Michele Grassia

The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia

BackgroundAlthough minimally invasive repair of giant hiatal hernias is a very surgical challenge which requires advanced laparoscopic learning curve, several reports showed that is a safe and effective procedure, with lower morbidity than open approach. In the present study we show the outcomes of 13 patients who underwent a laparoscopic repair of giant hiatal hernia.MethodsA total of 13 patients underwent laparoscopic posterior hiatoplasty and Nissen fundoplication. Follow-up evaluation was done clinically at intervals of 3, 6 and 12 months after surgery using the Gastro-oesophageal Reflux Health-Related Quality of Life scale, a barium swallow study, an upper gastrointestinal endoscopy, an oesophageal manometry, a combined ambulatory 24-h multichannel impedance pH and bilirubin monitoring. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge.ResultsThere were no intraoperative complications and no conversions to open technique. Symptomatic GORD-HQL outcomes demonstrated a statistical significant decrease of mean value equal to 3.2 compare to 37.4 of preoperative assessment (p < 0.0001). Combined 24-h multichannel impedance pH and bilirubin monitoring after 12 months did not show any evidence of pathological acid or non acid reflux.ConclusionAll patients were satisfied of procedure and no hernia recurrence was recorded in the study group, treated respecting several crucial surgical principles, e.g., complete sac excision, appropriate crural closure, also with direct hiatal defect where possible, and routine use of antireflux procedure.

Comparison of the 6th and 7th editions of the AJCC/UICC TNM staging system for gastric cancer focusing on the “N” parameter-related survival: the monoinstitutional NodUs Italian study

BackgroundA large number of Asian population studies examined the difference between the 6th and the 7th tumor, node, metastasis (TNM) while it is still poorly validated among Caucasian populations. This is a retrospective study aimed at investigating the efficacy of the 7th edition American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) staging system for gastric cancer focusing on the “N” parameter-related survival for prognostic assessment in gastric cancer patients of a single Western high-volume institution.MethodsFrom January 2002 to December 2009, the data of 274 patients with gastric cancer who underwent gastric surgery at the 8th General and Gastrointestinal Surgical Centre of the Second University of Naples were analyzed retrospectively. We collected data for patient demographics, tumor characteristics, surgical characteristics, and TNM stage. Particularly, the nodal status, with the number of dissected nodes and metastatic nodes, was reviewed from the pathology records. The same patient dataset was used to stage patients according to both the 6th and 7th edition criteria.ResultsAge at surgery, tumor location, histological grade, Lauren’s classification subtypes, and 6th and 7th AJCC/UICC N categories were found to have statistically significant associations with overall survival on univariate analysis. In the 6th edition staging system, the Kaplan–Meier plot did not show significant overlapped survival curves: significant differences were found between N0 and N1, P < .001; N1 and N2, P = .04; and N2 and N3, P < .001. On the contrary, in the 7th edition, among all five substages, there were similar survival curves between N categories 2 and 3a (P = .98) with a statistically significant discriminatory ability only between N1 versus N3b and N2 versus N3b (P = .02 and .04, respectively).ConclusionsBased on analysis, we found that several clinicopathological variables, especially histological grade and Lauren’s classification, were significant prognostic factors in our database. The 6th and 7th AJCC/UICC N classifications represent significantly independent prognostic factors, and the 6th AJCC/UICC N classification seems to be superior to the 7th AJCC/UICC N classification in terms of uniformity, differentiation, and monotonicity of gradients.

Large symptomatic gastric diverticula: Two case reports and a brief review of literature

Gastric diverticula are rare and uncommon conditions. Most gastric diverticula are asymptomatic. When symptoms arise, they are most commonly upper abdominal pain, nausea and emesis, while dyspepsia and vomiting are less common. Occasionally, patients with gastric diverticula can have dramatic presentations related to massive bleeding or perforation. The diagnosis may be difficult, as symptoms can be caused by more common gastrointestinal pathologies and only aggravated by diverticula. The appropriate management of diverticula depends mainly on the symptom pattern and as well as diverticulum size. There is no specific therapeutic strategy for an asymptomatic diverticulum. Although some authors support conservative therapy with antacids, this provides only temporary symptom relief since it is not able to resolve the underlying pathology. Surgical resection is the mainstay of treatment when the diverticulum is large, symptomatic or complicated by bleeding, perforation or malignancy, with over two-thirds of patients remaining symptom-free after surgery, while laparoscopic resection, combined with intraoperative endoscopy, is a safe and feasible approach with excellent outcomes. Here, we present two cases of uncommon large symptomatic gastric diverticula with a discussion of the cornerstones in management and report a minimally invasive solution, with a brief review of the literature.

Laparoscopic Nissen-Rossetti fundoplication is a safe and effective treatment for both Acid and bile gastroesophageal reflux in patients poorly responsive to proton pump inhibitor.

Purpose. The aim of this study was to evaluate the effectiveness of laparoscopic Nissen–Rossetti fundoplication in patients with gastroesophageal reflux disease (GERD) poorly responsive to standard dose proton pump inhibitor (PPI) therapy. Methods. A total of 35 patients (19 women, 16 men, mean age 44.6 ± 14.01 years) were enrolled. All the patients underwent symptom questionnaires, upper gastrointestinal endoscopy, esophageal manometry, and combined 24-hour esophageal pH and bilirubin monitoring. Following this, the patients with persistent pathological esophageal acid and/or bilirubin exposure underwent laparoscopic antireflux surgery, followed by clinical and instrumental 12-month follow-up. Results. One year after surgery, there was a significant improvement of symptom score, compared with standard PPI dose period (3.54 ± 1.67 vs 20.8 ± 10.9, P < .0001; paired t test) and mean percentage total time acid and bile exposure showed a significant decrease (4.9 ± 2.9 vs 2.03 ± 0.74 and 8.3 ± 3.03 vs 0.84 ± 0.56, P < .0001; paired t test). Conclusions. In patients with GERD poorly responsive to standard PPI dose, laparoscopic Nissen–Rossetti fundoplication appears to be a safe and effective treatment of symptoms, esophageal damage, as well as both acid and bile reflux.

Sarcomatoid Carcinoma of the lung: A rare case of three small intestinal intussusceptions and literature review

Highlights • There are rare reports of small intestinal intussusceptions caused by metastatic lung carcinosarcoma.• Medical treatment, chemotherapy, and radiotherapy are not active in this kind of tumor, so surgery is the treatment of choice.• Surgical treatment plays an important role in lung cancer patients with GI metastasis that cause bowel obstruction, perforation, or massive hemorrhage.• This presentation shows the third case in literature.

Sutureless jejuno-jejunal anastomosis in gastric cancer patients: a comparison with handsewn procedure in a single institute

BackgroundThe biofragmentable anastomotic ring has been used to this day for various types of anastomosis in the gastrointestinal tract, but it has not yet achieved widespread acceptance among surgeons. The purpose of this retrospective study is to compare surgical outcomes of sutureless with suture method of Roux-and-Y jejunojejunostomy in patients with gastric cancer.MethodsTwo groups of patients were obtained based on anastomosis technique (sutureless group versus hand sewn group): perioperative outcomes were recorded for every patient.ResultsThe mean time spent to complete a sutureless anastomosis was 11±4 min, whereas the time spent to perform hand sewn anastomosis was 23±7 min. Estimated intraoperative blood loss was 178±32ml in the sutureless group and 182±23ml in the suture-method group with no significant differences. No complications were registered related to enteroanastomosis. Intraoperative mortality was none for both groups.ConclusionsThe Biofragmentable Anastomotic Ring offers a safe and time-saving method for the jejuno-jejunal anastomosis in gastric cancer surgery, and for this purpose the ring has been approved as a standard method in our clinic. Nevertheless currently there are few studies on upper gastrointestinal sutureless anastomoses and this could be the reason for the low uptake of this device.

Applicability of the Proposed Japanese Model for the Classification of Gastric Cancer Location: The “PROTRADIST” Retrospective Study

ABSTRACT Background: The extension of lymphadenectomy for surgical treatment of gastric cancer remains discordant among European and Japanese surgeons. Kinami et al. (Kinami S, Fujimura T, Ojima E, et al. PTD classification: proposal for a new classification of gastric cancer location based on physiological lymphatic flow. Int. J. Clin. Oncol. 2008;13:320–329) proposed a new experimental classification, the “Proximal zone, Transitional zone, Distal zone” (PTD) classification, based on the physiological lymphatic flow of gastric cancer site. The aim of the present retrospective study is to assess the applicability of PTD Japanese model in gastric cancer patients of our Western surgical department. Methods: Two groups of patients with histologically documented adenocarcinoma of the stomach were retrospectively obtained: In the first group were categorized 89 patients with T1a–T1b tumor invasion; and in the second group were 157 patients with T2–T3 category. The data collected were then categorized according to the PTD classification. Results: In the T1a–T1b group there were no lymph node metastases within the r-GA or r-GEA compartments for tumors located in the P portion, and similarly there were no lymphatic metastases within the l-GEA or p-GA compartments for tumors located in the D portion. On the contrary, in the T2–T3 group the lymph node metastases presented a diffused spreading with no statistical significance between the two classification models. Conclusions: Our results show that the PTD classification based on physiological lymphatic flow of the gastric cancer site is a more physiological and clinical version than the Upper, Medium And Lower classification. It represents a valuable and applicable model of cancer location that could be a guide to a tailored surgical approach in Italian patients with neoplasm confined to submucosa. Nevertheless, in order to confirm our findings, larger and prospective studies are needed.

An unusual case of left hepatectomy for Focal Nodular Hyperplasia (FNH) linked to the use of Anabolic Androgenic Steroids (AASs).

Highlights • This is an unusual case of left hepatectomy for FNH.• Focal Nodular Hyperplasia(FNH), is the second most common benign tumor of the liver.• In our case the young patient was taking several herbal products and dietary supplements including anabolic androgenic steroids (AASs).• We have reported a rare case of left hepatectomy for FNH. We suppose that the increasing of the lesion, in two years in which the patient made use of anabolic steroids. Hormonal conditioning of these lesions is known, under use of oral anabolic steroids being proved the increase in volume of FNH. This could be the explanation for increasing of nodule.

Total Esophagectomy and Endoscopic Radiofrequency Ablation for a Case of Diffuse Esophageal Papillomatosis: Case Report

Esophageal squamous papilloma (ESP) is a benign epithelial lesion. ESP is extremely rare and it has been described in few cases in literature. The etiology of ESP may be associated to chronic mucosal irritation and HPV infection. It is usually asymptomatic and mostly discovered as an incidental finding during upper gastrointestinal endoscopy. It is considered a benign neoplasia but recent reports have stressed the potential malignant evolution of these lesions. A 53 year old caucasian woman presented with a four years history of disphagia not responsive to medical therapy. At upper endoscopy, esophageal mucosa appeared hyperemic and completely covered by numerous (>100) sessile peduncolate papules. Biopsies demostrating atypical epithelial proliferation confirmed the diagnosis of esophageal squamal papillomatosis with low grade and focal high grade dysplasia; in situ hybridization studies for HPV were perfomed and it was positive for the type 16. We report a case of diffuse esophageal papillomatosis with histologic and microbiologic findings of genotype 16 HPV and Lichen Planus infection successfully treated with an Ivor Lewis Esophagectomy and a second look endoscopy by radiofrequency ablation.

A rare case of Wunderlich syndrome five days after left hemicolectomy for colorectal cancer.

Highlights • This is a rare case of WS after surgery in patients with small AML.• Renal Angiomyolipoma (AML), a benign mesenchymal tumor, is the most frequent cause of WS.• Ten million people worldwide have such lesion.• We have reported a rare case of WS due to rupture of small AML after five days from colorectal surgery.• We suppose that the breaking of the lesion was favored by bridging therapy with low-molecular weight heparin.