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Stent implantation in patients with thoracic anastomotic leaks after esophagectomy is an easily available and effective treatment option with low morbidity, but stent migration does occur.

Reflux of duodenal juice in gastroesophageal reflux disease is more common than pH studies alone would suggest. The combined reflux of gastric and duodenal juices causes severe esophageal mucosal damage. The vast majority of duodenal reflux occurs at a pH range of 4 to 7, at which bile acids, the major component of duodenal juice, are capable of damaging the esophageal mucosa.

Tailored surgical antireflux procedures were done in 104 patients during a 7-year period. Presenting symptoms included heartburn in 95 patients (91%), regurgitation in 83 patients (80%), and dysphagia in 61 patients (60%). Evaluation before operation included video barium esophagography, endoscopy, 24-hour esophageal pH monitoring, and esophageal motility studies. On the basis of anatomic and functional findings, the following procedures were performed: 15 laparoscopic and 49 open transabdominal Nissen fundoplications, 23 transthoracic Nissen fundoplications, seven Belsey partial fundoplications, and 10 Collis gastroplasty and Belsey partial fundoplications. The severity of symptoms was assessed before and after operation according to a previously published grading score. Eighty-five of the 104 patients (82%) were able to be contacted for a follow-up evaluation by means of a standardized questionnaire. Median length of follow-up was 4 years, with 40 patients having follow-up beyond 5 years. The tailored operation cured the symptoms of heartburn in 97%, regurgitation in 91%, and dysphagia in 92%. Ninety-eight percent of the patients reported that operation had cured their preoperative symptoms and 93% were satisfied with the outcome of the operation. To obtain optimal results, surgical treatment of gastroesophageal reflux disease should be tailored to the patient's anatomic and functional assessments. For early, uncomplicated disease a transabdominal Nissen fundoplication is done, laparoscopically when expertise exists. Patients with complicated disease should undergo an open antireflux procedure tailored to specific anatomic or functional abnormalities.

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Esophageal replacement for end-stage achalasia can be accomplished with safety and marked improvement of preoperative symptoms. Despite multiple previous therapeutic failures, normal alimentation was restored in the majority of patients, with 93% judging the operation to be highly beneficial, improving their quality of life. Based on this success, guidelines for resection in end-stage achalasia are established.

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