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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. (Arch Surg. 1995;130:609-616)

Objective: To review our experiences in order to high-light some important lessons learned in the treatment of patients with neuroendocrine gut neoplasms. Design: Retrospective analysis of case series of 70 patients with neuroendocrine gut neoplasms treated between 1983 and 1993. The clinical features of individual patients illustrate lessons in surgical treatment. Setting: University hospitals with tertiary care referral practice. Interventions: The main intervention was abdominal exploration in 43 patients, with resection of the primary tumor in 39 and of hepatic metastases in four. Main Outcome Measures: To describe the tumors seen and to identify major lessons learned. Results: Of 70 patients with neuroendocrine tumors treated, 31 had carcinoid tumors, 10 each had insulinomas and gastrinomas, five had vipomas, nine had nonfunctioning islet cell tumors, three had glucagonomas, and one each had somatostatinoma and a possible cholecystokinin-secreting tumor (or CCKoma). Important lessons learned include: (1) the importance of preoperative tumor localization; (2) in multiple endocrine neoplasia, type I syndrome, the tumor found may not be the one responsible for the patient's symptoms; (3) solitary sporadic tumors secreting multiple peptides may mimic multiple tumors in multiple endocrine neoplasia, type I syndrome; (4) one needs to be prepared for the unexpected, such as the carcinoid crisis; (5) resection may sometimes be necessary even with advanced local disease; and (6) selected patients may benefit from pancreaticoduodenectomy. Conclusions: These rare tumors are interesting in their clinical presentation and can be challenging in their treatment. (Arch Surg. 1994;129:965-972)

• Between January 1977 and December 1979 (three years), 642 appendectomies were performed at the Childrens Hospital of Los Angeles. Two hundred seventy-two of the appendectomies were performed incidentally at the time of another abdominal operative procedure. Using known incidence of appendicitis, approximately 54 cases of acute appendicitis may have been obviated. In three patients, wound infections developed. Twenty-four of the appendices were histologically normal and 30 were abnormal in a clinically insignificant respect. If incidental appendectomy is appropriate in the age group, it is of more benefit to the pediatric patient because of the frequency of appendicitis in patients under 20 years of age. ( Arch Surg 1983;118:714-716)

• Recently, three new drug types have emerged to treat peptic ulceration. We compared the mechanism of action of omeprazole and somatostatin-14, both inhibitors of gastric acid, with that of tetraprenylacetone, a drug thought to be cytoprotective in the upper gut. Omeprazole and somatostatin-14 caused potent inhibition of meal-stimulated acid secretion in the dog (92% ± 6% and 97% ±1%, respectively). On the other hand, tetraprenylacetone had no significant inhibitory effect on acid secretion (4%±17%). In separate studies, tetraprenylacetone was shown to be a stimulant of gastric bicarbonate secretion in the rabbit, increasing bicarbonate secretion from a basal level of 0 to 86±28 pmol/2 h. Tetraprenylacetone was also found to be a strong stimulant of canine pancreatic bicarbonate secretion. The ability of tetraprenylacetone to stimulate endogenous bicarbonate secretion may explain its ability to heal ulcers both experimentally and clinically. (Arch Surg1987;122:447-450)