Fabrizio Rebecchi

Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results.

Objectives:To compare in a prospective, randomized trial the long-term results of laparoscopic Heller myotomy plus Dor fundoplication versus laparoscopic Heller myotomy plus floppy-Nissen for achalasia. Summary Background Data:Anterior fundoplication is usually performed after Heller myotomy to control GER; however, the incidence of postoperative GER ranges between 10% and 30%. Total fundoplication may aid in reducing GER rates. Methods:From December 1993 to September 2002, 153 patients with achalasia underwent Heller laparoscopic myotomy plus antireflux fundoplication. Of these, 9 were excluded from the study. The remaining 144 patients were randomly assigned to 2 treatment groups: Heller laparoscopic myotomy plus anterior fundoplication (Dor procedure) or Heller laparoscopic myotomy plus total fundoplication (floppy-Nissen procedure). The primary end point was incidence of clinical and instrumental GER after a minimum of 60 months follow-up. The secondary end point was recurrence of dysphagia. Follow-up clinical assessments were performed at 1, 3, 12, and 60 months using a modified DeMeester Symptom Scoring System (MDSS). Esophageal manometry and 24-hour pH monitoring were performed at 3, 12, and 60 months postoperative. Results:Of the 144 patients originally included in the study, 138 were available for long-term analysis: 71 (51%) underwent antireflux fundoplication plus a Dor procedure (H + D group) and 67 (49%) antireflux fundoplication plus a Nissen procedure (H + N group). No mortality was observed. The mean follow-up period was 125 months. No statistically significant differences in clinical (5.6% vs. 0%) or instrumental GER (2.8% vs. 0%) were found between the 2 groups; however, a statistically significant difference in dysphagia rates was noted (2.8% vs. 15%; P < 0.001). Conclusions:Although both techniques achieved long-term GER control, the recurrence rate of dysphagia was significantly higher among the patients who underwent Nissen fundoplication. This evidence supports the use of Dor fundoplication as the preferred method to re-establish GER control in patients undergoing laparoscopic Heller myotomy.

Robot-assisted vs laparoscopic adrenalectomy: a prospective randomized controlled trial

BackgroundThe aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for disorders of the adrenal gland in terms of feasibility, safety, and length of hospitalization.MethodsTwenty consecutive patients with benign lesions of adrenal gland were randomized into two groups: Patients in the laparoscopic group underwent traditional laparoscopic adrenalectomy (LAP), whereas those in the robotic group underwent robot-assisted adrenalectomy (ROBOT) using the da Vinci robotic system.ResultsThere was no significant difference between the groups in terms of age, sex, body mass index, and size or locations of lesions. Operative times were significant longer in the ROBOT group (total operative time, 169.2 min [range, 136–215] vs 115.3 min (range, 95–155) p < 0.001. Skin-to-skin time was 107 m (range, 77–154) vs 82.1 min (range, 55–120) (p < 0.001). There were no conversions to open surgery. However, conversion to standard laparoscopic surgery was necessary in four of 10 ROBOT patients (40%; left, one right). Perioperative morbidity was higher in the ROBOT group (20% vs 0%). There was no difference in length of hospital stay. In the following ROBOT group, hospital stay was 5.7 days (range, 4–9) vs 5.4 days (range, 4–8) in the LAP group (p = NS). The total cost of the ROBOT procedure (

Randomized clinical trial of robot-assisted versus laparoscopic Nissen fundoplication

3,467) was significantly higher than that for LAP (

Long-term functional results and quality of life after transanal endoscopic microsurgery

2,737) (p < 0.01).ConclusionLaparoscopic adrenalectomy is superior to robot-assisted adrenalectomy in terms of feasibility, morbidity, and cost.

Preoperative pneumatic dilatation represents a risk factor for laparoscopic Heller myotomy

Several studies have shown the safety and feasibility of robot‐assisted antireflux surgery but comparative data are lacking.

Gastroesophageal reflux disease and laparoscopic sleeve gastrectomy: a physiopathologic evaluation.

Of the few studies that have investigated quality‐of‐life (QoL) outcomes after transanal endoscopic microsurgery (TEM), the majority have reported only short‐term follow‐up data. This study assessed long‐term clinical and instrumental outcomes (QoL, sexual, urinary and sphincter function) after TEM for extraperitoneal rectal cancer.

Laparoscopic management of giant hiatal hernia: factors influencing long-term outcome

AbstractBackground: The development of minimally invasive surgery has renewed interest in the surgical therapy of achalasia. Methods: 21 patients with esophageal achalasia underwent Hellers laparoscopic myotomy with anterior fundoplication between August 1991 and March 1996. Results: There were two intraoperative perforations of the mucosa sutured laparoscopically with no postoperative sequelae; both complications occurred in patients previously treated with pneumatic dilatation; no perforations occurred in the 14 patients who had not been submitted to pneumatic dilatation (28% vs 0%). There were no surgical mortalities and no postoperative morbidities. Complete relief of dysphagia and modifications of radiological and manometric patterns were achieved in all patients. All patients remain asymptomatic at follow-ups ranging from 3 to 55 months after surgery. Conclusions: Laparoscopic Hellers myotomy is as effective as traditional surgery in treating symptoms and has all the advantages of pneumatic dilatation in terms of short hospital stay, quick recovery, and low cost; preoperative pneumatic dilatation is a risk factor for intraoperative mucosal perforation.

Barrett's oesophagus: long-term follow-up after complete ablation with argon plasma coagulation and the factors that determine its recurrence

Objective:To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) in morbidly obese patients. Background:Symptomatic GERD is considered by many a contraindication to LSG. However, studies evaluating the relationship between LSG and GERD by 24-hour pH monitoring are lacking. Methods:Consecutive morbidly obese patients selected for LSG were included in a prospective clinical study. Gastroesophageal function was evaluated using a clinical validated questionnaire, upper endoscopy, esophageal manometry, and 24-hour pH monitoring before and 24 months after LSG. This trial is registered with ClinicalTrials.gov (no. NCT02012894). Results:From June 2009 to September 2011, a total of 71 patients were enrolled into the study; 65 (91.5%) completed the 2-year protocol. On the basis of preoperative 24-hour pH monitoring, patients were divided into group A (pathologic, n = 28) and group B (normal, n = 37). Symptoms improved in group A, with the Gastroesophageal Reflux Disease Symptom Assessment Scale score decreasing from 53.1 ± 10.5 to 13.1 ±3.5 (P < 0.001). The DeMeester score and total acid exposure (% pH <4) decreased in group A patients (DeMeester score from 39.5 ± 16.5 to 10.6 ± 5.8, P < 0.001; % pH <4 from 10.2 ± 3.7 to 4.2 ± 2.6, P < 0.001). Real “de novo” GERD occurred in 5.4% group B patients. No significant changes in lower esophageal sphincter pressure and esophageal peristalsis amplitude were found in both groups. Conclusions:LSG improves symptoms and controls reflux in most morbidly obese patients with preoperative GERD. In obese patients without preoperative evidence of GERD, the occurrence of “de novo” reflux is uncommon. Therefore, LSG should be considered an effective option for the surgical treatment of obese patients with GERD.

Endoscopic ablation of Barrett's esophagus using argon plasma coagulation (APC) following surgical laparoscopic fundoplication

BackgroundThe laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate.MethodsIn this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. “Tension-free” repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis–Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction.ResultsThere was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis–Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique.ConclusionsTo reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis–Nissen procedure in such cases.

Improving the analysis of esophageal acid exposure by a new parameter: area under H+

Argon plasma coagulation seems to be a promising technique for ablation of Barrett’s oesophagus, yet few long‐term efficacy data are available.