Gianluca Russo

A total fundoplication is not an obstacle to esophageal emptying after heller myotomy for achalasia: results of a long-term follow up

Objective:The aim of this study was to evaluate the role and efficacy of a total 360° wrap, Nissen-Rossetti fundoplication, after esophagogastromyotomy in the treatment of esophageal achalasia. Summary Background Data:Surgery actually achieves the best results in the treatment of esophageal achalasia; the options vary from a short extramucosal esophagomyotomy to an extended esophagogastromyotomy with an associated partial fundoplication to restore the main antireflux barrier. A total 360° fundoplication is generally regarded as an obstacle to esophageal emptying. Matherials and Methods:Since 1992 to November 2003, a total of 195 patients (91 males, 104 females), mean age 45.2 years (range, 12–79 years), underwent laparoscopic treatment of esophageal achalasia. Intervention consisted of Heller myotomy and Nissen-Rossetti fundoplication with intraoperative endoscopy and manometry. Results:In 3 patients (1.5%), a conversion to laparotomy was necessary. Mean operative time was 75 ± 15 minutes. No mortality was observed. Overall major morbidity rate was 2.1%. Mean postoperative hospital stay was 3.6 ± 1.1 days (range, 1–12 days). At a mean clinical follow up of 83.2 ± 7 months (range, 3–141 months) on 182 patients (93.3%), an excellent or good outcome was observed in 167 patients (91.8%) (dysphagia DeMeester score 0–1). No improvement of dysphagia was observed in 4 patients (2.2%). Gastroesophageal pathologic reflux was absent in all the patients. Conclusions:Laparoscopic Nissen-Rossetti fundoplication after Heller myotomy is a safe and effective treatment of esophageal achalasia with excellent results in terms of dysphagia resolution, providing total protection from the onset of gastroesophageal reflux.

Laparoscopic redo surgery for recurrent hepatocellular carcinoma in cirrhotic patients: feasibility, safety, and results

BackgroundRecurrence of cancer and the need for several surgical treatments are the Achilles’ heel of the treatment for hepatocellular carcinoma (HCC) in cases of cirrhosis. The difficulty of reintervention is increased by the formation of adhesions after the previous hepatectomy that can make a new surgical procedure more difficult and less safe. With a minimally invasive approach, the formation of postoperative adhesions seems to be minimized, and the adhesiolysis procedure seems to be faster and safer in terms of blood loss and risk of visceral injuries.MethodsThis report describes a series of 15 patients submitted to a laparoscopic reintervention (hepatic resection or radiofrequency ablation) for a recurrence of HCC after a previous open (group 1) or laparoscopic (group 2) procedure for a primary tumor. It aims to explain the feasibility, safety, and results of repeated laparoscopic liver surgery.ResultsThe rates for overall postoperative mortality and morbidity were respectively 0% and 26.6% (4/15). No patients had a severe postoperative complication. Only one patient in group 2 presented with moderate ascites postoperatively, whereas two patients in group 1 reported atelectasis requiring physiotherapy and one experienced pneumonia, which was treated with antibiotics. In this series, the findings indicated that patients submitted first to an open hepatic resection (group 1) experience more intraabdominal adhesions. Moreover, in group 1, hypervascularized adhesions typical of cirrhotic patients were several and thicker, with a major potential risk of bleeding and bowel injuries at the time of reintervention. Although for group 2 the length of the intervention was shorter, for group 1, the operating times and safety in terms of bowel injuries were acceptable, demonstrating the feasibility of iterative laparoscopic surgery also for cirrhotic patients previously treated by the open surgical approach. The operative time for the second surgical procedure was shorter and the adhesiolysis easier for the patients previously treated with the laparoscopic approach (group 2). This underscores the advantages of the minimally invasive approach for managing the long oncologic history of cirrhotic patients.ConclusionLaparoscopic redo surgery for recurrent HCC in cirrhotic patients is a safe and feasible procedure with good short-term outcomes, but further prospective studies are needed to support these results.

Laparoscopic treatment of Bochdalek hernia without the use of a mesh

Bochdalek hernia is a rare pathology. The preoperative diagnosis is difficult, and few reports are available regarding its treatment. Herein we report the case of a 25-year-old woman referred for symptoms of dyspepsia, dysphagia, and thoracic pain exacerbated by pregnancy. Preoperative radiography, EGD, and CT scan revealed a paraesophageal hiatal hernia. Laparoscopic exploration showed the complete thoracic migration of the stomach through a left posterolateral diaphragmatic foramen. The diagnosis of a Bochdalek hernia was then made. The diaphragmatic defect was repaired without inserting a prosthesis, using five separate non-reabsorbable stitches (Rieder technique). The procedure was completed with a Nissen-Rossetti fundoplication. The duration of the procedure was 150 min. Hospital stay was 12 days. There were no complications. Postoperative Gastrografin radiography of the esophagus and stomach showed a normal-shaped fundoplication and confirmed the subdiaphragmatic location of the stomach. We conclude that the laparoscopic approach represents the gold standard for the diagnosis and treatment of Bochdalek hernia and any associated complications.

Laparoscopic Segment VI Liver Resection using a Left Lateral Decubitus Position: A Personal Modified Technique

BackgroundLaparoscopic technique for lesions located in the left liver is well described in the literature. On the contrary, the best laparoscopic approach for lesions located in the right liver, such as in segment VI, is still debated.AimIn this article, we provide a detailed description of a laparoscopic segment VI liver resection using a left lateral decubitus position with the right side up, facilitated by a personal technique. We also discuss potential advantages and disadvantages of this procedure.

Useful parameters helping proctologists to identify patients with defaecatory disorders that may be treated with pelvic floor rehabilitation

BackgroundNo studies have specifically reported on the use of a diagnostic tool based on physiatric assessment of constipated or incontinent patientsMethodsSixty-seven constipated and 37 incontinent patients were submitted to a standard protocol based on proctologic examination, clinico-physiatric assessment (puborectalis contraction, pubococcygeal test, perineal defence reflex, muscular synergies, postural examination) and instrumental evaluation (anorectal manometry, anal US and dynamic defaecography). Patients were offered pelvic floor rehabilitation (thoraco-abdominoperineal muscle coordination training, biofeedback, electrical stimulation and volumetric rehabilitation).ResultsAfter rehabilitation treatment, decreases of Wexner constipation score (p=0.0001) and Pescatori incontinence score (p=0.0001) were observed.ConclusionThis diagnostic protocol might improve the selection of patients with defaecatory disorders amenable for rehabilitation treatment.

Laparoendoscopic single site liver resection for recurrent hepatocellular carcinoma in cirrhosis: first technical note.

Introduction Single port access laparoscopic redo liver resection for hepatocellular carcinoma on cirrhosis through a single transumbilical skin incision has not been reported in the literature so far. Methods A wedge resection of segment III lesion with a laparoendoscopic single site surgical incision is described in detail analyzing the technical aspects of the procedure. Results There were no intraoperative complications with no intraoperative or perioperative blood transfusions. A Pringle maneuver was not used. Operating time was 130 minutes. The patient had an uneventful postoperative course and was discharged on the second postoperative day. The surgical resection margin was not invaded and had a width of 1.8 cm. Conclusions In this case report, we found that liver resection performed by laparoendoscopic single site surgery for peripherally located hepatocellular carcinoma on cirrhosis seems a feasible technique. Such technique is technically demanding and should be undertaken only with proper training and in high volume centers, by surgeons with expertize in both liver and advanced laparoscopic surgery.

Revision surgery for incidentally detected early gallbladder cancer in laparoscopic era.

BACKGROUND Incidentally detected early gallbladder cancer (IDEGB) is an early carcinoma first diagnosed on microscopic examination after a cholecystectomy for symptomatic benign gallbladder disease. After diagnosis of IDEGB it is often necessary a completion of treatment by a second tailored revision procedure. Despite early reports contraindicating laparoscopic approach because of high risk of neoplastic seeding, recent data seem to demonstrate that this approach per se does not influence clinical outcomes. We refer our experience in revision surgery by a totally laparoscopic approach that includes hepatic resection, lymphadenectomy, and port-sites excision. METHODS From January 2006 to March 2008, four patients with IDEGB were carried out to revision procedure by a totally laparoscopic approach. The mean operative time of procedure has been 162 minutes, whereas blood loss has been <100 mL (mean 85.1±23.3 mL). The postoperative course has been uneventful in all patients and perioperative mortality (within 40 days from intervention) 0. Hospital stay has been, respectively, 4, 5, 5, and 6 days (mean 5 days). During follow-up, at the last fluorine-18-labeled fluordesoxyglucose-positron emission tomography (FDG-PET) scan examination, respectively, 4, 3, and--for 2 patients--2 years after revision laparoscopic procedure, pathologic FDG accumulation was not reported. CONCLUSIONS Totally laparoscopic revision surgery for IDEGC seems to be a legitimate procedure, and, in our experience, reports satisfactory clinical outcomes in terms of perioperative and middle term oncological results. Larger and prospective studies are needed to support definitively oncological safety of this approach.

Laparoscopic treatment of an uncommon abdominal localization of Castleman disease.

Abstract: Castleman disease is a rare lymphoproliferative disorder overall localized in the mediastinum and rarely in the abdomen. It appears as a tumor-like mass characterized by a massive growth of lymphoid tissue. Benign forms are usually associated to a good prognosis even if multifocal variants present more aggressive behavior. Two different histologic types have been described: the hyaline vascular and the plasma cell form. The diagnosis is often achieved only at the histologic evaluation of the surgical specimen. Presented here is the rare occurrence of this disease in the abdominal cavity treated by the laparoscopic approach. No postoperative complications were observed. No recurrence has been detected at 12 months CT scan follow-up. Until now, no reports of this kind of treatment have been available in literature.

Single port laparoscopic cholecystectomy: a new evolving technique.

Although multiple groups have reported initial success with single port laparoscopy, no consensus exists concerning the technical aspect of this surgery. In this report, we describe in detail our technique to perform single port laparoscopic cholecystectomy. Twelve cases of single port laparoscopic cholecystectomy for gallbladder stones were performed in our surgical unit. There was only one conversion during the first operation of the series to standard laparoscopy, and never to open operation. No intraoperative adverse events or major perioperative complications were reported. All the patients have been discharged within 48 hours, with uneventful postoperative course, nearly painless, without any discomfort and no visible scar. Single port laparoscopic surgery is a promising option for the treatment of gallbladder stones providing that technical and oncological surgical principles are respected.

Laparoscopic conversion of an omega in a Roux-en-y reconstruction after mini-invasive total gastrectomy for cancer: a technical report.

Introduction Few cases of laparoscopic total gastrectomy have been published. Reconstruction of the digestive tract was generally accomplished with a Roux-en-y esophagojejunal mechanical anastomosis. Here we report the first 2 cases of laparoscopic conversion of an omega in a Roux-en-y reconstruction due to the occurrence of a severe alkaline esophagitis after mini-invasive total gastrectomy for cancer. Materials and Methods Two male patients presented in 2004. One year prior, at another facility, they had undergone laparoscopic total gastrectomy for cancer, with reconstruction of digestive tract by means of an esophagojejeunostomy with a jejunal loop and Brauns side-to-side enteroanastomosis. They complained of daily symptoms of nausea, regurgitation, heartburn, and early postprandial fullness with reduction of appetite and weight loss of almost 15 kg. Instrumental examination diagnosed alkaline esophagitis. Intervention was performed via laparoscopic approach and the digestive reconstruction was reconfigured in a Roux-en-y type with a proximal limb of almost 60 cm. Results Operative time was 135 to 180 minutes. No postoperative complications occurred. After 1-year follow-up, symptoms resolution and esophagitis healing have been observed in both patients. Conclusions Laparoscopic gastrectomy is gaining wide acceptance. In our opinion, a standardization of the technique is necessary: we believe Roux-en-y should be considered the preferred reconstruction route ensuring the best protection of the esophagus from alkaline reflux.