Postoperative functional result and quality of life after oesophageal reconstruction based on the type of cervical anastomosis.

INTRODUCTION: The keystone of the rate of postoperative complications and functional outcome in oesophageal reconstruction is the technique method of performing cervical anastomosis.Despite new technologies and improved technique in specialized centres, post-anastomosis complications have not significantly improved. PURPOSE: The goal of our study is to analyse the causes that make anastomosis with the oesophagus hypopharynx a particular case. If anatomical and morphological aspects cannot be adjusted (poor histological structure and vascularity etc.), some important elements for performing a good anastomosis can be identified and corrected. MATERIAL AND METHOD: Between 1981-2014, 195 oesophageal reconstructions were performed in our clinic. Our study involved an analysis of 72 cases (2000-2014), based on a statistical evaluation by Kaplan-Meier method that considered as eries of factors (oesophagus hypopharynx as anastomotic partner, stomach, jejuno-ileum, colon as visceral partner,pharyngotomy type, T-L, T-T, L-L, L-T type anastomosis,number of anastomotic layers). RESULTS were compared with those obtained by standard clinical and laboratory investigation,analysing the post-therapeutic outcome using three criteria (clinical aspects of swallowing, barium swallow and endoscopy) and by subjective assessment by each patient of his her state and complaints, with effects on long-term functional outcome (dysphagia, reflux, pain, asthenia, weight loss, hoarseness). RESULTS: Statistical analysis determined that only some of the analysed factors proved to be valuable. The higher the level of the anastomosis, the more intense the impairment of the digestive function. The jejunum and left colon proved to bemost effective anastomotic partners. The best method for implantation seems to be T-T or T-L and the number of anastomosis layers has no influence on postoperative outcome. CONCLUSIONS: Acquired data can influence to some extent the operatory technique, with a lower complication rate.Unfortunately, laborious technical aspects and specific anatomical limitations make this goal difficult to achieve.

Clinical and therapeutic considerations of GIST.

Gastrointestinal stromal tumors (GIST) are rare tumors of the digestive tract, with an incidence of about 1.5 per 100,000/year. Clinical features may vary depending on location, size and aggressiveness. The diagnosis is confirmed by immunohistochemistry tests that identify CD 117 or DOG1 (typical receptors/markers for most GISTs) at the level of biopsy specimen. The treatment of localized GIST is based primarily on the surgery, while for metastatic GIST the targeted therapy with tyrosine kinase inhibitors represents the current standard. The neoadjuvant and adjuvant therapy indications guided and depending on genetic analysis included in the diagnostic and treatment algorithm as well as the strategy for cases surveillance are listed in the journal. All these data obtained from the literature have been integrated in a practical experience of 19 cases of GIST, operated in the clinic in the last 10 years for which we have proposed an adapted diagnostic algorithm.

Motor criteria evaluation of iso-anisoperistaltic graft in oesophageal reconstruction -- an experimental study of isolated colic graft motility pattern in dogs.

In the medical literature there are more than one opinion in favour of the isoperistaltic interposed loop, considering it to render a higher propulsive activity and thus with much better functionality, with less intense symptoms of regurgitation,reflux or aspiration. Technically, however, due to anatomical relationships, anisoperistaltic graft interposition is more convenient. Is this detrimental to functionality? What is the best peristaltic model? At first sight, it seems that due to the local anatomy and surgical technique involved, we compromise at the expense of better functionality. To find the answer to these questions, starting from the typical pattern of colonic motility in the transverse and left colon, we need to identify new motor behaviour of the isolated colic segment. Because motor activity is generated by electric waves discharged from the area control centre, their electromyographic registration would allow finding the contractile pattern of a transplanted loop.

The vascularization pattern of the colon and surgical decision in esophageal reconstruction with colon. A selective SMA and IMA arteriographic study.

INTRODUCTION: No matter the reconstructive technique, the fundamental concepts in visceral reconstruction have as main grounds the mandatory vascular support for the graft replacement. Individual vascular particularities can influence or even oblige the surgeon to choose a certain procedure. This is why the vascularization is beyond doubt the dominant factor in mobilizing the colon for reconstruction. MATERIAL AND METHOD: Our arteriographic study entails an investigation upon the vascularization pattern of the two main sources that participate in the arterial irrigation of the colon via the emerging vessels: superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). We did not consider certain patients upon a specific criterion; also, we did not exclude any patients due to various reasons. We took into account 49 patients as study group, all of them having registered into the clinic for a reconstructive technique, throughout the years from 2000 to 2010. From 1981 to 2012 there have been 187 reconstructive techniques performed due to post caustic pathology. From a total of 49 patients, 11 had suffered major abdominal surgeries, 5 of which had had unsuccessful reconstructive attempts. RESULTS: Out of the 49 patients on whom we have performed the exploration, arteriography showed a favorable situation for reconstruction in 31 of them. In the other 18 patients anomalies or atypical distributions were identified, in 5 of the SMA and in 13 of the IMA, respectively. Operative decision was modified in 22 patients. One important thing to note from the point of view of the segment to be moved: we had no graft necrosis in patients with preoperative arteriographic examination. CONCLUSIONS: Due to the need for good mobilization, arterial ligations should be adjusted and modified depending on the particular vascular distribution, to maintain a sufficient blood flow in the marginal artery, in order to reach the colic sections and the straight arteries near them.

Molecular factors and criteria for predicting the response to neoadjuvant treatment in patients with esophageal squamous cell carcinoma (ESCC) -- responder/non-responder.

UNLABELLED: Regarding the mortality causes, esophageal squamous cell carcinoma (ESCC) is on the 7th place in the US and the 6th place in the world, with 5 year overall survival rate of 14%, which is still modest in comparison to other digestive neoplasia. Multiples strategies were involved to improve this percentage, associating surgical procedures and chemo- and radio- oncologic therapies. The distant results showed sensitive improvement, after introduction of multimodality neoadjuvant therapies. MATERIAL AND METHOD: Fifty-seven patients diagnosed with ESCC were evaluated between 2006 and 2010, male preponderance (77%), average age of 55. A multimodality therapeutic protocol was used: first - radio-chemotherapy (RCT), second - surgery and/or third - chemo- or radiotherapy. Four weeks post RCT all patients were evaluated to determine the response to neoadjuvant treatment followed by surgery - esophageal resection. Histopathological (HP) and immunohistochemical (IHC) analysis of the pathological specimens were performed in order to identify the molecular predictors with responsive or non responsive character; the studied markers were p53 (Dako 1:50), Ki-67 (Biogenex, 1:20), c-erbB-2 (Dako, 1:250). Based on these results, the working model used to determine the response to neoadjuvant therapy was tumor regression grade (TRG). RESULTS: After HP and IHC examination, the patients were included in two groups: responders and non responders (tumor cells > 10%). Complete neoplasia sterilization was achieved in 5 of the patients. CONCLUSIONS: We are able to state that the identification of potential predictive markers along with HP and IHC results represents a great perspective alternative in the ESCC therapy outcome. The detection of molecular type aggressiveness of the neoplastic process allows therapeutic orientation or guidance to certain therapy sequences or even to specific molecular targeted treatments.

Principles of surgical treatment of Zenker diverticulum.

BACKGROUND: Pharyngo-esophageal diverticula are most frequently described in elderly patients, having symptoms such as dysphagia, regurgitation, chronic cough, aspiration and weight loss. The etiology remains controversial, although most of the theories are linked to structural or functional abnormalities of the crico-pharyngeal muscle. With the therapeutic attitude varying from conservative to surgical (with associated morbidity and mortality), the importance of knowing the etiopathology and clinical implications of the disease for establishing the management of the case is mandatory. The aim of the study is the reevaluation of the methods and therapeutic principles in pharyngo-esophageal diverticular disease, starting from the etio pathogeny. MATERIALS AND METHODS: Our study group is made up of 11 patients with surgical indication for Zenker diverticulum, operated between 2001 and 2011. RESULTS: During that period, more patients were diagnosed with this pathology, but the surgical indication was carefully established, in conformity with the actual practice guides, which involve the evaluation of the clinical manifestations determined by the diverticulum, as well as the identification and interception of the pathological mechanisms by the therapeutic gesture. CONCLUSION: Although it has a "benign" pathology, the esophageal diverticulum requires complex surgical procedure that implies significant morbidity.

[Surgical treatment of esophageal diverticula]. / Tratamentul chirurgical al diverticulilor esofagieni.

The aim of this paper is to evaluate the methods and therapeutic principles of esophageal diverticula pathology. We analyze the main pathological mechanisms which establish the therapeutic attitude linked with a complex pretherapeutic evaluation. In our study we enrolled 12 patients operated between 2001-2009 for esophageal diverticula with different topography. In this period of time there were much more patients diagnosed with this pathology, but the need for surgery was establish very tight regarding the actual practical guide which impose the identification and interception of physiological mechanisms by the surgical procedure. We highlight the particular technical details, as well as the important differences of postoperatory complications according to the topography of the diverticula pouch.

[Gastrointestinal stromal tumor (GIST)--medical rarities?]. / Tumora stromala gastrointestinala (GIST) o raritate medicala?

Although their overall incidence is low, GISTs are distinctive subgroup of gastrointestinal mesenchymal tumors which express CD117 or platelet derived growth factor receptor alpha (PDGFRA). Considered as rare digestive cancers, tumors like schwannomas, neurofibromas, gastrointestinal leiomiomas are now reclassified as GIST based on immunohistochemistry studies. GIST are more frequent in stomach (40-70%), small bowel (20-40%), colon (5-15%), meanwhile locations such as mesentery, omentum, retro peritoneum in less of 5%. 10 GIST patients were surgically managed during 2004-2009. 5 gastric and 5 small bowel GIST. Most with symptomatic disease: palpable tumor, abdominal pain, anemia, fatigue, superior digestive hemorrhage or occlusion. Imagistic diagnosis consisted of: barium swallow, abdominal sonography, CT and PET-CT. Confirmation was made by hystopathological exam and immunohistochemistry. All patients had more or less wide surgical resections. For some patients there was also a specific adjuvant treatment. All patients survived after surgery. The principle of surgery for GIST is RO resection of the tumor. Tumor rupture or R1 resection of the primary tumor has a negative impact on disease free survival. Some patients (great volume tumors, R1 or R2 resection) had adjuvant treatment. Imatinib mesylate and derivates showed a significant improvement of recurrence free survival with one condition: permanent treatment. Surgery remains the mainstay of treatment in patients with localized, resectable GIST. Recurrence rate of 17-21% and 5 years survival rate of 48-70%, even in resectable GIST, impose an adjuvant treatment.

Cardiac peptides during exercise test in ischemic and non-ischemic heart failure patients.

BACKGROUND: Cardiac peptides are increased at rest in heart failure patients representing a useful diagnostic tool for this condition. Recently it has been demonstrated that cardiac peptides increase also during myocardial ischemia. Cardiac peptides increase during exercise in heart failure patients, but it has not been established yet if the increase is the same in ischemic and nonischemic patients. METHODS: There were studied 50 heart failure patients, 32 ischemic and 18 nonischemic, 35 males and 15 females aged 61.8 +/- 11.61 after the relief of congestive syndrome, which was submitted to a symptom-limited exercise stress test on a cycloergometer. Blood samples were obtained at rest and at a peak effort and the plasmatic values of NT-proBNP (NV<250 fmoles/mL) and of NT-proANP (NV<1950 fmoles/mL) were determined using the ELISA method. RESULTS: At rest, both NT-proBNP and NT-proANP were more increased in nonischemic (1104.33 +/- 730; 3275.55 +/- 3424) than in ischemic patients (685.68 +/- 452.01, 2265.0 +/- 2552.32) with significant differences only for NT-proBNP (p=0.016). During exercise NT-proBNP increase from 836.40 +/- 596.34 to 1403.92 +/- 2126.21 and NT-proANP from 2628.80 +/- 2903.41 to 3701.30 +/- 3237.76, the final values being again more increased in nonischemic patients (NT-proBNP-2945.44 +/- 3257.89; NT-proANP-3174 +/- 2905); for NT-proBNP p<0.05. The results suggest that the stretching effect during exercise is more increased at the ventricular level in comparison with the atrial level (67% increase for NT-proBNP and only 40% for NT-proANP). Surprisingly, myocardial ischemia does not increase additionally cardiac peptides either at rest or during exercise. Our data suggest that the intracardiac pressure is more important than ischemia in determining the increase of cardiac peptides in heart failure patients because the left ventricular ejection fraction was lower in nonischemic patients (40.03 +/- 5.5 vs 38.11 +/- 4.07). CONCLUSION: Cardiac peptides are increased, both at rest and during exercise, in nonischemic heart failure patients in comparison with ischemic ones, probably in relationship with the lower left ventricular systolic function.

[Cardiac failure in the newborn. Diagnostic pitfalls]. / Insuficienta cardiaca la nou-nascut. Capcane de diagnostic.

Echocardiography commonly represents the diagnostic clue in neonatal heart failure (HF). Congenital heart diseases are the most frequent causes of HF in this age group. Arterio-venous malformations are the most common noncardiac causes of HF. Normal cardiac structural findings on echocardiography require further investigations in order to exclude other causes of HF. We present three male patients admitted in the interval 2003-2007 with neonatal HF, systolic murmur, cardiomegaly, normal cardiac structure on echocardiography and intracranial bruit. All three cases were diagnosed with vein of Galen aneurysmal malformation (VGAM) by head ultrasound. According to age and malformation type, different presentation patterns were noticed: early neonatal intractable HF mimicking aortic coarctation, postnatal HF stabilized by drug treatment, and chronic HF in a VGAM with tendency to spontaneous regression. Both head ultrasound and cranial auscultation are mandatory in newborns or infants with no cardiac primary cause of HF.

[Small intestinal hemorrhage due to rare etiology. Diagnostic difficulties and therapeutic approaches]. / Hemoragia digestiva de cauza enterala atipica. Dificultati diagnostice si terapeutice.

Understanding of the pathogenesis, diagnosis, and treatment of lower GI bleeding has drastically changed during the last 50 years, but it continues to be a frequent cause of hospital admission and also a factor in hospital morbidity and mortality. Acute lower gastrointestinal hemorrhage (ALGIH) represents only 20% of the GI bleeding and the small intestine is the site of hemorrhage in about 1% of cases. Although in the last four decades, diagnostic methods for locating the precise bleeding point improved greatly, still the adequate localization of the lesion is very difficult to achieve through algorithmic approaches. We performed a clinical study and we retrospectively analyzed 5 patients (mean age = 59,8 years, 1 female) who had a surgical intervention for acute lower GI hemorrhage in the last decade, in order to emphasize diagnosis difficulties when the bleeding arises from small lesions in the small bowel that is not easily accessible for direct visualisation. Surgery was the treatment of choice in every case consisting in segmental resections of the involved small bowel, along with viscerolysis and exploratory gastro-jejunostoma. The mortality rate was 20% (1 postoperative death of cardiac etiology). There have been no specific postoperative complications in the other four patients and a good outcome was reported. The diagnosis is particularly difficult and when colonic and upper gastrointestinal evaluations fail to identify a source of bleeding, a small intestinal source should be considered. We can conclude that the most important factor in the management of ALGIH is determination of specific localization of the lesion.

Results of a long-term training program after acute myocardial infarction.

BACKGROUND: It is not well known what should be the benefits of a prolonged physical rehabilitation program after an acute myocardial infarction. METHODS: Our study is an open, randomized comparison of a long-term versus a standard rehabilitation program. Sixty-seven patients with acute myocardial infarction were included in an outpatient physical rehabilitation program of 6-8 weeks. Of these, 22 randomly selected patients continued the program until the 36th month (Group A). Twenty-five of the others were rechecked after 36 months, and represented the controls (Group B). For both groups, at the end of this period, a cycloergometer exercise test evaluated the exercise capacity of subjects and an echocardiogram was performed to determine left ventricular systolic and diastolic function. RESULTS: The maximal exercise capacity increased from 147 +/- 13.8 W to 178 +/- 16.4 W in Group A (p < 0.01), but it decreased from 144 +/- 13.2 to 132 +/- 12.8 W in group B. Functional aerobic impairment decreased from 29 +/- 2.7% to 22 +/- 2.1% in Group A, but it increased from 26 +/- 2.5% to 37 +/- 3.8% in Group B. The ejection fraction and diastolic function parameters were not significantly modified during the 36 months, for both groups. CONCLUSION: Long-term physical rehabilitation is useful in patients after an acute myocardial infarction to increase effort capacity, but left ventricular performance is not significantly changed.

[Preoperative modern evaluation of patient with esophageal stenosis]. / Evaluarea preoperatorie moderna a bolnavului cu stenoze esofagiene.

It is well known the difficulty of a precise evaluation in the pretherapeutic stage of any esophageal pathology, especially that of obstructive lesions. Preoperatory information should be as accurate as possible, any evaluation error leading to surgical manoeuvres that can later be regretted. From the current practice one can easily observe that there is no typical exploratory protocol, each having its own specific limits, high costs that are not negligible, and some of them are not always immediately available. It is obvious that para-clinic approach has changed, due to technological progress that has increased the accuracy of medical information, but has also increased costs. The standard protocol has lead to a retrospective analysis of the esophageal obstruction cases that were hospitalized in the Sf Maria Clinic of Surgery, during 1981-2002, regarding diagnostic algorythm and treatment used.

The effect of Simvastatin upon serum pseudocholinesterase and plasmatic factor VII.

UNLABELLED: The statins have a moderate lowering effect upon triglycerides, one hypothesis suggesting an inhibitory effect upon liver VLDL synthesis. Because VLDL synthesis is related to other hepatic protein synthesis we studied the effect of Simvastatin upon serum cholinesterase activity and factor VII activity, which are also synthetized at hepatic level. METHODS: 39 patients with ischaemic heart disease, proved by coronarography and moderate hypercholesterolaemia received for two months 20 mg Simvastatin (Zocor). The value of total Co, LDLCo, HDLCo, triglycerides, serum cholinesterase activity and factor VII activity were determined before and after treatment, by standard methods. RESULTS: Triglycerides were, together with total Co, significantly lowered during the two months treatment with Simvastatin, but the values of serum cholinesterase and factor VII activity were not significantly modified. This suggests that moderate doses of Simvastatin do not depress liver protein synthesis. CONCLUSION: Simvastatin does not lower the triglycerides level through depression of liver protein syntesis, other mechanisms being probably involved.

[Problems and difficulties in patients with esophageal reconstruction]. / Probleme si dificultati ridicate de reconstructia esofagiana.

The esophageal reconstruction, independent of the manner and indication represents a major challenge for any surgical team. The goal of the present study is the retrospective analysis of cases together with the technical possibilities of surgical approach, viewed through the diagnostical and therapeutical point of view. We analysed retrospectively 154 patients (140 post-caustical stenosis and 14 neoplasms) who have took benefit of reconstructive esophageal surgery, operated in the last 21 years (1981-2001) in the clinic of surgery, of "Saint Mary" Hospital. Although the esophageal substitution has multiple indications (malignancy, benign stenosis, iatrogenic fistulas, reflux disease with peptic stenosis, etc.), in our clinic the technique was performed for neoplasic lesions and post-caustical corrosive stenosis. In the first period of the study (1981-1990) the most utilised method of surgical approach was the gastric tubulisation after the Gavriliu I or II procedures; in a second period (1990-2001) it is obvious that the tendency was to use the colon or the whole stomach as principal visceras for reconstructions. About the immediate results, the majority of post-operative complications where minors, the most frequent problem being of pleuro-pulmonary nature. We have registered two deceases of patients with corrosive pathology and no post-operative mortality in the first 30 days in neoplasic patients. We evaluated the post-operative functional results using an evaluation score. The anastomotic functionality was good or excellent in most cases (80%), especially in non-malignant reconstructions. For the selection of the most suitable reconstructive procedure, a variety of factors must be explored and evaluated. After a long period in which the use of the colon, in different technical manners, represented the "golden standard" in esophageal reconstruction, we have observed a reevaluation of this attitude and also the more and more frequent utilisation of the whole stomach as esophageal substitute, especially in malignancy.

Endothelial transcytotic machinery involves supramolecular protein-lipid complexes.

We have demonstrated that the plasmalemmal vesicles (caveolae) of the continuous microvascular endothelium function as transcytotic vesicular carriers for protein molecules > 20 A and that transcytosis is an N-ethylmaleimide-sensitive factor (NSF)-dependent, N-ethylmaleimide-sensitive process. We have further investigated NSF interactions with endothelial proteins to find out 1) whether a complete set of fusion and targeting proteins is present in the endothelium; 2) whether they are organized in multimolecular complexes as in neurons; and 3) whether the endothelial multimolecular complexes differ from their neuronal counterparts, because of their specialized role in transcytosis. To generate the complexes, we have used myc-NSF, cultured pulmonary endothelial cells, and rat lung cytosol and membrane preparations; to detect them we have applied coimmunoprecipitation with myc antibodies; and to characterize them we have used velocity sedimentation and cross-linking procedures. We have found that both cytosolic and membrane fractions contain complexes that comprise beside soluble NSF attachment proteins and SNAREs (soluble NSF attachment protein receptor), rab 5, dynamin, caveolin, and lipids. By immunogold labeling and negative staining we have detected in these complexes, myc-NSF, syntaxin, dynamin, caveolin, and endogenous NSF. Similar complexes are formed by endogenous NSF. The results indicate that complexes with a distinct protein-lipid composition exist and suggest that they participate in targeting, fusion, and fission of caveolae with the endothelial plasmalemma.

Mechanisms for regulation of fluid shear stress response in circulating leukocytes.

We have shown that leukocytes retract their pseudopods and detach from substrates after exposure to physiological fluid shear stresses ( approximately 1.5 dyn/cm(2)). In inflammation, however, pseudopod projection during spreading and firm adhesion on endothelium is observed even in microvessels with normal blood flow and fluid shear stresses. Thus, we examined mechanisms that may serve to regulate the shear stress response of circulating leukocytes. In the presence of inflammatory mediators (platelet-activating factor [PAF] f-met-leu-phe), a subgroup of cells ceases to respond to shear stress. cGMP analogs and nitric oxide (NO) donors enhance the shear stress response and reverse the inhibitory effect of inflammatory mediators on the shear stress response, whereas depletion of cGMP leads to cessation of the shear stress response even in unstimulated leukocytes. The ability of cGMP to enhance the shear stress response is not associated with CD18 expression, because cGMP has no effect on CD18 expression in response to shear stress. The shear stress response of leukocytes in endothelial nitric oxide synthase (-/-) mice, in which NO level in blood is decreased, is attenuated compared with that in wild-type mice. In rat mesentery venules stimulated by PAF under normal blood flow, a cGMP analog diminishes pseudopod projection of leukocytes, whereas inhibition of NO leads to enhanced pseudopod projection and spreading. The evidence suggests that inflammatory mediators suppress the shear stress response of leukocytes leading to spreading even under normal physiological shear stress, whereas cGMP may serve to maintain shear stress response even in inflammation.

Platelet activating factor receptor (PAF-R) is found in a large endosomal compartment in human umbilical vein endothelial cells.

In previous studies, we have localized the platelet activating factor receptor (PAF-R) in situ on the surface of the endothelium in a number of microvascular beds without providing information on its intracellular location. In the present study, we used human umbilical vein cells (HUVECs) as a model to immunolocalize PAF-R by light and electron microscopic procedures. We raised two different polyclonal antibodies against synthetic peptides of the C- and N-terminal of PAF-R and used them for immunolocalization studies. By immunofluorescence, we found that the anti-C-terminal antibody (CPAF-R) stains an extensive intracellular tubular network. By electron microscopy, using a preembedding staining procedure, we detected PAF-R on the surface of the plasmalemma in a staining pattern similar to that described on microvascular endothelia in situ, but at a considerably lower density. Immunogold labeling of thin frozen sections revealed the presence of PAF-R on the plasmalemma, and especially in an extensive network of tubular-vesicular elements and vesicles associated with it. No detectable amounts of PAF-R were found in the endoplasmic reticulum (ER) or in Golgi cisternae. Double immunofluorescence labeling with antibodies for compartment marker proteins and PAF-R revealed that PAF-R localizes in an endosomal compartment. Confocal microscopy showed that PAF-R colocalizes in this compartment together with the transferrin receptor (Tf-R) and the thrombin receptor (TH-R), but it also showed that the colocalization was partial rather than complete. These findings suggest that the endosomal network is either discontinuous or, conversely, that the proteins in its membrane do not have a fully randomized distribution.

[Total duodenal diversion in hiatal hernia with pathological duodenoesophageal reflux (preliminary results)]. / Diversie duodenala totala în hernia hiatala cu reflux duodenoesofagian patologic (rezultate preliminare).

For some patients, reflux disease means also duodenogastric, as well as gastroesophageal reflux; they may suffer because of duodenoesophageal reflux. For these patients, a simple surgical restoration of the cardial competence may prove to be insufficient; on the contrary, an indirect approach, using vagotomy and duodenal diversion may be a good therapeutical option in selected cases. In our hands, total duodenal diversion has already proven to be a good technical solution for the surgical treatment of the postoperative reflux disease, so we decided to expand its first choice indications to hiatal hernia cases, in the presence of duodenoesophageal reflux. Therefore, our study presents the results of the first 7 cases, operated on since 1995. No case had been gastric operated before, but 4/7 had already suffered a cholecystectomy. Duodenoesophageal reflux is discussed: etiopathogenesis related to surgical approach, using standard antireflux surgery (failures of the hiatal techniques and their causes) or total duodenal diversion (technical aspects, antireflux efficiency, secondary functional effects, pros and cons, therapeutical indications).