Impact of total fundoplication on esophageal transit: analysis by combined multichannel intraluminal impedance and manometry.

BACKGROUND: Laparoscopic total fundoplication is considered the most effective surgical option for gastroesophageal reflux (GER) disease. Some authors assume that total fundoplication may expose the patient to delayed transit of the swallowed bolus and increased risk of dysphagia, particularly when peristaltic dysfunction is present. We undertook this study to evaluate by means of combined multichannel intraluminal impedance and esophageal manometry (MII-EM) the impact of fundoplication on esophageal physiology. An objective measurement of the influence of the total wrap on bolus transit may be helpful in refining the optimal antireflux wrap (ie, partial vs. total). METHODS: In this study, 25 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-EM and combined 24-hour pH and multichannel intraluminal impedance (MII-pH) before and after the surgical procedure. All patients completed preoperative and postoperative symptom questionnaires. The following were calculated for liquid and viscous deglutition lower esophageal sphincter pressure and relaxation, distal esophageal amplitude, the number of complete esophageal bolus transits and the mean total bolus transit time. The acid and nonacid GER episodes were calculated by MII-pH with the patient in both upright and recumbent positions. RESULTS: The postoperative MII-EM showed an increased lower esophageal sphincter pressure (P < 0.05), whereas lower esophageal sphincter relaxation and distal esophageal amplitude did not change after surgery (P = NS). Complete esophageal bolus transits and bolus transit time did not change for liquid swallows (P = NS), but was more rapid for viscous after surgery (P < 0.05). Twenty-four hour pH monitoring confirmed the postoperative reduction of both acid and nonacid reflux (P < 0.05). CONCLUSIONS: Laparoscopic Nissen-Rossetti is effective in controlling both acid and nonacid GER without impairment of esophageal function. Appropriate preoperative investigation, meticulous patient selection and correct surgical technique are extremely important in securing good results.

Weekly chemotherapy with cisplatin and paclitaxel and concurrent radiation therapy as preoperative treatment in locally advanced esophageal cancer: a phase II study.

We evaluated the association of a weekly cisplatin (35 mg/mq) and paclitaxel (45 mg/mq) regimen with radiotherapy (46 Gy) as primary treatment in locally advanced esophageal cancer (LAEC). The main end point was the activity in terms of pathologic complete response (pathCR) rate. Thirty-three LAEC patients received chemoradiation therapy during weeks 1-6 followed by esophagectomy. A pathCR was observed in 10/33 patients; 20/33 and 3/33 patients showed PR and SD, respectively. The EUS maximal transverse cross sectional area reduction >50% significantly correlated with pathCR. Three-year survival rate was 35%. These results support the activity and mild toxicity of this regimen.

Laparoscopic reoperation with total fundoplication for failed Heller myotomy: is it a possible option? Personal experience and review of literature.

Laparoscopic Heller myotomy with antireflux procedure seems the procedure of choice in the treatment of patients with esophageal achalasia. Persistent or recurrent symptoms occur in 10% to 20% of patients. Few reports on reoperation after failed Heller myotomy have been published. No author has reported the realization of a total fundoplication in these patient groups. The aim of this study is to evaluate the efficacy of laparoscopic reoperation with the realization of a total fundoplication after failed Heller myotomy for esophageal achalasia. From 1992 to December 2007, 5 out of a series of 242 patients (2.1%), along with 2 patients operated elsewhere, underwent laparoscopic reintervention for failed Heller myotomy. Symptoms leading to reoperation included persistent dysphagia in 3 patients, recurrent dysphagia in another 3, and heartburn in 1 patient. Mean time from the first to the second operation was 49.7 months (range, 4-180 months). Always, the intervention was completed via a laparoscopic approach and a Nissen-Rossetti fundoplication was realized or left in place after a complete Heller myotomy. Mean operative time was 160 minutes (range, 60-245 minutes). Mean postoperative hospital stay was 3.1 +/- 1.5 days. No major morbidity or mortality occurred. At a mean follow-up of 16.1 months, reoperation must be considered successful in 5 out of 7 patients (71.4%). The dysphagia DeMeester score fell from 2.71 +/- 0.22 to 0.91 +/- 0.38 postoperatively. The regurgitation score changed from 2.45 +/- 0.34 to 0.68 +/- 0.23. Laparoscopic reoperation for failed Heller myotomy with the realization of a total fundoplication is safe and is associated with good long-term results if performed by an experienced surgeon in a center with a long tradition of esophageal surgery.

Endoscopic cervical bariatric surgery: follow-up study in a porcine model.

BACKGROUND: The realisation of bariatric surgery has to date modified the digestive process solely through procedures within the abdominal cavity. However, endocrine surgeons have recently demonstrated the feasibility of a minimally invasive approach to the neck. In this study, we explored the feasibility, safety and weight progression of a bariatric procedure performed at the neck. METHODS: Eleven 40-50 kg Yorkshire pigs underwent endoscopic placement of an adjustable band to the cervical esophagus (ECB). Weight was monitored at postoperative days 15, 30, and after 7 weeks; weight progression was compared with an identical group of pigs who underwent a sham procedure. At autopsy, the surgical site was evaluated in a microscopic and macroscopic manner. RESULTS: Mean operating time was 66 +/- 5.76 min. All pigs tolerated the procedure well, except one subject that experienced food intolerance. The ECB group experienced significantly slower weight gain than the sham group (P = 0.005). Proper location of the band and absence of microscopic lesions at the esophageal wall were confirmed at autopsy and pathological examination. CONCLUSION: Bariatric surgery at the neck is feasible and produces effects on weight reduction. Further refinements and longer observation periods are required to propose this procedure as safe and effective alternative in humans.

Laparoscopic sleeve gastrectomy with duodeno-jejunal bypass: a new surgical procedure for weight control. Feasibility and safety study in a porcine model.

BACKGROUND: One limit of the Roux-en-Y gastric bypass (GBP) is the preclusion of exploring the bypassed stomach with conventional endoscopy and radiological studies. In this study, we explored the feasibility, safety, and weight progression of a new bariatric procedure that eliminates this inconvenience. METHODS: Eleven 40- to 50-kg Yorkshire pigs underwent laparoscopic sleeve gastrectomy and Roux-en-Y duodeno-jejunal bypass (SG-DJBP). Weight was monitored at postoperative days 15 and 30 and after 3 months; weight progression was compared with an identical group that underwent a sham procedure or GBP. At autopsy, surgical site was evaluated at microscopic and macroscopic level. RESULTS: Mean operating time was 66 +/- 5.76 min. All the survivors tolerated the procedure well, except one subject that experienced a gastric leak from the stapler line. The SG-DJBP had a had significantly slower weight gains than the sham group (P = 0.005). The absence of histological abnormalities in the duodenal wall was confirmed at autopsy. CONCLUSION: SG-DJBP is feasible and produces effects of weight progression comparable to those of GBP. Being a combination of previously standardized procedures, we are confident to propose this procedure as a bariatric alternative in humans. Long-term follow-up will be required to establish the efficacy on weight loss in humans.

Total fundoplication controls acid and nonacid reflux: evaluation by pre- and postoperative 24-h pH-multichannel intraluminal impedance.

BACKGROUND: Studies have demonstrated that Nissen fundoplication controls acid gastroesophageal reflux (GER). Combined 24-h pH and multichannel intraluminal impedance (MII-pH) allows detection of both acid and nonacid GER. Antireflux surgery is considered for any patient whose medical therapy is not efficient, particularly patients with nonacid gastroesophageal reflux disease (GERD). Nevertheless, fundoplication used to control nonacid reflux has not been reported to date. METHODS: In this study, 15 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-pH both before and after the surgical procedure. The numbers of acid and nonacid GER episodes were calculated with the patient in both upright and recumbent positions. RESULTS: The 24-h pH monitoring confirmed the postoperative reduction of exposure to acid (p < 0.05). Postoperatively, the total, acid, and nonacid numbers of GER episodes were reduced (p < 0.05). CONCLUSION: According to the findings, MII-pH is feasible and well tolerated. It provides an objective means for evaluating the effectiveness of Nissen-Rossetti fundoplication in controlling both acid and nonacid GER.

[Laparoscopic total fundoplication is not an obstacle to oesophageal emptying after oesophago-gastric myotomy for the surgical treatment of achalasia]. / La fundoplicatio totale non ostacola lo svuotamento esofageo dopo miotomia esofago-gastrica estesa per il trattamento chirurgico dell'acalasia esofagea.

There are different surgical possibilities for the treatment of oesophageal achalasia ranging from a short extramucosal oesophagomyotomy to an extended esophago-gastric myotomy combined with a partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to oesophageal emptying. The aim of this study was to evaluate the role and efficacy of total 360 degrees laparoscopic Nissen-Rossetti fundoplication after oesophago gastric myotomy in the treatment of oesophageal achalasia. From 1992 to January 2008, a total of 245 patients (112 males, 133 females), mean age 45.1 years (range: 12-79), were submitted to laparoscopic Nissen-Rossetti fundoplication after a Heller myotomy with endoscopic and manometric intraoperative monitoring. In 3 patients (1.2%), conversion to laparotomy was necessary. Mean operative time was 60 +/- 15 minutes. No mortality was observed. The overall morbidity rate was 1.6%. The mean postoperative hospital stay was 3.5 +/- 1.0 days (range: 1-12 days). A mean clinical follow-up of 100.2 +/- 7 months (range: 3-177) was possible for 228 patients (93.1%), and an excellent or good outcome was observed in 209 patients (91.7%) (DeMeester dysphagia score 0-1). No improvement in dysphagia was observed in 5 (2.2%) patients. Pathological gastro-oesophageal reflux was absent in all patients. Laparoscopic Nissen-Rossetti fundoplication after a Heller myotomy is a safe, effective treatment for oesophageal achalasia with excellent results in terms of dysphagia resolution, affording total protection from the onset of gastrooesophageal reflux.

Metabolic and nutritional status changes after 10% weight loss in severely obese patients treated with laparoscopic surgery vs integrated medical treatment.

BACKGROUND: Bariatric surgery is considered the most effective treatment for reducing excess body weight and maintaining weight loss (WL) in severely obese patients. There are limited data evaluating metabolic and body composition changes after different treatments in type III obese (body mass index [BMI] > 40 kg/m(2)). METHODS: Twenty patients (9 males, 11 females; 37.6 +/- 8 years; BMI = 50.1 +/- 8 kg/m(2)) treated with dietary therapy and lifestyle correction (group 1) have been compared with 20 matched patients (41.8 +/- 6 years; BMI = 50.4 +/- 6 kg/m(2)) treated with laparoscopic gastric bypass (LGBP; group 2). Patients have been evaluated before treatment and after >10% WL obtained on average 6 weeks after LGBP and 30 weeks after integrated medical treatment. Metabolic syndrome (MS) was evaluated using the Adult Treatment Panel III/America Heart Association (ATP III/AHA) criteria. Resting metabolic rate (RMR) and respiratory quotient (RQ) was assessed with indirect calorimetry; body composition with bioimpedance analysis. RESULTS: At entry, RMR/fat-free mass (FFM) was 34.2 +/- 7 kcal/24 h.kg in group 1 and 35.1 +/- 8 kcal/24 h.kg in group 2 and did not decrease in both groups after 10% WL (31.8 +/- 6 vs 34.0 +/- 6). Percent FFM and fat mass (FM) was 50.7 +/- 7% and 49.3 +/- 7% in group 1 and 52.1 +/- 6% and 47.9 +/- 6% in group 2, respectively (p = n.s.). After WL, body composition significantly changed only in group 1 (% FFM increased to 55.9 +/- 6 and % FM decreased to 44.1 +/- 6; p = 0.002). CONCLUSION: After >10% WL, MS prevalence decreases precociously in surgically treated patients; some improvements in body composition are observed in nonsurgically treated patients only. Further investigations are needed to evaluate long-term effects of bariatric surgery on body composition and RMR after stable WL.

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 Braun's 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.

Laparoscopic duodenal switch for pathologic duodenogastric reflux: initial experience.

Duodenogastric reflux (DGR) is barely responsive to medications and antireflux fundoplication is not able to control the gastric symptoms. Duodenal switch (DS) preserves the physiologic food transit while creating an effective Roux-en-Y diversion to duodenal juice. However, it never enjoyed great popularity, perhaps due to the invasiveness of the open approach. The paper reports our initial experience with laparoscopic DS. Preoperative assessment, surgical technique, and outcomes are described. Normalization of DGR was demonstrated by preoperative and postoperative 24-hour bilimetry and pH-multichannel intraluminal impedance. The procedure was completed under laparoscopy in all the cases with a mean operative time of 165 minutes. Mean blood loss was 200 mL. No patient required admission to the intensive care unit. Initial experience with laparoscopic DS encourages continued use of the minimally invasive approach. A meticulous preoperative evaluation is essential to place a correct indication.

Whole stomach transposition without gastric drainage procedure: a good surgical option to restore digestive continuity after esophagectomy.

After esophagectomy, the stomach is usually used to restore digestive continuity. To prevent postoperative delayed gastric emptying, most authors perform a gastric drainage procedure or transpose a tubulized stomach. The aim of our work is to evaluate the emptying of a transposed whole stomach without performing a pyloromyotomy or a pyloroplasty. From 1996 to January 2004, 45 patients underwent total esophagectomy for cancer or for caustic stenosis. Reconstruction of digestive continuity was realized through transposition of the whole stomach without performing a pyloric drainage procedure. At 12 months after the intervention, 35 patients (77.8%; 20 men and 15 women) were submitted to a gastric emptying scintigraphic study by means of ingestion of a mixed meal labeled with 37 MBq 99mTc-sulfur colloid. Mean half-emptying time was 71.4 minutes (range, 15-90 minutes; reference range, 83 +/- 34 minutes): all the patients were in the normal range except one. No patient complained of delayed gastric emptying symptoms. After esophagectomy, the transposition of the whole stomach without a pyloric drainage procedure seems to be an interesting option, and is not associated with delayed gastric emptying.

Gastroesophageal junction adenocarcinoma: what are the factors influencing long-term survival?

The incidence of gastroesophageal junction adenocarcinoma is increasing. About 30% of the tumors cannot be completely resected, and 40% of the patients relapse after complete resection. There is much controversy over the role of neoadjuvant therapy, the approach route, lymphadenectomy, and the extent of esophageal resection. The aim of our study was to report our experience in the treatment of gastroesophageal junction adenocarcinoma. From January 1987 until February 2005, 157 patients (125 men, 32 women), mean age 72.1 +/- 3.2 years, came for observation. One hundred sixteen patients underwent curative intervention. Mean operative time was 185 +/- 45 minutes. Mean postoperative hospital stay was 16.4 +/- 6.1 days. Postoperative complications were observed in 25 patients (21.6%); 6 patients (5.2%) died during the postoperative period. Overall survival was 36.2% and 27.6% at 3- and 5-year follow-up, respectively. Five-year survival rate was significantly lesser in R1/R2 versus R0 resections (0% versus 33.7%), N+ versus N- patients (11.3% versus 53.3%), and worsened with progression of pT histological staging (T1, 100%; T2, 24.1%; T3, 15.1%; T4, 0%). Determining prognostic factors are the radicality of resection, lymph nodal invasion, and histological staging.

[Endoscopic ultrasonography-guided management of mesenchymal tumors of the upper digestive tract]. / Il management ecoendoguidato dei tumori mesenchimali del tratto digestivo superiore.

Stromal tumours of the gastrointestinal tract can be defined by endoscopic ultrasonography as "hypoechoic intramural tumours" on the basis of their echostructure. Unfortunately, this definition is inadequate for distinguishing between the biological behaviour patterns of different types of stromal tumour. One hundred and twelve hypoechoic intramural tumours observed from 1998 to 2005 were classified in 4 distinct groups (leiomyomas, gastrointestinal stromal tumours, gastrointestinal stromal tumours suspected of malignancy, and malignant stromal tumours) according to more detailed endoscopic ultrasonography criteria in order to better plan the surgical treatment. The endoscopic ultrasonography diagnosis was compared with histology and immunochemistry findings in 33 patients who were operated on. The overall accuracy was 78.6% for the diagnosis of leiomyoma (sensitivity, specificity, positive predictive value, and negative predictive value were 92.3%, 90.0%, 85.7% and 94.7%, respectively). The corresponding data for the diagnosis of malignant stromal tumours were 80.0%, 95.2%, 88.9% and 91.7%. Endoscopic ultrasonography seemed to be less reliable only in relation to the diagnosis of gastrointestinal stromal tumours (specificity 80.9%, positive predictive value 75.0%). The surgical procedures planned on the basis of the endoscopic ultrasonography diagnosis proved adequate in 31 out of 33 cases.

[Esophageal perforation: which factors affect the prognosis? Results of a 10-year experience]. / Perforazioni esofagee: quali sono i fattori influenzanti la prognosi? Risultati di un'esperienza decennale.

Oesophageal perforations are a catastrophic event with a 10-40% mortality rate. The decisive prognostic factor is the time from the event to the diagnosis, while there is no agreement as to the therapeutic options. The aim of this study was to present our ten-year experience in the treatment of oesophageal perforations together with an evaluation of the prognostic factors. From January 1995 to January 2005, 18 patients (11 M, 7 F), mean age 49.3 years (range: 22-79), with oesophageal perforations were treated in our department. They were classified according to the cause and localization of the perforation and the time elapsing since the event. The perforation was localised in the cervical oesophagus in 4 patients (22.2%), in the abdominal oesophagus in 4 patients (22.2%) and in the thoracic oesophagus in 10 patients (55.5%). It was spontaneous in 4 patients (22.2%), traumatic in 4 (22.2%) and iatrogenic in the remaining 10 (55.5%). In 7 patients (38.9%), the treatment was started during the first 24 hours from the event, while the remaining 11 (61.1 %) were referred to us more than 24 hours after the perforation occurred. The overall mortality was 27.8% (5 patients). The only decisive prognostic factor was the time of observation: only 1 patient (14.3%) died in the group observed in the first 24 hours, while the remaining 4 who died (36.4%) were in the group treated more than 24 hours after the event (p < 0.05). Our series confirms that the time elapsing from the event to the diagnosis is the only decisive prognostic factor in the treatment of oesophageal perforations. There is no therapeutic option of choice since there is no significant influence of either cause or localisation of the perforation on outcome.

A mesenteric window to approach a posterior side leak after laparoscopic assisted stapled strictureplasty for Crohn's disease.

Strictureplasty leak in patients with Crohn's disease increases considerably morbidity rate. Intra-operative evaluation of the integrity of suture line and proficient management of any leakage after strictureplasty is mandatory to prevent post-operative complications. When a leakage is detected at the posterior side, through intra-operative insufflation or methylene blue test, it may be difficult to repair as the suture line is completely covered up by mesentery. The AA. describe the creation of a mesenteric window to reinforce the posterior side of a side-to-side stapled strictureplasty performed by laparoscopic assisted procedure. As far as we know, this new technical strategy may allow avoiding resection of small bowel.

Double loop reconstruction following pancreaticoduodenectomy for malignant tumor: Short-term outcome.

BACKGROUND: To evaluate the use of a double loop reconstruction following pylorus preserving proximal pancreaticoduodenectomy (PPPPD). METHODS: Morbidity and mortality were evaluated in 55 patients undergoing PPPPD for malignant tumors, followed by a double loop reconstruction. RESULTS: The mean intra-operative blood loss was 908mL±531. In-hospital mortality was 5.4% (3/55 pts). The mean length of hospital stay was 17±5 days (range 12-45 days). Postoperative complications occurred in 25 patients (46.2%). Five patients developed an anastomotic leak, one biliary and four pancreatic (4/55; 7%). Delayed gastric emptying occurred in 8 patients (14.5%). Reoperation was required in two patients for hemorrhage. CONCLUSIONS: A double loop alimentary reconstruction following PPPPD led to a low incidence of DGE and pancreatic fistula. Although mortality rate was higher than that reported by referral centres, this technique has been performed in a not specialized unit attaining acceptable results.

Adenocarcinoma of gastric cardia in the elderly: surgical problems and prognostic factors.

AIM: To analyze retrospectively, our results about patients who underwent surgical treatment for adenocarcinoma of the cardia in relation to age, in order to evaluate surgical problems and prognostic factors. METHODS: From January 1987 to March 2003, 140 patients with adenocarcinoma of the cardia underwent resection in the authors institution. They were divided into three groups with regard to age. Patients < 70 and > 60 year old (31) were excluded; we also excluded 18 out of 109 patients with poor general status or systemic metastases. So, we compared 51 elderly (> or = 70 year old) and 58 younger patients (> or = 60 year old). The treatment was esophagectomy for type I tumors, and extended gastrectomy and distal esophagectomy for type II and III lesions. RESULTS: Laparotomy was carried out in 91 patients (83.4%), 38 in the elderly (74.5%) and 53 in younger patients (91.3%, P<0.05). Primary resection was performed in 81 cases (89%) without significant differences between the two groups. Postoperative death was higher in the elderly (12.1%) than the other group (4.1%, P<0.05), while morbidity was similar in both groups. A curative resection (R0) was performed in 59 patients (72.8%), 69.6% in the elderly and 75% in the younger group (P>0.05). The overall 3- and 5-year survival rates were 26.7% and 17.8% respectively for the elderly and 40.7% and 35.1% respectively for younger patients (P=0.1544). Survival rates were significantly associated with R0 resection, pathological node-positive category and tumor differentiation in both groups. CONCLUSION: As the age of the general population increases, more elderly patients with gastric cardia cancer will be candidates for surgical resection. Age alone should not preclude surgical treatment in elderly patients with gastric cardia cancer and a tumor resection can be carried out safely. Certainly, we should take care in defining the surgical treatment in elderly patients, particularly as regarding the surgical approach; although the surgical approach does not influence the survival rate, the transhiatal way still remains the best one due, to the lower incidence of respiratory morbidity and thoracic pain.

Surgical therapy of adenocarcinoma of the esophagogastric junction: analysis of prognostic factors.

BACKGROUND/AIMS: The surgical strategy of adenocarcinoma of the esophagogastric junction (EGJ) is still controversial. This study aims at analyzing our surgical results about these lesions in order to define the prognostic factors. METHODOLOGY: From January 1987 to March 2003, 113 patients with adenocarcinoma of the cardia underwent resection in the authors' institution: 19 patients (16.8%) had type I tumors, 35 (30.9%) type II and 59 (52.2%) type III. The treatment was esophagectomy for type I tumors, and extended gastrectomy and distal esophagectomy for type II and III lesions. Morbidity, mortality and the survival rate were determined retrospectively. RESULTS: Primary resection was performed in 113 patients out of 150 (75.3%). Mortality and morbidity rates were 7.96 and 38.05% respectively. The overall 3- and 5-year survival rates were 35.1 and 26.3% respectively. Survival rates were significantly associated with R0 resection (P<0.001), pathological node-positive category (P<0.001) and tumor differentiation (P=0.0228). CONCLUSIONS: The prognosis of adenocarcinoma of the EGJ is still unfavorable, but the true prognostic factors are complete macroscopic and microscopic tumor resection, pN category and tumor differentiation. Although the surgical approach does not influence the survival rate, the transhiatal way still remains the best one due to the lower incidence of respiratory morbidity and thoracic pain.

Laparoscopic treatment of an uncommon abdominal localization of Castleman disease.

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.

Giant right post-traumatic diaphragmatic hernia: laparoscopic repair without a mesh.

Diaphragmatic ruptures are fairly frequent after thoraco-abdominal traumas (0.8-5%). In 90% of cases, they are left-sided. In the literature, very few cases are treated by laparoscopy. The aim of this study was to evaluate the feasibility and effectiveness of laparoscopic repair of a giant right post-traumatic diaphragmatic hernia without the use of a mesh. We present the case of a 28-year-old male operated by the laparoscopic approach for a giant right post-traumatic diaphragmatic hernia, diagnosed 18 months after the trauma. Surgical repair was carried out by means of 10 non-absorbable interrupted stitches, without the use of a mesh. The duration of the operation was 145 minutes. The patient was discharged 3 days after the surgical procedure, and no complications occurred. After a 40-month follow-up, the patient is asymptomatic and healthy. Laparoscopic repair of post-traumatic diaphragmatic hernias without the use of a mesh is safe and effective and affords an early postoperative recovery.