Swab test in biological fluids as predictor of COVID-19 transmission risk during surgery: a prospective cross-sectional study from an Italian COVID center.

BACKGROUND: The contamination of body fluids by Severe Acute Respiratory Syndrome Coronavirus 2 during surgery is current matter of debate in the scientific literature concerning CoronaVIrus Disease 2019. Surgical guidelines were published during the first wave of the COVID-19 pandemic and recommended to avoid laparoscopic surgery as much as possible, in fear that the chimney effect of high flow intraperitoneal gas escape during, and after, the procedure would increase the risk of viral transmission. AIM: The aim of this study was to evaluate the possibility of SARS-CoV-2 transmission during surgery by searching for viral RNA in serial samplings of biological liquids. METHODS: This is a single center prospective cross-sectional study. We used a real-time reverse transcriptase (RT) polymerase chain reaction (PCR) test to perform swab tests for the qualitative detection of nucleic acid from SARS-CoV-2 in abdominal fluids, during emergency surgery and on the first post-operative day. In the case of thoracic surgery, we performed a swab test of pleural fluids during chest drainage placement as well as on the first post-operative day. RESULTS: A total of 20 samples were obtained: 5 from pleural fluids, 13 from peritoneal fluids and two from biliary fluid. All 20 swabs performed from biological fluids resulted negative for SARS-CoV-2 RNA detection. CONCLUSION: To date, there is no scientific evidence of possible contagion by laparoscopic aerosolization of SARS-CoV-2, neither is certain whether the virus is effectively present in biological fluids.

COVID-19: identifying the main outcome predictors. A retrospective cohort study in Northern Italy.

OBJECTIVE: The need for efficient drugs and early treatment of patients with SARS-CoV-2 infection developing COVID-19 symptoms is of primary importance in daily clinical practice and it is certainly among the most difficult medical challenges in the current century. Recognizing those patients who will need stronger clinical efforts could effectively help doctors anticipate the eventual need for intensification of care (IoC) and choose the best treatment in order to avoid worse outcomes. PATIENTS AND METHODS: We enrolled 501 patients, consecutively admitted to our two COVID hospitals, and collected their clinical, anamnestic and laboratory data on admission. The aim of this retrospective study was to identify those data that are strictly associated with COVID-19 outcomes (IoC and in-hospital death) and that could somehow be intended as predictors of these outcomes. This allowed us to provide a "sketch" of the patient who undergoes, more often than others, an intensification of care and/or in-hospital death. RESULTS: Males were found to have a double risk of needing an IoC (OR=2.11) and a significant role was played by both the PaO2/FiO2 ratio on admission (OR=0.99) and serum LDH (OR=1.01). The main predictors of in-hospital death were age (OR=1.08) and the PaO2/FiO2 ratio on admission (OR=0.99). CONCLUSIONS: Male patients with high serum LDH on admission are those who undergo more often an intensification of care among COVID-19 inpatients. Both age and respiratory performances on admission modify the prognosis within the hospitalization period.

Laparoscopic versus open incisional hernia repair: a retrospective cohort study with costs analysis on 269 patients.

PURPOSE: To compare clinical outcomes and institutional costs of elective laparoscopic and open incisional hernia mesh repairs and to identify independent predictors of prolonged operative time and hospital length of stay (LOS). METHODS: Retrospective observational cohort study on 269 consecutive patients who underwent elective incisional hernia mesh repair, laparoscopic group (N = 94) and open group (N = 175), between May 2004 and July 2014. RESULTS: Operative time was shorter in the laparoscopic versus open group (p < 0.0001). Perioperative morbidity and mortality were similar in the two groups. Patients in the laparoscopic group were discharged a median of 2 days earlier (p < 0.0001). At a median follow-up over 50 months, no difference in hernia recurrence was detected between the groups. In laparoscopic group total institutional costs were lower (p = 0.02). At Cox regression analysis adjusted for potential confounders, large wall defect (W3) and higher operative risk (ASA score 3-4) were associated with prolonged operative time, while midline hernia site was associated with increased hospital LOS. Open surgical approach was associated with prolongation of both operative time and LOS. CONCLUSIONS: Laparoscopic approach may be considered safely to all patients for incisional hernia repair, regardless of patients' characteristics (age, gender, BMI, ASA score, comorbidities) and size of the wall defect (W2-3), with the advantage of shorter operating time and hospital LOS that yields reduced total institutional costs. Patients with higher ASA score and large hernia defects are at risk of prolonged operative time, while an open approach is associated with longer duration of surgical operation and hospital LOS.

Infiltrating lobular carcinoma of the breast presenting as gastrointestinal obstruction: a mini review.

One in twelve American women will develop breast cancer, with infiltrating lobular carcinoma (ILC) comprising approximately 15% of these cases. The incidence of ILC has been increasing over the last several decades. It has been hypothesized that this increase is associated with combined replacement hormonal therapy. Although pathologically distinct from infiltrating ductal carcinoma (IDC), ILC is treated in the same manner as IDC. However, ILC demonstrates significantly different patterns of late local recurrence and distant metastasis. The incidence of extra-hepatic gastrointestinal metastases is reported to be 6% to 18%, with stomach being most common. Herein, we present a brief review of the literature and a typical case involving ILC initially presenting as a small bowel obstruction. Evidence suggests that the late clinical patterns of ILC are distinctly separate from IDC and physicians need be cognizant of its late local recurrence and unique late metastatic pattern. Different follow up strategy should be entertained in patients with ILC.

Randomized clinical trial of the effect of preoperative dexamethasone on nausea and vomiting after laparoscopic cholecystectomy.

BACKGROUND: Preoperative dexamethasone may reduce disabling symptoms such as pain, nausea and vomiting after laparoscopic cholecystectomy. METHODS: This was a randomized, double-blind, placebo-controlled trial. Between March and December 2004, 101 patients undergoing laparoscopic cholecystectomy were randomized to receive 8 mg dexamethasone (n = 49) or placebo (n = 52) intravenously before surgery. Six patients were excluded from the study. All patients received a standardized anaesthetic, surgical and multimodal analgesic treatment. The primary endpoints were: first, postoperative nausea, vomiting and pain; second, postoperative analgesic and antiemetic requirements. The pain scores (visual analogue and verbal response scales), the episodes of nausea (verbal response scale) and vomiting were recorded at 1, 3, 6 and 24 h, respectively, after the operation. Analgesic and antiemetic requirements were also recorded. RESULTS: No apparent drug side-effects were noted. Seven patients (14 per cent) in the treatment group reported nausea and vomiting compared with 24 (46 per cent) in the control group (P = 0.001). In the group of patients treated with dexamethasone, five (10 per cent) required antiemetics versus 23 (44 per cent) of those receiving placebo (P < 0.001). No difference in postoperative pain scores and analgesic requirements was detected between groups. CONCLUSION: Preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy, with no side-effects, and may be recommended for routine use.

[Emergency surgery for complicated colorectal cancer. Retrospective study]. / Trattamento chirurgico del cancro colorettale complicato. Studio retrospettivo.

INTRODUCTION: Emergency surgery for the complications of colorectal cancer poses a significant surgical problem with published mortality rates as hight as 25% to 30%. We reviewed the results of the analysis and quantification of the influence of complications on the outcome of the patients who underwent emergency colectomy for colorectal cancer. MATERIALS AND METHODS: Retrospective study of the clinical features from, a series of 63 patients operated on from 1991 to 1997 (12% of all colorectal cancer operations in the same period). The correlations between complications and cancer stages were estimated by the KW (ANOVA method). RESULTS: Fifty-three patients underwent colorectal resection for intestinal occlusion (84%), 5 for perforation (8%) and 5 for lower gastrointestinal bleeding (8%). When the cancer complications were correlated to the different cancer stage at operation, the complications rate were 32%, 32%, and 36% in the stage II, stage III, and stage IV, respectively. This data was statistically significant: (KW = 58, p = 0.0001). The overall mortality rate was 8% (5 patients) and the total postoperative morbity rate was 32% (21 patients). The overall 5-year, 3-year, and 1-year survival was 47%, 48%, and 76% respectively. CONCLUSIONS: Emergency surgery for complicated colorectal cancer can be performed safely with low postoperative morbidity and mortality rate and can be advocated to realize both short and long-term survival rates comparable to elective surgery; the KW test supports the hypothesis that the a complication in the natural history of colorectal cancer doesn't correlate with the stage of disease.

[The ideal length of hospital stay in the surgical treatment of colorectal cancer]. / La lunghezza ideale del ricovero per il trattamento chirurgico del cancro colo-rettale.

In order to verify the safety of an ideal length of hospital stay (5-6 days) after open colectomy, we reviewed complications after 371 consecutive, elective colorectal resections for cancer at our institution between April 1991 and December 1998. Specifically, age of the patient, length of hospital stay and when the complication was diagnosed were registered. The median postoperative hospital stay was 9 days (range, 4-34 days). No difference in length of hospital stay was detected in patients < or = 65 years old versus > 65 years old (P = NS). All major complications (anastomotic leak, intestinal bleeding, intestinal occlusion, pneumonia, pulmonary embolism, pulmonary edema, stroke, angina pectoris, and fascial dehiscence) were diagnosed before the fifth postoperative day (P < 0.05). Among the minor complications (vomiting, packed red blood cells transfusion, diarrhea, wound infection, urinary tract infection, and pleural effusion), none requiring hospitalization was detected later then 5 days after the operation. We conclude that postoperative length of stay after colorectal resection for cancer can be reduced safely to five to six days after the operation.

Laparoscopic approach for esophageal achalasia with epiphrenic diverticulum.

We report the case of a 65-year-old woman with a 10-year history of dysphagia, regurgitation, cough, and 10-kg weight loss caused by an epiphrenic diverticulum associated with esophageal achalasia managed with a laparoscopic approach. A preoperative barium swallow showed a dilated sigmoid esophagus with a 6-cm epiphrenic diverticulum. Esophageal manometry confirmed the absence of peristalsis in the esophageal body. We performed a laparoscopic diverticulectomy and a 7-cm distal esophageal myotomy with a Dor fundoplication. The postoperative course was uneventful. On the third postoperative day a barium swallow showed no leak, and the patient started oral intake. She was discharged home 5 days after the operation free of symptoms and tolerating a soft diet. Sixteen months after surgery, she was asymptomatic and had gained 8 kg. A barium swallow showed a normal-size esophagus with regular emptying. We reaffirm the feasibility, safety, and efficacy of the laparoscopic diverticulectomy and distal myotomy with Dor fundoplication to manage epiphrenic diverticula resulting from esophageal achalasia.

[Malignancy: treatment and prognosis of gastrointestinal and pancreatic endocrine neoplasia: retrospective study of a series of 16 cases]. / Malignità: trattamento e prognosi delle Neoplasie Endocrine Gastrointestinali e del Pancreas: studio retrospettivo su una serie di 16 casi.

The aim of this study was to review our experience with endocrine tumours of the gastrointestinal tract and pancreas (ETGIP). Between February 1991 and March 2000, sixteen patients with ETGIP were operated on at our institution. Of these patients we reviewed preoperative symptoms, diagnostic techniques (ultrasound, CT, MRI, radiolabelled octreotide scintigraphy, angiography, immunohistochemical study), treatment (surgical operation, neoadjuvant and adjuvant chemotherapy, and radiometabolic therapy) and survival. Nine patients (56%) had a carcinoid tumour, three (19%) an unspecified endocrine tumour, and four (25%) an endocrine tumour associated with a non-endocrine neoplasm. Only five patients (31%) had a preoperative diagnosis of endocrine tumour. Eight patients (50%) had metastatic disease at the time of the operation. All patients without preoperative metastasis (eight patients, 50%) are still alive without recurrent disease, with a mean postoperative survival of 36 months (12-60 months). Of eight patients with metastatic disease, six (75%) died after a mean of 20.5 months (3-60 months) and two (25%) are still alive with the disease after 3 and 6 months, respectively. These data show that presence of metastasis strongly influence survival. Furthermore, survival of patients with metastatic disease seems to be longer as compared to other gastrointestinal tract malignancies. ETGIP are more common and aggressive than previously believed and, therefore, early diagnosis is crucial for cure. Nowadays, however, new diagnostic tools such as radiolabelled octreotide scintigraphy are available for diagnosis and postoperative follow-up. The optimal treatment for ETGIP is a multimodal approach with surgical operation, chemoradiation, radiometabolic, and genetic therapies.

Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms.

Laparoscopic fundoplication controls heartburn and regurgitation, but the effects on the respiratory symptoms of gastroesophageal reflux disease (GERD) are unclear. Confusion stems from difficulty preoperatively in determining whether cough or wheezing is actually caused by reflux when reflux is found on pH monitoring. To date, there is no proven way to pinpoint a cause-and-effect relationship. The goals of this study were to assess the following: (1) the value of pH monitoring in establishing a correlation between respiratory symptoms and reflux; (2) the predictive value of pH monitoring on the results of surgical treatment; and (3) the outcome of laparoscopic fundoplication on GERD-induced respiratory symptoms. Between October 1992 and October 1998, a total of 340 patients underwent laparoscopic fundoplication for GERD. From the clinical findings alone, respiratory symptoms were thought possibly to be caused by GERD in 39 patients (11%). These 39 patients had been symptomatic for an average of 134 months. They were all taking H2-blocking agents (21%) or proton pump inhibitors (79%). Seven patients (18%) were also being treated with bronchodilators, alone (3 patients) or in combination with prednisone (4 patients). Median length of postoperative follow-up was 28 months. In 23 patients (59%) a temporal correlation was found during 24-hour pH monitoring between respiratory symptoms and episodes of reflux. Postoperatively heartburn resolved in 91% of patients, regurgitation in 90% of patients, wheezing in 64% of patients, and cough in 74% of patients. Cough resolved in 19 (83%) of 23 patients in whom a correlation between cough and reflux was found during pH monitoring, but in only 8 (57%) of 14 of patients when this correlation was absent. Cough persisted postoperatively in the two patients who did not cough during the study. These data show that pH monitoring helped to establish a correlation between respiratory symptoms and reflux, and it helped to identify the patients most likely to benefit from antireflux surgery. Following laparoscopic surgery, respiratory symptoms resolved in 83% of patients when a temporal correlation between cough and reflux was found on pH monitoring; heartburn and regurgitation resolved in 90%.

[Short-stay surgery of inguino-crural hernia]. / La chirurgia dell'ernia inguino-crurale in regime di ricovero breve.

BACKGROUND: To evaluate the hospital stay, morbidity, and patients' compliance for short stay inguinal hernia repair. METHODS: Retrospective analysis of 669 patients (594 men and 75 women) who underwent short stay inguinal hernia repair (706 inguinal and 45 femoral repairs) at the Institute of General Surgery, University of Ferrara. Mean age was 60.7 years (range, 18-84 years). The anesthesia was: loco-regional in 495 patients (74%) and general or epidural in 174 (26%). RESULTS: Mean hospital stay was 1.2 days. Postoperative complications were: three scrotal hematomas, two ischemic orchitis, three prosthetic infections, one local anesthetic intolerance, and three high fever. Eighty-five percent of patients were satisfied of the surgical procedure in short hospital stay. Mean follow-up was 36 months. CONCLUSIONS: Short hospital stay in inguinal hernia repair is safe, effective, and widely accepted by patients.

Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia.

Until recently, pneumatic dilatation and intrasphincteric injection of botulinum toxin (Botox) have been used as initial treatments for achalasia, with myotomy reserved for patients with residual dysphagia. It is unknown, however, whether these nonsurgical treatments affect the performance of a subsequent myotomy. We compared the results of laparoscopic Heller myotomy and Dor fundoplication in 44 patients with achalasia who had been treated with medications (group A, 16 patients), pneumatic dilatation (group B, 18 patients), or botulinum toxin (group C, 10 patients). The last group was further subdivided according to whether there was (C2, 4 patients) or was not (C1, 6 patients) a response to the treatment. Results for groups A, B, C1, and C2, respectively, were: anatomic planes identified at surgery (% of patients)--100%, 89%, 100%, and 25%; esophageal perforation (% of patients)--0%, 5%, 0%, and 50%; hospital stay (hrs)--26+/-8, 38+/-25, 26+/-11, and 72+/-65; and excellent/good results (% of patients)--87%, 95%, 100%, and 50%. These results show that: (1) previous pneumatic dilatation did not affect the results of myotomy; (2) in patients who did not respond to botulinum toxin, the myotomy was technically straightforward and the outcome was excellent; (3) in patients who responded to botulinum toxin, the LES muscle had become fibrotic (perforation occurred more often in this setting, and dysphagia was less predictably improved); and (4) myotomy relieved dysphagia in 91% of patients who had not been treated with botulinum toxin. These data support a strategy of reserving botulinum toxin for patients who are not candidates for pneumatic dilatation or laparoscopic Heller myotomy.

Barrett's esophagus: a surgical disease.

Barrett's metaplasia can develop in patients with gastroesophageal reflux disease (GERD), and metaplasia can evolve into dysplasia and adenocarcinoma. The optimal treatment for Barrett's metaplasia and dysplasia is still being debated. The study reported herein was designed to assess the following: (1) the incidence of Barrett's metaplasia among patients with GERD; (2) the ability of laparoscopic fundoplication to control symptoms in patients with Barrett's metaplasia; (3) the results of esophagectomy in patients with high-grade dysplasia; and (4) the character of endoscopic follow-up programs of patients with Barrett's disease being managed by physicians throughout a large geographic region (northern California). Five-hundred thirty-five patients evaluated between October 1989 and February 1997 at the University of California San Francisco Swallowing Center had a diagnosis of GERD established by upper gastrointestinal series, endoscopy, manometry, and pH monitoring. Thirty-eight symptomatic patients with GERD and Barrett's metaplasia underwent laparoscopic fundoplication. Eleven other consecutive patients with high-grade dysplasia underwent transhiatal esophagectomies. Barrett's metaplasia was present in 72 (13%) of the 535 patients with GERD. The following results were achieved in patients who underwent laparoscopic fundoplication (n = 38): Heartburn resolved in 95% of patients, regurgitation in 93% of patients, and cough in 100% of patients. With regard to transhiatal esophagectomy (n = 11), the average duration of the operation was 339 +/- 89 minutes. The only significant complications were two esophageal anastomotic leaks, both of which resolved without sequelae. Mean hospital stay was 14 +/- 5 days. There were no deaths. The specimens showed high-grade dysplasia in seven patients and invasive adenocarcinoma (undiagnosed preoperatively) in four (36%). These results can be summarized as follows: (1) Barrett's metaplasia was present in 13% of patients with GERD being evaluated at a busy diagnostic center; (2) laparoscopic fundoplication was highly successful in controlling symptoms of GERD in patients with Barrett's metaplasia; (3) in patients with high-grade dysplasia esophagectomy was performed safely (invasive cancer had eluded preoperative endoscopic biopsies in one third of these patients); and (4) even though periodic endoscopic examination of Barrett's disease is universally recommended, this was actually done in fewer than two thirds of patients being managed by a large number of independent physicians in this geographic area.

Clinical presentation and evaluation of malignant pseudoachalasia.

Malignant pseudoachalasia can be indistinguishable from primary achalasia on routine clinical evaluation, often resulting in a delay in diagnosis. To better define the clinical features and appropriate management of this disease, the course of five patients discovered to have pseudoachalasia after being referred for a minimally invasive Heller myotomy was reviewed, as were 67 cases of pseudoachalasia previously reported in the literature. Patients with an occult malignancy tended to present with shorter durations of symptoms, greater weight loss, and at a more advanced age than patients with primary achalasia. Since contrast radiography and endoscopy frequently failed to differentiate these two diseases, persons with presumed achalasia meeting these criteria who are referred for minimally invasive surgery should undergo additional imaging to rule out an occult malignancy, since this condition cannot be reliably detected during the course of a thoracoscopic or laparoscopic esophagomyotomy.

Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated.

BACKGROUND: It has been said that a Heller myotomy cannot improve dysphagia in achalasia when the esophagus is markedly dilated or sigmoid shaped. Those who hold this belief recommend esophagectomy as the primary treatment in such cases. This study aimed to compare the results of laparoscopic Heller myotomy combined with Dor fundoplication in 66 patients with and without esophageal dilatation, all of whom had achalasia. METHODS: On the basis of the maximal diameter of the esophageal lumen and the shape of the esophagus, the patients were placed into four groups: group A (esophageal diameter <4.0 cm; 26 patients), group B (diameter 4.0-6.0 cm; 21 patients), group C1 (diameter >6.0 cm and straight esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 7 patients). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. RESULTS: The duration of the operation and the length of hospital stay were similar among the four groups. Excellent or good results were obtained in 88% of group A, 100% of group B, 83% of group C1, and 100% of group C2. No patient in this consecutive series ultimately required an esophagectomy. CONCLUSIONS: In patients with achalasia who have esophageal dilation, a laparoscopic Heller myotomy and Dor fundoplication (a) took no longer and was no more difficult, (b) was associated with no more postoperative complications, and (c) gave just as good relief of dysphagia. We conclude that esophageal dilation by itself should rarely serve as an indication for esophagectomy rather than myotomy as the initial surgical treatment.

In vitro versus in vivo assessment of vein wall properties.

Venous compliance reflects the mechanical properties of the vein wall. Clinical methods of measurement have not been validated by comparison with the accepted in vitro measurement. Despite this, clinical assessment of vein compliance may have a series of useful applications: (1) to assess the progression of chronic venous insufficiency and the related hemodynamic forces acting on the saphenous vein wall; (2) to determine the suitability of the saphenous vein for replacement of an arterial conduit by testing its mechanical properties; and (3) to select the saphenous vein with preferable mechanical performance for coronary artery bypass. The aim of this study is to assess the relationship between in vitro and two in vivo methods of compliance measurement. Compliance of the saphenous vein was determined in 20 patients, using both an invasive and a noninvasive (A and B, respectively) method. Duplex scanning was used for diameter measurement. Venous pressure was derived either intravenously with a needle transducer, or noninvasively with limb length measurement. Patients underwent saphenous excision with further in vitro compliance measurement of the same vein segment (method C). The compliance values obtained with the three methods showed different degrees of correlation (r= 0.516, p = 0.0001 for method A versus method C; r = 0.658, p = 0.0001 for method B versus method C; r = 0.993, p = 0.0001 for method A versus method B). The relationships with the in vitro measurements that were determined validate both in vivo methods for assessment of saphenous vein compliance. Due to its completely noninvasive design, method B appears to have potential use for clinical assessment of saphenous vein wall properties.

An analysis of operations for gastroesophageal reflux disease: identifying the important technical elements.

BACKGROUND: Better understanding of the pathogenesis of gastroesophageal reflux disease in recent years has not been accompanied by appreciable advances in the design of antireflux operations. In many cases, operations are still being performed just as they were described 30 years ago. It is important now to go beyond the eponymous procedures traditionally associated with antireflux operations and to identify the technical elements that contribute to effective and durable fundoplications. OBJECTIVES: To compare antireflux operations and identify the important technical elements. DESIGN AND SETTING: Retrospective study in a university-based tertiary care center. PATIENTS: Two hundred one patients had laparoscopic fundoplications for gastroesophageal reflux disease. The first 22 patients underwent Nissen-Rossetti procedures (360 degree wrap; no division of short gastric vessels). Subsequently, 82 patients had a total (360 degree Nissen wrap) fundoplication and 97 patients had a partial (240 degree Guarner wrap) fundoplication (both with the short gastric vessels divided), with the choice between them based on the quality of esophageal peristalsis. The 3 groups of patients were similar in age, duration of symptoms, incidence of hiatal hernia, and incidence of esophagitis. MAIN OUTCOME MEASURES: Resolution of heartburn, incidence of postoperative dysphagia, and stability of the reconstruction. RESULTS: The resolution of heartburn was achieved for 15 patients (68%) who had the Nissen-Rossetti procedure, 73 patients (89%) who had a 360 degrees Nissen wrap, and 88 patients (91%) who had a 240 degree Guarner wrap. Postoperative dysphagia occurred in 3 patients (14%) having the Nissen-Rossetti procedure, 5 patients (6%) having a 360 degree wrap, and 2 patients (2%) having a 240 degree wrap. Herniation or disruption of the wrap occurred postoperatively in 9 patients (4.5%). Review of the videotapes of these 9 operations showed that important technical elements had been omitted in 8. Seven patients required a second operation. CONCLUSION: Laparoscopic antireflux operations control symptoms without producing adverse effects if the following technical elements are included: the hernia is repaired and the hiatus reduced to a normal size, the short gastric vessels are divided, a total or partial wrap is used based on the quality of esophageal peristalsis, and the wrap is anchored in the abdomen.