
EFFECT OF PREVIOUS TREATMENT ON SURGICAL OUTCOME
Patients unsuccessfully treated by endoscopic dilation or in- trasphinteric botulinum toxin injection are often referred for surgery. Transient tissue damage in the mucosa-submucosa layer has been documented by high resolution endoscopic ultrasonography, but it is unknown whether previous endoscopic treatment may cause histopathological changes leading to periesophageal inflammation, difficult identification of the circular or sling fibres, or difficult dissection of the submucosal plane. Recently, it has been found that patients who previously responded to botulinum toxin show a marked fibrotic reaction at the gastroesophageal junction leading to a higher rate of intraoperative mucosal tears and postoperative dysphagia.
The increase in technical difficulties encountered at operation after injection therapy can be offset by adequate surgeon’s experience; however, these preliminary observations suggest that injection of botulinum toxin should be reserved to patients who are not candidates for pneumatic dilation or laparoscopic Heller myotomy.
The results of a double-blind trial of intrasphincteric injection of botulinum toxin compared with placebo showed that 66% of patients remained in remission six months after treatment, and the mean duration of a favourable response was 1.3 years. After a median follow-up of 2.4 years, only one-third of the patients were still in remission despite multiple injections. The response rate among patients older than 75 years was 75%, while it was 27% among individuals younger than 50 years. The short term safety and effectiveness of the procedure have been confirmed in a French multicentre study.
Based on these early results it seems reasonable to consider the use of the toxin in the elderly patients and in those at risk for more invasive procedures. It remains to be clarified how long the effects of the injection will last and whether repeated injections will prove to be safe in the long term.
Current treatment modalities for achalasia are palliative and aim at improving esophageal emptying by reducing lower esophageal sphincter resistance to passage of the bolus. This effect can be achieved endoscopically by means of either pneumatic dilation or botulinum toxin injection, and surgically by extramucosal myotomy. No firm consensus has been reached yet regarding the choice of the initial treatment. Retrospective studies have shown better results with myotomy performed by an experienced surgeon, and in the only prospective randomized trial myotomy gave better long term results compared with pneumatic dilation. Uncontrolled studies show that both procedures have equal success rates if skilled operators are available, and, therefore, the patient should be allowed to make his or her own decision. In the only controlled trial of botulinum toxin injection versus pneumatic dilation, both procedures were effective at one-year follow-up.
Two randomized, double-blind, placebo controlled trials have shown that chronic treatment with calcium-channel blockers, such as nifedipine or verapamil, does not significantly improve symptoms despite a marked decrease of lower esophageal sphincter pressure in up to 50% of the patients. This form of therapy may be considered for short term management in individuals with relatively mild symptoms or as a temporary measure when more invasive procedures are contraindicated.

Idiopathic achalasia is a motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and impaired peristalsis of the esophageal body. Defective eso- phageal emptying leads to progressive dilation and tortuosity of the esophagus. Anatomic and physiological studies suggest a dysfunction of the myenteric plexus in these patients, and an autoimmune pathogenesis has been hypothesized. The estimated annual incidence of the disease is 1/100,000 persons.
Dysphagia and regurgitation are the two major symptoms of the disease. Nocturnal regurgitation can lead to aspiration pneumonia and pulmonary abscess. Inability to swallow leads to weight loss in more than half of the patients. The incidence of squamous cell carcinoma of the esophagus is greater in patients with long standing achalasia than in the control population.
THE END OF A SERIES AND THE BEGINNING OF A JOURNEY
Upon addressing, debating and resolving the aforementioned topics and issues, the portfolio building process will be complete. Investment policy has been developed, macro- and micro- expectational factors relevant to investing have been identified, portfolio composition has been decided, and assets have been allocated and optimized. This is where your real financial journey begins.
As I approach the end of an odyssey that began almost a year ago in the May, 1999 issue of this journal, I again ponder whether I have done the right thing by delving into a practical step by step description of the IMC process.
To address the question about why I specifically chose not to write about current events and more topical issues of interest, my answer is as follows. In my tenure as an investment advisor, I have seen this profession attract some of the most successful sales professionals in the country and, among them, some of the most gifted raconteurs I have had the pleasure ofmeeting. Some of these individuals are far more gifted than myself at relaying current topical events, which would make for superior light reading. I can truly say, though, that most investors I have had the pleasure of dealing with stood to benefit from additional awareness of factual research, education and planning. Armed with the fundamentals of the IMC process, investors can be in a more empowered state of financial awareness, more capable of making the critical decisions necessary to nurture and maintain a successful portfolio. There is plenty of financial gossip, fruitless speculation and conjecture available to bemuse and bewilder the most avid ‘hot tip’ collector. It will serve no one to have me adding more fuel to that glowing fire.
Dollar cost averaging versus lump sum investing: Once money managers have been selected, either in the form of mutual fund managers or professional managers to whom you give discretionary power to make the day to day decisions in your investment accounts, the final decisions to be made are about the timing of the actual placement of cash into the fund or managed account.
Two options you need to choose between are ‘dollar cost- averaging’ and ‘lump sum investing’. When cost and performance of these approaches are evaluated, neither has been shown to be consistently preferable over the other.
‘Dollar cost averaging’ is the process of making multiple deposits of equal size at regular intervals over a specified period of time. This results in acquiring a particular type of asset slowly, which can decrease the risks of a sudden market downturn. Dollar cost averaging can be particularly useful when markets are unstable.
For the individual investor, cost averaging strategies are sometimes more feasible for purchasing mutual funds than for placement of money in separately managed accounts. As discussed previously in this article, in order to access the services of separate account managers, it is not unusual to have to meet a minimum initial account size requirement of $100 thousand to $1 million per mandate or manager.
‘Lump sum investing’ is exactly what you would expect – investing all the money intended, as specified in the asset allocation determined in the second step of the IMC process, over days or weeks. Some believe that this approach is preferable to dollar cost averaging, which is seen by proponents of lump sum investing as attempts at market timing; they argue that short – term market fluctuations have a negligible effect on the portfolio’s performance over the long term. As well, advocates of lump sum investing suggest that delays in getting into the market expose the investor to the risk of lost opportunity. Market timing versus strategic asset allocation: Fiduciaries, individual investors and investment consultants usually have quite different opinions on most investment management subjects. However, the subject of market timing is not one those subjects.

On the other hand, a large influx of cash from new investors may force the same manager to invest even when the markets are soft to prevent a larger cash position from pulling down the overall performance of the portfolio.
Diversification: Most equity mutual funds hold 80 to 120 different securities. In a separately managed stock portfolio, the number of securities is usually half that amount. For an investor who is comfortable with a bit more performance volatility in anticipation of greater returns, the more concentrated portfolio with fewer securities may be appropriate.
Tax deductibility of management fees: The management expenses and transaction costs incurred within a mutual fund cannot be deducted as an investment expense by the individual investor. These expenses are accounted for in calculating the net asset value of the fund. However, outside of a registered retirement savings plan (RRSP), individuals can claim the fees paid to a money manager of a separately managed account as part of their miscellaneous investment expense deductions. Brokerage expenses: Mutual fund expense ratios, often referred to as management expense ratios, do not include the brokerage costs incurred to buy and sell securities in and out of the fund, nor do they include custodial fees charged by the trust company who acts as custodian of the fund. It is not uncommon for a mutual fund to generate significant transaction costs by turning over an entire portfolio frequently. In addition, the trading activity from ongoing new contributions and redemptions adds to brokerage expenses. All things considered, the total costs shouldered by investors in any given mutual fund can be very similar to those of a separately managed account. Shareholder information provided: Investors with separately managed accounts receive annual and quarterly reports from the companies in which they hold shares unless they opt not to. This is appealing to investors who want to understand the stock analysis and selection process followed by the money manager to whom they have delegated their buy and sell decisions.