Is absorbable mesh useful in preventing parastomal hernia after emergency surgery? The PARTHENOPE study

PURPOSE

Colostomy is a frequent event in oncological or inflammatory bowel diseases. Its related morbidity includes retraction, infection and parastomal hernia (PH), which is a quite common late complication. Several surgical options are available for PH repair, the majority including mesh. However, results are often disappointing with relevant recurrence rates, up to 33%. The study aim was to assess the feasibility and effectiveness of prophylactic biosynthetic mesh (BIO-A^®, polyglycolide-trimethylene carbonate copolymer) placed during colostomy fashioning, in reducing PH. A prospective randomized controlled double-blind trial was conducted from January 2014 to December 2019 to compare conventional end-colostomy with end-colostomy reinforced with BIO-A mesh in ante-rectus position in patients undergoing colon diversion in emergency surgery.

METHODS

Patients were clinically followed up at 3, 6, and 12 months and received a CT scan at 6 and 12 months. The postoperative morbidity and wound events were also evaluated.

RESULTS

55 patients receiving conventional colostomy considered as Control Group and 55 patients receiving BIO-A mesh supported colostomy (Mesh Group) were included in the study. At 12 months, the incidence of PH was 9 (12.7%) and 24 (43.6%) in the Mesh Group and Control Group, respectively (p < 0.05). Postoperative morbidity was similar between Mesh Group and Control Group (7 [12.7%] vs 4 [7.3%], respectively; p = 0.340). The multivariable analysis showed that not using a mesh (p = 0.042), age > 70 years (p = 0.041), diabetes (p < 0.001), colon dilation > 7 cm (p < 0.0001) and COPD (p = 0.009) were all related with postoperative PH.

CONCLUSIONS

The prophylactic BIO-A mesh positioning during colostomy is an effective procedure reducing PH incidence at a 1 years follow-up guaranteeing low postoperative morbidity. STUDY DATASET IS AVAILABLE ON CLINICALTRIALS.

GOV ID

NCT04436887.

Optimal number of multiple rapid swallows needed during high-resolution esophageal manometry for accurate prediction of contraction reserve

BACKGROUND

Multiple rapid swallows (MRS) is a provocative test for assessment of contraction reserve, however reproducibility on repetitive MRS is incompletely understood. Our aim was to determine the optimal number of MRS sequences for consistent assessment of contraction reserve.

METHODS

One hundred and fifty-nine consecutive patients (79 IEM and 80 normal motility) who underwent high-resolution manometers were enrolled. Ten single swallows (SS) and 10 MRS were performed. Gold standard for evaluation of the contraction reserve was the ratio between the mean DCI of 10 MRS and the mean DCI of 10 SS (MRS/SS DCI ratio). Rates of false negatives and false positives were calculated for increasing numbers of MRS sequences, using either mean DCI or the MRS with the highest DCI.

KEY RESULTS

According to the gold standard, 50 IEM and 50 normal motility patients had contraction reserve. With progressively increasing numbers of MRS sequences, contraction reserve was detected using mean MRS DCI within three and four MRS sequences in IEM and normal motility respectively, whereas two and three MRS sequences were needed using the MRS sequence with the highest DCI. False positives were much higher with highest DCI method compared with mean DCI, (22% vs 9% respectively in IEM; 24% vs 9% in normal motility) when three MRS sequences were considered.

CONCLUSIONS & INFERENCES

At least three MRS are needed to reliably assess contraction reserve. The mean DCI of the three MRS sequences is the best variable to utilize as evidence of contraction reserve.

Postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance can link PPI-responsive heartburn to reflux better than acid exposure time

BACKGROUND

Acid exposure time (AET) is considered the most useful parameter to predict response of reflux-related heartburn to medical or surgical treatment. However, recent studies showed high rates of heartburn response to proton pump inhibitor (PPI) therapy in patients with normal AET. We aimed to compare the efficacy of postreflux swallow-induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) with AET in linking PPI-responsive heartburn to reflux.

METHODS

Off-therapy impedance-pH tracings from 425 patients, 317 with PPI-responsive and 108 with PPI-refractory heartburn were blindly re-analyzed. Demographic and endoscopic characteristics, conventional impedance-pH variables, PSPW index, and MNBI were assessed with multivariate logistic regression to identify factors independently associated with PPI responsiveness. Prediction models were developed to assess the strength of reflux linkage with factors independently associated with PPI responsiveness by calculating the area under the curve (AUC) at receiver-operating-characteristic (ROC) analysis.

KEY RESULTS

At multivariate logistic regression analysis, AET, MNBI, and PSPW index were the only factors independently associated with PPI responsiveness, abnormal values found in 60%, 76%, and 92% of PPI-responsive cases (P<.017). At ROC analysis, PSPW index (AUC:.794, P=.002) and MNBI (AUC: 0.742, P=.003), both separately and combined (AUC: 0.811, P<.001) linked reflux with PPI-responsiveness better than AET (AUC: 0.687).

CONCLUSIONS & INFERENCES

AET, PSPW index, and MNBI are independently associated with PPI-responsive heartburn. PSPW index and MNBI can link PPI-responsive heartburn to reflux better than AET and should become part of the standard analysis of impedance-pH tracings.

The added diagnostic value of postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance in refractory reflux disease studied with on-therapy impedance-pH monitoring

BACKGROUND

On-therapy impedance-pH monitoring in proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) yielded conflicting results. We aimed to assess the diagnostic value of postreflux swallow-induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI) in PPI-refractory heartburn.

METHODS

On-therapy impedance-pH tracings from 189 consecutive patients with PPI-refractory heartburn were blindly reviewed. Patients were subdivided into refractory reflux esophagitis (RRE), healed reflux esophagitis (HRE), non-erosive reflux disease (NERD), and functional heartburn (FH) according to endoscopic and conventional impedance-pH findings. The diagnostic accuracy of PSPW index and MNBI in separating NERD from FH was assessed with receiver-operating-characteristic (ROC) analysis. Objectively documented persistent reflux remission at 3-year follow-up in 53 patients who underwent laparoscopic fundoplication served to evaluate PSPW index and MNBI as independent predictors of PPI-refractory GERD confirmed by positive surgical outcome.

KEY RESULTS

Median PSPW index and MNBI values were significantly lower in 39 RRE (16%; 1145 Ω) than in 41 HRE (25%; 1741 Ω) and in 68 NERD (29%; 2374 Ω) patients, and in all three GERD subgroups compared to 41 FH cases (67%; 3488 Ω) (P<.008). At ROC analysis, comparing NERD to FH the area under the curve was 0.886 with PSPW index and 0.677 with MNBI (P=.005). PSPW index was an independent predictor of PPI-refractory GERD (odds ratio 0.6983, P=.012).

CONCLUSIONS & INFERENCES

At on-therapy impedance-pH monitoring, PSPW index and MNBI efficiently distinguish PPI-refractory NERD from FH. The PSPW index represents an independent predictor of PPI-refractory GERD.

Effects of losartan on left ventricular mass: a three-year follow-up in elderly hypertensives with myocardial hypertrophy despite successful conventional antihypertensive treatment

OBJECTIVE

Reversal of left ventricular hypertrophy (LVH) in hypertensive patients appears to be a desirable goal to the reduction cardiac risk. The Renin-Angiotensin System (RAS) seems to play a major role in the establishment and maintenance of LVH through the activated systemic RAS and the Intracardiac Angiotensin System (IAS). We focused on the effects of a three-year treatment with losartan supplement in hypertensive patients with LVH not responding to eight years of an effective previous antihypertensive pharmacological treatment.

PATIENTS AND METHODS

Two groups of 28 sex-, age- and therapy-matched subjects with essential hypertension and LVH were taken into consideration. The two groups were in effective pharmacological treatment (BP < 140/90) for eight years previous to their enrollment. Patients of Group A were treated for three years with a losartan (100 mg/die) on-top treatment, whereas patients of Group B continued the follow-up of the previous conventional therapy. Both groups were submitted to an echocardiographic follow-up.

RESULTS

Group A, showed a significant reduction of the mean LVH since the first step at six months with a further significant trend during the whole period (variance analysis: p < 0.001). Group B showed a non-significant trend toward LVH reduction during the three-year follow-up. No significant further reduction of systolic or diastolic blood pressure values was observed in both groups.

CONCLUSIONS

The effects of losartan in hypertensive and hypertrophic patients are in agreement with the results of LIFE Trial. However, the reduction of left ventricular hypertrophy in our patients seems to be related to changes inducted by losartan on the IAS, since no further hemodynamic effects were observed. Losartan induced both a significant reduction of LVH and an improvement of LV diastolic function with a subsequent expected beneficial shift on the prognosis.

The GerdQ questionnaire and high resolution manometry support the hypothesis that proton pump inhibitor-responsive oesophageal eosinophilia is a GERD-related phenomenon

BACKGROUND

Little is known about the relationship between proton pump inhibitor-responsive oesophageal eosinophilia (PPI-REE), eosinophilic esophagitis (EoE) and gastro-oesophageal reflux disease (GERD).

AIM

To compare high resolution manometry features and symptom profiles of patients with EoE, PPI-REE and GERD.

METHODS

Consecutive patients diagnosed with EoE or PPI-REE according to international criteria (presence of at least one typical symptom of oesophageal dysfunction; at least 15 eosinophils per high-power field at mid/proximal oesophagus, persistence or resolution of eosinophils after an 8-week PPI trial), and a group of patients with proven GERD and oesophageal eosinophilia, prospectively completed the GerdQ questionnaire and underwent high resolution manometry.

RESULTS

Thirty-five patients with EoE, 17 with PPI-REE and 27 with GERD were enrolled. When compared to GERD, both EoE and PPI-REE had higher rates of dysphagia (15% vs. 94% vs. 88%, P < 0.0001), patients with EoE reported heartburn and regurgitation less frequently (26% vs. 85%, and 17% vs. 74%, respectively; P < 0.001 for each and had lower GerdQ score [1 (0-6) vs. 8 (6-12), P < 0.001] than GERD patients. There was no significant difference comparing PPI-REE and GERD patients. Patients with PPI-REE had a higher prevalence of erosive oesophagitis than patients with EoE (35% vs. 9%, P = 0.04), which was similar to that of GERD (48%, P = 0.54). Patients with EoE had a lower frequency of high resolution manometry features associated with GERD than patients with PPI-REE. There was no significant difference between PPI-REE and GERD patients.

CONCLUSION

GERD, as assessed by GerdQ and high resolution manometry is common in patients with PPI-REE, which may share similar pathogenic mechanisms.

Vigor of peristalsis during multiple rapid swallows is inversely correlated with acid exposure time in patients with NERD

BACKGROUND

Multiple rapid swallowing (MRS) during high-resolution manometry (HRM) is increasingly utilized as provocative test to assess esophageal peristaltic reserve. The aim of this study was to evaluate the correlation between MRS response and impedance and pH (MII-pH) parameters in endoscopy negative heartburn (ENH) patients.

METHODS

We enrolled consecutive ENH patients, who underwent HRM and MII-pH study, with a selected MII-pH profile: abnormal MII-pH (pH+/MII+); normal MII-pH (pH-/MII-). HRM was performed with 10 wet swallows (WS) and one MRS. Mean distal contractile integral (DCI) during WS and MRS were calculated. MII-pH parameters including acid exposure time (AET), reflux events, baseline impedance levels (BI) and the efficacy of chemical clearance evaluated with the postreflux swallow-induced peristaltic wave (PSPW) index were measured.

KEY RESULTS

We analyzed 103 patients: 49 MII+/pH+ (27 male), and 54 MII-/pH- (19 male). Mean age was similar between the two groups. As expected, mean AET and number of refluxes were higher in pH+/MII+ (p < 0.05). HRM was normal in all selected patients. Mean DCI-WS was similar between two groups (p = n.s.). Mean DCI-MRS- was higher in MII-/pH- vs MII+/pH+ (p < 0.05). The increase in DCI-MRS was inversely correlated with AET (-0.699; p < 0.001) and directly correlated with BI values (0.631; p < 0.001) and PSPW index (0.626; p < 0.001).

CONCLUSIONS & INFERENCES

Following MRS, patients with abnormal impedance-pH test showed suboptimal contraction response as compared with those with normal impedance-pH test. Moreover, MRS response was inversely correlated with AET and directly correlated with BI values and PSPW index.

Esophagogastric junction contractility for clinical assessment in patients with GERD: a real added value?

BACKGROUND

The role of esophagogastric junction contractile integral (EGJ-CI) as assessed by high-resolution manometry (HRM) is unclear. We aimed to correlate the EGJ-CI with impedance-pH findings in gastro-esophageal reflux disease (GERD) patients.

METHODS

Consecutive patients with GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ-CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. A value below 13 was considered as a defective EGJ-CI. We also assessed EGJ morphology, esophageal acid exposure time (AET), number of reflux episodes (NRE), and symptom association analysis (SAA). A positive impedance-pH monitoring was considered in case of abnormal AET and/or NRE and/or positive SAA.

KEY RESULTS

Among 130 patients we enrolled, 91 had GERD (abnormal AET and/or elevated NRE and/or positive SAA) and 39 had functional heartburn (FH) (negative endoscopy, normal AET, normal NRE, and negative SAA). The GERD patients had a lower median value of EGJ-CI (11 [3.1-20.7] vs 22 [9.9-41], p < 0.02) compared to FH patients. Patients with a defective EGJ-CI had, more frequently, a positive impedance-pH monitoring or esophageal mucosal lesions at endoscopy (p < 0.05 and p < 0.05, respectively) than patients with a normal EGJ-CI. An EGJ-CI cut-off value of 5 mmHg cm yielded the optimal performance in identifying GERD at impedance-pH (sensitivity 89%-specificity 63%).

CONCLUSIONS & INFERENCES

A defective EGJ-CI at HRM is clearly associated with evidence of GERD at impedance-pH monitoring. Evaluating EGJ-CI may be useful to predict an abnormal impedance-pH testing.

Esophagogastric junction morphology is associated with a positive impedance-pH monitoring in patients with GERD

BACKGROUND

High-resolution manometry (HRM) provides information on esophagogastric junction (EGJ) morphology, distinguishing three different subtypes. Data on the correlation between EGJ subtypes and impedance-pH detected reflux patterns are lacking. We aimed to correlate the EGJ subtypes with impedance-pH findings in patients with reflux symptoms.

METHODS

Consecutive patients with suspected gastroesophageal reflux disease (GERD) were enrolled. All patients underwent HRM and impedance-pH testing off-therapy. EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and <2 cm); Type III, ≥ 2 cm separation. We measured esophageal acid exposure time (AET), number of total reflux episodes and symptom association analysis.

KEY RESULTS

We enrolled 130 consecutive patients and identified 46.2% Type I EGJ, 38.5% Type II, and 15.4% Type III patients. Type III subjects had a higher number of reflux episodes (61 vs 45, p < 0.03, vs 25, p < 0.001), a greater mean AET (12.4 vs 4.2, p < 0.02, vs 1.5, p < 0.001) and a greater positive symptom association (75% vs 72%, p = 0.732 vs 43.3%, p < 0.02) compared with Type II and I patients, respectively. Furthermore, Type II subjects showed statistically significant (overall p < 0.01) increased reflux when compared with Type I patients. Type III and II EGJ morphologies had a more frequent probability to show a positive multichannel intraluminal impedance pH monitoring than Type I (95% vs 84% vs 50%, p < 0.001).

CONCLUSIONS & INFERENCES

Increasing separation between LES and CD can cause a gradual and significant increase in reflux. EGJ morphology may be useful to estimate an abnormal impedance-pH testing in GERD patients.

Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons--personal experience and review of the literature

BACKGROUND AND AIMS

While in the past, thoracotomy represented the traditional surgical approach for the treatment of epiphrenic diverticula, actually mini-invasive approach seems to be the preferred treatment as many series have been published in the recent years. This article describes the authors' experience with the laparoscopic approach for performing diverticulectomy, myotomy, and Nissen-Rossetti fundoplication.

MATERIAL AND METHODS

From 1994 to 2010, 21 patients (10 men and 11 women), mean age 58.5 years (range 45-74 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy and Nissen-Rossetti fundoplication.

RESULTS

The mean operative time was 135 min (range = 105-190 min). Mean hospital stay was 14.2 days (range = 7-25 days). In 5 patients (23.8%), a partial suture staple line leak was observed. Conservative treatment achieved leak resolution in all the cases. One patient (4.8%) died of a myocardial infarction in the postoperative period. After a mean clinical follow-up period of 78 months (range = 6-192 months), excellent or good outcome was referred with no dysphagia in 16 patients (80%) and only mild occasional dysphagia in 4 patients (20%).

CONCLUSIONS

Surgical treatment of epiphrenic diverticula remains a challenging procedure also by mini-invasive approach, with major morbidity and mortality rates. For this reason, indications must be restricted only to selected and symptomatic patients in specialized centers.

Short-term outcomes after rehabilitation treatment in patients selected by a novel rehabilitation score system (Brusciano score) with or without previous stapled transanal rectal resection (STARR) for rectal outlet obstruction

PURPOSE

The purpose of this study was to examine short-term outcomes of rehabilitation treatment in patients with or without previous stapled transanal resection (STARR) for rectal outlet obstruction by using a novel rehabilitation score system (Brusciano score).

METHODS

This is a retrospective cohort study conducted at a single tertiary referral institution including all patients with chronic functional constipation admitted to the outpatient unit from 2004 to 2009.

RESULTS

Among 330 consecutive patients, 247 (74.8 %) (204 females and 43 males) showing a significantly higher rehabilitation score (mean of 15.7 ± 1.8; range, 7-25) than healthy controls (mean, 3.2 ± 1.2; range 2-6) (p < .0001) were selected for rehabilitation. Of the 247 patients evaluated, group A (no previous surgery) consisted of 170 patients (53 males; mean age, 44.8 ± 12.9 years; range, 19-80) of which 38 presented mixed constipation, whereas group B (previous surgery) consisted of 77 patients (18 males; mean age, 47.0 ± 11.2 years; range, 22-81). The Brusciano score, Agachan-Wexner score and quality of life improved in both groups of patients after treatment. Better improvements of Brusciano and Agachan-Wexner scores were observed in patients with previous STARR (group B).

CONCLUSIONS

The rehabilitation score system employed in this study seems to be a useful tool in selecting and assessing the outcome of patients who might benefit from rehabilitation treatment. Constipation and quality of life were significantly improved by the rehabilitation treatment. Further studies are needed to clarify either the impact of rehabilitation treatment on long-term outcome of patients treated for rectal outlet obstruction or its role in those who develop problems over time.

Total thyroidectomy without prophylactic central neck dissection combined with routine oral calcium and vitamin D supplements: is it a good option to achieve a low recurrence rate avoiding hypocalcemia? A retrospective study

AIM

Routine central neck dissection for differentiated thyroid cancer (DTC) to prevent a future recurrence is still a matter of discussion, due to the increased risk of injury to parathyroid glands, without a clear demonstrable benefits in terms of long-term survival. Aim of this study was to investigate if, treating patients with total thyroidectomy (TT) without prophylactic central lymphadenectomy can minimize the risk of hypocalcemia by routine administration of oral calcium and vitamin D supplements, providing at the same time a low recurrence rate.

METHODS

In the set of a retrospective study, 221 patients affected by DTC were enrolled. All of them underwent to TT without prophylactic central lymphadenectomy. In the early postoperative period, oral calcium 2g/d taken twice (1 g every 12 hours) and vitamin D 1 g/d taken twice (0.5 g every 12 hours) were administered; changes in serum calcium and hypocalcemia-related symptoms were recorded. Follow-up was based on neck ultrasound and monitoring of serum Tg and Tg-antibodies levels every 6 months during suppressive l-tiroxine treatment.

RESULTS

Symptomatic hypocalcemia developed only in 6.3% of patients, whereas laboratory hypocalcemia developed in 10%. Hypocalcemic symptoms were minimal in 4 patients. Intravenous calcium was administered to 6 patients with severe hypocalcemic symptoms. Permanent hypocalcemia developed in two patients.

CONCLUSION

Until a conclusive evidence of the actual benefit of prophylactic central lymphadenectomy in the treatment of DTC, it may be avoided. The oral calcium and vitamin D supplements can take a role in the prevention of postoperative hypocalcemia and for increasing the likelihood of a safe and early discharge from the hospital.

Role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy

AIM

to evaluate the role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy.

PATIENTS AND METHODS

50 consecutive patients, undergoing total thyroidectomy, were enrolled. Oral calcium and vitamin D were administered in the pre and post-operative time. The data concerning symptomatic and laboratoristic hypocalcemia were collected.

RESULTS

Incidence of symptomatic hypocalcemia was very low (6%); incidence of laboratoristic hypocalcemia was 10%. No permanent hypocalcemia developed.

CONCLUSIONS

Implementing oral calcium and vitamin D both before and after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.

Clinical and instrumental parameters in patients with constipation and incontinence: their potential implications in the functional aspects of these disorders

PURPOSE

The aims of this study were to evaluate several clinical and instrumental parameters in a large number of patients with constipation and incontinence as well as in healthy controls and discuss their potential implications in the functional aspects of these disorders.

METHODS

Eighty-four constipated and 38 incontinent patients and 45 healthy controls were submitted to a protocol based on proctologic examination, clinico-physiatric assessment, and instrumental evaluation.

RESULTS

Constipated and incontinent patients had significantly worse lumbar lordosis as well as lower rate in the presence of perineal defense reflex than controls. Constipated but not incontinent patients had a lower rate of puborectalis relaxation than controls. Furthermore, worse pubococcygeal tests and a higher rate of muscle synergies presence, either agonist or antagonist, were observed in both constipated and incontinent patients compared to controls.

CONCLUSIONS

This study has demonstrated strong correlations between physiatric disorders and the symptoms of constipation and incontinence. Further studies designed to demonstrate a causal relationship between these parameters and the success of a specific treatment of the physiatric disorders on the proctology symptoms are warranted.

A common CTLA4 polymorphism confers susceptibility to autoimmune thyroid disease in celiac children

BACKGROUND

Cytotoxic T-lymphocyte-associated protein 4 (CTLA4) is a strong candidate gene in autoimmunity susceptibility. In particular, the CTLA4 CT60 A/G dimorphism has been associated with celiac disease (CD) and was reported to be strongly associated with autoimmune thyroid disease (AITD).

AIMS

This study aimed to investigate the possible influences of the CTLA4 CT60 A/G polymorphism in the susceptibility of Italian children to CD and in the predisposition to develop AITD in children with CD.

PATIENTS AND METHODS

We genotyped 317 Italian celiac children, including 44 patients (13.9%) who developed AITD after CD diagnosis and 350 controls.

RESULTS

The CTLA4 CT60 GG genotype distribution did not show any significant difference between children with CD and control population (p=0.4). On the contrary, the frequency of the GG genotype was significantly higher in patients with CD complicated with AITD than in control subjects (p=0.002) and CD patients without AITD (p=0.02).

CONCLUSION

Our data show a significant effect of the CTLA4 CT60G allele at the homozygous state on the risk of developing AITD in children with CD and suggest that the reported association of the CTLA4 CT60 A/G polymorphism with CD is limited to the subgroup of patients who are or will be complicated with AITD.

Objective assessment of gastroesophageal reflux after extended Heller myotomy and total fundoplication for achalasia with the use of 24-hour combined multichannel intraluminal impedance and pH monitoring (MII-pH)

This study aims to evaluate by the use of 24-hour combined multichannel intraluminal impedance and pH monitoring (MII-pH) the efficacy of the Nissen fundoplication in controlling both acid and nonacid gastroesophageal reflux (GER) in patients that underwent Heller myotomy for achalasia. It has been demonstrated that fundoplication prevents the pathologic acid GER after Heller myotomy, but no objective data exists on the efficacy of this antireflux surgery in controlling all types of reflux events. The study population consisted of 20 patients that underwent laparoscopic Heller myotomy and Nissen fundoplication for achalasia. All patients were investigated with manometry and MII-pH. MII-pH showed no evidence of postoperative pathologic GER. The overall number of GER episodes was normal in both the upright and recumbent position. This reduction was obtained because of the postoperative control of both the acid and nonacid reflux episodes. The Nissen fundoplication adequately controls both acid and nonacid GER after extended Heller myotomy. Further controls with MII-pH are warranted to check at a longer follow-up for the efficacy of this antireflux procedure in achalasic patients.

Total fundoplication does not obstruct the esophageal secondary peristalsis: investigation with pre- and postoperative 24-hour pH-multichannel intraluminal impedance

AIM

To determine the impact of total fundoplication on the spontaneous esophageal clearance, known as secondary peristalsis.

BACKGROUND

Although there is general agreement that total fundoplication is not an obstacle to bolus swallowing (primary peristalsis), whether it is an obstacle to spontaneous esophageal clearance (secondary peristalsis) is still not clear. Based on 24-hour monitoring, multichannel intraluminal impedance was used to calculate the time of spontaneous bolus clearance (BCT).

METHODS

Mean BCT was prospectively calculated in 15 consecutive patients before and after total fundoplication. BCT was calculated in seconds including all the gastroesophageal reflux episodes, whereas bolus swallows (solid meals and liquid swallows) were excluded from the analysis.

RESULTS

BCT was extrapolated from 1,057 episodes in the 623 h of study. Overall, BCT did not change after surgery (13.6 +/- 4 vs. 15.2 +/- 10 s; p = nonsignificant) and in the upright (12.2 +/- 3 vs. 16.5 +/- 7 s; p = nonsignificant) and recumbent position (22.9 +/- 9 vs. 23.0 +/- 9 s; p = nonsignificant).

CONCLUSIONS

In this study total fundoplication did not affect the BCT by combined 24-hour ph monitoring and multichannel intraluminal impedance.

Influence of age on outcome of total laparoscopic fundoplication for gastroesophageal reflux disease

AIM: To demonstrate that age does not influence the choice of treatment for gastroesophageal reflux disease (GERD). We hypothesized that the outcome of total fundoplication in patients > 65 years is similar to that of patients aged ≤ 65 years.

METHODS: Four hundred and twenty consecutive patients underwent total laparoscopic fundoplication for GERD. Three hundred and fifty-five patients were younger than 65 years (group Y), and 65 patients were 65 years or older (group E). The following elements were considered: presence, duration, and severity of GERD symptoms; presence of a hiatal hernia; manometric evalu-ation, 24 h pH-monitoring data, duration of operation; incidence of complications; and length of hospital stay.

RESULTS: Elderly patients more often had atypical symptoms of GERD and at manometric evaluation had a higher rate of impaired esophageal peristalsis in compari-son with younger patients. A mild intensity of heartburn often leads physicians to underestimate the severity of erosive esophagitis. The duration of the operation was similar between the two groups. The incidence of intraoperative and postoperative complications was low and the difference was not statistically significant between the two groups. An excellent outcome was observed in 92.9% young patients and 91.9% elderly patients.

CONCLUSION: Laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients, warranting low morbidity and mortality rates and a significant improvement of symptoms comparable to younger patients.

[The Nissen-Rossetti fundoplication: outcomes and lessons learned in 35 years experience with the same procedure]

AIM

The total fundoplication achieves most effective long-term control of gastro-esophageal reflux disease (GERD). However, the different types of total fundoplication lead to heterogeneous outcomes. In 1972, we standardized a personally modified Nissen-Rossetti which includes the routine use of intraoperative manometry and endoscopy to calibrate and check the wrap. This paper aims to describe the technical details and the outcomes of this procedure adopted since 35 years without modifications as a unique procedure to treat all patients with GERD.

METHODS

The study population consisted of all patients affected by GERD who underwent laparoscopic Nissen-Rossetti fundoplication by a single surgeon with one year minimum of follow-up. Technical details of the procedure and data from clinical and instrumental follow-up are described.

RESULTS

Clinical follow-up (median 83 months; range 1-13 years) was achieved in 96% of the patients. Ninety-two percent of the patients were satisfied of the procedure and would undergo the same operation. At 12 months, lower esophageal sphincter pressure increased to 27+/-5 mmHg (P<0.05), 24-h monitoring became negative in 91.6% of the patients (P<0.05). DeMeester score was 4.1+/-0.7 (P <0.05).

CONCLUSIONS

The laparoscopic Nissen-Rossetti fundoplication with the routine use of the intraoperative manometry and endoscopy, adopted as a unique procedure to treat all the patients with GERD, achieved long-term patient satisfaction in the great majority of the cases. Meticulous preoperative investigation together with a correct surgical technique are needed in securing these results.

Laparoscopic Nissen-Rossetti fundoplication is effective to control gastro-oesophageal and pharyngeal reflux detected using 24-hour oesophageal impedance and pH monitoring (MII-pH)

The study aims to evaluate, at medium- and long-term follow-up, the efficacy of Nissen-Rossetti fundoplication to control both gastro-oesophageal and pharyngeal reflux, detected with the use of 24-hour pH-multi-channel intra-luminal impedance. Of the 1000 patients who underwent Nissen-Rossetti fundoplication in our Division since 1972, the laparoscopic approach was adopted in 428 consecutive patients with gastro-oesophageal reflux disease. The study population consisted of patients from this group with one-year follow-up. Thirty-one patients had undergone pre-operative evaluation with pH-multi-channel intra-luminal impedance and were classified on the basis of clinical assessment into gastro-oesophageal, or pharyngeal reflux disease group. Pre-operative data are reported. Comparison between gastro-oesophageal reflux and pharyngeal reflux are extrapolated from pH-multi-channel intra-luminal impedance. No conversion to open surgery and no mortality occurred. A major complication occurred in 4 patients (1.1%) and led to a re-intervention in 3. An excellent outcome was reported in 92.9% of the patients at mean follow-up of 83.2 +/- 7 months. Instrumental outcomes are discussed. In conclusion, Nissen-Rossetti fundoplication provides excellent protection from gastro-oesophgeal and pharyngeal reflux. The use of pH-multi-channel intra-luminal impedance is suitable in patients candidate to anti-reflux surgery to detect non-acid reflux.