Andrea Sironi

One hundred consecutive patients treated with magnetic sphincter augmentation for gastroesophageal reflux disease: 6 years of clinical experience from a single center

BACKGROUNDnThis study was undertaken to evaluate our clinical experience during a 6-year period with an implantable device that augments the lower esophageal sphincter for gastroesophageal reflux disease (GERD). The device uses magnetic sphincter augmentation (MSA) to strengthen the antireflux barrier.nnnSTUDY DESIGNnIn a single-center, prospective case series, 100 consecutive patients underwent laparoscopic MSA for GERD between March 2007 and February 2012. Clinical outcomes for each patient were tracked post implantation and compared with presurgical data for esophageal pH measurements, symptom scores, and proton pump inhibitor (PPI) use.nnnRESULTSnMedian implant duration was 3 years (range 378 days to 6 years). Median total acid exposure time was reduced from 8.0% before implant to 3.2% post implant (p < 0.001). The median GERD Health Related Quality of Life score at baseline was 16 on PPIs and 24 off PPIs and improved to a score of 2 (p < 0.001). Freedom from daily dependence on PPIs was achieved in 85% of patients. There have been no long-term complications, such as device migrations or erosions. Three patients had the device laparoscopically removed for persistent GERD, odynophagia, or dysphagia, with subsequent resolution of symptoms.nnnCONCLUSIONSnMagnetic sphincter augmentation for GERD in clinical practice provides safe and long-term reduction of esophageal acid exposure, substantial symptom improvement, and elimination of daily PPI use. For candidates of antireflux surgery who have been carefully evaluated before surgery to confirm indication for MSA, MSA has become a standard treatment at our institution because control of reflux symptoms and pH normalization can be achieved with minimal side effects and preservation of gastric anatomy.

Removal of the Magnetic Sphincter Augmentation Device: Surgical Technique and Results of a Single-Center Cohort Study.

Objective: The aim of this study was to identify patients’ characteristics that may predict failure and removal of the Linx sphincter augmentation device, and to report the results of 1-stage laparoscopic removal and fundoplication. Background: The Linx device is a long-term magnetic implant that was developed as a less disruptive and more reproducible surgical option for patients with early-stage gastroesophageal reflux disease (GERD). Removal of the device has been shown to be feasible, but no long-term results of this procedure have been reported yet. Methods: A review of the prospectively collected research database of antireflux surgery was performed to identify all patients who underwent a Linx implant between 2007 and 2015 in our Institution. Demographics, duration of symptoms and proton pump inhibitor (PPI) therapy, GERD-Health Related Quality of Life scores, esophageal acid exposure, lower esophageal sphincter pressure, number of beads (size) of the implanted device, concurrent crura repair, angle of inclination of the device at postoperative chest film, operative time, postoperative complications, and length of stay were recorded. Data of the explanted patients were compared with those with the device in situ in an attempt to identify factors associated with Linx removal. Results: Over the study period, 164 patients underwent a laparoscopic Linx implant and had a median follow-up of 48 months [interquartile range (IQR) 36]. Eleven (6.7%) of these patients were explanted at a later date. The estimated removal-free probability at 80 months was 0.91 [confidence interval (CI) 0.86–0.96]. Supine esophageal acid exposure before the index operation was associated with Linx removal (odds ratio 1.05, CI 1.01–1.11, P = 0.037). The main presenting symptom requiring device removal was recurrence of heartburn or regurgitation in 5 patients (46%), followed by dysphagia (n = 4, 37%) and chest pain (n = 2, 18%). In 2 patients, full-thickness erosion of the esophageal wall with partial endoluminal penetration of the device occurred. The median implant duration was 20 months, with 82% of the patients being explanted between 12 and 24 months after the implant. Device removal was most commonly combined with partial fundoplication. There were no conversions to laparotomy and the postoperative course was uneventful in all patients. At the latest follow-up, ranging from 12 to 58 months, the GERD-HRQL score was within normal limits in all patients. Conclusions: Laparoscopic removal of the Linx device can be safely performed as a 1-stage procedure and in conjunction with fundoplication even in patients presenting with device erosion.

Effect of the Informed Consent Process on Anxiety and Comprehension of Patients Undergoing Esophageal and Gastrointestinal Surgery

ObjectiveThis study seeks to evaluate the level of anxiety, recall, and comprehension of the provided information in patients undergoing esophageal and gastrointestinal surgery.MethodsSixty-one patients without cognitive disorders entered a prospective study designed to assess the effect of a surgical informed consent process. The written informed consent was administered to all patients and was supported by a verbal explanation and a schematic drawing of the operation. The State Trait Anxiety Inventory test was used to assess state anxiety and tract anxiety. The test was repeated after the informed consent process. A disease-specific feedback questionnaire was subsequently administered to assess the actual comprehension of the provided information.ResultsA significant decrease of the state anxiety scores was documented in most patients (pu2009<u20090.001). This effect was more evident in the elderly (pu2009=u20090.021) and in those who used Internet as a previous source of information (pu2009=u20090.032). The mean correct exact answer rate on the disease-specific questionnaire was 76% (IQ range 66.7–85%). No statistically significant relationship was found between the rate of correct answers and the state anxiety scores.ConclusionsAn exhaustive surgical informed consent process was effective in providing comprehension and decreasing anxiety in patients who are candidates to minimally invasive esophageal and gastrointestinal surgical procedures.

Early outcome of thoracoscopic and hybrid esophagectomy: Propensity-matched comparative analysis

BACKGROUNDnTransthoracic esophagectomy remains the current therapeutic standard for localized esophageal carcinoma. Minimally invasive surgery has proven at least equivalent to open surgery regarding the early outcomes, but only 1 randomized study has compared the thoracoscopic with the thoracotomy approach. The primary objective of this study was to assess the early outcome of the thoracoscopic prone esophagectomy (TPE) and the hybrid Ivor Lewis (HIL) esophagectomy in 2 concurrent patient cohorts.nnnMETHODSnWe compared the 1-year outcome of 3-stage TPE and 2-stage HIL done over the same time period in a single center. The propensity score matching method was used to reduce selection bias by creating 2 groups of patients similarly likely to receive a treatment on the basis of measured baseline characteristics. After generating propensity scores using the covariates of age, sex, body mass index, forced expiration volume at 1 second, Charlson comorbidity index, American Society of Anesthesiologists score, histologic tumor type, tumor site, pTNM stage, and neoadjuvant therapy, 93 TPE patients were matched with 197 HIL patients using a 1:1 ratio and the nearest-neighbor score matching. Main outcome measure was the incidence of postoperative complications.nnnRESULTSnOperative time was longer in TPE patients (P < .01). All postoperative outcomes, including morbidity, mortality, nodal harvest, R0 resection rate, and 1-year survival rates were similar in the 2 matched groups.nnnCONCLUSIONnBoth operative approaches are safe and effective; using 1 or the other depends on the tumor site, surgeon experience and preference, and patient expectations.

Laparoscopic management of large hiatus hernia: five-year cohort study and comparison of mesh-augmented versus standard crura repair

AbstractObjectivesnTo evaluate objective and subjective outcomes of patients undergoing laparoscopic repair of large hiatal hernia, either with or without resorbable mesh augmentation. The primary outcome of the study was anatomical recurrence rate as measured by endoscopy. Secondary outcomes were safety, efficacy, and long-term quality of life.MethodsThis was an observational cohort study. Patients who underwent laparoscopic repair of large (≥5xa0cm) type III hiatal hernia were included. Criteria of exclusion were previously failed hiatus hernia repair and emergency procedures. Patients were stratified into mesh group (mesh-augmented crura repair plus fundoplication) and non-mesh group (standard crura repair plus fundoplication). Preoperative and postoperative symptoms were assessed using the GERD-HRQL questionnaire. Upper gastrointestinal endoscopy was routinely performed between 6 and 12xa0months postoperatively and was repeated over the follow-up every 1–2xa0years or as needed. Anatomical hernia recurrence was defined as the maximum vertical length of stomach being at least 2xa0cm above the diaphragm.nResultsA total of 84 patients, 41 in the mesh group and 43 in the non-mesh group, operated between October 2009 and October 2014, were included in the study. All surgical procedures were completed laparoscopically. The median follow-up was 24 (IQR 29) months. There were 12 endoscopic recurrences, 4 in the mesh group and 8 in the non-mesh group. The five-year recurrence-free probability was similar in the two groups, but an earlier failure rate was noted in the non-mesh group at 12xa0months (pxa0=xa00.299). Three of the 12 patients with anatomical recurrence were symptomatic but did not require a reoperation. Univariate Cox proportional hazard analysis indicated that Toupet fundoplication may reduce the recurrence rate compared to Nissen fundoplication. No mesh-related complications occurred.ConclusionsLaparoscopic repair of large hiatal hernia is effective and durable. Crura reinforcement with a resorbable synthetic mesh is safe and may protect from early anatomical recurrence.

Health-related quality of life after laparoscopic Heller myotomy and Dor fundoplication for achalasia

Background. In addition to symptom scores, a persons perception of health and quality of life assessment is an important indicator of quality of treatment and can provide an efficient index to compare different therapeutic modalities in chronic disease states. Only a few studies have investigated quality of life comprehensively in patients with achalasia, and therefore the controversy regarding the best treatment algorithm continues. The primary study outcome was pre‐ and postoperative quality of life in patients with achalasia undergoing laparoscopic Heller myotomy and Dor fundoplication. Methods. The study is a retrospective, observational cohort. The hospital registry and the updated research database were reviewed to identify all patients who were treated for achalasia between 2010 and 2015. Patients were eligible for the study if they had a minimum 1‐year follow‐up and had pre‐and postoperative Eckardt, Short Form‐36, and Gastro‐Esophageal Reflux Disease Health‐Related Quality of Life scores. Patients with previous operative and/or endoscopic treatments for achalasia were excluded. Results. One‐hundred and eighteen patients were identified. The median follow‐up was 40 months (interquartile range 27). The proportion of patients with Eckardt stage II–III decreased from 94.9–13% (P < .001). The mean Eckardt score decreased from 6.9 ± 1.9 to 1.7 ± 1.2 (P < .001); the mean Short Form‐36 scores significantly increased in all 8 domains; the mean Gastro‐Esophageal Reflux Disease Health‐Related Quality of Life score decreased from 13.9 ± 5.7 to 5.5 ± 5.4 (P < .001). Finally, 88% (confidence interval 81–93) of patients were satisfied regarding their present condition. Conclusion. Quality of life assessed with generic and disease‐specific validated instruments significantly improved after laparoscopic Heller myotomy combined with Dor fundoplication.

Hybrid and total minimally invasive esophagectomy: how I do it

Esophagectomy is a major surgical procedure associated with a significant risk of morbidity and mortality. Minimally invasive esophagectomy is becoming the preferred approach because of the potential to limit surgical trauma, reduce respiratory complications, and promote earlier functional recovery. Various hybrid and total minimally invasive surgical techniques have been introduced in clinical practice over the past 20 years, and minimally invasive esophagectomy has been shown equivalent to open surgery concerning the short-term outcomes. Implementation of a minimally invasive esophagectomy program is technically demanding and requires a significant learning curve and the infrastructure of a dedicated multidisciplinary center where optimal staging, individualized therapy, and perioperative care can be provided to the patient. Both hybrid and total minimally invasive techniques of esophagectomy have proven safe and effective in expert centers. The choice of the surgical approach should be driven by preoperative staging, tumor site and histology, comorbidity, patients anatomy and physiological status, and surgeons experience.

Open Versus Laparoscopic Management of Incisional Abdominal Hernia: Cohort Study Comparing Quality of Life Outcomes.

BACKGROUND AND AIMSnIncisional hernia is a common complication of laparotomy. The long-term effectiveness of the laparoscopic repair compared to the open approach remains to be proven. We investigated the 1-year impact of open and laparoscopic repair of incisional hernia on quality of life outcomes.nnnMETHODSnSingle-center cohort study. The clinical data of patients who underwent open or laparoscopic surgery for primary midline incisional hernia were retrieved from hospital records and from a research database. Criteria of exclusion were emergency procedures, associated bowel resection, and recurrent incisional hernia. Complications and recurrence rates were analyzed. The visual analog scale (VAS) and the Short-Form 36 (SF-36) were used to assess pain and quality of life 1 year after surgery in patients free of recurrence.nnnRESULTSnOne hundred twenty-four patients were eligible for inclusion in the study. The mean follow-up was 3u2009±u20092 years (interquartile range [IQR] 2.0). Overall, 9% of patients in the open group and 7% in the laparoscopic group presented with hernia recurrence (Pu2009=u2009.685). Sixty-six of the 124 patients, who were operated between 2009 and 2014 by the same surgical team with expertise in advanced laparoscopic surgery, were considered for the study. Nine (14%) of these patients were lost to follow-up and three (5%) had a recurrent hernia, reducing the final sample size to 54 patients of whom 26 operated through an open approach and 28 through laparoscopy. The two groups were comparable according to demographic variables, comorbidity, and postoperative morbidity. The laparoscopic approach required less operative time (<.001) and length of hospital stay (Pu2009=u2009.002). The VAS and the SF-36 scores were similar in the 54 patients, 26 in the open group and 28 in the laparoscopic group, who completed the 1-year assessment.nnnCONCLUSIONSnHealth-related quality of life at 1 year was similar in patients undergoing open or laparoscopic repair of incisional abdominal hernia.

Toothpick ingestion complicated by cecal perforation: case report and literature review

BackgroundDiverticulitis and carcinoma represent the most common causes of colon perforation, but other causes, like ingestion of foreign bodies, should be taken into account.Case presentationWe report the case of a 64-year old man presenting in our Emergency Department with a 2xa0days history of right lower abdominal pain, nausea, vomiting and low grade fever. Physical examination evocated mild pain with positive rebound tenderness in the right lower abdominal quadrant, and positive right costovertebral angle tenderness. Routine blood tests, abdominal X-rays and CT scan were inconclusive for perforation. At explorative laparoscopy a cecal perforation with localized peritonitis was found, and a right colectomy was performed due to the suspicion of cancer. Histological examination confirmed the presence of a perforation caused by a piece of wood (toothpick) of 6xa0cm in length.ConclusionsForeign body ingestion should be taken into account in the evaluation of acute abdominal pain. A detailed patient’s history may be crucial for a correct diagnosis and treatment.

Proposal of a Punch Biopsy Protocol as a Pre-requisite for the Establishment of a Tissue Bank from Resected Esophageal Tumors

With the development of tissue banking, a need for homogeneous methods of collection, processing, and storage of tissue has emerged. We describe the implementation of a biological bank in a high-volume, tertiary care University referral center for esophageal cancer surgery. We also propose an original punch biopsy technique of the surgical specimen. The method proved to be simple, reproducible, and not expensive. Unified standards for specimen collection are necessary to improve results of specimen-based diagnostic testing and research in surgical oncology.