V. Maffettone

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 Nissen-Rossetti fundoplication with routine use of intraoperative endoscopy and manometry: technical aspects of a standardized technique.

BackgroundSeveral different ways of fashioning a total fundoplication lead to different outcomes. This article addresses the technical details of the antireflux technique we adopted without modifications for all patients with GERD beginning in 1972. In particular it aims to discuss the relation between the mechanism of function of the wrap and the physiology of the esophagus.MethodsThe study population consisted of 380 patients affected by GERD with a 1-year minimum of follow-up who underwent laparoscopic Nissen-Rossetti fundoplication by a single surgeon.ResultsNo conversion to open surgery and no mortality occurred. Major complications occurred in 4 patients (1.1%). Follow-up (median 83 months; range: 1–13 years) was achieved in 96% of the patients. Ninety-two percent of the patients were satisfied with the results of the procedure and would undergo the same operation again. Postoperative dysphagia occurred in 3.5% of the patients, and recurrent heartburn was observed in 3.8%.ConclusionsLaparoscopic Nissen-Rossetti fundoplication with the routine use of intraoperative manometry and endoscopy achieved good outcomes and long-term patient satisfaction with few complications and side-effects. Appropriate preoperative investigation and a correct surgical technique are important in securing 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.

Influence of esophagealmotility on the outcome of laparoscopic total fundoplication

The aim of this study is to evaluate if esophageal dysmotility can influence the outcome of laparoscopic total fundoplication for gatro-esophageal reflux disease (GERD). The advent of laparoscopic fundoplication has greatly reduced the morbidity of antireflux surgery and by now, it should be considered the surgical treatment of choice for GERD. Some authors assert that total versus partial fundoplication should improve the rate of postoperative dysphagia or gas bloat syndrome, particularly in patients with esophageal dysmotility. From September 1992 to December 2005, 420 consecutive patients 171 male and 249 female, mean age 42.8 years (range 12-80) underwent laparoscopic Nissen-Rossetti fundoplication. At manometric evaluation, we divided patients into two groups: group A (163/420; 38.8%) with impaired esophageal peristalsis (peristaltic waves with a pressure < 30 mmHg), and group B (257/420; 61.2%) without impaired peristalsis. We followed up clinically 406 out of 420 (96.7%) patients, 156/163 patients (95.7%) in group A and 250/257 patients (97.3%) in group B. An excellent outcome was observed in 143/156 (91.7%) group A patients and in 234/250 (93.6%) group B patients (P = NS). Both groups showed significant improvement in clinical symptom score with no statistically significant difference between patients with normal and impaired peristalsis. Thus, preoperative defective esophageal peristalsis is not a contraindication to total laparoscopic fundoplication.

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.

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.

Clinical and instrumental parameters in patients with constipation and incontinence: their potential implications in the functional aspects of these disorders.

PurposeThe aims of this study were to evaluate several clinical and instrumental parameters in a large number of patients with constipation and incontinence as well as in healthy controls and discuss their potential implications in the functional aspects of these disorders.MethodsEighty-four constipated and 38 incontinent patients and 45 healthy controls were submitted to a protocol based on proctologic examination, clinico-physiatric assessment, and instrumental evaluation.ResultsConstipated and incontinent patients had significantly worse lumbar lordosis as well as lower rate in the presence of perineal defense reflex than controls. Constipated but not incontinent patients had a lower rate of puborectalis relaxation than controls. Furthermore, worse pubococcygeal tests and a higher rate of muscle synergies presence, either agonist or antagonist, were observed in both constipated and incontinent patients compared to controls.ConclusionsThis study has demonstrated strong correlations between physiatric disorders and the symptoms of constipation and incontinence. Further studies designed to demonstrate a causal relationship between these parameters and the success of a specific treatment of the physiatric disorders on the proctology symptoms are warranted.

Biliary Lithiasis in Patients with Gastroesophageal Reflux (Acid and Alkaline)

Gastroesophageal reflux (GERD) and cholelithiasis are both very common diseases. It is estimated that 15–20 million people in the United States have gallstones [1] and that 36% of the American population complains of at least one episode of heart-burn per month. In Spain, 10% of the population has ultrasonographically demonstrated cholelithiasis [2] and 30% of the population suffers from reflux symptoms, 10% of these on a weekly basis [3]. The two diseases have been connected for years. Saint’s triad [4], a well-known association of hiatal hernia with cholelithiasis and colon diverticula that was much in fashion during the 1980s, represented a paradigmatic expression of Westernization-induced gastrointestinal disturbances. However, this argument is very contentious, and we will try to analyze the controversy in this chapter.

What are the rules to follow in the surgical treatment of megaesophagus

The aim of surgical treatment of esophageal achalasia is to remove dysphagia by means of LES activity annulment; in fact, the absence or inadequacy of LES relaxation determines the extent of dysphagia. This result is obtained by disconnecting the muscle fibers of the esophageal junction during the whole length of the high pressure zone of LES activity. This surgical procedure, which was described by Heller in 1913, and called extramucosal “cardias” myotomy, has been modified many times in recent years.