Teres cardiopexy was compared with Nissen fundoplication in a prospective randomized study of surgery for gastro-oesophageal reflux disease refractory to medical treatment. Follow-up at 3 months of ten patients undergoing each procedure showed good clinical results and improvement of the mean symptom score in both groups, for cardiopexy from 7.8 to 1.1 (P < 0.01) and for fundoplication from 5.7 to 0.2 (P < 0.01). After 1 year, six of the ten patients undergoing cardiopexy required a second antireflux procedure because of recurrent disease, whereas one reoperation was performed after fundoplication. The mean symptom score after 1 year was higher in patients submitted to cardiopexy than in those receiving fundoplication (3.9 versus 0.3, P < 0.01). The mean endoscopic oesophagitis score after 1 year was no different from preoperative values after cardiopexy (1.9 versus 1.9) but was significantly lower after fundoplication (1.5 versus 0.3, P = 0.01). Ambulatory 24-h pH monitoring showed a significantly higher proportion of total time at pH < 4 after cardiopexy than fundoplication (24.0 versus 3.8 per cent, P < 0.05). Cardiopexy is significantly less effective than fundoplication for the treatment of gastro-oesophageal reflux disease assessed at 1-year follow-up. This study does not support the use of cardiopexy either in conventional or laparoscopic antireflux surgery.

The technique of 24 hour esophageal pH monitoring (24 hour pH test) is described. Experience with the 24 hour pH test in 393 patients with suspected esophageal disease has shown the clinical usefulness of the test in objectively determining the presence of gastroesophageal reflux. The test was effective in evaluating atypical symptoms of gastroesophageal reflux such as respiratory symptoms and chest pain and, in children, failure to thrive and recurrent pneumonia. The 24 hour pH test was particularly useful in evaluating patients who were referred with other abdominal or thoracic disease and had, in addition, symptoms suggestive of gastroesophageal reflux on history. The test helped to unsnarl the cause of recurrent symptoms after an esophageal myotomy for achalasia or an antireflux procedure. Of 179 patients with typical symptoms of gastroesophageal reflux, 27% had normal 24 hour test results and were subsequently diagnosed as having another cause for their symptoms. Of 146 patients who had normal findings on esophagoscopy, 54% were shown to have abnormal gastroesophageal reflux on 24 hour pH monitoring, indicating lack of sensitivity of endoscopy to detect reflux. In addition, the 24 hour pH test identified patterns of abnormal reflux and indicated those patients most at risk for development of stricture. The test is well tolerated by the patients, simple to use, and dependable when performed and read as described. The clinical use of the 24 hour pH test brings objectivity to the evaluation of exophageal disease that has hitherto not been available.

To clarify the mechanism by which gastrointestinal peptides influence calcium homeostasis, we studied 1) the effect of pentagastrin (PG) on serum Ca and serum immunoreactive calcitonin (iCT) concentrations and 2) the effect of gastric acid inhibitors on PG- and histamine-induced hypocalcemia. Fasted male Holtzman rats (80–100 g) were used in groups of five to eight. In sham-operated rats (laparotomy), PG (25μg, iv) resulted in a rise of serum iCT from a basal value of 39 ± 5 pg/ml (mean ± SE) to a peak value of 60 ± 10 pg/ml (P < 0.05) at 2 min after injection. In these animals, the serum Ca decreased from a basal concentration of 10.2 ± 0.17 to 8.3 ± 0.15 mg/dl (P < 0.001) 30 min after the injection. In gastrectomized, thyroidintact animals, serum iCT increased from 31 ± 3 pg/ml to a peak value of 59 ± 9 pg/ml 5 min after PG (P < 0.01), a response which did not differ significantly from that of sham-operated rats. Despite this, serum Ca did not decrease from basal values at 30 min in gastrectomized animals. Finally, in acutely thyroparathyroidectomized rats, iCT values were undetectable at all times. However, Ca decreased from 9.1 ± 0.23 to 8.0 ± 0.17 mg/ dl 30 min after PG (P < 0.005) in these animals. In studies related to the effect of inhibitors of gastric acid secretion, the administration of PG alone in sham-operated animals was followed by a Ca decrease of 2.1 mg/dl or greater. However, this PG-induced hypocalcemia was completely in inhibited by atropine (4 μg), secretin (1U), or metiamide (0.12 mg) when these agents were administered with PG. None of these gastric acid inhibitors influenced Ca when given alone. The administration of histamine base (1.0 mg) was followed by a similar decrease in Ca of 1.7 mg/dl or greater 30 min after its injection. The injection of either atropine (2 μg) or metiamide (0.48 mg) completely inhibited all hypocalcemia resulting from the histamine. However, secretin in doses as large as 10 U had no inhibitory effect on the lowering of serum calcium by histamine. Finally, transabdominal vagotomy significantly reduced the Ca-lowering activity of both PG and histamine. These studies clearly demonstrate that PG in pharmacological doses is a CT secretagogue in the rat, although not a potent one. However, the decrease of Ca after PG appears to be independent of hypercalcitoninemia and only occurs when an intact stomach is present. Furthermore, the findings that 1) atropine and metiamide abolish all PG- and histamine-induced hypocalcemia, 2) secretin blocks PG- but not histamine-induced hypocalcemia, and 3) transabdominal vagotomy decreases the hypocalcemia after both PG and histamine administration strongly suggest that a gastric factor related to acid secretion plays the most important role in mediating the influence of these gastrointestinal factors on serum calcium levels in the rat.

Hyperthyroidism of Graves' disease may be treated very effectively by antithyroid pills, such as PTU and Tapazole, by radioactive iodine therapy, and by subtotal thyroidectomy. Each form of therapy has advantages and disadvantages, and thus treatment should be individualized. While therapy with radioactive iodine would appear to be ideal since it does not require an operation and is less expensive than surgical management, it suffers from a high rate of progressive hypothyroidism and from the fact that the time until a euthyroid state is obtained is often prolonged. In addition, the long-term carcinogenic risk of the therapy for thyroid neoplasia has never been completely defined since the data most often quoted have a mean follow-up time of only eight years. Furthermore, new "low-dose" radioiodine regimens may be more dangerous in this regard. Subtotal thyroidectomy, while not totally without complications, remains a rapid, safe, and effective treatment for Graves' disease. The careful use of propranolol has facilitated the preparation of some patients and has lessened the risk of operation. Thyroidectomy should remain the treatment of choice for young adults with this disease.