Long-term functional results and quality of life after transanal endoscopic microsurgery.

BACKGROUND: Of the few studies that have investigated quality-of-life (QoL) outcomes after transanal endoscopic microsurgery (TEM), the majority have reported only short-term follow-up data. This study assessed long-term clinical and instrumental outcomes (QoL, sexual, urinary and sphincter function) after TEM for extraperitoneal rectal cancer. METHODS: Preoperative and postoperative anorectal function was assessed in consecutive patients with benign rectal lesions or early rectal cancer, based on clinical scores and anorectal manometry. RESULTS: Between January 2000 and July 2005, 93 patients undergoing TEM completed the 60-month study protocol. The mean Wexner continence score increased from baseline at 3 months, began to decline within 12 months, and had returned to the preoperative value at 60 months. Urgency was reported by 65·0, 30·0 and 5 per cent of patients at 3, 12 and 60 months respectively (P < 0·050). A significant improvement was noted in various clinical and QoL scores at 12 and 60 months. Postoperative manometry values at 3 months were significantly lower than at baseline (P < 0·050), but had returned to preoperative values at 12 months. Tumour size of 4 cm or above was the only factor that significantly (P = 0·008) affected the rectal sensitivity threshold, the urge to defaecate threshold and the maximum tolerated volume at 3 months after TEM. CONCLUSION: TEM had no long-term effect on anorectal function or QoL. Lower anal resting pressure at early follow-up was not associated with defaecation problems in patients who were continent before surgery.

Barrett's oesophagus: long-term follow-up after complete ablation with argon plasma coagulation and the factors that determine its recurrence.

BACKGROUND: Argon plasma coagulation seems to be a promising technique for ablation of Barrett's oesophagus, yet few long-term efficacy data are available. AIM: To report on a long-term follow-up and the factors that determine the recurrence of intestinal metaplasia in a cohort of patients with non dysplastic, intestinal type Barrett's oesophagus, after complete ablation of the metaplastic mucosa with argon plasma coagulation. METHODS: Ninety-six patients underwent endoscopic argon plasma coagulation with adequate acid suppression obtained through a continuous omeprazole therapy (50 patients) or through laparoscopic fundoplication (46 patients). Complete ablation was achieved in 94 patients who underwent follow-up. Endoscopic and histological examinations were performed every 12 months. RESULTS: The median follow-up of the patients was 36 months (range 18-98). A recurrence of intestinal metaplasia was found in 17 patients (18%), with an annual recurrence rate of 6.1%. Neither dysplasia, nor adenocarcinoma were found during the follow-up. Through the use of logistic regression analysis, previous laparoscopic fundoplication was associated with a reduced recurrence rate of intestinal metaplasia (odds ratio 0.30, 95% confidence interval 0.10-0.93). CONCLUSIONS: The long-term recurrence of intestinal type Barrett's oesophagus was low after complete ablation with argon plasma coagulation. The control of oesophageal acidity acid exposure with laparoscopic fundoplication seems to reduce the recurrence rate.

[Mid and long term results in the laparoscopic surgical treatment of gastroesophageal reflux]. / Risultati a medio lungo termine nel trattamento chirurgico laparoscopico della malattia da reflusso gatro-esofageo (MRGE).

AIM: The advent of laparoscopic surgery produced a new interest in the surgical treatment of many benign and functional gastrointestinal diseases; one of the most commonly treated is the gastroesophageal reflux disease (GERD). In this paper the Authors report their 15 years experience in the laparoscopic surgical management of GERD. METHODS: From October 1991 to June 2005, 581 patients with GERD were treated by a laparoscopic fundoplication with a 360 degrees wrap (524 cases) or with a 270 degrees wrap (29 cases) or with a Collis gastroplasty (28 cases). RESULTS: The absence of intraoperative mortality, a low conversion to open surgery (0.7%) and a low postoperative morbidity (2.4%) with good clinical and instrumental long term results let the Authors to think that GERD represent an ideal indication for laparoscopic surgery. CONCLUSIONS: Good results are possible in the laparoscopic management of GERD with a precise selection of patients and with a good open and laparoscopic surgical experience in the management of functional esophageal diseases.

Laparoscopic management of giant hiatal hernia: factors influencing long-term outcome.

BACKGROUND: The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate. METHODS: In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. "Tension-free" repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis-Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction. RESULTS: There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis-Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique. CONCLUSIONS: To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis-Nissen procedure in such cases.

Randomized clinical trial of robot-assisted versus laparoscopic Nissen fundoplication.

BACKGROUND: Several studies have shown the safety and feasibility of robot-assisted antireflux surgery but comparative data are lacking. METHODS: Fifty consecutive patients scheduled for laparoscopic antireflux surgery were randomized into two groups. Twenty-five patients underwent robot-assisted surgery and 25 standard laparoscopic fundoplication. All robot-assisted procedures were performed with the da Vinci Surgical System. RESULTS: There were no significant differences in age, sex, body mass or preoperative reflux pattern between the groups. Operating times were significantly longer for robot-assisted than standard laparoscopic operations (mean total operating time 131.3 versus 91.1 min, P < 0.001; skin-to-skin time 78.0 versus 63.5 min, P = 0.001). There was no conversion to open surgery. Conversion to standard laparoscopy was necessary in one of 25 robot-assisted procedures. The length of hospital stay was similar in both groups. Robot-assisted surgery was associated with significantly higher mean total costs (euro 3157 versus euro 1527; P < 0.001). There were no significant differences in clinical, endoscopic and functional outcomes between groups. There was no procedure-related mortality. CONCLUSION: Robot-assisted laparoscopic fundoplication is comparable to the standard laparoscopic procedure in terms of feasibility and outcome, but costs are higher owing to longer operating times and the use of more expensive instruments.

[Prevention of ischemic colitis following aortic reconstruction: personal experience of the role of transmural oximetry in the decision for inferior mesenteric artery reimplantation]. / Prevenzione della colite ischemica successiva a ricostruzione aortica. Nostra esperienza sul ruolo della ossimetria transmurale nella decisione del reimpianto dell'arteria mesenterica inferiore (AMI).

BACKGROUND: The colonic ischemic necrosis is one of the most serious complication in the surgical reconstruction of abdominal aorta aneurysm (AAA) due to surgical inappropriate binding of the inferior mesenteric artery (IMA). METHODS: A retrospective analyzed of a group of 118 infrarenal AAA surgically treated is presented. RESULTS: The most common cause of ischemic colitis (75% of cases) is the surgical binding of an opened IMA or its failed reimplantation. CONCLUSIONS: In this paper according to their personal experience and the literature data, the authors outline a diagnostic behaviour to select the patients needing the reimplantation of IMA; they suggest to complete the pre operative information with an instrumental evaluation during the surgical treatment.

Endoscopic ablation of Barrett's esophagus using argon plasma coagulation (APC) following surgical laparoscopic fundoplication.

BACKGROUND: Barrett's esopagus (BE) is considered a risk factor for the development of esophageal carcinoma. Recently, partial restoration of squamous mucosa after ablation of BE with endoscopic techniques has been described. METHODS: From November 1996 to November 1999, 23 patients with histologically proven BE have been treated by endoscopic argon plasma coagulation (APC) following suppression of gastro-esophageal reflux by laparoscopic fundoplication. Histological follow-up after completed ablation ranged from 16 to 45 months (mean, 31.9 months). RESULTS: Histologically, complete squamous reepithelialization was observed in 20/23 patients, whereas a regrowth of a mixed squamous and gastric type mucosa was observed in 1 patient. Small islands of intestinal metaplasia were observed under the neosquamous epithelium in two patients (9%) during follow-up. CONCLUSION: The success rate of APC ablation following laparoscopic antireflux surgery in our series may be as high as 91%. Nevertheless, small islands of intestinal metaplasia under the new squamous epithelium may persist in some patients. In these circumstances, the authors recommend that endoscopic ablation of BE should be confined to controlled clinical trials.

[Indications for the surgical treatment of abdominal aortic aneurysms]. / Indicazioni al trattamento chirurgico degli aneurismi dell'aorta addominale.

BACKGROUND: On the basis of a literature review and of personal experience, the authors analyze the main indications and the best strategy for elective surgical repair of infrarenal abdominal aortic aneurysm (AAA). METHODS: Personal experience concerning elective surgical treatment of 110 patients with infrarenal AAA, is presented. RESULTS: No operative deaths have been observed and the postoperative recovery was regular in 108 patients. Two early complications (colon ischemia) and ten late postoperative complications (5 pseudoaneurysms, 5 sexual dysfunctions) occurred. CONCLUSIONS: The main therapeutic guidelines concerning the management of AAA should follow specific indications (aneurysm dimensions and growth rates). Indications for operative repair of aneurysms obviously should be judged in relation to the presence or absence of associated risk factors or concomitant medical conditions. In most cases, aneurysm repair can be performed safely, despite associated medical risks, by careful preoperative evaluation and preparation.

[Adrenal synchronous metastasis from non small cell lung carcinoma (NSCLC): combined surgical treatment? Case report and review of the literature]. / Metastasi surrenalica sincrona da carcinoma del polmone non microcitoma (NSCLC): trattamento chirurgico combinato? Case report e revisione della Letteratura.

The adrenal gland is a frequent site for metastases from non small cell lung carcinoma (NSCLC). Surgical strategy in patients with operable NSCLC with adrenal synchronous metastases is yet unclear. On the basis of a literature survey and of a personal case report, the authors analyze the main indications and the best strategy for solitary synchronous metastases in the adrenal gland from NSCLC.