Marco Cimmino

Hiatal Hernia Recurrence: Surgical Complication or Disease? Electron Microscope Findings of the Diaphragmatic Pillars

IntroductionAlthough laparoscopic Nissen fundoplication has been recognized as the standard of care for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty have been reported as a common mechanism of failure after primary repair. Different surgical techniques for diaphragmatic pillars closure have been proposed, but the problem remains unsolved. The authors hypothesized that ultrastructural illness may be implicated in this recurrence. The aim of this study was to investigate the presence of changes at esophageal hiatal area in patients with and without HH.Materials and MethodsOne hundred and thirty-two laparoscopic samples from phrenoesophageal membrane and diaphragmatic crura were collected from 33 patients with gastroesophageal reflux disease and HH (HH group) and 60 samples from 15 patients without HH enrolled as the control group (NHH group). All specimens were processed and analyzed by transmission electron microscopy.ResultsMuscular and connective samples from the NHH group showed no ultrastructural alterations; similar results were found in phrenoesophageal ligament samples from the HH group. In contrast, 94% of the muscular samples obtained from the crura of the HH group have documented four main types of alterations. In 75% of HH patients, the pillar lesions were severe.ConclusionPatients with hiatal hernia have ultrastructural abnormalities at the muscular tissue of the crura that are not present in patients with a normal gastroesophageal junction. There is no difference in the microscopic damage at the connective tissue of the phrenoesophageal membrane surrounding the esophagus of the two groups of patients. The outcome of antireflux surgery could depend not only on the adopted surgical technique but also on the underlying status of the diaphragmatic crura.

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.

Is Nasogastric Decompression Useful in Prevention of Leaks After Laparoscopic Sleeve Gastrectomy? A Randomized Trial

ABSTRACT Introduction: Although its excellent results, laparoscopic sleeve gastrectomy (LSG) presents major complications ranging from 0% to 29%. Among them, the staple line leak presents an incidence varying from 0% to 7%. Many trials debated about different solutions in order to reduce leaks’ incidence. No author has investigated the role of gastric decompression in the prevention of this complication. Aim of our work is to evaluate if this procedure can play a role in avoiding the occurrence of staple line leaks after LSG. Materials and Methods: Between January 2008 and November 2012, 145 patients were prospectively and randomly included in the study. Seventy patients composed the group A, whose operations were completed with placement of nasogastric tube; the other 75 patients were included in the group B, in which no nasogastric tube was placed. Results: No statistical differences were observed between group A and group B regarding gender distribution, age, weight, and BMI. No intraoperative complications and no conversion occurred in both groups. Intraoperative blood loss (50.1 ± 42.3 vs. 52.5 ± 37.6 ml, respectively) and operative time (65.4 ± 25.5 vs. 62.6 ± 27.8 min, respectively) were comparable between the two groups (p: NS). One staple line leak (1.4%) occurred on 6th postoperative day in group A patients. No leak was observed in group B patients. Postoperative hospital stay was significantly longer in group A vs. group B patients (7.6 ± 3.4 vs. 6.2 ± 3.1 days, respectively, p: 0.04). Conclusions: Routine placement of nasogastric tube in patients operated of LSG seems not useful in reducing leaks’ incidence.

Is the advanced age a contraindication to GERD laparoscopic surgery? Results of a long term follow-up

BackgroundIn this prospective non randomized observational cohort study we haveevaluated the influence of age on outcome of laparoscopic totalfundoplication for GERD.MethodsSix hundred and twenty consecutive patients underwent total laparoscopicfundoplication for GERD. Five hundred and twenty-four patients were youngerthan 65 years (YG), and 96 patients were 65 years or older (EG). Thefollowing parameters were considered in the preoperative and postoperativeevaluation: presence, duration, and severity of GERD symptoms, presence of ahiatal hernia, manometric and 24 hour pH-monitoring data, duration ofoperation, incidence of complications and length of hospital stay.ResultsElderly patients more often had atypical symptoms of GERD and at manometricevaluation had a higher rate of impaired esophageal peristalsis incomparison with younger patients. The duration of the operation was similarbetween the two groups. The incidence of intraoperative and postoperativecomplications was low and the difference was not statistically significantbetween the two groups. An excellent outcome was observed in 93.0% of youngpatients and in 88.9% of elderly patients (p = NS).ConclusionsLaparoscopic antireflux surgery is a safe and effective treatment for GERDeven in elderly patients, warranting low morbidity and mortality rates and asignificant improvement of symptoms comparable to younger patients.

Shedding some light on the use of mesh in gastroesophageal junction surgery

Background Postoperative complications such as failure or disruption of the crura repair and intrathoracic migration of the wrap are the most common anatomic reasons for the failure of Laparoscopic Nissen Fundoplication. The authors hypothesized that ultrastructural illness may be implicated in this recurrence. The aim of this study was to investigate the presence of changes at esophageal hiatal area in patients with and without HH and to shed some light on the use of mesh in this surgery.

A rare case of extraovarian primary peritoneal carcinoma in a 72 year-old woman.

Background Extraovarian Primary Peritoneal Carcinoma (EOPPC) was first described by Swerdlow in 1959 [1]. Basically, EOPPC is a malignancy that spreads widely inside the peritoneal cavity involving mostly the omentum with minimal or no ovarian involvement. Most of the EOPPC cases reported have been of serous histology; histopathological, immunohistochemical, and clinical similarities have been observed between EOPPC and Epithelial Ovarian Cancer (EOC).

Overall survival and quality of life in elderly patients treated for rectal cancer: results of a five year follow-up

Background The study was conducted on a population of 74 patients undergoing surgery for rectal adenocarcinoma with 5-year follow-up. The aim is to evaluate the survival and Quality of Life (QoL) in two groups of patients: Y group with age <60 years and E group with age ≥ 60 years. QoL was determined by administration of C30 Quality of Life Questionnaire (QLQ C30) and the module ColoRectal-29 (CR-29) [1].

Prosthetic repair of left diaphragmatic defect in an elderly patient: a rare case report

Background Partial or complete agenesis of the hemidiaphragm is a rare congenital malformation whose embryological basis is unknown. Late presentation is extremely rare and older patients are asymptomatic for a long time without developing ventilator insufficiency, because of the associated lung hypoplasia. Thus, only 7 cases of hemidiaphragmatic agenesis have been reported in adult patients.