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Background: To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) and gastric bypass (LGB) on gastroesophageal reflux disease (GERD). Methods: GERD was evaluated by the Modified Italian Gastroesophageal reflux disease—Health-Related Quality of Life (MI-GERD-HRQL) questionnaire, pH-manometry, endoscopy, and Rx-esophagogram, before and 12 months after surgery. Based on these exams, patients without GERD underwent LSG, and patients with GERD underwent LGB. Results: Thirteen and six patients underwent LSG and LGB, respectively. After LSG, the only statistically significant difference observed at pH-manometry was the median DeMeester score, from 5.7 to 22.7 (P =.0026). De novo GERD occurred in 6 patients (46.2%), with erosive esophagitis in one. The median MI-GERD-HRQL score improved from 3 to 0. Overall, nine patients underwent LGB, but three were lost to follow-up. Preoperative pH-manometry changed the surgical indication from LSG to LGB in 7 out of 9 patients (77.8%). Six patients who underwent LGB completed the study, and at pH-manometry, statistically significant differences were observed in the percentage of total acid exposure time, with the number of reflux episodes lasting >5 minutes and DeMeester score (P =.009). The median MI-GERD-HRQL score improved from 6.5 to 0. Statistically significant differences were not observed at endoscopy and Rx-esophagogram findings in both groups. Conclusions: LSG has a negative impact on GERD, even in patients without preoperative GERD. LGB confirmed to be the intervention of choice in patients with GERD. Preoperative pH-manometry may identify patients with silent GERD, to candidate them to LGB rather than LSG. pH-manometry should be used more liberally to establish the correct surgical indication on objective grounds. [ABSTRACT FROM AUTHOR]

Purpose: Effects of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) symptoms are controversial. Our aim is to evaluate the effects of LSG on GERD symptoms in obese patients using a validated quality-of-life questionnaire. Methods: Records of 100 patients (median body mass index [BMI] 44.4 kg/m2, range 35-63.6) without hiatal hernia or severe GERD were analyzed. GERD symptoms were evaluated by GERD Health-Related Quality-of-Life (HRQL) questionnaire before and after surgery. Weight loss and comorbidity resolution were recorded. Results: Median GERD-HRQL scores decreased from 7 (range 0-44) to 3 (0-34) (P = .025) (median follow-up 56 months [range 7-136]). GERD-HRQL scores improved in 55 patients and worsened in 21; de novo GERD was observed in 10; no change occurred in 14 patients (differences being statistically significant: P = <.0001). On multilinear regression analysis, total preoperative GERD-HRQL score and postoperative BMI were independent variables for overall postoperative GERD-HRQL score: higher total preoperative GERD-HRQL score was associated with improved postoperative GERD-HRQL scores, whereas higher postoperative BMI was associated with worse total postoperative GERD-HRQL score. Resolution of diabetes, hypertension, and sleep apnea syndrome occurred in 84.4%, 68%, and 89.7% of patients, respectively. Conclusions: In obese patients, although LSG was associated with statistically significantly improved postoperative GERD-HRQL scores at mid-term follow-up in 55% of patients, only preoperative GERD-HRQL score and postoperative BMI were independent predictors of GERD after LSG. Higher overall preoperative GERD-HRQL score was associated with improved postoperative GERD-HRQL score. However, further research is needed to assess how to predict GERD outcome. [ABSTRACT FROM AUTHOR]

Introduction. In obese patients with hiatal hernia (HH), laparoscopic sleeve gastrectomy (LSG) with cruroplasty is an option but use of prosthetic mesh crura reinforcement is debated. The aim was to compare the results of hiatal closure with or without mesh buttressing during LSG. Methods. Gastroesophageal reflux disease (GERD) was assessed by the Health-Related Quality of Life (GERD-HRQL) questionnaire before and after surgery in two consecutive series of patients with esophageal hiatus ≤ 4 cm2. After LSG, patients in group A (12) underwent simple cruroplasty, whereas in group B patients (17), absorbable mesh crura buttressing was added. Results. At mean follow-up of 33.2 and 18.1 months for groups A and B, respectively (p=0.006), the mean preoperative GERD-HRQL scores of 16.5 and 17.7 (p=0.837) postoperatively became 9.5 and 2.4 (p=0.071). In group A, there was no difference between pre- and postoperative scores (p=0.279), whereas in group B, a highly significant difference was observed (p=0.002). The difference (Δ) comparing pre- and postoperative mean scores between the two groups was significantly in favor of mesh placement (p=0.0058). Conclusions. In obese patients with HH and mild-moderate GERD, reflux symptoms are significantly improved at medium term follow-up after cruroplasty with versus without crura buttressing during LSG. [ABSTRACT FROM AUTHOR]

Background: The latest Liver Imaging Reporting and Data System (LI-RADS) classification by the American College of Radiology has been recently endorsed in the American Association for the Study of Liver Disease (AASLD) guidelines for Hepatocellular carcinoma (HCC) management. Although the LI-RADS protocol has been developed as a diagnostic algorithm, there is some evidence concerning a possible correlation between different LI-RADS classes and specific pathological features of HCC. We aimed to investigate such radiological/pathological correlation and the possible prognostic implication of LI-RADS on a retrospective cohort of HCC patients undergoing surgical resection. Methods: We performed a retrospective analysis of the pathological characteristics of resected HCC, exploring their distribution among different LI-RADS classes and analyzing the risk factors for recurrence-free, overall and cancer-specific survival Results: LI-RADS-5 (LR-5) nodules showed a higher prevalence of microvascular invasion (MVI), satellitosis and capsule infiltration, as well as higher median values of alpha-fetoprotein (αFP) compared to LI-RADS-3/4 (LR-3/4) nodules. MVI, αFP, satellitosis and margin-positive (R1) resection resulted as independent risk factors for recurrence-free survival, while LI-RADS class did not exert any significant impact. Focusing on overall survival, we identified patient age, Eastern Cooperative Oncology Group performance status (ECOG-PS), Model for End Stage Liver Disease (MELD) score, αFP, MVI, satellitosis and R1 resection as independent risk factors for survival, without any impact of LI-RADS classification. Last, MELD score, log10αFP, satellitosis and R1 resection resulted as independent risk factors for cancer-specific survival, while LI-RADS class did not exert any significant impact. Conclusions: Our results suggest an association of LR-5 class with unfavorable pathological characteristics of resected HCC; tumor histology and underlying patient characteristics such as age, ECOG-PS and liver disease severity exert a significant impact on postoperative oncological outcomes. [ABSTRACT FROM AUTHOR]

Aims: Indocyanine green (ICG) fluorescence angiography (FA) is used for several purposes in general surgery, but its use in bariatric surgery is still debated. The objective of the present pilot study is to evaluate the intraoperative utility of ICG-FA during bariatric surgery in order to focus future research on a reliable tool to reduce the postoperative leak rate., Methods: Thirteen patients (4 men, 30.8%, 9 women, 69.2%) with median age of 52 years (confidence interval, CI, 95% 46.2-58.7 years) and preoperative median body mass index of 42.6 kg/m 2 (CI, 95% 36 to 49.3 kg/m 2 ) underwent bariatric surgery with ICG-FA in our center. Three mL of ICG diluted with 10 cc sterile water were intravenously injected after gastric tube creation during laparoscopic sleeve gastrectomy (LSG) and after the gastric pouch and gastro-jejunal anastomosis creation during laparoscopic gastric by-pass (LGB). For the ICG-FA, Karl Storz Image 1S D-Light system (Karl Storz Endoscope GmbH & C. K., Tuttlingen, Germany) placed at a fixed distance of 5 cm from the structures of interest and zoomed vision modality were used to identify the vascular supply. The perfusion pattern was assessed by the surgical team according to a score. The score ranged from 1 (poor vascularization) to 5 (excellent vascularization) based on the intensity and timing of fluorescence of the vascularized structures., Results: Fom January 2021 to February 2022, six patients underwent LSG (46.2%), three patients underwent LGB (23.1%), and four patients underwent re-do LGB after LSG (30.8%). No adverse effects to ICG were observed. In 11 patients (84.6%) ICG-FA score was 5. During two laparoscopic re-do LGB, the vascular supply was not satisfactory (score 2/5) and the surgical strategy was changed based on ICG-FA (15.4%). At a median follow-up of five months postoperatively, leaks did not occur in any case., Conclusions: ICG-FA during bariatric surgery is a safe, feasible and promising procedure. It could help to reduce the ischemic leak rate, even if standardization of the procedure and objective fluorescence quantification are still missing. Further prospective studies with a larger sample of patients are required to draw definitive conclusions., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Balla, Corallino, Quaresima, Palmieri, Meoli, Cordova Herencia and Paganini.)

Aim: Anastomotic leakage (AL) after anterior rectal resection unresponsive to diverting ileostomy is difficult to manage. Endoscopic vacuum-assisted (E-VAC) wound closure system is a new approach based on co-axial sponge positioning under endoscopic control. If the abscess is not co-axial, however, endoscopic positioning is not feasible. Aim is to report an original method of sponge positioning., Case Experience: A 62-year-old woman with chronic AL after anterior rectal resection for cancer was referred. AL had been treated with diverting ileostomy without healing. Due to the peri-rectal abscess anatomy, standard E-VAC positioning was not possible. A combined endoscopic-interventional radiology procedure for Endo-SPONGE® (B. Braun Aesculap AG, Germany) positioning was thus employed. Under general anesthesia, a guidewire was passed after small counter-incision on the left gluteus and through the left levator muscle, reaching the anastomotic dehiscence and rectal lumen through the chronic abscess. The guidewire was retrieved through the anus and connected to a long silk thread. By retracting the trans-gluteal guidewire, the silk thread was pulled through the abscess to exit from the gluteal skin incision. A tailored Endo-SPONGE® was then connected to the trans-anal silk thread. By pulling on the gluteal silk thread, the sponge was positioned inside the abscess. The silk thread remained in place under a medication for sponge replacements., Discussion and Results: Twelve Endo-SPONGE replacements under sedation were required until AL completely resolved after 35 days., Conclusion: When traditional endoscopic sponge insertion into AL is not possible, this original "pulley system" proved effective for sponge introduction and replacement., Key Words: Anastomotic leakage (AL), Anterior rectal resection, Endo-SPONGE, Endoscopic-Interventional radiology, Pulley system.

Laparoscopic adrenalectomy (LA) is the treatment of choice for management of adrenal tumors. Several approaches are proposed, including the transperitoneal one with patient in lateral or supine position, and the retroperitoneal one, with patient in lateral or prone position. The best approach, however, has yet to be defined. In patients with gallstones and common bile duct (CBD) stones, available options are one-stage [including laparoscopic cholecystectomy (LC) with CBD exploration (LC-LCBDE) and LC with endoscopic rendez-vous (LC-ERV)], or two-stage management [LC and pre or postoperative Endoscopic-Retrograde-Cholangio-Pancreatography (ERCP) with endoscopic sphincterotomy (ES)]. Both are safe and effective, with lower hospital stay after one-stage option. The decision for one or the other depends on local resources and patient conditions. We report the case of a hypertensive 53-years-old man with Cushing's disease from pituitary ACTH-secreting adenoma, after three failed trans-sphenoidal pituitary gland surgical resection procedures, and recurrent biliary symptoms from gallstones and CBD stones. The patient underwent laparoscopic transperitoneal bilateral adrenalectomy in supine position (anterior approach on the right, submesocolic approach on the left) together with LC, intraoperative cholangiography, choledochotomy, CBD exploration, T-tube drainage. In this challenging case, laparoscopic transperitoneal bilateral adrenalectomy with patient in supine position together with one-stage laparoscopic management of gallstones and CBD stones, offered the patient the opportunity to solve both adrenal and biliary problems in the same session, reducing hospital stay and costs. In experienced hands, the transperitoneal combination of different surgical approaches during the same anesthesia with patient in supine position may provide safe and effective patient management. KEY WORDS: Bilateral adrenalectomy, Laparoscopic adrenalectomy (LA), Choledochotomy, Common bile duct (CBD) stones, Laparoscopic cholecystectomy (LC) Laparoscopic common bile duct exploration (LCBDE), Submesocolic approach, Transperitoneal anterior approach.

Aim: Minimally invasive adrenalectomy is the treatment of choice for benign adrenal lesions including pheocromocytoma (PHE) and in selected patients with malignant lesions. The aim of the present study is to evaluate the authors' results after laparoscopic left anterior transperitoneal submesocolic adrenalectomy (LLATSA) for unilateral PHE., Material of Study: This study is a retrospective analysis of prospectively collected data. From 1994 to 2018, 552 patients underwent laparoscopic adrenalectomy (LA). Of these, 34 patients (14 men, 20 women, mean age 52.8 years) underwent LLATSA for PHE., Results: Mean operative time was 93.1 ± 44.9 minutes. Conversion to open surgery occurred in two patients due to difficult identification of the anatomy. Intraoperative blood pressure and heart rate instability were observed in four cases, but with no need for conversion. Postoperative morbidity was nil. One American Society of Anesthesiologists (ASA) III patient died on postoperative day 4 from acute myocardial infarction. Mean postoperative hospital stay was 3.8 ± 1.8 days (range 2 - 8)., Discussion: The main advantage of this approach is the early ligation of the main adrenal vein prior to any gland manipulation. This reduces the risk of catecholamines' spread and consequently the risk of hemodynamic instability. Intraperitoneal dissection is limited and there is no need to mobilize the colon or pancreas, with a lower risk of complications from organ manipulation., Conclusions: LLATSA is feasible and safe for the treatment of PHE. A randomized trial design and a larger cohort of patients would be required to confirm these conclusions., Key Words: Adrenal tumors, Adrenal lesions, Laparoscopic adrenalectomy, Pheochromocytoma, Transperitoneal anterior approach, Laparoscopic left anterior transperitoneal submesocolic adrenalectomy (LLATSA).

Aim: The aim of the study is analyze the results after Transanal Endoscopic Microsurgery (TEM) and Trans-Anal Minimally Invasive Surgery (TAMIS) for rectal cancer in terms of Quality of Life (QoL) and anorectal function., Material of Study: The authors have conducted a review of the literature through the PubMed database using the following keywords: "quality of life", "rectal cancer", "transanal surgery", "TEM" and "TAMIS"., Results: Six and five studies were included on TEM and TAMIS, respectively, for a total of 619 patients with a follow up of up to five years. QoL and anorectal function were evaluated by questionnaires and anorectal manometry in four out of eleven studies. At postoperative evaluation, patients reported temporary changes (from 3 weeks to 36 months) but no long-term effects on anorectal function and QoL. There were no differences in the postoperative functional outcome between surgery with rigid (TEM) or soft (TAMIS) devices. Some of the studies reported postoperative changes at manometry that were not clinically confirmed by the questionnaires., Discussion: During TEM and TAMIS the risk of pelvic autonomic nerves damage, that may compromise urinary and sexual function and the risk of permanent sphincter damage with the need to perform a stoma, are very low., Conclusions: Quality of life and anorectal function after TEM or TAMIS for the treatment of rectal tumors are good with no postoperative sequelae at mid-term follow up., Key Words: Quality of Life (QoL), Rectal cancer, Transanal surgery, Transanal Endoscopic Microsurgery (TEM), Trans-Anal Minimally Invasive Surgery (TAMIS).