Global Forum of Cancer Surgeons: Cancer Surgery During the COVID-19 Pandemic: Impact and Lessons Learned.

BACKGROUND: The purpose of this article is to summarize the opinions of the surgical oncology leaders from the Global Forum of Cancer Surgeons (GFCS) about the global impact of COVID-19 pandemic on cancer surgery. METHODS: A panel session (virtual) was held at the annual Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care to address the impact of COVID-19 on cancer surgery globally. Following the virtual meeting, a questionnaire was sent to all the leaders to gather additional opinions. The input obtained from all the leaders was collated and analyzed to understand how cancer surgeons from across the world adapted in real-time to the impact of COVID-19 pandemic. RESULTS: The surgical oncology leaders noted that the COVID-19 pandemic led to severe disruptions in surgical cancer care across all domains of clinical care, education, and research. Several new changes/protocols associated with increased costs were implemented to deliver safe care. Leaders also noted that preexisting disparities in care were exacerbated, and the pandemic had a detrimental effect on well-being and financial status. CONCLUSIONS: The COVID-19 pandemic has led to severe disruptions in surgical cancer care globally. Leaders of the GFCS opined that new strategies need to be implemented to prepare for any future catastrophic events based on the lessons learned from the current events. The GFCS will embark on developing such a roadmap to ensure that surgical cancer care is preserved in the future regardless of any catastrophic global events.

Fashioning enterotomy closure after totally laparoscopic ileocolic anastomosis for right colon cancer: a multicenter experience.

BACKGROUND: Laparoscopic right hemicolectomy is a commonly performed procedure. Little is known on how to perform the enterotomy closure after stapled side-to-side intracorporeal anastomosis. METHOD: A multicentric case-controlled study has been designed to compare different ways to fashion enterotomy closure: double layer versus single layer, sewn versus stapled, and robotic versus laparoscopic approach. Furthermore, additional characteristics including sutures' materials, interrupted versus running suture and the presence of deep corner suture has been investigated. RESULTS: We collected data for 1092 patients who underwent right hemicolectomy at ten centers. We analyzed 176 robotic against 916 laparoscopic anastomosis: no significant differences were found in terms of bleedings (p = 0.455) and anastomotic leak (p = 0.405). We collected data from 126 laparoscopic sewn single-layer versus 641 laparoscopic sewn double-layer anastomosis: a significant reduction was recorded in terms of leaks in double-layer group (p = 0.02). About double-layer characteristics, we found a significant reduction of bleedings (p = 0.008) and leaks (p = 0.017) with a running suture; similarly, a reduction of bleedings (p = 0.001) and leaks (p = 0.005) was observed with the usage of deep corner closure. The presence of a barbed suture thread seemed to significantly reduce both bleedings (p = 0.001) and leaks (p = 0.001). We found no significant differences in terms of bleedings (p = 0.245) and anastomotic leak (p = 0.660) comparing sewn versus stapled anastomosis. CONCLUSIONS: Fashioning a stapled ileocolic intracorporeal anastomosis, we can recommend the adoption of a double-layer enterotomy closure using a running barbed suture in the first layer. Totally, stapled closure and robotic assistance have to be considered a non-inferior alternative.

3D MRI segmentation and 3D circumferential resection margin evaluation for a standard rectal cancer assessment.

AIM: Recent studies focused on rectal cancer suggested that a 3D imaging segmentation obtained from MRI data could contribute in the definition of the circumferential resection margin (CRM) and in the assessment of the tumor regression following neo-adjuvant treatments. Here, we propose a method for defining and visualizing the circumferential margins using 3D MRI segmentation; this methodology was tested in a clinical study comparing 3D CRM assessment vs standard MRI imaging. PATIENTS AND METHODS: MRI scans performed before neo-adjuvant treatments were selected and reviewed. 3D mesorectal/tumor segmentations were obtained using Digital Imaging and COmmunications in Medicine (DICOM) data; CRMs were calculated using 3D volumes plus a color scale for the closest distances. RESULTS: 3D reconstructions were possible in all selected cases and 3D images implemented by the color scale were positive for immediate CRM visualization. Statistical analyses comparing standard radiology disclosed that the degree of consistency, the reliability of ratings, the correlation and precision were optimal considering the overall cases, but lower in the CRM>0 mm sub-group. CONCLUSIONS: This new method is not inferior comparing standard radiology; moreover, the imaging segmentation we obtained was highly promising and could be helpful in defining a standard CRM measurement, thus it could improve clinical practice.

Prognostic implications of the lymph node count after neoadjuvant treatment for rectal cancer.

BACKGROUND: The aim of this study was to investigate the effect of neoadjuvant chemoradiotherapy on the lymph node yield of rectal cancer surgery. METHODS: Data for patients who underwent neoadjuvant chemoradiotherapy followed by surgery for resectable rectal cancer from June 1992 to June 2009 were reviewed. The primary outcomes measured were the number of lymph nodes retrieved, their status, and patient survival. RESULTS: In total, 345 patients underwent neoadjuvant chemoradiotherapy followed by surgery, and 95 patients had surgery alone. Neoadjuvant chemoradiotherapy decreased both the median (range) number of lymph nodes retrieved (7 (1-33) versus 12.5 (0-44) respectively; P < 0.001) and the number of positive lymph nodes (0 (0-11) versus 0 (0-16); P = 0.001). After neoadjuvant chemoradiotherapy, the number of retrieved lymph nodes was inversely correlated with tumour regression, and with the interval between treatment and surgery. The 5-year overall and disease-free survival rates were 86.5 and 79.1 per cent respectively. After neoadjuvant therapy, lymph node status was found to be an independent predictor of survival, whereas the number of retrieved lymph nodes did not represent a prognostic factor for either overall or disease-free survival. CONCLUSION: Low lymph node count after neoadjuvant chemoradiotherapy for rectal cancer does not signify an inadequate resection or understaging, but represents an increased sensitivity to the treatment.

cDNA-microarray analysis as a new tool to predict lymph node metastasis in gastric cancer.

BACKGROUND: The aim of the present study was to investigate whether microarray gene expression analysis can be used to predict lymph node status in gastric cancer. METHODS: Twenty-nine patients undergoing gastrectomy for cancer were enrolled and subdivided according to the pathologic nodal involvement of their disease (N+ vs. N0). Molecular profiling was performed by cDNA microarray on tumor tissue and healthy mucosa. Data were processed to identify differently expressed genes. Selected genes were categorized with gene ontology. RESULTS: Compared to healthy gastric mucosa, 52 genes were differently expressed in N+ patients, and 50 genes in N0 patients. Forty-five genes were similarly regulated in N+ and N0 patients, whereas 12 genes were differently expressed between N+ and N0 patients. Seven genes were exclusively expressed in N+ patients: Egr-1 was upregulated; Claudin-18, AKR1C2, Cathepsin E, CA II, TFF 1, and progastricsin were downregulated. Five genes were exclusively expressed in N0 patients: Complement C5 receptor 1, PLA2/VII, and MMP- 9 were upregulated; MAO-A and ID-4 were downregulated. CONCLUSIONS: Microarray analysis could be a valuable tool to identify genes associated with lymph node metastasis in gastric cancer. This technique could improve the selection of patients with locally advanced disease who are candidates for extended lymph node dissection, multimodal treatment options, or alternative therapeutic strategies.

Association between colorectal cancer and Streptococcus gallolyticus subsp. pasteuranus (former S. bovis) endocarditis: clinical relevance and cues for microbiota science. Case report and review of the literature.

OBJECTIVE: The purpose of this paper is to contextualize the case of a patient with a synchronous diagnosis of colorectal cancer (CRC) and endocarditis from S. gallolyticus subsp. pasteuranus (former S. Bovis) within the current evidence, in order to determine if this condition is indicative of an underlying CRC and if it has any pathophysiologic significance. PATIENTS AND METHODS: First, we describe the clinical case. Then, we review the literature focused on the association between infections from the former S. Bovis group and CRC and on the possible role of certain microbiota species on the occurrence of CRC. At last, we discuss the implications of this case considering the current evidence. RESULTS: There is a strong association between all the species of the former S. Bovis group and CRC. There is initial evidence that these bacteria may contribute to CRC by a genomic passenger mechanism. CONCLUSIONS: There are two main conclusions for this paper. The first one is that CRC neoplasms and endocarditis from all species of the former S. bovis group have a strong association. Any case of infection by these subspecies should prompt to a diagnostic completion by colonoscopy. The second one is that there is an increased need for detailed reports/series and original articles based on the evaluation of gut microbiota in patients with CRC, with the aim to clarify if the association between bacteria and CRC is causative or sporadic and to better understand the possible causative mechanism of specific bacteria in initiating and promoting CRC.

Surgical issues after neoadjuvant treatment for gastric cancer.

Gastric carcinoma is one of the most frequent malignancies in the world and its clinical behavior depends on the metastatic potential of the tumour. Particularly, lymphatic metastasis is one of the main predictor of tumour recurrence and survival and current pathologic staging systems reflect the concept that lymphatic spread is the most relevant prognostic factor in patients resected with curative intent. This is deducted by the observation that two thirds of gastric cancers in the western world present at an advanced stage, with nearly 85% of tumors accompanied by lymph node metastasis at diagnosis. To date most therapeutic efforts are directed toward individualization of therapeutic protocols, tailoring the extent of resection integrated by the administration of preoperative and postoperative treatment. The goal of such strategies is to improve prognosis towards the achievement of a curative resection (R0-resection) with minimal morbidity and mortality, with better postoperative quality of life. A brief review of literature about preoperative therapy for gastric carcinoma will be herein illustrated. The rationale and the general drawbacks of preoperative treatments will be both discussed in order to demonstrate its value in terms of safety and efficacy.

European Society of Surgical Oncology's strategy for clinical research: Paving the way for a culture of research in cancer surgery.

As part of its mission to promote the best surgical care for cancer patients, the European Society of Surgical Oncology (ESSO) has been developing multiple programmes for clinical research along with its educational portfolio. This position paper describes the different research activities of the Society over the past decade and an action plan for the upcoming five years to lead innovative and high quality surgical oncology research. ESSO proposes to consider pragmatic research methodologies as a complement to randomised clinical trials (RCT), advocates for increased funding and operational support in conducting research and aims to enable young surgeons to be active in research and establish partnerships for translational research activities.

The role of local excision in rectal cancer after complete response to neoadjuvant treatment.

Correlation between pathological response of primary tumour and mesorectal lymph node involvement was prospectively evaluated to assess the role of local excision (LE) in rectal cancer after complete response to neoadjuvant treatment. A series of 272 consecutive rectal cancer, submitted to neoadjuvant radiochemotherapy (RCT) and surgery with total mesorectal excision (TME) were analysed. Tumour downstaging (pT) and tumour regression grade (TRG) together with sex, age, location of the tumour, pre-treatment clinical stage, type of chemoradiation and operation performed entered in an univariate and multivariate analysis. Pathological complete response on primary tumour was found in 56 patients (20.6%). Lymph node metastases were found in 72 patients (26.5%). The rate of positive nodes was 1.8% for pT0 and TRG1 cases, respectively, to go up to 6.3% for pT1 and 24.1% for TRG 2 cases, respectively. At the univariate analysis, factors with a statistically significant correlation with the risk of lymph node metastasis were: clinical pre-treatment N stage (p<0.05), pT stage (p<0.001) and TRG (p<0.001). At the multivariate analysis, the best predictors of pathologic lymph node involvement were pT stage (p=0.0013 ) and TRG (p=0.0011). Because LE is an adequate technique to assess the tumour pathological response and nodal involvement in pT0 or TRG1 cases seems extremely infrequent, radical resection is probably not justified after pathological complete response. Prospective randomized trials are necessary to establish if, in these cases, LE can guarantee the same oncologic results offered by the currently adopted protocols of RCT followed by radical resections.

A case-control study comparing methylene blue directed biopsies and random biopsies for detecting pre-cancerous lesions in the follow-up of gastric cancer patients.

OBJECTIVES: To compare the accuracy of Methylene Blue (MB) targeted biopsies with random biopsies in detecting intestinal metaplasia and dysplasia in the follow-up of patients after gastrectomy for gastric cancer. METHODS: Thirty patients (21 Billroth II, 9 Billroth 1) for cancer, referred to the Gastroenterology Unit for an elective esophagogastroduodenoscopy (EGD), were enrolled. All endoscopies were performed with a high-resolution videoendoscope with an adjustable image magnification: EG-485ZH (Fujinon, Omiya, Japan). During EGD three random biopsies were taken in the stomach and, after staining with MB, three targeted biopsies were taken from every stained area. RESULTS: In 28 patients traditional endoscopy showed hyperemia of the anastomosis, in 2 patients a lesion. After MB in 6/30 there were stained area (2 lesions seen with traditional endoscopy and 4 blue areas in other patients). As regards histology: 24 patients showed inflammation, while 2 patients with alterations in traditional endoscopy and with MB showed metaplasia and high grade dysplasia. In 4/30 (13.3%) patients MB guided biopsies showed significant lesions (3 intestinal metaplasia, 1 low grade dysplasia) while random biopsies showed only inflammation. CONCLUSIONS: After partial gastrectomy, the mucosa of the residual stomach usually undergoes severe changes, and these lesions are known to be pre-cancerous. The diagnostic accuracy of the MB technique seems to be superior to random biopsies for identification of intestinal metaplasia, dysplasia, and may be helpful in targeting biopsies and early endoscopic treatment.

Response to neoadjuvant chemotherapy and effects of tumor regression in gastric cancer.

AIMS: Aim of this study is the evaluation of the effects induced by neoadjuvant chemotherapy (NACT) and its impact on survival on a series of locally advanced gastric carcinomas. METHODS: Downstaging was assessed comparing pre-treatment clinical and laparoscopic staging with post-operative pathologic staging on 30 consecutive patients who completed a 3-year follow-up. Tumor downstaging and the grade of pathologic response were included in a statistical correlation between tumor regression induced by NACT and 3-year survival. RESULTS: In this series tumor downstaging was obtained in 13 out of 30 patients. After the completion of 3-year follow-up, overall survival was >37.5months with an overall survival rate of 56.7%; this figure reached up to 70.8% in those cases who benefited from a R0-resection (24/30 patients: R0-resection rate 80.0%). CONCLUSIONS: In this study the 3-year survival for locally advanced gastric cancer treated by NACT prior to "D2" surgical resection, compares favourably with historical series treated by surgery alone. Patients who obtained T-downstaging and subsequently benefited from a R0-resection had a definitely better chance of cure, according to a complete 3-year follow-up.

Does a minimum number of 16 retrieved nodes affect survival in curatively resected gastric cancer?

BACKGROUND: According to the TNM classification, the analysis of 16 or more lymph nodes is required for the appropriate staging of gastric cancer. The aim of this study was to evaluate whether this number of resected lymph nodes also affects survival. METHODS: This was a multicenter retrospective study based on an analysis of 992 patients with gastric adenocarcinoma who underwent curative resection between January 1980 and December 2009. Patients were classified according to the number of resected lymph nodes (<16 and ≥16 lymph nodes), the anatomical extent of lymph node dissection (D2 vs. D1), and the staging criteria of the seventh edition of the UICC/AJCC TNM staging system. Survival estimates were determined by univariate and multivariate analyses. RESULTS: Based on the univariate and multivariate analyses, the resection of 16 or more lymph nodes was associated with significantly better survival [p = 0.002; hazard ratio (HR) (95% confidence interval [CI]): 0.519 (0.345-0.780)]. Patients with a lymph node count <16 had a significantly worse survival rate than patients with a lymph node count ≥16 in the pN0 (p = 0.001), pN1 (p = 0.007) and pN2 (p = 0.001) stages. In the majority of cases, ≥16 lymph nodes were retrieved when D2 dissection was performed. CONCLUSIONS: In gastric cancer the retrieval of less than 16 lymph nodes may cause inaccurate staging and/or inadequate treatment, thus affecting survival rates. These patients should be considered a high-risk group for stage migration and worse survival compared with those who have a retrieval of more than 16 lymph nodes.

Thyroid cancer in suppressed contralateral lobe of patients with hot thyroid nodule.

We studied 60 patients with thyrotoxicosis due to single toxic nodule. At surgery in 3 patients (5%) a papillary carcinoma has been detected in the contralateral suppressed lobe. Thyroid function tests and thyroid scan confirmed thyrotoxicosis. Thyroid stimulating hormone (TSH) was undetectable in all patients. It is common opinion that differentiated thyroid tumour growth is TSH dependent. On the basis of our study two hypotheses are possible: (1) the development of thyroid carcinoma precedes the adenoma and suppressed TSH levels inhibit tumour growth; (2) suppressed TSH levels do not protect patients from the occurrence of cancer. In the evaluation of hot thyroid nodule we suggest careful ultrasonographic control in order to look for nodules outside the adenoma. A complete surgical examination of the whole thyroid gland is required and intraoperative biopsies are advocated in abnormal areas.

Extent of axillary dissection preceding irradiation for carcinoma of the breast.

"Limited" surgery and irradiation have become more popular therapeutic options for women with stage I and stage II breast cancer, and surgical attention to the axilla is part of this approach. To understand the limitations of whatever axillary procedure is recommended, we undertook a retrospective analysis of the records of 277 women who had undergone radical or modified radical mastectomy. Of this group, 127 had metastases to at least one axillary or interpectoral lymph node. Skip metastases occurred in 13% of women with positive nodes; two women (1.6%) had metastases only to level III nodes, and two women had metastases only to interpectoral nodes. The extremely uncommon occurrence of metastases to level III alone or to interpectoral nodes alone, but the greater likelihood of skip metastases to level II, argues for both level I and level II axillary dissection preceding irradiation for patients with invasive carcinomas of the breast.

The role of acid and alkaline reflux in laryngeal squamous cell carcinoma.

HYPOTHESIS: At present, main factors considered responsible for the onset of squamous cell carcinoma are tobacco smoking, alcohol abuse, and exposure to viral and toxic agents. In last years, great interest has been focused on gastroesophageal reflux as independent carcinogenic factor and co-carcinogen in association with smoking and alcohol assumption. STUDY DESIGN: Initially, the aim of this study was to objectively evaluate the presence of distal and proximal esophageal reflux with multielectrode pH measurement in patients with cancer of the larynx and/or hypopharynx (group A). However, in the course of the study, pharyngolaryngeal cancer was also observed in 4 patients with achlorhydria; therefore, the hypothesis that alkaline reflux might be involved in the onset of laryngeal cancer was tested (group B). METHODS: Twenty-one consecutive patients with laryngeal or hypopharyngolaryngeal squamous cell carcinoma (group A) entered the study. Twenty-one patients without laryngo-pharyngeal diseases were used as control subjects. A validated questionnaire of the clinical history was completed by all patients who underwent 24-hour pH monitoring. Group B included 40 consecutive gastrectomized patients (28 males and 12 females) in whom biliary or alkaline reflux was directly consequent to Billroth I or Billroth II operation. The control group was composed of 40 non-gastrectomized dyspeptic patients. The clinical history was controlled and obtained; EDGS and ENT examination with videolaryngoscopy was performed in all patients. RESULTS: In group A, pH measurement showed pathological reflux in 80.9% (17 of 21) of patients with no typical symptoms in 63.7% of them. The difference was significant with respect to the control group. In group B, 6 of 40 (15%) had preneoplastic lesions or a history of laryngeal tumor. The difference was significant with respect to the control group. A total of 7.5% of group B patients had previously undergone CO2 laser cordectomy for laryngeal squamous cell carcinoma and 7.5% had leukoplakia. We found a significantly higher incidence (<.05) of neoplastic and preneoplastic disease of the larynx in patients undergoing Billroth II and total gastrectomy than in those undergoing Billroth I and Roux-en-Y resection. We also found a significant increase (<.01) in ENT lesions in the group of patients who had undergone gastrectomy more than 20 years previously. CONCLUSIONS: In agreement with literature reports, results obtained in group A confirmed that gastroesophageal reflux is often present in patients with neoplastic lesions of the pharynx and larynx. Furthermore, gastric resection is indicated for the first time as an additional risk factor or cofactor of precancerosis and squamous cell carcinoma of the pharynx or larynx. Further studies are necessary to establish the cause and effect relationship between biliary reflux and pharyngo-laryngeal tumors.

Esophageal diverticula. Physiopathological basis for surgical management.

From 1980 to 1990, 31 patients were treated surgically in our department for esophageal diverticula: 12 Zenker's diverticula (ZD); 11 mid-thoracic diverticula (MTD); 8 epiphrenic diverticula (ED). Cricopharyngeal dysfunction was detectable in 8 of 12 ZD patients (66.6%). Cricopharyngeal myotomy with diverticulectomy was performed in all cases. There were no deaths. Relief of dysphagia was obtained in all cases. No recurrences of dysphagia or diverticulum were observed at a mean follow-up of 3 years. A motility disorder was observed in 10 of 11 MTD (90.9%). An extended esophageal myotomy with diverticulectomy was performed in 3 cases, an extended myotomy alone in 3 cases, a diverticulectomy alone in 5 cases; an anti-reflux procedure was added in 6 cases. One patient died on the 7th postoperative day. All remaining patients were free of symptoms at a mean follow-up of 3.2 years. A motor dysfunction was detected in all 8 ED patients (100%). No diverticulectomy was performed. Six patients underwent Heller-Dor myotomy and 2 underwent Nissen fundoplication. There were no deaths. Relief of symptoms was obtained in all patients, at a mean follow-up of 3.1 years. Myotomy with diverticulectomy represents the treatment of choice in ZD. As regards MTD and ED, the treatment of the underlying motor disorder is the main therapeutic goal, whereas diverticulectomy is reserved to selected patients.

DNA flow cytometric analysis in patients with operable non-small cell lung carcinoma.

Fresh surgical specimens of tumors from 60 patients with previously untreated non-small cell lung carcinoma (NSCLC) who underwent radical surgery between January 1991 and October 1992 were investigated by means of flow-cytometry. The nuclear DNA measurement was carried out using a Facscan (Becton, Dickinson, USA). Analysis of the DNA content was performed in all 60 patients whilst cell cycle analysis was possible in 41 cases (68.3%). Forty-two of the 60 cases (70%) were aneuploid and 18 (30%) were diploid. The overall mean value of DNA index was 1.5. Diploid NSCLC were compared with aneuploid tumors: no significant differences in age distribution, sex ratio, histology and staging were found between the two groups (P > 0.05). An S-phase proportion of more than 10% was found in 30 out of 41 patients (73.2%). Early cancer deaths were reported in four patients (6.6%): the aneuploidy rate was very close in these patients (75%) and in the remaining surviving patients (69.6%). An S-phase proportion of more than 10% was found in 100% of early cancer deaths and in 70.2% of the remaining cases; such a difference seems of some importance although it was not statistically significant (P = 0.071). In conclusion, flow-cytometry studies seem to be a useful tool in the understanding of the biological behavior of patients with NSCLC. In the present prospective report there were no significant correlations between DNA measurements and clinical outcome, however, these results suggest that a high S-phase proportion should be seen as a possible prognostic indicator.(ABSTRACT TRUNCATED AT 250 WORDS)

[The impact of the fine needle aspiration in the management of thyroid nodules]. / Impatto dell'esame citologico aspirativo (FNA) nella gestione dei noduli tiroidei.

BACKGROUND: The aim of this retrospective analysis is to evaluate the impact of preoperative fine needle aspiration biopsy (FNA) on the thyroid nodules management. METHODS: On a consecutive series of 434 thyroidectomies carried out in the last 3 years, the role of FNA on 139 cases has been statistically evaluated. All cytologic diagnoses have been classified in three subsets: malignant (group 1); suspect (follicular or Hurtle cell proliferation) (group 2); benign (group 3). RESULTS: Our data confirm previous observations about the high specificity of FNA in case of diagnosis of malignancy (97.6%). On the other hand 51.6% of our cases are included in group 2; only 31.9% of these cases have shown a postoperative diagnosis of malignancy, following a suspect at FNA. In this study, the sensibility of FNA has been calculated including among positive results the cytologic diagnoses of group 1 + group 2: the resulting figure of 87.3% weighs the impact of FNA on our surgical decision process. CONCLUSIONS: FNA plays a crucial role in the management of nodular diseases of the thyroid, even if its overall value is limited by the burden of "suspect" cytologic diagnoses. In our hands, the integration of FNA results with all relevant clinical data has undoubtedly contributed to increase the portion of thyroidectomies carried out for cancer, from 12.8% of our historical series to 23.2% of the last 3 years.

Intraoperative esophageal manometry in surgical treatment of achalasia: a reappraisal.

BACKGROUND/AIMS: Intraoperative Esophageal Manometry is used during surgery for gastroesophageal reflux disease to obtain a better lower esophageal sphincter pressure, or during the Heller procedure for achalasia to verify the myotomy. The effectiveness of this manometry is not explicit. MATERIAL AND METHODS: From 1977 to 1987, 58 patients underwent surgery for achalasia at our Institution. A transabdominal Heller's myotomy and a modified Dor's anterior fundoplication were performed in all cases. During the operation, Lower Esophageal Sphincter Pressure was measured in 38 patients (A group) to verify the completeness of the càr-diomyotomy; the fundoplication-induced pressure increase was also recorded. Twenty patients (B group) underwent surgery without intraoperative manometry. Forty-six patients (30 of A group and 16 of B group) were followed up for 24 to 120 months (median 68 months) by means of a clinical questionnaire, barium meal, manometry and 24-hour esophageal pH monitoring. RESULTS: In 21 cases, intraoperative manometry showed the completeness of the myotomy at the first record, while in the remaining 17 it revealed the persistence of a High Pressure Zone; in these, a more accurate incision of the muscle layers on the anterior surface of the esophagus was subsequently performed up to a complete abolition of the HPZ. Long-term results were excellent or good in 27 (90%) patients of A group and in 9 (56%) patients of B group. Dysphagia and gastro-esophageal reflux were the commonest findings in patients with poor results. CONCLUSION: The usefulness of intraoperative manometry in the surgical treatment of achalasia is emphasized and some technical details are reported.