[Analysis of short-term respiratory adverse events in 183 bronchial thermoplasty procedures].

Objective: To analyze the short-term (3 weeks) adverse respiratory events after bronchial thermoplasty(BT) in patients with severe asthma. Methods: The China-Japan Friendship Hospital recruited 62 patients with severe asthma for BT treatment from March 2014 to July 2016, with a total of 183 BT procedures. The data of adverse respiratory events within 3 weeks after procedure were collected to analyze the factors that might potentially influence the occurrence of adverse events. Results: Forty-three patients (69.4%) experienced adverse respiratory events within 3 weeks after treatment. Totally 153 adverse respiratory events occurred after 87 procedures(47.5%). The main adverse events were cough (15 events, 8.20%), sputum production (37 events, 20.22%), temporary PEF reduction (37 events, 20.22%), chest distress (12 events, 6.56%), blood in sputum (11 events, 6.01%), asthma exacerbation (10 events, 5.46%), and pneumonia(6 events, 3.28%). Most events were relieved or resolved with standard therapy in 1 week. No severe adverse events including tracheal intubation, malignant arrhythmias or death occurred within 3 weeks after procedure. The baseline eosinophil percentage in induced sputum and blood, operation times, and preoperative FEV(1) (% predicted) might influence the occurrence of adverse events after treatment. Patients with preoperative FEV(1) (% predicted) ≥60% had lower risk of adverse events. Conclusion: BT showed a good security profile in treating patients with severe asthma within 3 weeks after procedure.

Resultados de la miectomía anorrectal posterior en el tratamiento del estreñimiento crónico idiopático / Outcome of posterior anorectal myectomy for the treatment of idiopathic chronic constipation

Objetivo. Evaluar los resultados clínicos del tratamiento quirúrgico de pacientes con estreñimiento crónico incontrolable con tratamiento médico. Material y métodos. Estudio descriptivo de pacientes con estreñimiento crónico severo tratados mediante miectomía anorrectal posterior (técnica de Lynn). Se recogen los resultados de los últimos 15 años, con periodo de seguimiento postoperatorio mínimo de 1 año. Se incluyen pacientes con larga historia de estreñimiento, refractarios a tratamiento médico. Pruebas complementarias: enema opaco, manometría anorrectal y biopsias rectales. El resultado clínico de la técnica se clasifica según los siguientes criterios: Curación: >3 movimientos intestinales por semana, sin incontinencia/encopresis y sin necesidad de tratamiento médico. Mejoría: >3 movimientos intestinales por semana, sin incontinencia/ encopresis y con necesidad de laxante. Resultados. Se realizaron 19 miectomías (edad media de 8,47 años). Tiempo medio de estreñimiento previo de 7,89 años. Los hallazgos en la anatomía patológica fueron: presencia de células ganglionares en 10, ausencia de células ganglionares en 4 y otras alteraciones en 5. Manometría en 6 pacientes, 4 presentaron reflejo inhibitorio anal. Cuatro pacientes se diagnosticaron de enfermedad de Hirschsprung (uno se curó con la miectomía, dos precisaron cirugía correctora y uno no acudió a revisiones). En los 15 restantes, cumplieron criterios de curación 8 pacientes (53,3%), 4 mejoraron (26,6%), 1 sin mejoría sigue tratamiento fisioterápico. Dos pacientes no continuaron las revisiones. No se registró incontinencia fecal ni otras complicaciones. Conclusiones. La miectomía de Lynn es un procedimiento eficaz y seguro para los pacientes con estreñimiento crónico severo refractario al tratamiento médico. También resulta el tratamiento definitivo en la enfermedad de Hirschsprung de segmento ultracorto

Objectives. The aim of this study is to assess the outcome of surgery (Lynn’s myectomy) in patients with chronic persistent constipation and failure of medical treatment. Material and methods. Descriptive study of patients with severe chronic constipation treated by posterior anorectal myectomy (Lynn’s technique). We report data from the last 15 years, with a minimum postoperative follow-up of one year. Patients included in the study suffered from a long-term constipation refractory to medical management. Data regarding contrast enema, anorectal manometry and rectal biopsy were recorded. The procedure’s outcome is classified following clinical criteria: Asymptomatic: >3 bowel movements per week, with no soiling/ incontinence and with no medical treatment. Improvement: >3 bowel movements per week, with no soiling/ incontinence but using laxatives occasionally. Results. Nineteen myectomies were performed (median age of 8.47 years). Median time of constipation before surgery was 7.89 years. Rectal biopsy findings: 10 with ganglion cells, 4 without ganglion cells and other abnormalities in 5. Anorectal manometry was performed in 6 patients, 4 presented rectoanal inhibitory reflex. Four patients were diagnosed of Hirschsprung’s disease (1 was asymptomatic after myectomy, 2 needed further surgery and 1 was lost in follow-up). Of the remaining 15 patients, 8 were asymptomatic (53.3%), 4 experienced improvement (26.6%) and 1 without clinical changes is on pelvic floor physiotherapy. Two were lost in follow-up. There were no other postoperative complications after long term follow-up. Conclusions. Lynn’s myectomy is an effective and safe procedure in patients suffering from persistent chronic constipation despite of medical treatment. It is also the definitive treatment for patients with ultrashort-segment Hirschsprung’s disease

A Skin Crease Preserving Modification of Open-Sky Mullerectomy for Blepharoptosis Correction.

PURPOSE: To report the results of skin crease preservation with a modified technique of open-sky Muller's muscle-conjunctival resection that precludes the need to reconstruct the upper eyelid skin crease with full thickness sutures. METHODS: A nonrandomized, retrospective audit of 45 eyelids of 37 consecutive patients with acquired blepharoptosis, undergoing surgical correction by a single surgeon, between November 2011 and July 2014. Surgical technique involved subtotal resection of Muller's muscle plus underlying conjunctiva, under direct visualization. The stump of Muller's muscle was then reattached to the superior tarsus with buried 7-0 Vicryl. Wound closure was achieved using interrupted buried 7-0 Vicryl, without full thickness skin crease reformation. Outcomes were evaluated according to standards recommended by the British Oculoplastic Surgery Society National Ptosis survey. These included assessment of upper margin reflex distance (MRD1), skin crease, eyelid contour and symmetry and surgical complications. RESULTS: In total, all 45 eyelids met the outcome criteria for success. The median MRD1 increased from 0 mm preoperatively (range: -2 to 2) to 3.1 mm (range: 3-5 mm) following surgery, p value < 0.01. For patients with unilateral blepharoptosis, the average postoperative eyelid height difference between right and left was 0.17 mm (range: 0-1 mm). All patients achieved good eyelid contour and symmetry and none required reoperation as assessed at final follow up following surgery (mean 77 days, range: 24-366). Skin crease was lowered and normalized in all patients with median preoperative and postoperative measurements of 12 mm and 10 mm, respectively, p value < 0.01. Two cases (4.4%) developed early asymptomatic superficial punctate keratopathy, which resolved spontaneously by 4 weeks. Nonstandardized patient experience survey achieved high scores for overall satisfaction and likelihood to recommend treatment to friends and family, with low scores for postoperative pain and swelling. CONCLUSIONS: Skin Crease Preserving modified open-sky Muller's muscle-conjunctival resection is an effective technique for correcting blepharoptosis, while normalizing the skin crease.

Promising future therapies for asthma.

Asthma affects 300 million people worldwide and that number has been increasing especially in developed countries. The current standard of care for asthma treatment is based on 2 key pathological features of asthma, airway inflammation and airway obstruction. Improving bronchodilation can be accomplished with ultra-long acting beta2 agonists or long-acting muscarinic agonists used in combination with inhaled corticosteroids. These combinations have already been used effectively for the treatment of COPD. An inhaled phosphodiesterase inhibitor has been shown to improve bronchodilation and decrease airway inflammation. Directly altering the airway smooth muscle with bronchial thermoplasty in select patients has demonstrated long-term benefits but must be measured with immediate post procedure complications. The development of monoclonal antibodies to directly target specific cytokines has had mixed results. In eosinophilic asthma blocking IL-4, IL-5 and IL-13 have improved asthma outcomes. The promise of more directed therapy for asthma appears closer than ever with increased options available for the clinician in the near future.

Intractable chronic constipation in children: outcome after anorectal myectomy.

BACKGROUND: Many children with constipation fail to respond with conventional medical therapy. Surgery can produce a good result in dysfunction of the colon secondary to aganglionosis. However, its role in treating idiopathic constipation is more controversial. PATIENTS AND METHODS: A consecutive series of 44 patients with chronic idiopathic intractable constipation were included in this study. All children were investigated by barium enema and anorectal manometry. Due to inadequate response to medical therapy, all of these patients were selected for internal sphincter myomectomy. Patients were followed-up from 3 to 12 months. RESULTS: Short-term (3 months) and long-term (6 months) follow-up was available for all patients. The histology examinations showed normal ganglion cells in 32, hypoganglionosis in eight and aganglionosis in four patients. In short-term, regular bowel habits, without the need for laxatives or low dose drugs were recorded in 35 patients (79.5%). Overall there was an improvement in 68.2% of the children after 6 months follow-up. There was not any correlation between histopathological findings, duration of symptoms, age and sex of operation and response to myectomy. CONCLUSION: anorectal myectomy is an effective procedure in patients with intractable idiopathic constipation. It relieves symptoms in 68.2% of patients with chronic refractory constipation.

The problematic Soave cuff in Hirschsprung disease: manifestations and treatment.

PURPOSE: Following a Soave pull-through for Hirschsprung disease (HD), some children struggle with obstructive symptoms. We hypothesized that these symptoms could result from a functional obstruction of the pull through caused by the Soave cuff, and that cuff resection might improve bowel emptying. METHODS: We reviewed patients referred to our center from 2008 to 2012 with obstructive problems following a Soave pull-through for HD (CCHMC IRB # 2011-2019). Only patients with an obstructing Soave cuff were analyzed. Patients with other reasons for obstruction (anastomotic stricture, transition zone, aganglionic segment) were excluded. RESULTS: Thirty-six patients underwent reoperation at our center for obstructive symptoms after an initial Soave pull-through. Seventeen of these patients had a Soave cuff only as the potential source of obstruction. Pre-operative symptoms included enterocolitis (10), constipation (6), and failure to thrive (1). Nine patients (53%) required irrigations to manage distension or enterocolitis pre-operatively. 14/17 patients (82%) had a palpable cuff on rectal exam. Eight patients (47%) had radiographic evidence of a cuff demonstrated by distal narrowing (4) or a prominent presacral space (4). Four children (23%) underwent excision of the cuff only. Thirteen (76%) had removal of the cuff and proximally dilated colon [(average length 7.2cm) (12 performed transanally, and five needed laparotomy as well.)] Post-operatively, episodes of enterocolitis were reduced to zero, and need for irrigation to treat distension was reduced by 50%. Nine patients have voluntary bowel movements, and five are clean on enemas. 3/6 patients with pre-operative constipation or impaction now empty without enemas. (Follow up 1-17months, mean 7months.) CONCLUSIONS: Recurrent enterocolitis, constipation, or failure to thrive can indicate a functional obstruction due to a Soave cuff when no other pathologic cause exists. Physical exam or contrast enema can identify a problematic cuff. Reoperation with cuff resection can dramatically improve bowel emptying.

Comparison of botulinium toxin injection and posterior anorectal myectomy in treatment of internal anal sphincter achalasia.

OBJECTIVE: We compared the efficacy of intra-sphincteric botulinum toxin (BT) injection and posterior anorectal myectomy (PARM) for the treatment of internal anal sphincter achalasia (IASA). METHODS: Twenty eight of 120 patients (23%) with chronic constipation, who were referred to our clinic from September 2005 to December 2006, were evaluated. Patients had an absence of rectoanal inhibitory reflex on anorectal manometry (ARM) and showed no transitional region on barium enema. Fourteen patients each underwent rectal biopsy, and were treated with either intrasphincteric BT injection (Group I) or PARM (Group II). Nine patients were excluded because of absent ganglion cells on histology or positive acetylcholinesterase staining (AChE). The remaining 19 patients were followed up. All patients underwent ARM and constipation severity score (CSS) assessment 2 weeks before, and 1 and 6 months after the treatment. Patients were followed up telephonically at 12 months after treatment. RESULTS: Clinically good response was seen after 12 months in 3 patients each in Groups I and II. The median values of resting rectal pressure in Group I before and 6 months after BT injection were 60 mmHg and 40 mmHg (p< 0.0001), respectively, while in Group II the corresponding values were 60 mmHg and 45 mmHg (p< 0.0001), respectively. Compared to pre-treatment, median CSS improved in both Group I (14 to 13) and Group II (16 to 14) at 6 months after treatment (p< 0.0001 for both). However, there was no difference in resting rectal pressure and CSS between the groups. Three patients in Group II developed local abscess, postoperatively. CONCLUSIONS: BT injection has a similar efficacy as compared with PARM for the treatment of IASA, is less invasive and, is also associated with fewer complications.

Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma.

RATIONALE: Bronchial thermoplasty (BT) is designed to reduce airway smooth muscle and improve asthma control. OBJECTIVES: This study was conducted to determine the safety and efficacy of this procedure in subjects with symptomatic, severe asthma. METHODS: Adults who were symptomatic despite treatment with fluticasone or equivalent at more than 750 mug/day, a long-acting beta(2)-agonist, and other medications, which could include 30 mg or less of oral prednisolone/day, were randomized to BT or to a control group. After treatment, subjects entered a 16-week steroid stable phase (Weeks 6-22), a 14-week steroid wean phase (Weeks 22-36), and a 16-week reduced steroid phase (Weeks 36-52). MEASUREMENTS AND MAIN RESULTS: BT resulted in a transient worsening of asthma symptoms. Seven hospitalizations for respiratory symptoms occurred in 4 of 15 BT subjects during the treatment period. Five hospitalizations were within 3 days of treatment. Two subjects had segmental collapse involving the most recently treated lobe; one required bronchoscopy and aspiration of a mucus plug. There were no hospitalizations during this period in the 17 control subjects. The rate of hospitalizations was similar in both groups in the post-treatment period. At 22 weeks, BT subjects had significant improvements versus control subjects in rescue medication use (-26.6 +/- 40.1 vs. -1.5 +/- 11.7 puffs/7 d, P < 0.05), prebronchodilator FEV(1)% predicted (14.9 +/- 17.4 vs. -0.94 +/- 22.3%, P = 0.04), and Asthma Control Questionnaire scores (-1.04 +/- 1.03 vs. -0.13 +/- 1.00, P = 0.02). Improvements in rescue medication use and Asthma Control Questionnaire scores remained significantly different from those of controls at 52 weeks. CONCLUSIONS: BT is associated with a short-term increase in asthma-related morbidity. However, there is preliminary evidence of long-lasting improvement in asthma control. Clinical trial registered with www.clinicaltrials.gov (NCT 00214539).

Assessments of anorectal myectomy for short segment hypoganglionosis in childhood.

BACKGROUND/AIMS: To clarify the significance of anorectal myectomy (ARM) in childhood patients with short segment hypoganglionosis (Hypo), we analyzed the clinical features of these patients before and after ARM. METHODOLOGY: A consecutive series of twenty-nine patients with short segment Hypo were included in this study. These were sixteen males and thirteen females, aged between 6 and 15 years with a mean age of 9.8 years. We performed an analysis of the clinical findings and outcomes for patients with short segment Hypo before and after ARM. Stool frequencies were less than twice per week (0.5-2 per week, mean: 1.6 per week) despite the use of laxatives, suppositories, and enema before ARM. RESULTS: About 90% of patients had an onset of constipation before the age of 6 years. In addition, significant differences were noted between 0 months < or = to <1 year and 1 year < or = to < or =15 years (P < 0.0001). There were no sexual differences. Difficulty in defecation was the most common symptom, followed by abdominal fullness, abdominal pain and soiling. In abdominal fullness and pain, there were significant differences between positive and negative groups (P < 0.0001, P = 0.0038, respectively). No patients responded to use of laxatives, suppositories, and enema before ARM. In patients after ARM, the most common outcome was good (65.5%; bowel movement every day without laxatives and no other symptoms), followed by satisfactory (20.7%; bowel movement 2-3 times per week without laxatives and no other symptoms) and poor (13.8%; no improvement) in decreasing order. Significant differences of patient numbers were noted between good and the remaining outcomes (P = 0.0181). Spontaneous evacuation without the need for laxatives, suppositories, and enema was recorded in 100% patients of good outcome, and 42.9% those of satisfactory outcome after ARM. Patients with poor outcome still required for laxatives, suppositories, and enema. Central nervous, psychological, and psychiatric disorders were recognized in patients with satisfactory outcome, and constipation was maintained to these patients. However, the necessity for medication to them was lost. Moreover, clinical symptoms disappeared. Redundant colon was only found in patients with poor outcome. CONCLUSIONS: Patients with short segment Hypo, especially those with redundant colon, psychological, psychiatric, or central nervous disorders, may experience persistent constipation after ARM.

Open versus laparoscopy-assisted radical cystectomy: results of a prospective study.

BACKGROUND AND PURPOSE: Laparoscopic radical cystectomy is confined to centers where advanced laparoscopy is performed, and its role is not yet well clear. Our aim was to evaluate, through a prospective comparative study, the advantages of the laparoscopic compared with an open approach. PATIENTS AND METHODS: From November 2002 to December 2005, all the patients in our center who were found to have muscle-invasive bladder cancer without clinical evidence of lymph-node involvement and an American Society of Anesthesiologists (ASA) score <4 were included in a prospective nonrandomized study. Group A (N = 22) underwent open radical cystectomy, whereas group B (N = 20) underwent laparoscopy-assisted radical cystectomy. The two groups were demographically comparable. We evaluated the mean age, clinical stage, ASA score, operative time, blood loss, intraoperative complications and transfusions, type of diversion, time of catheterization, analgesic consumption, start of oral nutrition, rate of postoperative complications, length of hospital stay, pathologic diagnosis of the specimen, number of lymph nodes removed, and the oncologic outcome. RESULTS: No significant statistical difference was observed between the two groups in intraoperative and postoperative parameters except for analgesic consumption and the start of oral nutrition (P < 0.05). The mean operative time was 260 minutes (range 210-290 minutes) for group A and 284 minutes (range 260-305 minutes) for group B. The mean blood loss was 770 mL (range 450-870 mL) in group A and 520 mL (range 400-620 mL) in group B. The rate of autologous transfusion was 18% in group A and 10% in group B. Seventeen ileal diversions and five neobladder creations were performed in group A, whereas the Bricker diversion was used in 10 cases in group B, and a neobladder was chosen in the 10 other cases. CONCLUSION: Laparoscopy-assisted radical cystectomy is a safe procedure, like open surgery, but it offers the advantage of minimal invasiveness, represented by reduced analgesic consumption and early recovery of peristalsis with rapid oral nutrition.

Asthma control during the year after bronchial thermoplasty.

BACKGROUND: Bronchial thermoplasty is a bronchoscopic procedure to reduce the mass of airway smooth muscle and attenuate bronchoconstriction. We examined the effect of bronchial thermoplasty on the control of moderate or severe persistent asthma. METHODS: We randomly assigned 112 subjects who had been treated with inhaled corticosteroids and long-acting beta2-adrenergic agonists (LABA) and in whom asthma control was impaired when the LABA were withdrawn to either bronchial thermoplasty or a control group. The primary outcome was the frequency of mild exacerbations, calculated during three scheduled 2-week periods of abstinence from LABA at 3, 6, and 12 months. Airflow, airway responsiveness, asthma symptoms, the number of symptom-free days, use of rescue medication, and scores on the Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire (ACQ) were also assessed. RESULTS: The mean rate of mild exacerbations, as compared with baseline, was reduced in the bronchial-thermoplasty group but was unchanged in the control group (change in frequency per subject per week, -0.16+/-0.37 vs. 0.04+/-0.29; P=0.005). At 12 months, there were significantly greater improvements in the bronchial-thermoplasty group than in the control group in the morning peak expiratory flow (39.3+/-48.7 vs. 8.5+/-44.2 liters per minute), scores on the AQLQ (1.3+/-1.0 vs. 0.6+/-1.1) and ACQ (reduction, 1.2+/-1.0 vs. 0.5+/-1.0), the percentage of symptom-free days (40.6+/-39.7 vs. 17.0+/-37.9), and symptom scores (reduction, 1.9+/-2.1 vs. 0.7+/-2.5) while fewer puffs of rescue medication were required. Values for airway responsiveness and forced expiratory volume in 1 second did not differ significantly between the two groups. Adverse events immediately after treatment were more common in the bronchial-thermoplasty group than in the control group but were similar during the period from 6 weeks to 12 months after treatment. CONCLUSIONS: Bronchial thermoplasty in subjects with moderate or severe asthma results in an improvement in asthma control. (ClinicalTrials.gov number, NCT00214526 [ClinicalTrials.gov].).

Role of anorectal myectomy in the treatment of short segment Hirschsprung's disease in young adults.

Basic pathological disorder in Hirschsprung's disease (HD) comes into being by the abnormal innervations of the aganglionic distal intestine. The nonserious forms of this congenital disease may reach the young by proceeding with chronic, obstinate constipation that does not respond to diet. Myectomy of the short segment of aganglionic part may provide diagnostic and therapeutic value. Between 1993 and 2003, anorectal posterior myectomy was performed in 19 patients diagnosed with HD. The mean age of patients was 23 years. Previous or concomitant anterior resection was added to the procedure in seven cases due to dolicomegacolon. In addition to the deficiency of anorectal inhibitor reflex (ARIR) among all patients, the frequency of defecation was 12.5 days (range, 6-30 days) before operation. Anorectal length before widening was an average of 5.5 cm (range, 2-8 cm). All pathologic specimens were found to be aganglionic. Postoperatively, the mean of first regular defecation interval was 1.5 days (range, 1-3 days). Involution of rectum was evaluated with a rectal examination and barium enema X-rays during follow-up. ARIR of patients also returned to normal. In conclusion, anorectal posterior myectomy is an effective operation in diagnosis and treatment of short-segment HD. Furthermore, colon resection annexed to this operation, in the condition of dolicomegacolon, is also used to remove obstinate constipation.

Colonic obstruction due to sigmoid muscular hyperplasia.

We report a case of acute colonic obstruction initially presumed to be secondary to acute diverticulitis, necessitating emergent surgical intervention. Pathologic examination failed to reveal evidence of inflammation, fibrosis or neoplasia. Marked hypertrophy of the sigmoid circular muscle layer was documented and thought to be the etiology of the colonic obstruction.

Preliminary results of muscle cuff cervicoplasty in the ewe for the treatment of urinary incontinence.

OBJECTIVE: Muscle cuff cervicoplasty consists of dissecting a strip of the superior slip of the levator ani muscle, by sectioning it flush with the symphysis pubis, and applying it like a cuff around the urethra below the bladder neck. METHODS: We conducted a preliminary study in 12 ewes, including preoperative urodynamic assessment, intravenous urography with retrograde cystography on day 15, and another urodynamic assessment 1 and 3 months after the operation. Two animals died, but the other 10 animals were able to be evaluated. An increase in the urethral functional length with an infracervical plateau was revealed on all postoperative urethral profiles. Only transrectal electrostimulation, performed on the last 5 ewes, demonstrated an elevation of the closure pressure by 5-10 cm H2O. At sacrifice of the animals at 4 months, in situ stimulation of the muscle strip induced muscle contraction in 7 of 10 cases. Histological examination demonstrated persistence of muscle fibers in the cuff, despite the presence of marked fibrosis. RESULTS: The preliminary results are encouraging: urinary continence was improved with a minimal risk of retention, and cervicoplasty appears to retain its contractile activity, suggesting the possibility of a long-term sphincteric and proprioceptive action. CONCLUSION: This technique could be proposed in women suffering from urinary stress incontinence with sphincter hypoactivity.

Laparoscopic esophagomyotomy and antireflux procedure with intraoperative manometry.

We have been routinely performing laparoscopic cholecystectomy and antireflux procedures. Having this experience, we decided to assess the feasibility and safety of performing a laparoscopic esophagomyotomy and antireflux procedure. Here we present a case of a 37-year-old man with a history of progressive dysphagia and a diagnosis of achalasia, made on the basis of clinical, endoscopic, and manometric studies. Preoperative manometry reported a pressure of 52 mm Hg (normal, 15-25 mm Hg) for 4.5 cm (normal, > 3 cm). Laparoscopic esophagomyotomy and anterior fundoplication were performed. The esophagomyotomy included a 6-cm segment of distal esophagus and 2 cm of stomach; postoperative manometry was 18 mm Hg for 3 cm. Eight months postoperatively, a barium swallow demonstrated no reflux. Laparoscopic esophagomyotomy and antireflux procedure can be performed with efficacy and safety, with the advantage of a shorter hospitalization and an early recovery compared with the traditional procedure. Also, we emphasize the importance of the intraoperative manometry in the relevance of a concomitant antireflux procedure.