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Kahrilas. Esophagogastric junction distensibility: a factor contributing to sphincter incompetence. Am J Physiol Gastrointest Liver Physiol 282: G1052-G1058, 2002 10.1152/ ajpgi.00279.2001.-To quantify the effect of hiatus hernia (HH) on esophagogastric junction (EGJ) distensibility, eight normal subjects and nine gastroesophageal reflux disease (GERD) patients with HH were studied with concurrent manometry, fluoroscopy, and stepwise controlled barostatic distention of the EGJ. The minimal barostatic pressure required to open the EGJ during the interswallow period was determined. Thereafter, barium swallows were imaged in 5-mmHg increments of intrabag pressure. EGJ diameter and length were measured at each pressure during deglutitive relaxation. The EGJ opening diameter was greater in hernia patients compared with normal subjects during deglutitive relaxation at all pressures, and EGJ length was 23% shorter. EGJ opening pressure among hernia patients was lower than normal subjects during the interswallow period. In conclusion, the EGJ of GERD patients with HH was more distensible and shorter than normal subjects. These findings partially explain why HH patients are predisposed to reflux by mechanisms other than transient lower esophageal sphincter relaxations, sustain greater volumes of refluxate, and have a reduced ability to discriminate gas from liquid reflux. hiatus hernia; gastroesophageal reflux disease THE CARDINAL ABNORMALITY of gastroesophageal reflux disease (GERD) is incompetence of the esophagogastric junction (EGJ) to reflux of gastric secretions. This functional compromise can be attributable to perturbation of a number of anatomical or physiological components of the EGJ, including the intrinsic lower esophageal sphincter (LES), the extrinsic compression of the distal esophagus at the diaphragmatic hiatus, the intra-abdominal location of the LES, or the physiology of transient LES relaxations (tLESRs). Physiological investigations suggest that the net result of these perturbations is an increased number of acid reflux events by three mechanisms: 1) tLESR, 2) strain-induced reflux in the setting of a hypotensive LES, or 3) free reflux during periods of low LES pressure or deglutitive relaxation (1,12,19).Gaining acceptance as a cofactor in the pathogenesis of GERD is anatomical distortion of the EGJ inclusive of, but not limited to, hiatus hernia (7,9,13,14). When examining GERD in the context of hiatus hernia, certain distinctions become evident. Patients with more severe forms of GERD, such as erosive esophagitis and Barrett's metaplasia, almost invariably have a hiatus hernia (2, 18), and GERD patients with hiatus hernia have increased esophageal acid exposure compared with patients without hiatus hernia (8, 18). The mechanistic profile for reflux in hiatus hernia patients is also distinct. Whereas tLESRs can account for up to 90% of reflux events in normal subjects or in patients without hiatus hernia, patients with hiatus hernia have a more heterogeneous mechanistic profile with reflux episod...

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With increasing experience and standardization of technique, LDN is a safe and effective procedure. Patients undergoing LDN demonstrate clinically significant, more rapid postoperative recoveries and shorter hospital stays than ODN patients. Excellent initial graft function and long-term graft survival have been observed with LDN kidneys. Urologic complications can be avoided. LDN has become the preferred surgical approach for living kidney donation at our center.

Patients: One hundred twenty-nine patients were surgically treated between January 1, 1977, and December 31, 2000. There were 73 men and 56 women, with a median age of 55 years (age range, 19-82 years). Median follow-up was 36 months. Main Outcome Measures: Presenting symptoms and signs, operations performed, and surgical pathologic features were analyzed and survival curves were generated. Results: Clinical findings included abdominal pain (63%), vomiting (48%), weight loss (44%), and gastrointestinal tract bleeding (23%). The distribution of tumors by histological features was as follows: adenocarcinoma (33%), carcinoid tumor (29%), lymphoma (19%), and sarcoma (19%). Cumulative 5-year survival rate was 37% in the adenocarcinoma group, 64% in the carcinoid tumor group, 29% in the lymphoma group, and 22% in the sarcoma group. Significant prognostic predictors of overall survival for the entire cohort and for each tumor subtype included complete resection and American Joint Committee on Cancer tumor stage (PϽ.05). Patient age, tumor location, histological grade, and use of chemotherapy and radiation therapy did not significantly influence survival. Curative resections were accomplished in 83 patients (64%) with a median survival of 37 months compared with 46 patients undergoing incomplete or palliative resections with a median survival of 10 months (PϽ.05). Adjacent organ resection was required in 18 (22%) of the 83 patients undergoing potentially curative resections. The median time to recurrence was 16 months. Twenty-one patients (16%) developed associated primary cancers. Conclusions: Aggressive surgical resection in an attempt to achieve complete tumor removal seems warranted. Despite complete resections, patients with highstage tumors remain at risk for recurrence.

Fundoplication (FP) efficacy is a trade-off between protection against reflux and postoperative dysphagia from the surgically altered mechanical balance within the esophagogastric segment. The purpose of the study was to contrast quantitatively the mechanical balance between normal and post-FP esophageal emptying. Physiological data were combined with mathematical models based on the laws of mechanics. Seven normal controls (NC) and seven post-FP patients underwent concurrent manometry and fluoroscopy. Temporal changes in geometry of the distal bolus cavity and hiatal canal, and cavity-driving pressure were quantified during emptying. Mathematical models were developed to couple cavity pressure to hiatal geometry and esophageal emptying and to determine cavity muscle tone. We found that the average length of the hiatal canal post-FP was twice that of NC; reduction of hiatal radius was not significant. All esophageal emptying events post-FP were incomplete (51% retention); there was no significant difference in the period of emptying between NC and post-FP, and average emptying rates were 40% lower post-FP. The model predicted three distinct phases during esophageal emptying: hiatal opening (phase I), a quasi-steady period (phase II), and final emptying (phase III). A rapid increase in muscle tone and driving pressure forced normal hiatal opening. Post-FP there was a severe impairment of cavity muscle tone causing deficient hiatal opening and flow and bolus retention. We conclude that impaired esophageal emptying post-FP follows from the inability of distal esophageal muscle to generate necessary tone rapidly. Immobilization of the intrinsic sphincter by the surgical procedure may contribute to this deficiency, impaired emptying, and possibly, dysphagia.