control littermates, (2) those prevented from swallowing amniotic fluid by esophageal ligation (EL), (3) those with EL plus intragastric carrier infusion, and (4) those with EL plus intragastric HGF infusion. At Day 28 of gestation, fetal stomachs were harvested and analyzed for gastric weight, DNA content, and H+/K(+)-ATPase expression. In control fetuses, gastric weight was 470 +/- 30 mg, gastric DNA content was 741 +/- 59 micrograms, and gastric H+/K(+)-ATPase expression was 25.4 +/- 2.7 micrograms. EL resulted in a 45% decrease in gastric weight (P = 0.001), a 34% decrease in DNA content (P = 0.04), and a 43% decrease in H+/K(+)-ATPase expression (P = 0.007). These inhibitory effects were not reversed by intragastric carrier infusion. Although intragastric HGF infusion did not significantly restore gastric weight or gastric DNA content, it restored gastric H+/K(+)-ATPase expression to levels no different from those of unoperated controls (23.9 +/- 2.8 micrograms), but significantly greater than those of the EL or carrier infusion groups (P = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of medical and minimally invasive surgical therapy for primary esophageal motility disorders

OBJECTIVE

To compare medical with minimally invasive surgical therapy in the treatment of primary esophageal motility disorders.

DESIGN

Prospective study.

SETTING

University-based tertiary care center.

PATIENTS

Eighty-nine patients (46 men and 43 women) with either achalasia or nutcracker esophagus and diffuse esophageal spasm (DES). Choice of treatment was based not on randomization but on the preference of the referring physician, the patient's choice, and/or the patient's eligibility to access the University of California, San Francisco, for treatment.

INTERVENTIONS

Nineteen patients with achalasia and 30 patients with nutcracker esophagus and DES were treated with dilatations and/or medications. Thirty patients with achalasia and 10 with nutcracker esophagus and DES underwent a thoracoscopic myotomy.

MAIN OUTCOME MEASURES

Dysphagia, pain, and overall quality of life.

RESULTS

In the surgical group, 80% of the patients with nutcracker esophagus and DES and 87% of the patients with achalasia had good or excellent results. In contrast, in the medical group, 26% of the patients with nutcracker esophagus and DES and 26% of the patients with achalasia had good or excellent results.

CONCLUSIONS

Surgery by minimally invasive techniques offers a better chance than does medical therapy or dilatation of rendering the patient with achalasia, nutcracker esophagus, and DES asymptomatic.

Impaired release of gallbladder calcitonin gene-related peptide in human gallstone disease

Calcitonin gene-related peptide (CGRP) is a neurotransmitter present in the peripheral ends of sensory neurons of the gut and may modulate reflexes of the enteric nervous system. We studied the release of CGRP in normal human gallbladders and in those containing gallstones to test the hypothesis that abnormalities of regulation of CGRP release participate in gallstone formation. Human gallbladder strips were obtained from histologically normal organs removed during liver surgery (n = 8) or from patients operated upon for symptomatic cholelithiasis (n = 14). After removal of the mucosa, muscle strips were superfused with oxygenated Kreb's buffer in an organ bath at 37 degrees C. Pharmacologic agents were added to the superfusate and samples were collected at 2-min intervals for analysis. CGRP release was measured by a sensitive and specific radioimmunoassay and adjusted for tissue weight. In normal gallbladders, CGRP release was stimulated sixfold over basal by capsaicin (10(-5) M) to 363 +/- 75 pg per gram of muscle per 2 min. This release was abolished by addition of somatostatin (SS) or the neural blocker tetrodotoxin (TTX). Lesser degrees of CGRP release were observed after nonspecific stimulation with K+ or phosphodiesterase inhibition with caffeine. In gallbladders with gallstones, capsaicin-induced CGRP release was 74 +/- 16 pg per gram of muscle per 2 min (20% of normal, P < 0.001). Release induced by caffeine and K+ was also inhibited compared to normal gallbladder strips. Release of CGRP from diseased strips was abolished by TTX and inhibited by SS to degrees similar to normal tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal peptides and their relevance in pediatric disease

Gastrointestinal (GI) endocrinology has undergone rapid change during recent years. A greater appreciation has been gained for the role of gut peptides in the regulation of GI motility, secretion, blood flow, absorption, and immunity. Furthermore, it is increasingly recognized that these peptides function in both the brain and the gut as neurotransmitters. Many effects initially attributed to hormonal influences are now known to be neurocrine in origin. GI peptides can be classified into families based on their structural homology. In this article, the physiology of the major gut peptides is reviewed, and their role in the pathophysiology of GI disorders is highlighted.