Sacral nerve modulation for patients with fecal incontinence: long-term outcome and effects on sexual function.

Sacral nerve modulation has become an established treatment for fecal and urinary incontinence, and sexual disorders. The objective of this study was to evaluate the long-term outcome of sacral neuromodulation in patients with fecal or combined fecal and urinary incontinence (double incontinence), assessing its safety, efficacy, and impact on quality of life and sexual function. This was a multicentric, retrospective, cohort study including patients with fecal or double incontinence who received sacral neuromodulation at seven European centers between 2007 and 2017 and completed a 5-year follow-up. The main outcome measures included improvements of incontinence symptoms and quality of life compared with baseline, evaluated using validated tools and questionnaires at 1-, 6-, 12-, 36- and 60-month follow-up. 108 (102 women, mean age 62.4 ± 13.4 years) patients were recruited, of whom 88 (81.4%) underwent definitive implantation of the pacemaker. Patients' baseline median Cleveland Clinic Incontinence Score was 15 (10-18); it decreased to 2 (1-4) and 1 (1-2) at the 12- and 36-month follow-up (p < 0.0001), remaining stable at the 5-year follow-up. Fecal incontinence quality of life score improved significantly. All patients with sexual dysfunction (n = 48) at baseline reported symptom resolution at the 5-year follow-up. The study was limited by the retrospective design and the relatively small patient sample. Sacral nerve modulation is an effective treatment for fecal and double incontinence, achieving satisfactory long-term success rates, with resolution of concomitant sexual dysfunction.

Rectal Prolapse Pathological Features: Findings in Patients With Outlet Obstruction Treated With Stapled Transanal Rectal Resection.

BACKGROUND: Obstructed defecation syndrome is a common multifactorial disease for which treatment is based primarily on clinic presentation for the lack of reliable instrumental and anatomopathological criteria. OBJECTIVE: The study aimed to analyze the pathological findings of the resected rectal specimens after stapled transanal rectal resection in patients affected by outlet obstruction. DESIGN: Retrospective cohort study. SETTINGS: University hospital. PATIENTS: Patients who underwent rectal resection for obstructed defecation syndrome due to internal rectal prolapse were included. INTERVENTIONS: Specimens of patients with obstructed defecation syndrome were analyzed through conventional histology and morphometric image analysis and compared with those of rectal specimens excised for oncological diseases. MAIN OUTCOME MEASURES: Analysis of the anatomopathological impairments underlying rectal prolapse. RESULTS: From January 2017 to December 2020, 46 specimens from the stapled transanal rectal resection group were compared with 40 specimens from the control group. In the stapled transanal rectal resection group, conventional histology revealed 34 samples (73.9%) had moderate- to severe-grade fibrosis with moderate-grade nerve degeneration in 33 cases (71.7%). In the control group, conventional histology revealed the absence of fibrosis in 31 specimens (77.5%), whereas the absence of nerve degeneration was detected in 37 specimens (92.5%). In the stapled transanal rectal resection group, morphometric image analysis showed severe-grade fibrosis in 25 cases (54.4%) compared to only low-grade fibrosis in 11 cases (27.5%). LIMITATIONS: The small sample size and the retrospective design of the study were limitations. Moreover, there was no chance to use specimens from healthy volunteers as the control group. CONCLUSIONS: Stapled transanal rectal resection specimens showed a higher rate of fibrosis and nerve dysplasia, an important parameter that is typically not considered preoperatively and could lead patients with rectal prolapse to the best treatment approach. See Video Abstract at http://links.lww.com/DCR/B928 . CARACTERSTICAS ANATOMOPATOLGICAS EN EL PROLAPSO DE RECTO HALLAZGOS EN PACIENTES CON OBSTRUCCIN DEL TRACTO DE SALIDA TRATADOS CON RESECCIN RECTAL TRANSANAL CON GRAPAS: ANTECEDENTES:El síndrome de obstrucción del tracto de salida, es una afección multifactorial común, cuyo tratamiento está basado principalmente en la presentación clínica, ésto, debido a la falta de criterios confiables tanto instrumentales como anatomopatológicos.OBJETIVO:Analizamos los hallazgos histopatológicos de las piezas de resección rectal obtenidas por vía transanal mediante grapas, realizadas en pacientes que presentaban obstrucción del tracto de salida.DISEÑO:Este fue un estudio de cohorte retrospectivo.AJUSTE:El escenario fue un hospital universitario.PACIENTES:Aquellos sometidos a resección rectal por síndrome obstructivo del tracto de salida causada por un prolapso rectal interno.INTERVENCIONES:Los especímenes de pacientes con síndrome obstructivo defecatorio fueron analizados mediante histología convencional y análisis de imágenes morfométricas, comparados con especímenes rectales resecados por enfermedad oncológica.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario se concentró en la investigación de las deficiencias anatomopatológicas subyacentes del prolapso rectal interno.RESULTADOS:Desde enero de 2017 hasta diciembre de 2020, se compararon 46 especímenes del grupo de resección rectal transanal con grapas con 40 especímenes del grupo de control. En histología convencional, el grupo de resección rectal transanal con grapas, 34 muestras (73,9%) presentaron un grado de fibrosis moderada-severa con un grado moderado de degeneración neurógena en 33 casos (71,7%). En el grupo control, la histología convencional reveló ausencia de fibrosis en 31 especímenes (77,5 %), mientras que la ausencia de degeneración neurógena se detectó en 37 controles (92,5 %). En el grupo de resección rectal transanal con grapas, el análisis de imágenes morfométricas mostró fibrosis moderada y fibrosis severa en 19 (41,3%) y 25 (54,4%) casos, respectivamente. En el grupo control, el análisis de imágenes morfométricas mostró solo un bajo grado de fibrosis en 11 casos (27,5%). Se encontró una diferencia significativa en todos los grados de fibrosis y displasia neurógena entre los grupos en las evaluaciones de análisis de imagen morfométrica e histología convencional (p < 0,001).LIMITACIONES:El pequeño tamaño de la muestra y el diseño retrospectivo del estudio. Además, no existe la posibilidad de utilizar un grupo de control con muestras de voluntarios sanos.CONCLUSIONES:Los especímenes de resección rectal transanal con grapas mostraron una mayor tasa de fibrosis y displasia neurógena, parámetro importante que actualmente no está considerado antes de la operación y en un futuro muy cercano podría orientar a los pacientes con prolapso rectal interno hacia un mejor enfoque de tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B928 . (Traducción-Dr. Xavier Delgadillo ).

Long-Term Outcomes of Sectorial Longitudinal Augmented Prolapsectomy for Asymmetric Muco-hemorrhoidal Prolapse: An Observational Study of 433 Consecutive Patients.

PURPOSE: Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis. METHODS: Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work. RESULTS: We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2. CONCLUSIONS: The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse.

Combined LOCalizer™ and Intraoperative Ultrasound Localization: First Experience in Localization of Non-palpable Breast Cancer.

BACKGROUND: Wire-guided localization is the gold-standard for the detection of non-palpable breast lesions, although with acknowledged limitations. The aim of this study was to evaluate the combined use of LOCalizerr™ (Hologic, Santa Carla, CA, USA), and intraoperative ultrasound (IOUS) for localization and surgery of non-palpable breast cancer. PATIENTS AND METHODS: Patients with non-palpable breast lesions underwent localization procedure with LOCalizer™ and IOUS. After the placement of the marker, eight measures were made to guide the excision. LOCalizerr™ Pencil and IOUS were performed to obtain the distance between the dissection plane and the margins of lesions. RESULTS: The procedure was feasible in the five enrolled patients and associated with clear oncological margins in all cases. Moreover, a high satisfaction according to Likert scale for surgeons, radiologists and patients, performing limited and tailored resections, was reported. CONCLUSION: Combining LOCalizerr™ and IOUS is an effective method for locating non-palpable breast cancer, guarantying excellent oncological and cosmetic results.

Prolonged iatrogenic thoracic duct chylous fistula in neck surgery: conservative management or surgery? A literature review.

BACKGROUND: Thoracic duct chylous fistula is a rare complication following neck surgery, especially for malignant disease. Despite its low incidence, it can be a life-threatening postoperative complication increasing the risk of infection, bleeding, hypovolemia, electrolyte imbalance, and malnutrition. Currently, the management of thoracic duct fistula is not standardized yet. It can range from conservative to surgical approaches, and even when surgery indication occurs, there is no unanimous agreement on timing and operative steps, so the surgical approach still remains mostly subjective, in accordance with clinical conditions of the patients and with surgeon's experience. AIMS: The aim of the study was to search into Literature a common accepted behaviour in thoracic duct chylous fistula occurring. METHODS: A literature review was carried out. Conservative treatments include fasting associated with total parental nutrition or low-fat diet, compressive dressings, and octreotide administration. If conservative treatment fails, in order to avoid dangerous consequences, functional repair of the thoracic duct injury with lymphovenous microanastomosis should be the preferred solution, rather than an approach that obliterates the thoracic duct or lymphatic-chylous pathways, such as thoracic duct embolization, therapeutic lymphangiography, and thoracic duct ligation. CONCLUSIONS: In our experience, patients undergone thyroidectomy and neck dissection for thyroid-differentiated cancer, who report an unrecognized thoracic duct chylous fistula after surgery, must be treated via integrated conservative and surgical treatment. A literature review about thoracic duct chylous fistula following neck surgery, focusing on the current management and therapeutic approach, was furthermore carried out, in order to delineate the actual therapeutic options in case of thoracic duct chylous fistula occurrence.

Late rectal anastomotic leakage treated with diode laser FiLaC probe. A case report of a new minimal invasive treatment.

INTRODUCTION: Anastomotic Leakage (AL) is one of the most important early postoperative complication of the adenocarcinoma's surgical treatment. Fistula Laser Closure (FiLaC®) is a minimal invasive technique that use diode laser energy to obtain the fistula track obliteration and it is finding large application for other affection characterized by fistula tracts presence. PRESENTATION OF CASE: A 56 years old male, with no clinical history of adenocarcinoma in his family, underwent a laparoscopic low anterior resection with ileostomy for a rectal adenocarcinoma. Approximately 3 months after the procedure an anastomotic leak with an associated abscess was found. The patient underwent an endoscopic FiLaC off-label procedure on the AL and after further 4 months, he obtained a complete resolution of the anastomosis dehiscence. DISCUSSION: The literature is poor about the minimal invasive AL treatment and there is no paper about the management of the AL with the FiLaC® procedure. For asymptomatic patients a conservative solution is preferred, it could be considered a drain positioning for emptying abscesses and for irrigation or the use of an Endosponge to decrease the resolution time. The FiLaC® procedure could be a more feasible technique that could also reduce the healing time as well with no discomfort for the patient. CONCLUSION: Considering the results and our patient healing time, we think that an off-label application of FiLaC® procedure on asymptomatic low anastomotic leak could be an opportunity for a morbidity resolution shorter than the simple wait and see strategy, and more sustainable for the patient.

Ultrasound guided percutaneous dilatation tracheotomy (US-PDT) to prevent potentially life-threatening complications: A case report.

INTRODUCTION: Percutaneous dilatation tracheotomy (PDT) is a relatively recent technique that enables non surgeons to perform tracheotomies at bedside reducing operation rooms schedules. It is burdened by a moderate risk of postoperative bleeding. PRESENTATION OF CASE: The patient was a 57 years old with a temporal intraparenchymal hematoma, submitted to percutaneous dilatation tracheotomy. Despite the favorable anatomical features, a pre-procedural US was performed, identifying a pulsating vessel with an arterial pattern, 2 cm above the hollow. The procedure was then considered at high risk, an operation room was required for the technique and an on-call surgeon was alerted. The procedure was ended safely and any bleeding was avoided because the technique was practiced with the best precautions. DISCUSSION: PDT strength is the possibility for non surgeons to perform tracheotomies in selected patients at bedside, reducing operation rooms congestion. Such technique though is a "blind" technique, and postoperative bleedings can occur and represent a feared complication. Conversely, the surgical tracheotomy permits a better control of hemorrhages, but needs the involvement of a surgeon and availability of an operation room. Performing a PDT guided by a neck ultrasound is useful to identify eventual aberrant vessel whose course could complicate the tracheotomy, it is part of PDT guidelines of some States. CONCLUSION: US-PDT could help reducing procedure related complications selecting those high risk patients still in need of operating room and surgical assistance. US-PDT feasibility combined to its easy availability and low costs encourage its introduction into everyday practice.

Dynamic transperineal ultrasonography correlates with prolonged pudendal nerve latency in female with fecal incontinence.

The pelvic floor is a complex anatomical entity and its neuromuscular assessment is evaluated through debated neurophysiological tests. An innovative approach is the study of pelvic floor through dynamic transperineal ultrasound (DTU). The aim of this study is to evaluate DTU sensitivity in recognizing patients with fecal incontinence and to evaluate its concordance with the results of the motor latency studied via pudendal nerve terminal motor latency (PNTML). Female patients affected by FI addressed to our center of coloproctology were prospectively assessed. After a coloproctological evaluation, comprising the PNTML assessment to identify pudendal neuropathy, patients were addressed to DTU to determine anterior and posterior displacement of puborectalis muscle by a blinded coloproctologist. In order to compare the data, a cohort of female healthy volunteers was enrolled. Sixty-eight subjects (34 patients and 34 healthy volunteers) were enrolled. The sensitivities of anterior displacement, posterior displacement and either anterior or posterior displacement in determining the fecal incontinence were 82%, 67% and 91%, respectively. A further high correlation of either anterior or posterior displacement with PTNML was also noted (88%). DTU is an indirect, painless and reproducible method for the identification of the pelvic floor neuromuscular integrity. Its findings seem to highly correlate with FI symptoms and with PNTML results. In the near future, after larger comparative studies, DTU would be considered a potential reliable non-invasive and feasible indirect procedure in the identification of fecal incontinence by pudendal neuropathy. Trial registration number is NCT03933683.

Constipação com obstrução à saída e incontinência fecal: o tratamento de reabilitação é o caminho? Mito ou realidade / Outlet obstructed constipation and fecal incontinence: is rehabilitation treatment the way? myth or reality

ABSTRACT Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist's scrupulous hard work, especially as regards the patient's emotional and psychic state, and finally the patient's compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from "real" success to illusion "myth".

RESUMO A reabilitação do assoalho pélvico visa abordar alterações funcionais e anatômicas perineais, bem como disfunções mecânicas torácicas-abdominais que levam a doenças procto-urológicas como prisão de ventre, incontinência fecal e urinária e dor pélvica. Requerem uma abordagem multidimensional, com impacto significativo na qualidade de vida dos pacientes. Um protocolo clínico e instrumental exaustivo para avaliar os transtornos de defecação deve incluir avaliação clínica e instrumental, bem como diversos parâmetros clínicos/fisiátricos. Todos esses parâmetros devem ser considerados para reconhecer e definir qualquer fator potencial desempenhando um papel nos aspectos funcionais da incontinência, prisão de ventre e dor pélvica. Após tal avaliação, tendo identificado com precisão quaisquer alterações anatômicas e funcionais tóraco-abdomino-perineais, um programa de reabilitação pelvi-perineal pode ser realizado para corrigir as alterações acima mencionadas e obter melhora clínica. O sucesso do processo de reabilitação está ligado a diversos fatores, como uma avaliação cuidadosa do paciente, visando selecionar a terapia de reabilitação direcionada mais adequada e específica, além do trabalho árduo e escrupuloso do terapeuta, especialmente no que diz respeito ao estado emocional e psíquico do paciente e, finalmente, a conformidade do paciente em realizar a terapia em si, especialmente em casa. Esses fatores podem influenciar profundamente os resultados globais das terapias de reabilitação, que vão desde o sucesso "real" até o "mito" ilusório.

OUTLET OBSTRUCTED CONSTIPATION AND FECAL INCONTINENCE: IS REHABILITATION TREATMENT THE WAY? MYTH OR REALITY.

Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist's scrupulous hard work, especially as regards the patient's emotional and psychic state, and finally the patient's compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from "real" success to illusion "myth".

Sleeve Gastrectomy and Anterior Fundoplication (D-SLEEVE) Prevents Gastroesophageal Reflux in Symptomatic GERD.

BACKGROUND: A worrying increase of gastroesophageal reflux disease (GERD) and Barrett esophagus has been reported after sleeve gastrectomy (SG). Recent reports on combined fundoplication and SG seem to accomplish initial favorable results. However, no study included manometry or pH monitoring to evaluate the impact of fundoplication in SG on esophageal physiology. METHOD: In this study, 32 consecutive bariatric patients with GERD and/or esophagitis had high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) before and after laparoscopic sleeve gastrectomy associated to anterior fundoplication (D-SLEEVE). The following parameters were calculated at HRiM: lower esophageal sphincter pressure and relaxation, peristalsis, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH, symptom index association (SI), and symptom-association probability (SAP) were also analyzed. RESULTS: At a median follow-up of 14 months, HRiM showed an increased LES function, and MII-pH showed an excellent control of both acid exposure of the esophagus and number of reflux events. Bariatric outcomes (BMI and EWL%) were also comparable to regular SG (p = NS). CONCLUSION: D-SLEEVE is an effective restrictive procedure, which recreates a functional LES pressure able to control and/or prevent mild GERD at 1-year follow-up.

Effects of Extracorporeal Magnetic Stimulation in Fecal Incontinence.

Background: Fecal incontinence (FI) is a common condition that has devastating consequences for patients' QOL. In some patients, the conventional functional pelvic floor electrical stimulation has been effective but is an invasive and embarrassing treatment. The object of the study was to evaluate the feasibility of functional extracorporeal magnetic stimulation (FMS) in strengthening the pelvic floor muscles without an anal plug and the embarrassment of undressing. Materials and Methods: Thirty patients (26 female and 4 males) with FI were enrolled. All patients were assessed during a specialized coloproctology evaluation followed by endoanal ultrasonography and anorectal manometry. All patients underwent an FMS treatment once weekly for 8 weeks. Patients' outcome was assessed by the Cleveland Clinic Fecal Incontinence Score (CCFIS) and by the fecal incontinence QOL questionnaire (FIQL). Results: After 8 weeks, the number of solid and liquid stool leakage per week was significantly reduced (p<0.05) with a significant improvement of the CCFIS and of the FIQL (p<0.05). Moreover, the authors recorded a missed recruitment of the agonist and antagonists' defecation muscles. Conclusion: FMS is a safe, non-invasive and painless treatment for FI. It could be recommended for selected patients with non-surgical FI to ensure a rapid clinical improvement.

Postoperative discomfort and pain in the management of hemorrhoidal disease: laser hemorrhoidoplasty, a minimal invasive treatment of symptomatic hemorrhoids.

Hemorrhoidal disease (HD) treatment still remains controversial. In fact, despite many surgical progresses, postoperative pain, and discomfort remain the major weaknesses. Laser hemorrhoidoplasty (LHP) is a minimal invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser. The aim of the current study is to analyze the feasibility and efficacy of LHP in patients with II-III degrees hemorrhoids. Consecutive patients with II-III degree hemorrhoids were enrolled in the study and underwent an LHP treatment using a 1470-nm diode laser. Operative time, postoperative pain and complications, resolution of symptoms, and length of return to daily activity were prospectively evaluated. Recurrence of prolapsed hemorrhoid or symptoms at a minimum follow-up of 6 months was evaluated. Fifty patients (28 males and 22 females) were enrolled in the study. No significant intraoperative complications occurred. Postoperative pain score (at 12, 18, and 24 h postoperatively), evaluated through visual analogue scale, was extremely low (mean value 2). No postoperative spontaneous bleeding occurred. The 100% of our population came back to daily activity 2 days after surgery. At a mean follow-up period of 8.6 months, we reported a recurrence rate of 0%. LHP demonstrated a large efficacy in selected patients. The greatest strength points were low postoperative pain, the presence of slightly significant peri-anal wounds, no special anal hygienic measures and low surgical time. Thus, resulting in a negligible postoperative discomfort, LHP could be considered a painless and minimal invasive technique in the treatment of HD.

D-shape asymmetric excision in recurrent pilonidalis disease: an analytic longitudinal long-term evaluation.

Sacrococcigeal pilonidalis disease (SPD) recurrence is a major factor influencing surgical outcomes. Several different surgical treatments have been reported, however, there is a lack of long-term data on reoperation. Aim of this study was to analyze outcomes of a single center adopting a standardized off-midline asymmetric procedure (D-shape). Analytic longitudinal assessment of 83 patients (median age 35 years, range 23-59 years) with recurrent SPD that completed the 5-year study design following D-shape reoperation. Among a cohort of 607 patients, we enrolled 83 recurrent SPD. After D-shape reoperation, second recurrence rate was 9.6% (8/83). Second recurrence rate was not statistically significantly different among patients undergone D-shape as first surgery compared to patients of symmetric excision group (11.8% vs. 7.4%, p = 0.57). Similarly, there was no statistical difference among patients who underwent D-shape as first surgery compared to patients who underwent symmetric excision elsewhere (11.8% vs. 9.1%, p = .75). D-shape is a safe and effective when adopted as revisional surgery at a long-term follow-up. Comparative evaluation is warranted to establish the potential superiority over different surgical surgery in case of recurrence.

Pre-operative clinical and instrumental factors as antireflux surgery outcome predictors.

Gastroesophageal reflux disease (GERD) is nowadays a highly prevalent, chronic condition, with 10% to 30% of Western populations affected by weekly symptoms. Many patients with mild reflux symptoms are treated adequately with lifestyle modifications, dietary changes, and low-dose proton pump inhibitors (PPIs). For those with refractory GERD poorly controlled with daily PPIs, numerous treatment options exist. Fundoplication is currently the most commonly performed antireflux operation for management of GERD. Outcomes described in current literature following laparoscopic fundoplication indicate that it is highly effective for treatment of GERD; early clinical studies demonstrate relief of symptoms in approximately 85%-90% of patients. However it is still unclear which factors, clinical or instrumental, are able to predict a good outcome after surgery. Virtually all demographic, esophagogastric junction anatomic conditions, as well as instrumental (such as presence of esophagitis at endoscopy, or motility patterns determined by esophageal high resolution manometry or reflux patterns determined by means of pH/impedance-pH monitoring) and clinical features (such as typical or atypical symptoms presence) of patients undergoing laparoscopic fundoplication for GERD can be factors associated with symptomatic relief. With this in mind, we sought to review studies that identified the factors that predict outcome after laparoscopic total fundoplication.