A1240 SSAT ABSTRACTS GASTROENTEROLOGY, Vol. 108, No. 4

LAPAROSCOPIC OR THORACOSCOPIC HELLER MYOTOMY FOR ACHALASiA- AN EVALUATION OF ANTIREFLUX PROCEDURES. Raiser F. Hinder RA. Swenstrom LL. Filioi CJ. Katada N. McBride PJ. Nearv PF Departments of Surgery, Creighton University Medical School, Omaha NE & Oregon Health Sciences University, Portland OR

Achalasia results from failure of lower esophageal sphincter (LES) relaxation. Surgical intervention by means of esophagocardiomyotomy offers definitive treatment by division of the nonrelaxing sphincter. Due to the high incidence of postoperative reflux in these patients, it is preferable to add an antireflux procedure (ARP), effectively replacing the obstructive LES with a lower resistance antireflux barrier. Because of weak esophageal body motility a partial fundoplication such as the anterior Dor or posterior Toupet are used. We have compared the Dor and Toupet ARP's in conjunction with modified Heller myotomy via both the laparoscopic and thoracoscopic approach. 29 patients with achalasia diagnosed on history, barium swallow, EGD, and manometry underwent an esophageal myotomy with an ARP. There were 9 Dot and 20 Toupet procedures. Four had a thoracoscopic myotomy with Dor. Patients were compared postoperatively using a symptom questionnaire and manometry. Complications were the same for both procedures, consisting of mucosal perforations in 22% of Dor and 20% of Toupet patients. All were recognized intraoperatively and successfully repaired. The mean number of days until return to normal activity was less for laparoscopy patients vs. thoracoscopy patients (1S vs. 42). Mean LES pressure decreased by a similar amount in both groups (Dor group 10.5 + 4.0 mmHg, Toupet group 16.7 + 3.7 mmHg). No patient in either group had abnormal reflux on 24 hour pH analysis, but 14% of Toupet and 63% of Dor patients complained of some heartburn after surgery (p < 0,05). Some residual dysphagia occurred in 33% of Toupet vs. 86% of Dor patients (p < 0.05). This was milder among Toupet patients than Dor patients by symptom scoring (p < 0.05). One Dor patient required reoperation for recurrent dysphagia. The Dor, which lies over the myotomy, seems to pull the edges of the myotomy together, limiting mucosal bulging. By doing so it predisposes the patient to persistent or recurrent dysphagia. The posterior Toupet holds the myotomy open but still prevents reflux. We conclude that the laparoscopic Toupet fundoplication is the best procedure to accompany esophageal myotomy in patients with achalasia.

PITFALLS OF DISTAL PANCREATECTOMY FOR RELIEF OF PAIN IN CHRONIC PANCREATITIS. Rattner DW, Fernandez-del Castillo C, Warshaw AL,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Ma. Purpose: To assess efficacy of distal pancreatectomy for relief of pain in patients with chronic pancreatitis apparently localized to the distal pancrea s associated with stricture or obstruction of the mid pancreatic duct. Methods: Retrospective review of authors experience 1991-94. Patients undergoing concomitant retrograde drainage procedure were excluded. Results: Distal pancreatectomy was performed in 20 patients for relief of pain. Seven patients had pseudocysts of the tail of the pancreas; the remaining 13 underwent distal pancreatectomy based on findings of a mid- pancreatic duct stricture, CT evidence of distal pancreatic enlargement with inflammation, or operative findings of inflammation localized to the tail of the pancreas. 6/7 patients with pseudocysts are currently pain free and none have required rehospitaliztion. 9/13 patients without pseudocysts have had recurrent symptoms, 6 have required readmission, 5 require narcotics for pain relief, and 2 have undergone completion pancreatectomy. 3/13 patients were found to have pancreatic carcinoma. Only 4/13 patients without pseudocyts are pain free. Conclusions: Even when anatomic evidence suggests that chronic pancreatitis primarily involves the tail of the pancreas and there is a stricture of the mid-pancreatic duct which is believed to cause the symptoms, distal pancreatectomy infrequently provides sustained pain relief. Unsuspected carcinoma of the body and tail of the pancreas occurs frequently in this subset of patients with chronic pancreatitis.

THE ROLE OF LOCAL RESECTION IN THE MANAGEMENT OF AMPULLARY TUMORS Rattner DW, Brugge W, Fernandez-del Castillo C, Warshaw AL, Departments of Surgery and Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, Ma. Purpose: To delineate those factors which predict successful short and long term outcomes for local resection of ampullary neoplasms.Methods: Retrospective review of the authors experience 1988- 1994 Results: 17 patients with small neoplasms of the ampulla were identified. The most common presenting symptoms were jaundice(5) and pancreatitis(3). When utilized, Endoscopic Ultrasound(EUS) accurately predicted depth of invasion, but often failed to detect nodal metastases. In 4/12 mucosal neoplasms preoperative biopsies failed to correctly identify malignancy(2 false negative and 2 false positive). 4/6 patients with malignant lesions(2 adenocarcinoma, 1 carcinoid, 1 gastrinoma) underwent local resections and are free of recurrent disease with an average follow up of 26 months. 7/11 patients with benign lesions were treated with local resection and none have had recurrent disease. Among ii patients undergoing local resection there were no complications and the average length of stay was i0 ±3 days. Among 6 patients undergoing pancreaticoduodenectomy there were 4 complications and length of stay averaged 17 ± 5 days(p<.05). Conclusions: EUS is a useful tool in predicting local resectability of ampullary lesions. Since preoperative biopsies are inaccurate in 1/3 of cases and selected patients with malignant lesions can be cured by local excision, benign and malignant lesions less than 2 cm in size that are stage T1 by EUS are optimally treated by local excision.

INFLAMMATORY PROPERTIES OF BILE FROM DOGS WITH PIGMENT GALLSTONES. RV Rege and JB Prystowsky. Depts. of Surg, VA Lakeside Med. Ctr. and Northwestern Univ. Med School, Chi- cago, IL.

The causes of gallbladder inflammation or cholecystitis are poorly un- derstood. We recently demonstrated that bUiary crystals induce an in- flammatory response from WBCs in vitro and from guinea pig gallblad- der when placed into its lumen. We here examine inflammatory proper- ties of canine bile collected sterilely from 6 normal dogs (NL) and 6 dogs with methionine-deficient diet-induced pigment gallstones (MDD). Dog bile (I ml) was placed into guinea pig gallbladder for 4 hrs. Gall- bladders were excised and mucus layer thickness (darkfield microscopy), IL-I 3 activity (uptake of H-thymidine by routine thymocytes) and mye- loperoxidase activity (inflammatory enzyme) were measured. Net so- dium flux (Jnet) was determined in an Ussing chamber. RESULTS: (mean _+ STD, n=6/group) IL-1 activity (626+_241 vs. 180_+42 cpm/mg tissue), myeloperoxidase activity (2378+__ 133 vs. 1273_+ 154 units/gm- rain), and mucus thickness (1210_+ 20 vs. 586_+ 33 lain) were increased (p< 0.05) in gallbladder walls of MDD vs. NL dogs. Results in guinea pig gailbladders exposed to dog bile are:

IL-I Myeloperoxidase Mucus Thickness Jnet cpm/mg units/gm-min p.m ~tmol/cm2-hr

NL 70± 29 925±150 147_+ 19 10.8± 2.8 MDD 364_+50 * 2150_+179' 254_+ 50* 5.3_+ 1.5"

• Statistical significance from normal by ANOVA, p<0.05 MDD dog bile in guinea pig gallbladders markedly increased IL-1 and myeloperoxidase activity, caused a 1 l-fold increase in mucus thickness, and decreased Jnet by over 50 %. Effects were not eliminated by ce n- trifugation of bile (100,000 g x 2 hrs) to remove stones and crystalg: C O N C L U S I O N S : 1. Methionine-deficient diet causes inflammation and mucus hypersecretion in canine gallbladder, 2. Bile from MDD dogs in- duces inflammation in normal guinea pig gallbladder, and 3. Ultracen- trifugation does not eliminate these effects. Bile from a canine model of pigment gallstones contains factors capable of inducing inflammation in the guinea pig and canine gallbladder wall.