HypoparaNet: A Database of Chronic Hypoparathyroidism Based on Expert Medical-Surgical Centers in Italy.

Hypoparathyroidism is a rare disease characterized by low serum calcium levels and absent or deficient parathyroid hormone level. Regarding the epidemiology of chronic hypoparathyroidism, there are limited data in Italy and worldwide. Therefore, the purpose of this study was to build a unique database of patients with chronic hypoparathyroidism, derived from the databases of 16 referral centers for endocrinological diseases, affiliated with the Italian Society of Endocrinology, and four centers for endocrine surgery with expertise in hypoparathyroidism, to conduct an epidemiological analysis of chronic hypoparathyroidism in Italy. The study was approved by the Institutional Review Board. A total of 537 patients with chronic hypoparathyroidism were identified. The leading etiology was represented by postsurgical hypoparathyroidism (67.6%), followed by idiopathic hypoparathyroidism (14.6%), syndromic forms of genetic hypoparathyroidism (11%), forms of defective PTH action (5.2%), non-syndromic forms of genetic hypoparathyroidism (0.9%), and, finally, other forms of acquired hypoparathyroidism, due to infiltrative diseases, copper or iron overload, or ionizing radiation exposure (0.7%). This study represents one of the first large-scale epidemiological assessments of chronic hypoparathyroidism based on data collected at medical and/or surgical centers with expertise in hypoparathyroidism in Italy. Although the study presents some limitations, it introduces the possibility of a large-scale national survey, with the final aim of defining not only the prevalence of chronic hypoparathyroidism in Italy, but also standards for clinical and therapeutic approaches.

A magnetic levitation robotic camera for minimally invasive surgery: Useful for NOTES?

BACKGROUND: Minimally invasive surgery (MIS) is rising in popularity generating a revolution in operative medicine during the past few decades. Although laparoscopic techniques have not significantly changed in the last 10 years, several advances have been made in visualization devices and instrumentation. METHODS: Our team, composed of surgeons and biomedical engineers, developed a magnetic levitation camera (MLC) with a magnetic internal mechanism dedicated to MIS. Three animal trials were performed. Porcine acute model has been chosen after animal ethical committee approval, and laparoscopic cholecystectomy, nephrectomy and hernioplastic repair have been performed. RESULTS: MLC permits to complete efficiently several two-port laparoscopy surgeries reducing patients' invasiveness and at the same time saving surgeon's dexterity. CONCLUSIONS: We strongly believe that insertable and softly tethered devices like MLS camera will be an integral part of future surgical systems, thus improving procedures efficiency, minimizing invasiveness and enhancing surgeon dexterity and versatility of visions angles.

Multi-port versus single-port cholecystectomy: results of a multi-centre, randomised controlled trial (MUSIC trial).

BACKGROUND: Single-port laparoscopic surgery as an alternative to conventional laparoscopic cholecystectomy for benign disease has not yet been accepted as a standard procedure. The aim of the multi-port versus single-port cholecystectomy trial was to compare morbidity rates after single-access (SPC) and standard laparoscopy (MPC). METHODS: This non-inferiority phase 3 trial was conducted at 20 hospital surgical departments in six countries. At each centre, patients were randomly assigned to undergo either SPC or MPC. The primary outcome was overall morbidity within 60 days after surgery. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov (NCT01104727). RESULTS: The study was conducted between April 2011 and May 2015. A total of 600 patients were randomly assigned to receive either SPC (n = 297) or MPC (n = 303) and were eligible for data analysis. Postsurgical complications within 60 days were recorded in 13 patients (4.7 %) in the SPC group and in 16 (6.1 %) in the MPC group (P = 0.468); however, single-access procedures took longer [70 min (range 25-265) vs. 55 min (range 22-185); P < 0.001]. There were no significant differences in hospital length of stay or pain VAS scores between the two groups. An incisional hernia developed within 1 year in six patients in the SPC group and in three in the MPC group (P = 0.331). Patients were more satisfied with aesthetic results after SPC, whereas surgeons rated the aesthetic results higher after MPC. No difference in quality of life scores, as measured by the gastrointestinal quality of life index at 60 days after surgery, was observed between the two groups. CONCLUSIONS: In selected patients undergoing cholecystectomy for benign gallbladder disease, SPC is non-inferior to MPC in terms of safety but it entails a longer operative time. Possible concerns about a higher risk of incisional hernia following SPC do not appear to be justified. Patient satisfaction with aesthetic results was greater after SPC than after MPC.

Radiofrequency-Based Identification Medical Device: An Evaluable Solution for Surgical Sponge Retrieval?

BACKGROUND: A retained surgical item in patients (gossypiboma) is a persisting problem, despite consistent improvements and existing guidelines in counting instruments and sponges. Previous experiences with radiofrequency identification technology (RFID) tracking sponges show that it could represent an innovation, in order to reduce the criticism and increase the effectiveness during surgical procedures. We present an automated system that allows reduction of errors and improves safety in the operating room. METHODS: The system consists of 3 antennas, surgical sponges containing RFID tags, and dedicated software applications, with Wi-Fi real-time communication between devices. The first antenna provides the initial count of gauzes; the second a real-time counting during surgery, including the sponges thrown into the kick-bucket; and the third can be used in the event of uneven sponge count. The software allows management at all stages of the process. RESULTS: In vitro and in vivo tests were performed: the system provided excellent results in detecting sponges in patients' body. Hundred percent retained sponges were detected correctly, even when they were overlapped. No false positive or false negative was recorded. The counting procedure turned out to be more streamlined and efficient and it could save time in a standard procedure. CONCLUSIONS: The RFID system for sponge tracking was shown to be experimentally a reliable and feasible method to track sponges with a full detection accuracy in the operating room. The results indicate the system to be safe and effective with acceptable cost-effective parameters.

Natural humoral immune response to ribosomal P0 protein in colorectal cancer patients.

BACKGROUND: Tumor associated antigens are useful in colorectal cancer (CRC) management. The ribosomal P proteins (P0, P1, P2) play an important role in protein synthesis and tumor formation. The immunogenicity of the ribosomal P0 protein in head and neck, in breast and prostate cancer patients and the overexpression of the carboxyl-terminal P0 epitope (C-22 P0) in some tumors were reported. METHODS: Sera from 72 colorectal tumor patients (67 malignant and 5 benign tumors) were compared with 73 healthy donor sera for the presence of antibodies to CEA, EGFR, ErbB2 and ribosomal P proteins by western blotting or ELISA. Expression of the C-22 P0 epitope on tissues and colon cancer cells was determined by immunoperoxidase staining and indirect immunofluorescence/western blotting, respectively, employing MAb 2B2. Biological effects of MAb 2B2 on colon cancer cells were assessed by the Sulforhodamine B cell proliferation assay, trypan blue exclusion test and cleaved caspase-3 detection. Fisher's exact test was used to compare the number of auto-antibodies positive patients with healthy donors. Variation in the C-22 P0 expression, and in the number of apoptotic cells was evaluated by Student's t-test. Variation in cell survival and cell death was evaluated by Newman-Keuls test. RESULTS: No significant humoral response was observed to CEA, EGFR and ErbB2 in CRC patients. Conversely, 7 out of 67 CRC patient sera reacted to ribosomal P proteins. The prevalence of P proteins auto-antibodies in CRC patients was significant. Five patients showed restricted P0 immunoreactivity, while two patients reacted simultaneously to all P proteins. The C-22 P0 epitope was homogenously expressed both in malignant tumors and the adjacent mucosa, but the intensity of expression was higher in the tumor. Starved colon cancer cells showed a higher C-22 P0 epitope plasma membrane expression compared to control cells. MAb 2B2 inhibited colon cancer cell growth and induced cell death in a dose dependent manner. CONCLUSIONS: Our study shows a spontaneous humoral immune response to ribosomal P0 protein in CRC patients and the inhibition of in vitro cancer cell growth after C-22 P0 epitope targeting. The ribosomal P0 protein might be a useful immunological target in CRC patients.

Ligation of the intersphincteric fistula tract (LIFT): a minimally invasive procedure for complex anal fistula: two-year results of a prospective multicentric study.

INTRODUCTION: The surgical management of anal fistulas is still a matter of discussion and no clear recommendations exist. The present study analyses the results of the ligation of the intersphincteric fistula tract (LIFT) technique in treating complex anal fistulas, in particular healing, fecal continence, and recurrence. METHODS: Between October 2010 and February 2012, a total of 26 consecutive patients underwent LIFT. All patients had a primary complex anal fistula and preoperatively all underwent clinical examination, proctoscopy, transanal ultrasonography/magnetic resonance imaging, and were treated with the LIFT procedure. For the purpose of this study, fistulas were classified as complex if any of the following conditions were present: tract crossing more than 30% of the external sphincter, anterior fistula in a woman, recurrent fistula, or preexisting incontinence. Patient's postoperative complications, healing time, recurrence rate, and postoperative continence were recorded during follow-up. RESULTS: The minimum follow-up was 16 months. Five patients required delayed LIFT after previous seton. There were no surgical complications. Primary healing was achieved in 19 patients (73%). Seven patients (27%) had recurrence presenting between 4 and 8 weeks postoperatively and required further surgical treatment. Two of them (29%) had previous insertion of a seton. No patients reported any incontinence postoperatively and we did not observe postoperative continence worsening. CONCLUSION: In our experience, LIFT appears easy to perform, is safe with no surgical complication, has no risk of incontinence, and has a low recurrence rate. These results suggest that LIFT as a minimally invasive technique should be routinely considered for patients affected by complex anal fistula.

Surgery for fistula-in-ano in a specialist colorectal unit: a critical appraisal.

BACKGROUND: Several techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. We conducted a prospective study to assess type of presentation, treatment strategy and outcome over a 5-year period. METHODS: Between 1st January 2005 and 31st March 2011,247 patients presenting with anal fistulas were treated at the University Hospital Tor Vergata and were included in the present prospective study. Mean age was 47 years (range 16-76 years); minimum follow-up period was 6 months (mean 40, range 6-74 months).Patients were treated using 4 operative approaches: fistulotomy, fistulectomy, seton placement and rectal advancement flap. Data analyzed included: age, gender, type of fistula, operative intervention, healing rate, postoperative complications, reinterventions and recurrence. RESULTS: Etiologies of fistulas were cryptoglandular (n = 218), Crohn's disease (n = 26) and Ulcerative Colitis (n = 3). Fistulae were classified as simple -intersphincteric 57 (23%), low transphincteric 28 (11%) and complex -high transphicteric 122 (49%), suprasphincteric 2 (0.8%), extrasphinteric 2 (0.8%), recto-vaginal 7 (2.8%) Crohn 26 (10%) and UC 3 (1.2%).The most common surgical procedure was the placement of seton (62%), usually applied in case of complex fistulae and Crohn's patients.Eighty-five patients (34%) underwent fistulotomy, mainly for intersphincteric and mid/low transphincteric tracts. Crohn's patients were submitted to placement of one or more loose setons.The main treatment successfully eradicated the primary fistula tract in 151/247 patients (61%). Three cases of major incontinence (1.3%) were detected during the follow-up period; Furthermore, three patients complained minor incontinence that was successfully treated by biofeedback and permacol injection into the internal anal sphincter. CONCLUSIONS: This prospective audit demonstrates an high proportion of complex anal fistulae treated by seton placement that was the most common surgical technique adopted to treat our patients as a first line. Nevertheless, a good outcome was achieved in the majority of patients with a limited rate of faecal incontinence (6/247 = 2.4%). New technologies provide promising alternatives to traditional methods of management particularly in case of complex fistulas. There is, however, a real need for high-quality randomized control trials to evaluate the different surgical and non surgical treatment options.

Laparoscopic treatment of a huge mesenteric chylous cyst.

Mesenteric chylous cysts are rare pathologic entities that often present with unspecific symptoms. The preoperative diagnosis requires all the common abdominal imaging techniques, but usually the correct diagnosis may be made only at the operation stage or during the histological examination. The treatment of choice is the complete surgical excision that may be safely performed by laparoscopy. A 58-year-old man underwent laparoscopic excision of a huge mesenteric chylous cyst. The technique entails the perfect control of the major abdominal vessels running near the tumor and the complete sealing of the chylous and blood vessels to and from the cyst.

A Surgical Instrument Cover for the Prevention of Thermal Injuries During Laparoscopic Operations.

INTRODUCTION: Accidental thermal injuries are infrequent, nonetheless, dangerous complications in laparoscopic surgery. Burns are produced because of direct contact, lack of instrument insulation and capacitive coupling. Biological fluids on the surface of laparoscopic instruments behave as electric conductors on the sheath and may be responsible for accidental thermal injuries. Our hypothesis is that using an insulator device may prevent those injuries. MATERIALS AND METHODS: After evaluating different materials for dielectric properties, costs, and temperature increase tolerance, we selected polytetrafluoroethylene (PTFE) to develop a sleeve that works as an electrical insulator when applied on the sheath of laparoscopic instruments. Efficacy of this PTFE cover in reducing conduction of electricity was tested on both reusable and disposable laparoscopic instruments. RESULTS: Electric conduction of the laparoscopic instrument sheaths was tested using an ex vivo model that reproduces the abdominal environment in basal conditions and in presence of blood. Electric conduction of laparoscopic instruments was measured before and after the placement of the PTFE cover. We measured a significant difference in electric resistance on the sheath's surface without and with blood, revealing a weak electrical conduction: infinity versus a median value of 251.11 Mohm, respectively. CONCLUSIONS: This ex vivo study demonstrated that a PTFE sleeve may reduce electricity conduction of laparoscopic instruments. A pilot in vivo study is planned to test its safety and efficacy.

Stapled hemorrhoidopexy: a prospective study from pathology to clinical outcome.

Stapled hemorrhoidopexy is widely accepted to treat hemorrhoids, but serious complications have been reported. In this prospective audit, we correlated clinical outcome with pathological findings. From January 2003 to April 2007, 94 patients underwent hemorrhoidopexy. Macroscopic appearance of the specimen (shape, size, and depth) was recorded. Microscopically, the presence of columnar, transitional, and squamous epithelium, the involvement of circular/longitudinal smooth muscle, and features of mucosal prolapse were assessed. Clinical outcome was evaluated by a validated questionnaire. Postoperative pain, secretion, and bleeding durations were 12.7+/-10.6, 5.6+/-9.6, and 6.3+/-8.4 days. Patient's return to work averaged 16.7+/-10.7 days. Fissure, skin tags, and anal strictures were observed in 23.4%. Seven patients experienced pain for a significantly longer period of time. All specimens contained columnar mucosa, but 29.8% contained columnar and transitional epithelium and 12.8% contained columnar, anal transitional, and stratified squamous epithelium. Smooth muscle was observed in 62.7%. Pain was significantly increased if transitional epithelium was present in the specimen. No correlation or differences were observed if smooth muscle was present, although postoperative bleeding was more frequent. Hemorrhoidopexy is safe and effective. The specimen should always be sent for pathology examination. Only columnar epithelium should be present and, although the presence of smooth muscle does not influence the outcome in terms of functional results, its presence may play a role in postoperative bleeding.

Squamous cell carcinoma of the breast. Report of two cases.

Squamous Cell Carcinoma (SCC) of the breast is a rare entity, not well known, nevertheless literature reports several signalings from different authors. Regarding ethiopathogenesis, SCC of the breast is still the object of numerous discordances and controversies. We report two cases of SCC of the breast referred to our institution in the last year. The first case interests a 35 years-old woman with a lesion of the left breast referred to us with a 3 month history of breast mass. The second case regards a 49 year-old women with multicentric lesions of the right breast operated in two different times. The SCC is a rare breast entity with a controversial histogenesis. The development is characterized by metastasis frequency. The treatment remains not codified. The treatment is currently the same as for infiltrating ductal carcinoma. Indeed, the limited number of this kind of tumor doesn't allow the assessment of different therapeutic protocols.

Skeletal muscle metastases from renal cell carcinoma: a case report.

In this paper, we describe a case of a 73-year old female with late skeletal muscle metastases from a clear-type renal cell carcinoma 8 years after total nephrectomy. The metastases were located in the right femoral quadriceps, in the sartorius muscle and adductor magnus muscle. A full clinical work-up was performed with blood examinations, radiological and pathological assessment. A complete surgical resection with a wide margin was performed for all lesions, and the final pathological report deposed for metastatic renal carcinoma clear-type cells. In this case report, we discuss the crucial rule of accurate radiological and pathological assessment and aggressive surgical management.

Minilaparoscopic appendectomy for acute appendicitis.

BACKGROUND: Minilaparoscopic appendectomy for appendicitis is not a well-established procedure. This approach provides less abdominal wall trauma, fewer complications, and excellent cosmetic results. Our aim was to show the feasibility and safety of the minilaparoscopic approach. METHODS: Minilaparoscopic appendectomy was performed in 37 patients. Two 2.2-mm trocars were used to manipulate a 2.2-mm, 0-degree laparoscope and for grasper access. A 5-mm trocar was used for the ultrasonic scalpel. RESULTS: No deaths occurred. In 3 patients (8%), appendectomy was aborted due to pathology of the ovary. Conversion to the open approach occurred in 2.7% of patients. The average operating time was 34 minutes (range, 15 to 80), and the median length of hospital stay was 1.2 day (range, 1 to 5). CONCLUSIONS: The minilaparoscopic approach a) has the same advantages as the conventional laparoscopic approach in terms of better diagnostic accuracy and safety; b) a low incidence of complications; and c) yields excellent cosmetic results.

Robotic systems and surgical education.

This experimental study aimed at evaluating the efficiency of robots in the learning of surgical techniques. We recruited 40 surgeons, divided them into 2 groups of 20, each of which used the robotic system. The first group consisted of experienced physicians, and the second group comprised physicians in training. Each surgeon was allowed to use the da Vinci robotic system for 30 minutes twice in the span of 24 hours. The practice time period was divided into 15 minutes for tying and placement of sutures and 15 minutes for incisions and vascular suturing. We recorded the times required for the performances, and a statistically significant outcome was obtained. With variance analysis (ANOVA), it has been shown that the time needed to perform the exercises depends in a statistically significant way on the kind of test to be performed (P<0.01), the experience of the surgeon (P<0.001), and the kind of operation (P<0.025). Robotic systems can be an optimal tool both for residents and experienced surgeons, for learning of basic surgical tasks and for perfection of clinical skills. The use of the system has great potential in surgical training, offering a reduction in the learning period, enabling checking for errors, and allowing an evaluation of the capabilities obtained. Final goals are a drastic reduction in the learning curve, a better technique, with a significant reduction in surgical errors and complications, with greater safety for the patient.

[Impact of laparoscopic surgery in the treatment of chronic abdominal pain syndrome]. / L'impatto della chirurgia laparoscopica nel trattamento della sindrome del dolore addominale cronico.

Chronic abdominal pain syndrome is becoming increasingly important with regard to the quality of life of the patients and its social and economic impact, in terms of cost of hospitalization, income loss due to sick leave, and pharmaceutical costs for treatments which fail to offer either significant clinical improvement or resolution of the pain symptoms. The main symptom is chronic abdominal pain, which may vary in intensity and may be associated with constipation and episodes of vomiting, when the clinical picture evolves toward one of subocclusion or total occlusion of the bowel. We considered the following criteria in our selection of patients for this study: 1) quality of life, 2) constant use of antispastic and analgesic medications, 3) absence of any other diagnosticable pathology prior to the operation. From August 1992 to April 2000 we operated on 105 patients with this syndrome (16 males and 89 females). Among these 8 patients had never been subjected to a laparotomy, while 97 had previously undergone surgical procedures (126 laparotomies). In the first 85 patients in the series (81%) we used a 10 mm laparoscope (0-30 degrees) to evaluate the presence of abdominal-visceral adhesions based on the type of surgery the patient had undergone previously, as well as the location of the pain reported by the patient. In 41 cases (48.2%) the pneumoperitoneum was obtained with the Veress needle. In another 44 cases (51.8%) the Hasson technique was used. Since June 1999, we have carried out the exploration of the abdominal cavity in 20 patients (19%) using a trocar and 2.2 mm laparoscope in the left hypochondrium along with a mini-trocar placed either in the right or left flank. (The positioning of the trocars depended on the previous surgical procedures performed). The exploration included inspection of the abdominal cavity. In 8 of the patients the procedure was carried out under local anaesthesia We performed laparoscopic adhesiolysis in 93 cases; in 7 cases no signs of adhesions were seen, while in another 5 cases it was necessary to convert the original laparoscopic procedure to a laparotomy. The types of adhesions found were fine-filmy (46%), dense-vascularised (46%), and cohesive (16%). In 6 cases during lysis of the adhesions complications of serous-muscular lesions occurred, which required laparotomic repair. In 5 cases we diagnosed a pathological condition which was not suspected. The average postoperative hospital stay was 2 days (range: 1-7); no major postoperative complications were noted. In the course of the follow-up of 78 patients over an average of 37 months (range: 6-72) the results obtained were as follows; 47 patients (60.2%) had complete pain relief, 18 patients (23.1%) had partial pain relief, and the remaining 13 patients (16.7%) had no significant pain relief. Laparoscopic exploration in patients with chronic abdominal pain is technically feasible in a simple manner in most patients. By means of careful and accurate preoperative selection of the patients partial if not complete pain relief can be achieved in a high percentage of cases (83.3% in our series).

Harmonic Focus™ versus "knot tying" during total thyroidectomy: a randomized trial.

The objective of the study is to compare the outcome of total thyroidectomy (TT) using the Harmonic Focus™ (HF) versus conventional "knot tying" (KT) in terms of operative time, parathyroid function and post-operative complications. This prospective study was designed with a random allocation of subjects using a drawing technique. Eighty-one consecutive patients were submitted to TT in 2010 and randomly divided into two groups: 43 patients operated using HF (HF group) and 38 patients operated using KT (KT group). Parathyroid function was evaluated by parathyroid hormone (PTH) level at 1 h postoperatively and calcium level at first post-operative day. Indications for medical therapy were PTH < 15 pg/ml and/or calcium < 8.0 mg/dl and/or clinical signs or symptoms of hypocalcemia. Main outcomes were operative time, PTH and calcium levels, need for medical therapy and post-operative complications. Mean operative time was significantly lower in HF group compared with KT group (100 ± 34 vs. 119 ± 30 min). There were no significant differences concerning transient hypoparathyroidism requiring calcium and/or vitamin D therapy: 17 patients (39.5%) in HF group versus 21 (55.3%) in KT group. Five patients (11.6%) in HF group experienced symptomatic hypocalcemia versus 6 (15.8%) in KT group, without statistically significant difference. No patients experienced recurrent nerve injury. HF is a new ergonomic, reliable device developed for thyroid surgery. According to our results, HF is a safe, time-saving alternative to "knot tying" thyroidectomy, with no influence on parathyroid function, medical therapy and nerve injury.

Reinterventions for specific technique-related complications of stapled haemorrhoidopexy (SH): a critical appraisal.

INTRODUCTION: Stapled haemorrhoidopexy (SH) is an attractive alternative to conventional haemorrhoidectomy (CH) because of reduced pain and earlier return to normal activities. However, complication rates are as high as 31%. Although some complications are similar to CH, most are specifically technique-related. In this prospective audit, we report our experience with the management of some of these complications. METHODS: Data on patients undergoing SH at our unit or referred to us are prospectively entered in a database. The onset or duration of specific SH-related complications as well as reinterventions for failed or complicated SH was recorded. RESULTS: From 1/03 to 10/07, 110 patients underwent SH, while 17 patients were referred after complicated/failed SH. Overall early and late complication rates after SH were 12.7% and 27.2%, respectively. Overall reintervention rate was 9.1%. Among the referred SH-group, one patient underwent Hartmann's procedure because of rectal perforation. The remaining 16 patients experienced at least one of the following: recurrence, urgency, frequency, severe persistent anal pain, colicky abdominal pain, anal fissure and stenosis. Four patients underwent CH with regular postoperative recovery. Two patients underwent exploration under anaesthesia because of persisting pain. One patient underwent anoplasty. CONCLUSIONS: SH presents unusual and challenging complications. Abuses should be minimized and longer-term studies are needed to further clarify its role.

Evidence-based appraisal of antireflux fundoplication.

OBJECTIVE: To highlight the current available evidence in antireflux surgery through a systematic review of randomized controlled trials (RCTs). SUMMARY BACKGROUND DATA: Laparoscopic fundoplication is currently suggested as the gold standard for the surgical treatment of gastroesophageal reflux disease, but many controversies are still open concerning the influence of some technical details on its results. METHODS: Papers related to RCTs identified via a systematic literature search were evaluated according to standard criteria. Data regarding the patient sample, study methods, and outcomes were abstracted and summarized across studies. Defined outcomes were examined for 41 papers published from 1974 to 2002 related to 25 RCTs. A meta-analysis was performed pooling the results as odds ratios (OR), rate differences (RD), and number needed to treat (NNT). Data given as mean and/or median values were pooled as a mean +/- SD (SD). RESULTS: No perioperative deaths were found in any of the RCTs. Immediate results showed a significantly lower operative morbidity rate (10.3% versus 26.7%, OR 0.33, RD -12%, NNT 8), shorter postoperative stay (3.1 versus 5.2 days, P = 0.03), and shorter sick leave (20.1 versus 35.8 days, P = 0.03) for laparoscopic versus open fundoplication. No significant differences were found regarding the incidence of recurrence, dysphagia, bloating, and reoperation for failure at midterm follow-up. No significant differences in operative morbidity (13.1% versus 9.4%) and in operative time (90.2 versus 84.2 minutes) were found in partial versus total fundoplication. A significantly lower incidence of reoperation for failure (1.6% versus 9.6%, OR 0.21, RD -7%, NNT 14) was found after partial fundoplication, with no significant differences regarding the incidence of recurrence and/or dysphagia. Routine division of short gastric vessels during total fundoplication showed no significant advantages regarding the incidence of postoperative dysphagia and recurrence when compared with no division. The use of ultrasonic scalpel compared with clips or bipolar cautery for the division of short gastric vessels showed no significant effect on operative time, postoperative complications, and costs. CONCLUSIONS: Laparoscopic antireflux surgery is at least as safe and as effective as its open counterpart, with reduced morbidity, shortened postoperative stay, and sick leave. Partial fundoplication significantly reduces the risk of reoperations for failure over total fundoplication. Routine versus no division of short gastric vessels showed no significant advantages. A word of caution is needed when implementing these results derived from RCTs performed in specialized centers into everyday clinical practice, where experience and skills may be suboptimal.