Paolo Parise

Barrett's esophagus: surgical treatments

The following on surgical treatments for Barretts esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non‐GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.

Technical pro & cons of the laparoscopic lymphadenectomy.

Laparoscopy has been introduced in treatment of gastric cancer to reduce surgical trauma and to improve post-operative functional recovery. Most of international guidelines allow the use of this minimally invasive approach in general surgical practice only in clinical stage I. One of the most important concerns in fact is the feasibility of D2 lymphadenectomy through laparoscopy. Reduced numbers of harvested lymph nodes have been reported, particularly in stations with a more difficult access. Nevertheless subsequent papers reported adequate numbers of total number of nodes retrieved, even with D2 dissection and even in complex stations but results from randomized controlled trials still lack. Laparoscopic approach has been proven safe and effective also in extremely complex maneuvers as spleen-preserving retropancreatic lymphadenectomy. The minimally invasive approach in D2 lymphadenectomy seems to be associated to comparable incidence of specific complications as compared to open surgery. The use of laparoscopy has extended the operating time but has reduced the blood loss. Because of high complexity of this kind surgery, laparoscopic gastric surgery for cancer should be done only in referral centers.

Treatment of Zenker’s Diverticulum With Endoscopic Stapled Esophago-divertisculostomy (ESD): Analysis of Long-term Outcome

Background: Endoscopic Zenker diverticulum (ZD) treatment has become quite common because of the low complication rates, reduced procedure time, and shorter hospital stay. Many endoscopic treatments are available including the endoscopic stapled esophago-diverticulostomy (ESD). Many data regarding ESD are available on the short-term outcomes, but few on the long-term ones. Materials and Methods: From March 1998 to July 2016, 126 patients with ZD were candidate for ESD. Since 2009, 2 stay sutures were routinely positioned at the lateral edges of the septum using Medtronic Endostitch 10 mm suturing device. Demographic and perioperative data, symptoms, and surgical outcomes were recorded. Long-term ESD results were analyzed. An extra-analysis on the surgical outcome was performed comparing patients treated with or without stay sutures. Results: In total, 117 patients successfully underwent ESD. The mean age was 69.9 years with a male predominance. Intraoperative complications occurred in 6.8% of cases. Only 2.6% of the patients reported postoperative complications. For the long-term analysis, we were able to contact 92 patients for a mean period follow-up of 65.3 months. At 6-month outpatient visit 77.68% of patients were completely asymptomatic. In total, 22.3% of the patients needed an extratreatment due to incomplete section of the septum, reaching a success rate of 95.5%. The long-term resolution rate remained high (91.3%). The use of stay sutures did not statistically influence the operative time (22.8 vs. 26.7 min, P=0.070), nor intraoperative and postoperative complication rate, but a statistically significant higher complete resolution rate of symptoms with a single session of ESD was observed respect those treated without (87.3% vs. 65.3%, respectively). Conclusions: ESD is a safe and effective treatment of ZD and it can control symptoms even in a long-term follow-up. In our experience, the use of stay sutures placed with Endostitch increases short and long-term results reducing the need for further treatments.