A modified Nissen fundoplication: subjective and objective midterm results.

PURPOSE: The failure rate of laparoscopic anti-reflux surgery is approximately 10-20%. The aim of our prospective study was to investigate whether a modified Nissen fundoplication (MNF) can improve reflux symptoms and prevent surgical treatment failure in the midterm. METHODS: The MNF consisted of (1) suturing the esophagus to the diaphragmatic crura on each side using four non-absorbable stitches, (2) reinforcing clearly weak crura with a tailored Ultrapro mesh, and (3) fixing the upper stitch of the valve to the diaphragm. Forty-eight consecutive patients experiencing typical gastroesophageal reflux disease (GERD) symptoms at least three times per week for 6 months or longer were assessed before and after surgery using validated symptom and quality of life (GERD-HRQL) questionnaires, high-resolution manometry, 24-h impedance-pH monitoring, endoscopy, and barium swallow. RESULTS: Mortality and perioperative complications were nil. At median follow-up of 46.7 months, the patients experienced significant improvements in symptom and GERD-HRQL scores. One patient presented with severe dyspepsia and another complained of dysphagia requiring a repeat surgery 12 months after the first operation. Esophageal acid exposure (8.8 vs 0.1; p < 0.0001), reflux number (62 vs 8.5; p < 0.0001), and symptom-reflux association (19 vs 0; p < 0.0001) significantly decreased postoperatively. The median esophagogastric junction contractile integral (EGJ-CI) from 31 cases (8.2 vs 21.2 mmHg cm; p = 0.0003) and the abdominal length of the lower esophageal sphincter (LES) (0 vs 16 mm; p = 0.01) increased postoperatively. CONCLUSIONS: Our data demonstrate that the MNF is a safe and effective procedure both in the short term and midterm.

Superior Mesenteric Artery Syndrome: a Prospective Study in a Single Institution.

BACKGROUND: Superior mesenteric artery syndrome (SMAS) is a rare cause of duodenal obstruction, resulting from the compression of the duodenum between superior mesenteric artery and aorta. This prospective registry aims to describe demographic, clinical, and outcome features of patients suffering from SMAS and to point out the indications for surgery. METHODS: Between 2008 and 2016, patients with chronic gastrointestinal symptoms and diagnosis of SMAS were included. Demographics, clinical presentation, diagnosis, and surgical outcome were recorded. Symptoms were investigated with a standardized questionnaire. The diagnosis was achieved through barium swallow, CT/MR angiography (aortomesenteric angle ≤ 22°, distance ≤ 8 mm), endoscopy. All patients underwent duodenojejunostomy ± distal duodenum resection. At follow-up, symptom score and barium swallow were re-evaluated. RESULTS: Thirty-nine patients (11 M/28 F, median age 38 years, median BMI 17.8 kg/m2) were included. Barium swallow showed a gastroduodenal dilation in 57% of patients, and a delayed gastroduodenal emptying in 38%. Median aortomesenteric angle was 11° and distance was 5 mm. All patients underwent duodenojejunostomy, and in 32 patients, a distal duodenum resection was also performed. At a median follow-up of 47 months, the overall symptom score significantly dropped (10 vs. 32, p < 0.0001) and BMI increased (19.5 vs. 17.8, p < 0.0001). Barium swallow at 2 months postoperatively showed an improvement in terms of gastroduodenal dilation and emptying in 38% of patients with preoperative pathological findings. CONCLUSIONS: SMAS is a rare condition that should be suspected in cases of chronic, refractory upper digestive symptoms, particularly in females with low BMIs. Surgical treatment may improve symptoms and quality of life, although it is not curative in all cases. ClinicalTrials.gov Identifier: NCT03416647.

Cost analysis of incisional hernia repair with synthetic mesh and biological mesh: an Italian study.

Repair of an incisional hernia (IH) generates costs on several levels and domains of society. The aim of this study was to make a complete cost analysis of incisional hernia repair (IHR) with synthetic and biological mesh and to compare it with financial reimbursement. Patients were grouped into three levels to determine the complexity of their care, and hence, the costs involved. Group 1 included patients without comorbidities, who underwent a "standard" incisional hernia repair (SIHR), with synthetic mesh. Group 2 included patients with comorbidities, who underwent the same surgical procedure. Group 3 included all patients who underwent a "complex" IHR (CIHR) with biological mesh. Total costs were divided into direct (including preoperative and operative phases) and indirect costs (medications and working days loss). Reimbursement was calculated according to Diagnosis-Related Group (DRG). From 2012 to 2014, 76 patients underwent prosthetic IHR: group 1 (35 pts); group 2 (30 pts); and group 3 (11 pts). The direct costs of preoperative and operative phases for groups 1 and 2 were €5544.25 and €5020.65, respectively, and €16,397.17 in group 3. The total reimbursement in the three groups was €68,292.37 for group 1, €80,014.14 for group 2, and €72,173.79 for group 3, with a total loss of €124,658.43, €69,675.36, and €100,620.04, respectively. All DRGs underestimate the costs related to IHR and CIHR, thus resulting in an important economic loss for the hospital. The cost analysis shows that patient-related risk factors do not alter the overall costs. To provide a correct "cost-based" reimbursement, different DRGs should be created for different types of hernias and prostheses.

A modification of Nissen fundoplication improves patients' outcome and may reduce procedure-related failure rate.

BACKGROUND: Laparoscopic anti-reflux surgery has a failure rate of 10-20%. We aimed to investigate whether a modification of Nissen fundoplication (MNF) may improve patients' outcome and reduce failure rate. MATERIALS & METHODS: We prospectively compared 40 consecutive patients with gastroesophageal reflux disease who underwent anti-reflux surgery: 20 Nissen fundoplication (NF) and 20 the MNF approach. Eight cases in the MNF group needed redo surgery. The MNF consisted in suturing the esophagus to the diaphragmatic crura on each side by means of 4 non-absorbable stitches and in fixing the upper stitch of the valve to diaphragm. In case of clearly weak crura, a reinforcement with Ultrapro mesh was used. All patients were assessed before and after surgery using validated symptoms and quality of life (GERD-HRQL) questionnaires, manometry and 24-h impedance-pH monitoring, endoscopy and barium-swallow. RESULTS: Mortality and postoperative complications were nil. At a median follow-up of 36 months, no significant differences emerged between the MNF and NF group in terms of symptoms, GERD-HRQL scores, manometric findings, and impedance-pH features. Dysphagia was not reported by the MNF group, while it was quite common (20% vs.0%, p = ns) in the NF group. Anti-reflux surgery was successful in all patients in the MNF group, whereas two patients in the NF group presented a slipped wrap and one recurrent reflux; two of these cases required redo-surgery (10% vs. 0%, p = ns). CONCLUSIONS: Our preliminary data demonstrated that the MNF is a safe and effective procedure. Further, it seems to reduce the failure rate associated to the surgical procedure.