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Background Psoas abscess is a relatively rare clinical condition that can occur worldwide, is difficult to diagnose, and has a severe clinical course. Conventional treatment ranges from antibiotic therapy alone to computed tomography (CT)-guided and/or open surgical drainage. Retroperitoneoscopic drainage represents a minimally invasive and potentially definitive therapeutic option. Materials and methods A systematic review of the literature on minimally invasive extraperitoneal access for drainage of psoas abscess was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the PRISMA statement guidelines. We considered only studies in English and with a full text. The quality of all selected articles was assessed for the risk of methodological bias. Additional literature sources were used to put into context the indications and limits of retroperitoneoscopic drainage. Results Seven papers published between 2004 and 2020, including a total of 56 patients, met the eligibility criteria and were included in the qualitative analysis. Causative agents of psoas abscess included Mycobacterium tuberculosis, Klebsiella pneumoniae, Enterobacter aerogenes, Staphylococcus aureus, and Streptococcus spp. Tuberculous abscess was more common than pyogenic abscess (92.8% vs. 7.2%). Main clinical findings were back pain (76.8%) and fever (53.6%). All patients were preoperatively evaluated by CT or magnetic resonance imaging. Only 4 patients (7.1%) had previously undergone CT-guided percutaneous drainage. Retroperitoneoscopic drainage was combined with antibiotic therapy in all cases. No Clavien-Dindo grade >3 complications occurred, and there was no 30-day postoperative mortality. The recurrence rate was 1.8% at a mean follow-up of 21 months. Conclusion Retroperitoneoscopic surgical drainage is a safe and effective approach for the treatment of psoas abscess.

The association of a solitary tumor of the pleura with paraneoplastic refractory hypoglycemia is a very rare clinical condition. An 86-year-old gentleman with an incidentally discovered large mass in the left chest and a long-standing history of refractory hypoglycemia was referred for surgical consultation. Computed tomography and PET (Positron Emission Tomography) scan confirmed the presence of a homogeneous mass leaning on the left hemidiaphragm with no tracer uptake. After tumor board discussion, the mass was radically excised through a left thoracotomy. Histopathology revealed a benign solitary fibrous tumor of the pleura. At 1‑year follow-up the patient was doing well and did not further complain of hypoglycemia-related symptoms. Doege–Potter syndrome is a life-threatening condition associated with severely impaired quality of life. Prompt identification and surgical treatment are mandatory.

Background Esophageal lipomatous tumors, also reported as fibrovascular polyp, fibrolipoma, angiolipoma, and liposarcoma, account for less than 1% of all benign mesenchymal submucosal tumors of the esophagus. Clinical presentation and therapy may differ based on location, size, and morphology. A comprehensive and updated systematic review of the literature is lacking. Methods A systematic review of the literature was performed according to PRISMA guidelines. Pubmed, Embase, Cochrane, and Medline databases were consulted using MESH keywords. Non-English written articles and abstracts were excluded. Sex, age, symptoms at presentation, diagnosis, tumor location and size, surgical approach and technique of excision, pathology, and morphology were extracted and recorded in an electronic database. Results Sixty-seven studies for a total of 239 patients with esophageal lipoma or liposarcoma were included in the qualitative analysis. Among 176 patients with benign lipoma, the median age was 55. The main symptoms were dysphagia (64.2%), transoral polyp regurgitation (32.4%), and globus sensation (22.7%). The majority of lipomas (85.7%) were intraluminal polyps, with a stalk originating from the upper esophagus. Overall, 165 patients underwent excision of the mass through open surgery (65.5%), endoscopy (27.9%), or laparoscopy/thoracoscopy (3.6%). Only 5 (3%) of patients required esophagectomy. Of the 11 untreated patients with an intraluminal polyp, 7 died from asphyxia. Overall, liposarcoma was diagnosed in 63 patients, and 12 (19%) underwent esophagectomy. Conclusion Esophageal lipomatous tumors are rare but potentially lethal when are intraluminal and originate from the cervical esophagus. Modern radiological imaging has improved diagnostic accuracy. Minimally invasive transoral and laparoscopic/thoracoscopic techniques represent the therapeutic approach of choice.

The magnetic sphincter augmentation (MSA) device has been proven safe and effective in controlling typical reflux symptoms and esophageal acid exposure for up to 6-year follow-up. Longer term outcomes have not been reported yet. A prospectively maintained database was reviewed to assess long-term safety and efficacy of the laparoscopic MSA procedure at a single referral center. Gastro-Esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), use of proton-pump inhibitors (PPI), and esophageal acid exposure were compared to baseline. Favorable outcomes were defined as ≥ 50% improvement of GERD-HRQL total score and PPI discontinuation. Between March 2007 and March 2020, 335 patients met the study inclusion criteria, and 124 of them were followed from 6 to 12 years after surgery (median 9 years, IQR 2). Mean total GERD-HRQL score significantly improved from 19.9 to 4.01 (p p 15 (OR 4.09). We confirm long-term safety and efficacy of MSA in terms of symptom improvement, decreased drug dependency, and reduced esophageal acid exposure.

Background/Aims According to the Chicago classification version 3.0, high-resolution manometry (HRM) should be performed in the supine position. However, with the patient in the upright/sitting position, the test could more closely simulate real-life behavior and may be better tolerated. We performed a systematic review of the literature to search whether the manometric variables and the final diagnosis are affected by positional changes. Methods A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies published in English that compared HRM results in different body positions were included. Moreover, the change in diagnosis of esophageal motility disorders according to the shift of body position was investigated. Results Seventeen studies including 1714 patients and healthy volunteers met the inclusion criteria. Six studies showed a significant increase in lower esophageal sphincter basal pressure in the supine position. Integrated relaxation pressure was significantly higher in the supine position in 10 of 13 studies. Distal contractile index was higher in the supine position in 9 out of 10 studies. One hundred and fifty-one patients (16.4%) out of 922 with normal HRM in the supine position were diagnosed with ineffective esophageal motility (IEM) when the test was performed in the upright position (P < 0.001). Conclusions Performing HRM in the upright position affects some variables and may change the final manometric diagnosis. Further studies to determine the normal values in the sitting position are needed. (J Neurogastroenterol Motil 2020;26:335-343)

Background At present, little research has been done to clarify why some achalasia patients do not lose weight or are even obese and to investigate their nutritional status. The aim of this study was to identify predictive factors of malnutrition in these patients and to assess their response to treatment. Methods We conducted a retrospective cohort study on consecutive patients referred to a tertiary-care center for laparoscopic or endoscopic treatment of achalasia. Demographics, anthropometric variables, presenting symptoms, and results of the objective investigation were recorded on a prospectively collected database. The severity of symptoms and the nutritional risk were assessed by the Eckardt score and the Malnutrition Universal Screening Tool (MUST), respectively, before and after treatment. Results Between 2013 and 2019, 171 patients met the study inclusion criteria. There were 87 (50.9%) male and the median age was 53.0 (39-66) years. The median Eckardt score was 6 (interquartile range 3). Based on the MUST score, 121 (70.8%) patients were classified at moderate/high risk of malnutrition. Of these, 93 (76.9%) were overweight or obese. Compared to low-risk group, predictive factors of moderate/high risk of malnutrition were higher Eckardt score [odds ratio (OR) 1.63; 95% CI, 1.35-1.99], more severe dysphagia (OR 2.68, 95% CI, 1.66-4.30), and greater absolute weight loss (OR 2.37; 95% CI, 1.77-3.17). The latter was the only independent predictive factor of malnutrition (OR 2.54; 95% CI, 1.69-3.82). After treatment, the measured MUST score was 0 in 96% of patients. Conclusions Over 70% of achalasia patients were at moderate/high risk of malnutrition. These individuals may benefit from a perioperative multidisciplinary approach including dietary intervention to stabilize weight and improve their nutritional status.

Background: Safety and effectiveness of absorbable meshes for laparoscopic hiatus hernia repair are still debated. This may be due to patient selection, technique of repair, type and shape of mesh,...

Laparoscopic Toupet fundoplication has gained progressive consideration in the management of patients with gastroesophageal reflux disease and hiatus hernia. Previous studies showed equivalent results in terms of reflux control with lower rate of side effects compared to the Nissen fundoplication. However, multiple technical variations may account for the long-lasting reputation of decreased durability and poor long-term reflux control. Inspired by the “critical view” concept, a step-by-step laparoscopic Toupet fundoplication is described and illustrated. During the study period, 2012–2017, 348 consecutive patients underwent laparoscopic Toupet fundoplication according to a standardized procedure. A large hiatus hernia was present in 39% of patients, and 14% had volvulus of the intrathoracic stomach. Sixty-four (18.4%) patients had one or more previously failed antireflux procedures. The median follow-up was 37 months (range 12–61). The Gastroesophageal Reflux Disease Health-Related Quality of Life score significantly improved compared to baseline (p

Objective: The aim of this study was to describe anastomotic techniques used for total minimally invasive transthoracic esophagectomy (ttMIE) and to analyze the associated morbidity. Background: ttMIE faces increasing application in surgical treatment of esophageal cancer. For esophagogastric reconstruction, different anastomotic techniques are currently used, but their effect on postoperative anastomotic leakage and morbidity has not been investigated. Patients and Methods: Patients were selected from a basic dataset, collected during a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the Clavien-Dindo classification and the Comprehensive Complication Index (CCI). Results: Five anastomotic techniques were identified in 966 patients after ttMIE: intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n = 90, purse-string n = 337), intrathoracic (n = 109) or cervical (n = 255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n = 175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs 17.2%, P = 0.601), but overall complications (56.7%% vs 63.7%, P = 0.029) and median 90-day CCI {21 [interquartile range (IQR) 0-36] vs 29 [IQR 0-40], P = 0.019} favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%), and cervical side-to-side linear-stapled esophagogastrostomies (11.8%) (P < 0.001). Multivariable analysis confirmed anastomotic technique as independent predictor of leakage after ttMIE. Conclusion: Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.

Minimally invasive enucleation is the treatment of choice in symptomatic patients with esophageal leiomyoma. Comprehensive long-term follow-up data are lacking. Aim of this study was to review the clinical outcomes of three procedures for enucleation of leiomyoma of the esophagus and esophagogastric junction. A single institution retrospective review was performed using a prospectively collected research database and individual medical records. Demographics, presenting symptoms, use of proton-pump inhibitors (PPI), tumor location and size, treatment modalities, and subjective and objective clinical outcomes were recorded. Barium swallow and upper gastrointestinal endoscopy were routinely performed during the follow-up. Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and Short-Form 36 questionnaires were used to compare quality of life before and after treatment. Between 2002 and 2017, 35 patients underwent minimally invasive leiomyoma enucleation through thoracoscopy (n = 15), laparoscopy (n = 15), and endoscopy (n = 5). The overall morbidity rate was 14.3% and there was no mortality. All patients had a minimum of 1-year follow-up. The median follow-up was 49 (IQR 54) months, and there were no recurrences of leiomyoma. At the latest follow-up, the SF-36 scores were unchanged compared to baseline. However, there was a higher incidence of reflux symptoms (p

The role of splenectomy in proximal gastric cancer is still debated. The objective of the present meta-analysis was to provide more-robust evidence about the effect of spleen-preserving total gastrectomy on postoperative infectious complications, overall morbidity, and 5-year overall survival (os). PubMed, embase, and the Web of Science were consulted. Pooled effect measures were calculated using an inverse-variance weighted or Mantel&ndash, Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I2 index and Cochran Q-test. Three randomized controlled trials published between 2000 and 2018 were included. Overall, 451 patients (50.1%) underwent open total gastrectomy with spleen preservation and 448 (49.9%) underwent open total gastrectomy with splenectomy. The patients ranged in age from 24 to 78 years. No differences were found in the number of harvested lymph nodes (p = 0.317), the reoperation rate (p = 0.871), or hospital length of stay (p = 0.347). The estimated pooled risk ratios for infectious complications, overall morbidity, and mortality were 1.53 [95% confidence interval (ci): 1.09 to 2.14, p = 0.016], 1.51 (95% ci: 1.11 to 2.05, p = 0.008), and 1.23 (95% ci: 0.40 to 3.71, p = 0.719) respectively. The estimated pooled hazard ratio for 5-year os was 1.06 (95% ci: 0.78 to 1.45, p = 0.707). Spleen-preserving total gastrectomy should be considered in patients with curable gastric cancer because it is significantly associated with decreased postoperative infectious complications and overall morbidity, with no difference in the 5-year os. Those observations appear worthwhile for establishing better evidence-based treatment for gastric cancer.

Laparoscopic distal pancreatectomy with splenectomy is the standard procedure for body and tail pancreatic tumors. Technical difficulties arising from the strict anatomical relationship between pancreas and splenic vessels generally impose a concomitant splenectomy. Previous retrospective studies have shown a reduced risk of postoperative complications and infections in spleen preserved patients, but this is still a debated issue. Aim of this systematic review and meta-analysis was to provide a more robust evidence on the effect of spleen preserving laparoscopic distal pancreatectomy.PubMed, MEDLINE, Embase, and Cochrane databases were consulted. Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using ITen observational studies were eligible, and 632 patients were included in the quantitative analysis. Overall, 296 (46.8%) patients underwent laparoscopic distal pancreatectomy with splenectomy (Group S), and 336 (53.2%) patients underwent spleen-preserving laparoscopic distal pancreatectomy (Group SP). In-hospital mortality was 0%. In the group S, the estimated pooled odds ratio of postoperative surgical site infection (SSI) and overall complications was 1.51 (95% confidence interval [CI]: 1.01-2.28; P = .048) and 2.30 (95% CI: 1.11-4.76; P = .024). The estimated pooled odds ratio of pancreatic fistula, postoperative bleeding, and reoperation was 1.64 (P = .094), 1.01 (P = .987), and 1.24 (P = .776), respectively.Spleen-preserving laparoscopic distal pancreatectomy may reduce postoperative SSI and overall complications. These results should be interpreted with caution but seem meaningful to establish a better evidence-based treatment for distal pancreatic tumors. Further studies are warranted to analyze the role of spleen preserving laparoscopic distal pancreatectomy on long-term outcomes.

Gastric conduit dysfunction after esophagectomy is a disabling condition that may require revisional surgery. Rumination syndrome is an uncommon and poorly recognized functional foregut disorder of unknown etiology characterized by effortless oral regurgitation of recently ingested food. Rumination is associated with increased intragastric pressure generated by an unconscious mechanism eliciting contraction of the abdominal wall and relaxation of the diaphragm. Rumination syndrome after esophagectomy has not been previously reported in the literature. Two female patients were referred for inability to eat and weight loss due to severe food regurgitation following esophagectomy and gastric conduit replacement. Their previous medical and psychiatric history was apparently unremarkable. Symptoms occurred within the first postoperative year and progressively worsened. High-dose proton pump inhibitors, erythromycin, metoclopramide, antidepressant medications, pneumatic pyloric dilatation, and laparoscopic pyloromyotomy failed to relieve symptoms, and both patients eventually required permanent tube jejunostomy for nutritional support. Subsequently, thoracoscopic implant of a neurostimulator and a laparoscopic Roux-en-Y gastrojejunostomy were performed and failed in both patients. All medical and surgical attempts to relieve symptoms were clinically unsuccessful in these patients in whom radiological and endoscopic investigations did not demonstrate trans-diaphragmatic hernia or mechanical obstruction of the gastric conduit. Eventually, the diagnosis of rumination syndrome was made based on the Rome IV criteria. In the absence of anatomical or other functional abnormalities of the gastric conduit, revisional surgery is contraindicated; rather, the diagnosis of rumination syndrome should be considered. The role of behavioral therapy integrated with diaphragmatic breathing training and biofeedback should be investigated in these patients.

Summary Background Breast cancer may present with distinct cutaneous manifestations that may be paraneoplastic or secondary to direct skin infiltration, distant skin metastases, or dermal lymphatic tumor embolization (inflammatory breast carcinoma). Case report A 51-year-old Asian woman visited the emergency care department during the outbreak of COVID-19 in Northern Italy. About 6 months before, she had noted the onset of right breast swelling accompanied by skin redness and itching. She never consulted a physician, and, over time, the local skin condition progressed to a large scaly plaque covering the entire breast surface including the nipple. At presentation, abduction of the right upper limb was impaired due to severe shoulder pain. CT scan showed the presence of bilateral breast masses with necrotic and colliquative features, and multiple skeletal, nodal, pulmonary, and brain images suggestive of metastases. An ultrasound-guided core biopsy of the contralateral breast showed grade 2 non-special type infiltrating carcinoma. The patient was referred to the breast oncology unit and is currently being treated with aromatase inhibitors and chemotherapy. Conclusion The COVID-19 pandemic has disrupted the entire spectrum of oncological care including breast cancer. Hopefully, telemedicine will contribute to increase patients’ confidence and will provide earlier diagnosis and treatment while minimizing the risk of contagion.

Background and study aims Esophageal cancer (EC) is one of the most lethal malignancies worldwide. Staging of EC is performed with computed tomography (CT), positron-emission tomography (PET), and endoscopic ultrasonography (EUS). Patient management mostly depends on lymph node status. Compared to histopathology, the accuracy of EUS for T and N parameters is about 85 % and 75 %, respectively. Errors in staging may change prognosis. The aim of this study was to assess the role of EUS in T2-N0 EC considering the experience of two high-volume digestive endoscopic centers. Methods Two prospectively collected databases were queried to identify all patients with EC, staged as cT2N0 by EUS, with no distant metastases at CT/PET scan and who underwent transthoracic esophagectomy. Preoperative EUS staging (cTNM) was compared to histopathology of the surgical specimen (pTNM) to evaluate accuracy. Results Of 729 consecutive patients with EC between January 2011 and September 2018, 72 (49 men) had cT2N0 disease. CT and PET scans confirmed the absence of distant metastasis. In 43 of 72 patients (60 %), the evaluation was correct, 23 of 72 (31,7 %) were understaged, and six of 72 patients (8,3 %) were overstaged. Among the understaged patients, eight were understaged by tumor depth (35 %), seven by nodal involvement (30 %), and eight by both (35 %). All six patients who were overstaged had T1b-N0 disease. EUS accuracy was 77 % in staging for tumor depth and 82 % in staging for nodal metastases. The positive predictive value (PPV) for cT2N0 EC was 60 % (43 pT2N0 /72 cT2N). Conclusions The accuracy of EUS staging of T2N0 EC is low, with only 60 % of patients undergoing appropriate therapy based on histopathology.

Item does not contain fulltext BACKGROUND: Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity. OBJECTIVE: Although the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival. METHODS: Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival. RESULTS: A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication [ie, (re)intervention, organ dysfunction, or death]. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25-2.24]. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30-2.58). For all other complications, no significant association with long-term survival was found. CONCLUSION: The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients.

Background: Malignant rhabdoid tumor is a kidney childhood tumor with aggressive clinical behavior and a wide spectrum of histologic, immunophenotypic, and cytogenetic findings. Extra-renal rhabdoid tumors have been reported in the brain, breast, liver, pancreas, bladder, vulva, prostate, and colon. To date, only nine cases of esophageal rhabdoid tumors have been described, all in patients over 50-year old. We add to the current literature the case of an esophageal, poorly differentiated rhabdoid tumor occurring in a young man.Case Report: A 24-year-old man was referred for progressive dysphagia, retrosternal pain, nausea, and food regurgitation. Esophagogastroduodenoscopy showed an obstructing neoplastic lesion of the distal esophagus associated with Barrett's esophagus. Biopsies revealed undifferentiated esophageal cancer with epithelial morphology and immunohistochemistry positive for CK pan, CK 7 e CK 8-18. Minimally invasive esophagectomy and extended lymphadenectomy was performed. Histopathology showed a poorly differentiated tumor, with morphologic characteristics of rhabdoid tumor, central necrosis and transmural infiltration of the esophageal wall. Definitive immunohistochemistry was positive for vimentin, CD34, synaptophysin, and INI1.Conclusion: Esophageal rhabdoid tumor is extremely rare and highly aggressive, with only few patients alive at 1 year follow-up, according to our review. Immunohistochemistry characterization is critical for diagnosis. Minimally invasive esophagectomy is an appealing and possibly less morbid option compared to open surgery. However, further research is needed to investigate the potential role of targeted immunotherapy.

Objectives We aimed to assess extracellular volume (ECV) through non-gated, contrast-enhanced computed tomography (CT) before and after radiation therapy (RT) in patients with esophageal cancer (EC). Materials and methods EC patients who had undergone CT before and after RT were retrospectively assessed. Patients with preexisting cardiovascular disease or with heavily artifacted CT were excluded. ECV was calculated using density values for the myocardial septum and blood pool. Data were reported as mean and standard deviation or median and interquartile range according to their distribution; t test or Wilcoxon and Pearson r or Spearman ρ were subsequently used. Results Twenty-one patients with stage ≥ IB EC, aged 64 ± 18 years, were included. Mean and maximum RT doses were 21.2 Gy (16.9–24.1) and 42.5 Gy (41.8–49.2), respectively. At baseline (n = 21), hematocrit was 39% ± 4%, ECV 27.9% ± 3.5%; 35 days (30–38) after RT (n = 20), hematocrit was 36% ± 4%, lower than at baseline (p = 0.002), ECV 30.3% ± 8.3%, higher than at baseline (p = 0.081); at follow-up 420 days (244–624) after RT (n = 13), hematocrit was 36% ± 5%, lower than at baseline (p = 0.030), ECV 31.4% ± 4.5%, higher than at baseline (p = 0.011). No patients showed signs of overt cardiotoxicity. ECV early after RT was moderately positively correlated with maximum RT dose (ρ = 0.50, p = 0.036). Conclusions In EC patients, CT-derived myocardial ECV was increased after RT and may thus appear as a potential early biomarker of cardiotoxicity.

Esophageal foreign bodies, including food bolus impaction, represent a common clinical problem. The prevalence of underlying esophageal disease depends on study design and degree of suspicion of a structural or functional esophageal abnormality. Aim of this study was to analyze factors associated with recurrent impaction.The prospectively collected database at a University Hospital and Swallowing Center was reviewed from January 2012 to June 2019 to identify all patients admitted for esophageal foreign bodies. Patients who underwent an emergency endoscopic procedure represented the final study sample. Patient characteristics, including history of previous esophageal foreign bodies, and type of endoscopic procedure were collected.Sixty-five patients, 41 males and 24 females with a median age of 59 years, underwent emergency endoscopy for esophageal foreign bodies during the study period. Food bolus was the most common foreign body (n = 43, 66%). Flexible endoscopy was successful in retrieving or pushing the foreign bodies in the stomach in 91% of patients. In 54% of patients, impaction was secondary to an underlying esophageal disorder, which was previously unrecognized in half of them. Recurrent impaction was more common in patients with esophageal disease (P0.011). Surgical therapy was required in 4 patients (6.1%).Food bolus impaction is a common sentinel event in patients with underlying esophageal disease and is associated with recurrent impaction. Diagnostic endoscopy with biopsies should possibly be performed at the first episode of impaction. Patients with negative biopsies should undergo barium swallow study and high-resolution esophageal manometry.

Highlights • Gallbladder gangrene can present during hospital stay for COVID-19. • Protective measures are mandatory to prevent transmission to hospital personnel. • Subtotal laparoscopic cholecystectomy is feasible, safe, and effective., Introduction Management of acute abdomen during COVID-19 pandemic may be challenging. Presentation of case A 42-year old man was hospitalized for Covid-19 pneumonia. Fever, respiratory symptoms and hypoxemia significantly improved over the next 2 weeks, but the patient developed abdominal pain, nausea, and low-grade fever. Computed tomography scan revealed absence of contrast enhancement of gallbladder wall and a micro-perforation of the fundus. At laparoscopy, gallbladder gangrene was confirmed and a subtotal cholecystectomy performed. Special precautions were adopted for patient transportation from the ward to a dedicated operating room, and two teams with adequate personal protective equipment took charge of the procedure. The patient was discharged home on postoperative day 7 under protective lockdown measures for 2 weeks. Discussion The pathogenesis of acute acalcolous gangrenous cholecystitis is multifactorial. It is unknown whether a prothrombotic state induced by COVID-19 contributes to wall ischemia and perforation. Percutaneous cholecystostomy should be avoided in patients with gallbladder gangrene. Contraindications to laparoscopy are not evidence-based since aerosolization is produced during both open and laparoscopic surgical procedures. However, personal protective equipment is key for prevention. Conclusion Early diagnosis and surgical therapy are critical in patients with gangrenous cholecystitis. Subtotal laparoscopic cholecystectomy for gangrenous gallbladder is safe and effective.

Coronavirus Disease-19 (COVID-19) outbreak has significantly burdened healthcare systems worldwide, leading to reorganization of healthcare services and reallocation of resources. The Italian Society for Study of Esophageal Diseases (SISME) conducted a national survey to evaluate changes in esophageal cancer management in a region severely struck by COVID-19 pandemic. A web-based questionnaire (26 items) was sent to 12 SISME units. Short-term outcomes of esophageal resections performed during the lockdown were compared with those achieved in the same period of 2019. Six (50%) centers had significant restrictions in their activity. However, overall number of resections did not decrease compared to 2019, while a higher rate of open esophageal resections was observed (40 vs. 21.7%; P = 0.034). Surgery was delayed in 24 (36.9%) patients in 6 (50%) centers, mostly due to shortage of anesthesiologists, and occupation of intensive care unit beds from intubated COVID-19 patients. Indications for neoadjuvant chemo (radio) therapy were extended in 14% of patients. Separate COVID-19 hospital pathways were active in 11 (91.7%) units. COVID-19 screening protocols included nasopharyngeal swab in 91.7%, chest computed tomography scan in 8.3% and selective use of lung ultrasound in 75% of units. Postoperative interstitial pneumonia occurred in 1 (1.5%) patient. Recovery from COVID-19 pandemic was characterized by screening of patients in all units, and follow-up outpatient visits in only 33% of units. This survey shows that clinical strategies differed considerably among the 12 SISME centers. Evidence-based guidelines are needed to support the surgical esophageal community and to standardize clinical practice in case of further pandemics.

With the development of newer meshes and approaches to hernia repair, it is currently difficult to evaluate their performances while considering the patients’ perspective. The aim of the study was to assess the clinical outcomes and quality of life consequences of abdominal hernia repairs performed in Italy using Phasix and Phasix ST meshes through the analysis of real-world data to support the choice of new generation biosynthetic meshes. An observational, prospective, multicentre study was conducted in 10 Italian clinical centres from May 2015 to February 2018 and in 15 Italian clinical centres from March 2018 to May 2019. The evaluation focused on patients with VHWG grade II–III who underwent primary ventral hernia repair or incisional hernia intervention with a follow-up of at least 18 months. Primary endpoints included complications’ rates, and secondary outcomes focused on patient quality of life as measured by the EuroQol questionnaire. Seventy-five patients were analysed. The main complications were: 1.3% infected mesh removal, 4.0% superficial infection requiring procedural intervention, 0% deep/organ infection, 8.0% recurrence, 5.3% reintervention, and 6.7% drained seroma. The mean quality of life utility values ranged from 0.768 (baseline) to 0.967 (36 months). To date, Phasix meshes have proven to be suitable prostheses in preventing recurrence, with promising outcomes in terms of early and late complications and in improving patient quality of life.

Background Venous thromboembolism, presenting as deep vein thrombosis or pulmonary embolism, can be associated with considerable morbidity after major abdominal and pelvic surgery. Perioperative thromboprophylaxis with low-molecular-weight heparin is well established, but the duration of treatment remains debated. We aimed to assess the efficacy and safety of extended (4-week) versus conventional (1-week) thromboprophylaxis with low-molecular-weight heparin in patients undergoing abdominopelvic surgery. Methods Using MEDLINE databases (PubMed, EMBASE, and Web of Science), we conducted an electronic, systematic search of randomized controlled trials comparing post-operative extended versus conventional low-molecular-weight heparin on venous thromboembolism, deep vein thrombosis, and pulmonary embolism rates. Results Four randomized controlled trials met the predefined criteria. Extended prophylaxis with low-molecular-weight heparin after major abdominal and pelvic surgery decreased rates of postoperative venous thromboembolism, deep vein thrombosis, and proximal deep vein thrombosis without increased postoperative bleeding. Numbers needed to treat to prevent venous thromboembolism, overall deep vein thrombosis, and proximal deep vein thrombosis were 14, 14, and 44, respectively. Rates of postoperative symptomatic PE were rare, and the incidence was similar in both groups. Conclusion Extended prophylaxis with low-molecular-weight heparin is associated with a decrease in asymptomatic venous thromboembolism. There remains sparse evidence regarding its impact on pulmonary embolism because of the overall low incidence. Extended prophylaxis should be considered in high-risk patients.

Resume Introduction Les patients ayant un cancer de l’œsophage associe a une cirrhose ont un risque operatoire eleve pouvant faire contre-indiquer l’œsophagectomie. Nous avons fait une revue systematique de la litterature avec meta-analyse afin d’evaluer les resultats de la chirurgie dans cette population. Methodes Les etudes rapportant les resultats de l’œsophagectomie en cas de cirrhose ont ete recherchees dans les bases de donnees Medline, Embase, Cochrane Library, ISI Web of Science, and Scopus jusqu’a juin 2017, avec les mots cles « liver cirrhosis », « esophageal neoplasm » and/or « esophageal surgery ». Etaient extraites les donnees concernant l’article, l’etude, les caracteristiques des patients, le type de chirurgie, et les resultats postoperatoires. Une revue systematique bayesienne etait effectuee. Resultats Cinq etudes observationnelles retrospectives a un bras avec un total de 157 patients etaient retenues. La principale cause de deces etait l’insuffisance hepatique, suivie des pneumopathies et des desunions anastomotiques. L’ascite et les epanchements pleuraux etaient les complications les plus frequentes (respectivement, 36 % et 34 %). La morbidite globale etait de 74 % (IC95 % 46–81 %) et la mortalite de 18 % (IC95 % 17–27 %). L’heterogeneite etait faible (0,046 to 0,080). Une decouverte fortuite de la cirrhose etait rapportee dans 15,6 % des cas dans une etude. La survie a 5 ans etait comparable en cas de cirrhose mais statistiquement meilleure chez les patients ayant un score MELD Conclusions Les donnees scientifiques robustes sur l’efficacite et les resultats de l’œsophagectomie pour cancer en cas de cirrhose associee sont faibles. Il est necessaire d’etablir des criteres de selection chez ces patients fragiles en vue de reduire la morbidite et la mortalite postoperatoires.

There are a variety of surgical approaches for the management of right-sided colonic neoplasms. To date, no method has been shown superior in terms of surgical and perioperative outcomes. This meta-analysis compared open (ORH), laparoscopic-assisted (LRH), total laparoscopic (TLRH), and robotic right hemicolectomy (RRH) to assess surgical outcomes and perioperative morbidity and mortality. We conducted an electronic systematic search using PubMed, EMBASE, and Web of Science that compared RRH, TLRH, LRH, and ORH. Forty-eight studies met the inclusion criteria: 5 randomized controlled trials, 25 retrospective, and 18 prospective studies totalling 5652 patients were included. The overall complication rate was similar between RRH and TLRH (RR 1.0; Crl 0.66–1.5). The anastomotic leak rate was higher in LRH and ORH compared to RRH (RR 1.9; Crl 0.99–3.6 and RR 1.2; Crl 0.55–2.6, respectively), whereas it was lower in TLRH compared to RRH (RR 0.88 Crl 0.41–1.9). The risk of reoperation was significantly higher in ORH compared to TLRH (RR 3.3; Crl 1.3–8.0). Operative time was similar in RRH compared to LRH (RR − 27.0; Crl − 61.0 to 5.9), and to TLRH (RR − 24.0; Crl − 70.0 to 21.0). The hospital stay was significantly longer in LRH compared to RRH (RR 3.7; Crl 0.7–6.7). The surgical management of right-sided colonic disease is evolving. This network meta-analysis observed that short-term outcomes following RRH and TLRH were superior to standard LRH and ORH. The adoption of more advanced minimally invasive techniques can be costly and have associated learning phases, but will ultimately improve patient outcomes.

Intraoperative hyperthermic chemotherapy (HIPEC) is increasingly used in combination with cytoreductive surgery for the treatment of peritoneal carcinomatosis. The potential survival benefit of adjuvant HIPEC after curative gastrectomy has not been conclusively demonstrated. We describe a newly developed closed system for HIPEC and report the preliminary results of a pilot study. Patients with locally advanced gastric carcinoma at a high risk for peritoneal recurrence were identified from a prospectively collected database. Laparoscopic total or subtotal gastrectomy combined with standard D2 lymphadenectomy was performed. Immediately after resection and 15 min before HIPEC treatment, intravenous induction chemotherapy with folinic acid and 5‑fluorouracil was administered. A closed-system HIPEC with turbulent-flow circuit (Combat PRS™, Peritoneum Recirculation System, Galmaz Biotech, Madrid, Spain) was used to perfuse the peritoneal cavity with a solution of oxaliplatin and glucose during 60 min. After washout of the peritoneal cavity and re-establishment of pneumoperitoneum, a Roux-en-Y esophagojejunostomy or gastrojejunostomy was performed. Between June 2017 and February 2018, 6 patients were treated according to this protocol. No major postoperative complications occurred. There were no intra- or postoperative complications related to the HIPEC procedure. All patients are alive and disease-free at 3–11 months of follow-up. The preliminary results of this pilot study indicate the safety and feasibility of the closed HIPEC system with CO2 recirculation in selected patients undergoing laparoscopic total or subtotal gastrectomy for locally advanced gastric carcinoma.

Trans-oral endoscopic access to the pancreaticobiliary system is challenging after Roux-en-Y gastric bypass (RYGB). Trans-gastric ERCP (TG-ERCP) has emerged as a viable option to manage patients with symptomatic post-RYBG choledocolithiasis. The aim of this systematic review and meta-analysis was to examine the outcomes of TG-ERCP to better define the risk-benefit ratio of this procedure and to guide clinical decision-making. A literature search was conducted to identify all reports on ERCP after RYGB. Pubmed, MEDLINE, Embase, and Cochrane databases were thoroughly consulted matching the terms “ERCP” AND “gastric bypass.” Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were calculated using Freeman-Tukey double arcsine transformation and DerSimonian-Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I2-index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders. Thirteen papers published between 2009 and 2017 matched the inclusion criteria. Eight hundred fifty patients undergoing 931 procedures were included. The most common clinical indications for TG-ERCP were biliary (90%) and pancreatic (10%). The majority of patients underwent an initial laparoscopic approach (90%). Same-day ERCP was successfully achieved in 703 cases (75.5%). Pooled prevalence of ERCP success rate, ERCP-related morbidity, post-procedural infectious complications, and overall morbidity were 99% (95% CI = 98–100%), 3.1% (95% CI = 1.0–5.8%), 3.4% (95% CI = 1.7–5.5%), and 14.2% (95% CI = 8.5–20.8%), respectively. TG-ERCP is a safe and effective therapeutic option in patients with symptomatic post-RYGB choledocolithiasis.

Achalasia is a rare disease characterized by impaired lower esophageal sphincter relaxation loss and of peristalsis in the esophageal body. Endoscopic balloon dilation and laparoscopic surgical myotomy have been established as initial treatment modalities. Indications and outcomes of esophagectomy in the management of end-stage achalasia are less defined. A literature search was conducted to identify all reports on esophagectomy for end-stage achalasia between 1987 and 2017. MEDLINE, Embase, and Cochrane databases were consulted matching the terms “achalasia,” “end-stage achalasia,” “esophagectomy,” and “esophageal resection.” Seventeen articles met the inclusion criteria and 1422 patients were included in this narrative review. Most of the patients had previous multiple endoscopic and/or surgical treatments. Esophagectomy was performed through a transthoracic (74%) or a transhiatal (26%) approach. A thoracoscopic approach was used in a minority of patients and seemed to be safe and effective. In 95 per cent of patients, the stomach was used as an esophageal substitute. The mean postoperative morbidity rate was 27.1 per cent and the mortality rate 2.1 per cent. Symptom resolution was reported in 75 to 100 per cent of patients over a mean follow-up of 43 months. Only five series including 195 patients assessed the long-term follow-up (>5 years) after reconstruction with gastric or colon conduits, and the results seem similar. Esophagectomy for end-stage achalasia is safe and effective in tertiary referral centers. A thoracoscopic approach is a feasible and safe alternative to thoracotomy and may replace the transhiatal route in the future.

Early detection of anastomotic leakage after esophagectomy has the potential to reduce morbidity and mortality. Prompt suspicion of leak may help to exclude patients from fast-track protocols, thereby avoiding early oral feeding and early hospital discharge which could aggravate the prognosis of a clinically occult leak. Observational retrospective cohort study. Patients with diagnosis of esophageal cancer who underwent elective minimally invasive esophagectomy were included. The following data were collected: age, gender, BMI, comorbidities, ASA score, tumor histology, TNM staging, use of neo-adjuvant therapy, type of operation, operative time, morbidity, and 90-day mortality. A panel of biomarkers including C-reactive protein (CRP), procalcitonin (PCT), white blood cells (WBC), and percentage of neutrophils (PN) were measured at baseline and on postoperative days 3, 5, and 7. Two hundred forty-three patients operated between 2012 and 2017 were included in the study. Anastomotic leakage occurred in 29 patients. There was a statistical association over time between anastomotic leakage and CRP (p

Pseudoachalasia due to an occult malignant tumor accounts for about 5% of patients presenting with clinical features of achalasia. Pleural mesothelioma is a rare cause of pseudoachalasia and may present without respiratory symptoms or chest pain. We present two cases of pseudoachalasia from pleural mesothelioma diagnosed by laparoscopic biopsy over a 10-year period. In both patients, the onset of the disease was atypical, with dysphagia and weight loss being the predominant symptoms; no dyspnea or chest pain was reported. Prolonged (>40 years) occupational exposure to asbestos was reported only by one of the patients. Treatment was palliative and consisted of endoscopic stenting and chemotherapy. The diagnosis of pseudoachalasia is not always straightforward. Laparoscopy is a safe and effective method for obtaining a biopsy.

Esophagectomy is a major surgical procedure associated with a significant risk of morbidity and mortality. Minimally invasive esophagectomy is becoming the preferred approach because of the potential to limit surgical trauma, reduce respiratory complications, and promote earlier functional recovery. Various hybrid and total minimally invasive surgical techniques have been introduced in clinical practice over the past 20 years, and minimally invasive esophagectomy has been shown equivalent to open surgery concerning the short-term outcomes. Implementation of a minimally invasive esophagectomy program is technically demanding and requires a significant learning curve and the infrastructure of a dedicated multidisciplinary center where optimal staging, individualized therapy, and perioperative care can be provided to the patient. Both hybrid and total minimally invasive techniques of esophagectomy have proven safe and effective in expert centers. The choice of the surgical approach should be driven by preoperative staging, tumor site and histology, comorbidity, patient's anatomy and physiological status, and surgeon's experience.

Open esophagectomy is a high-risk procedure in patients with liver cirrhosis. With the advent of minimally invasive surgical techniques, the overall morbidity and mortality rates of esophagectomy have decreased. The aim of this study was to describe short-term outcomes of minimally invasive esophagectomy in patients with proven liver cirrhosis.Retrospective observational cohort study. Demographics, preoperative clinical characteristics, and outcomes of patients undergoing minimally invasive esophagectomy for carcinoma were analyzed. Patients with concomitant liver cirrhosis were compared to patients without liver cirrhosis undergoing similar surgical procedures. In addition, variables possibly associated with postoperative morbidity and mortality in patients with cirrhosis were investigated.Out of 443 patients undergoing minimally invasive esophagectomy, 18 (4.1%) had concomitant liver cirrhosis. Demographics and preoperative clinical variables were similar in the 2 patient groups. While the overall morbidity rate was similar, the 90-day mortality rate was significantly higher in patients with liver cirrhosis (P = .023). There was a significantly higher rate of sepsis and anastomotic, respiratory, and hemorrhagic complications in patients with liver cirrhosis who died in the postoperative period.Minimally invasive esophagectomy is feasible in patients with liver cirrhosis. Future strategies should focus on total minimally invasive procedures and early recognition of surgical complications.

The potential utility of both non-absorbable and absorbable meshes to reinforce the esophageal hiatus and prevent recurrent hernia has been investigated in observational studies and a few randomized clinical trials. Use of absorbable mesh has been associated with lesser side-effects, but the long-term safety and effectiveness are still debated. This rather scanty clinical evidence is due to heterogeneity and bias regarding the type of mesh and operation used, the modalities of follow-up, and the reporting of objective results. The aim of the study was to assess safety, quality of life, and recurrence-free probability after laparoscopic repair of hiatal hernia reinforced with a synthetic absorbable mesh. Observational, retrospective, single-center cohort study. All patients with hiatal hernia who underwent laparoscopic crura repair using a biosynthetic mesh (Gore Bio A® tissue reinforcement, Flagstaff, AZ) were included. Pre- and post-operative symptoms were assessed with the GERD-HRQL questionnaire. Objective follow-up consisted of upper gastrointestinal endoscopy and barium swallow study. From September 2011 to March 2016, a total of 100 patients underwent hiatal hernia repair using a Bio-A® mesh. All surgical procedures were completed laparoscopically. Postoperative morbidity rate was 10%. All patients had a minimum follow-up of 6 months, and the median follow-up was 30 (IQR = 22) months. No mesh-related complications occurred. The incidence of recurrent hernia ≥2 cm was 9%, and eight of the nine patients had a preoperative type III hernia. The median GERD-HRQL score was significantly reduced after operation (p

Pressure ulcers related to nasogastric tubes (NGT) are underestimated in clinical practice and rarely reported in the literature. Improper tube fixation around the nostril quickly induces tissue ischemia, possibly leading to skin ulcers and permanent full-thickness lesions. Epidemiological and clinical studies on this subject are lacking. This was an observational, cross-sectional study performed in a tertiary-care hospital. Consecutive hospital records of patients undergoing elective surgical procedures under general anesthesia, with an NGT inserted before or during surgery and maintained in place after the operation, were examined. Demographic and clinical data were extracted to investigate factors possibly associated with the occurrence of pressure ulcers of the nostril. Between 2011 and 2015, 2131 patients underwent elective surgical procedures. The overall prevalence of NGT-induced ulcers was 4.8%, with esophagectomy being the most common index operation. Univariate analysis did not show a statistically significant association between the presence of ulcers and the examined variables, with the exception of operative time (p < 0.012). The prevalence of nostril ulcers statistically differed across operative procedure time (p < 0.001), with a positive significant linear trend (p < 0.001), and lesions were significantly more frequent when the operative procedure lasted longer than 4 h (Confidence interval [CI] 9.2–17.1). Twenty-one (20.5%) patients required plastic surgery consultation due full-thickness lesions with severe cosmetic sequelae. Nostril pressure ulcers related to NGT are common in clinical practice and necessitate a high index of suspicion and vigilance during the perioperative period. The only factor significantly associated with NGT-induced pressure ulcers was the length of the operative procedure.

BACKGROUND Magnetic sphincter augmentation with the Linx® system is a novel laparoscopic procedure for the treatment of gastro-esophageal reflux disease (GERD). Only few data are available regarding the impact of Linx on high-resolution manometry (HRM) variables. METHODS The prospectively collected database of patients who underwent Linx procedure at a single institution was queried. All patients who completed pre- and postoperative HRM, GERD health-related quality of life (GERD-HRQL) questionnaire, and functional outcome swallowing scale (FOSS) questionnaire were included in the study. KEY RESULTS Forty-five out of 304 patients were included. At a median follow-up of 12 months (IQR 10) after surgery, a statistically significant increase of lower esophageal sphincter (LES) total length (P = .002), intra-abdominal length (P = .001), integrated relaxation pressure (IRP), intrabolus pressure (IBP), and esophagogastric contractile integral (EGJ-CI) was noted (P

Background: Although gastric carcinoma is the fifth most commonly diagnosed cancer, optimal treatment of perforated cancer remains debated. Materials and Methods: The study was conducted according ...

The esophagus traverses three body compartments (neck, thorax, and abdomen) and is surrounded at each level by vital organs. Injuries to the esophagus may be classified as foreign body ingestion, caustic ingestion, esophageal perforation, and esophageal trauma. These lesions can be life-threatening either by digestive contamination of surrounding structures in case of esophageal wall breach or concomitant damage of surrounding organs. Early diagnosis and timely therapeutic intervention are the keys of successful management.

Interleukin (IL)-33 is a member of the interleukin (IL)-1 family of cytokines linked to the development of inflammatory conditions and cancer in the gastrointestinal tract. This study is designed to investigate whether IL-33 has a direct effect on human gastric epithelial cells (GES-1), the human gastric adenocarcinoma cell line (AGS), and the gastric carcinoma cell line (NCI-N87) by assessing its role in the regulation of cell proliferation, migration, cell cycle, and apoptosis. Cell cycle regulation was also determined in ex vivo gastric cancer samples obtained during endoscopy and surgical procedures. Cell lines and tissue samples underwent stimulation with rhIL-33. Proliferation was assessed by XTT and CFSE assays, migration by wound healing assay, and apoptosis by caspase 3/7 activity assay and annexin V assay. Cell cycle was analyzed by means of propidium iodine assay, and gene expression regulation was assessed by RT-PCR profiling. We found that IL-33 has an antiproliferative and proapoptotic effect on cancer cell lines, and it can stimulate proliferation and reduce apoptosis in normal epithelial cell lines. These effects were also confirmed by the analysis of cell cycle gene expression, which showed a reduced expression of pro-proliferative genes in cancer cells, particularly in genes involved in G0/G1 and G2/M checkpoints. These results were confirmed by gene expression analysis on bioptic and surgical specimens. The aforementioned results indicate that IL-33 may be involved in cell proliferation in an environment- and cell-type-dependent manner.

Morbid obesity is a life threatening condition. Currently, surgery represents the only effective and durable therapeutic option to treat it. The first aim of the study was to estimate and compare the major surgical complications and the 30-day rate of mortality between laparoscopic and open Roux-en-Y gastric bypass (LRYGB and RYGB). The second aim was to evaluate the change in outcomes, complications, and deaths, with increased experience over the time period of the review. A random effect of the meta-analysis and meta-regression was used to evaluate surgical complications (i.e., reoperation, stenosis, bleeding, surgical site infection, fistula, internal hernia, and incisional ventral hernia) and the rate of mortality after LRYGB and RYGB over time. A search of literature from 2000 to 2014 led to the selection of 17 papers. When looking at surgical techniques separately, we observed a higher rate of mortality for open surgery (death rate 0.82 %, 95 % CI = 0.49-1.23) compared to laparoscopic surgery (death rate 0.22 %, 95 % CI = 0.09-0.40). This difference resulted highly significant when the two techniques were formally compared (p

To evaluate objective and subjective outcomes of patients undergoing laparoscopic repair of large hiatal hernia, either with or without resorbable mesh augmentation. The primary outcome of the study was anatomical recurrence rate as measured by endoscopy. Secondary outcomes were safety, efficacy, and long-term quality of life. This was an observational cohort study. Patients who underwent laparoscopic repair of large (≥5 cm) type III hiatal hernia were included. Criteria of exclusion were previously failed hiatus hernia repair and emergency procedures. Patients were stratified into mesh group (mesh-augmented crura repair plus fundoplication) and non-mesh group (standard crura repair plus fundoplication). Preoperative and postoperative symptoms were assessed using the GERD-HRQL questionnaire. Upper gastrointestinal endoscopy was routinely performed between 6 and 12 months postoperatively and was repeated over the follow-up every 1–2 years or as needed. Anatomical hernia recurrence was defined as the maximum vertical length of stomach being at least 2 cm above the diaphragm. A total of 84 patients, 41 in the mesh group and 43 in the non-mesh group, operated between October 2009 and October 2014, were included in the study. All surgical procedures were completed laparoscopically. The median follow-up was 24 (IQR 29) months. There were 12 endoscopic recurrences, 4 in the mesh group and 8 in the non-mesh group. The five-year recurrence-free probability was similar in the two groups, but an earlier failure rate was noted in the non-mesh group at 12 months (p = 0.299). Three of the 12 patients with anatomical recurrence were symptomatic but did not require a reoperation. Univariate Cox proportional hazard analysis indicated that Toupet fundoplication may reduce the recurrence rate compared to Nissen fundoplication. No mesh-related complications occurred. Laparoscopic repair of large hiatal hernia is effective and durable. Crura reinforcement with a resorbable synthetic mesh is safe and may protect from early anatomical recurrence.

Transthoracic esophagectomy remains the current therapeutic standard for localized esophageal carcinoma. Minimally invasive surgery has proven at least equivalent to open surgery regarding the early outcomes, but only 1 randomized study has compared the thoracoscopic with the thoracotomy approach. The primary objective of this study was to assess the early outcome of the thoracoscopic prone esophagectomy (TPE) and the hybrid Ivor Lewis (HIL) esophagectomy in 2 concurrent patient cohorts.We compared the 1-year outcome of 3-stage TPE and 2-stage HIL done over the same time period in a single center. The propensity score matching method was used to reduce selection bias by creating 2 groups of patients similarly likely to receive a treatment on the basis of measured baseline characteristics. After generating propensity scores using the covariates of age, sex, body mass index, forced expiration volume at 1 second, Charlson comorbidity index, American Society of Anesthesiologists score, histologic tumor type, tumor site, pTNM stage, and neoadjuvant therapy, 93 TPE patients were matched with 197 HIL patients using a 1:1 ratio and the nearest-neighbor score matching. Main outcome measure was the incidence of postoperative complications.Operative time was longer in TPE patients (P.01). All postoperative outcomes, including morbidity, mortality, nodal harvest, R0 resection rate, and 1-year survival rates were similar in the 2 matched groups.Both operative approaches are safe and effective; using 1 or the other depends on the tumor site, surgeon experience and preference, and patient expectations.

Metastasis to the esophagus is a rare event that can occur by direct infiltration of malignancies from nearby organs or, more infrequently, via lymphatic or hematogenous spread. We reviewed the hospital charts of a patient presenting with dysphagia in whom a distant metastasis to the esophagus from a primary lung adenocarcinoma was documented. A review of the pertinent literature was performed. A 74 year-old man with previous history of lung cancer and transoral septum stapling for Zenker’s diverticulum presented with subtotal dysphagia and chest pain. On upper gastrointestinal endoscopy, a vegetating mass of the middle esophagus, covered by fragile and bleeding mucosa, was found. Esophageal biopsies demonstrated metastasis from a poorly differentiated lung adenocarcinoma with evidence of thyroid transcription factor (TTF) positive neoplastic cells. A computed tomography scan revealed a radiopaque mass in the upper right lung. Combination chemotherapy was initiated and a partially covered stent was placed endoscopically. A distant metastatic tumor to the esophagus with mucosal infiltration is an exceptional event. In our patient, immunohistochemistry was useful to confirm the diagnosis of primary lung carcinoma.

Laparoscopic resection is a well-established approach for colorectal cancer surgery. In patients with rectal cancer treated by neoadjuvant chemoradiotherapy, it may be difficult to identify a clear safety margin for endostapling and subsequent anastomosis. We designed an innovative technical approach to assist colorectal anastomosis in these patients.A four-trocar laparoscopic approach is used. After exploration of the abdominal cavity, the left colic flexure is completely mobilized. Using a medial to lateral approach, the inferior mesenteric artery and vein are divided between clips, and the left colon proximal to the tumor is transected with a linear stapler. A total mesorectal excision is performed. At this point, if the free margin distal to the tumor site cannot be clearly identified, a blunt tip trocar (BTT, 10 mm; Medtronic, Minneapolis, MN) is inserted into the anus and the proximal foam sponge is secured to the anal verge to avoid displacement and gas leakage. Under low flow rate gas insufflation, a 0° scope inserted into the trocar allows a clear observation of the distal margin of the lesion and guides the low rectal laparoscopic dissection and the precise placement of the stapler. The BTT is then removed to perform the transanal colorectal anastomosis; at the end of the procedure, the BTT can be reinserted to check the anastomosis for bleeding and leakage.We used this novel technique on 3 patients who underwent neoadjuvant therapy for T3 rectal cancer. In all of them, identification of the distal tumor margin was difficult at laparoscopy. All surgical procedures were safely completed and resulted in R0 resection. The average length of stay was 6 days. All patients were free from recurrences at 1 year follow-up.Endoluminal videoendoscopy through a transanal BTT is a useful ancillary technique to achieve a safe free margin during low rectal resection.

Psoas abscess is a rare and occasionally life-threatening condition. In the past, the major cause of psoas abscess was a descending infection originating from spine tuberculosis (Pott’s disease). Subsequently, secondary infection from spondylodiscitis or Crohn’s disease has become the prevalent aetiology. Conventional treatment ranges from antibiotic therapy alone to CT-guided and/or surgical drainage. We present the case of a 67-year-old man with a complex history, including pneumonia, sepsis and previous muscle-skeletal trauma. The patient subsequently developed a psoas abscess that was successfully treated with a minimally invasive retroperitoneoscopic approach and antibiotics. Blood cultures and pus yielded Gram-positive Streptococcus sp, and transesophageal echocardiography identified endocarditis as a possible source of sepsis. Postoperative clinical course was complicated by recurrent sepsis that required a change of antibiotic therapy. The patient was eventually discharged to rehabilitation care without further complications. The retroperitoneoscopic approach is safe and effective for the treatment of cryptogenic psoas abscess.

Minimally invasive esophagectomy has become the preferred approach for invasive Barrett's adenocarcinoma because it can speed recovery and enhance patient's quality of life. Multiple minimally invasive surgical techniques have been described during the last two decades. Preoperative staging, anatomy and physiological patient's status, comorbidity, and experience of the surgical team should drive the choice of the surgical approach. The trans-thoracic Ivor Lewis esophagectomy, either hybrid or totally minimal invasive, remains the preferred approach in these patients. Lymph node yield and short-term clinical outcomes have proven similar to open surgery, while quality of life appears improved. To establish a minimally invasive esophagectomy program, a steep learning curve and a multidisciplinary approach are required in order to provide optimal staging, personalized therapy, and adequate perioperative care. The role of minimally invasive surgery in the treatment of invasive Barrett's adenocarcinoma will continue to expand in synergy with enhanced recovery after surgery pathways.

The most troublesome complications of inguinal hernia repair are recurrent herniation and chronic pain. A multitude of technological products dedicated to abdominal wall surgery, such as self-gripping mesh (SGM) and glue fixation (GF), were introduced in alternative to suture fixation (SF) in the attempt to lower the postoperative complication rates. We conducted an electronic systematic search using MEDLINE databases that compared postoperative pain and short- and long-term surgical complications after SGM or GF and SF in open inguinal hernia repair. Twenty-eight randomized controlled trials totaling 5495 patients met the inclusion criteria and were included in this network meta-analysis. SGM and GF did not show better outcomes in either short- or long-term complications compared to SF. Patients in the SGM group showed significantly more pain at day 1 compared to those in the GF group (VAS score pain mean difference: − 5.2 Crl − 11.0; − 1.2). The relative risk (RR) of developing a surgical site infection (RR 0.83; Crl 0.50–1.32), hematoma (RR 1.9; Crl 0.35–11.2), and seroma (RR 1.81; Crl 0.54–6.53) was similar in SGM and GF groups. Both the SGM and GF had a significantly shorter operative time mean difference (1.70; Crl − 1.80; 5.3) compared to SF. Chronic pain and hernia recurrence did not statistically differ at 1 year (RR 0.63; Crl 0.36–1.12; RR 1.5; Crl 0.52–4.71, respectively) between SGM and GF. Methods of inguinal hernia repair are evolving, but there remains no superiority in terms of mesh fixation. Ultimately, patient’s preference and surgeon’s expertise should still lead the choice about the fixation method.

Background Esophagectomy has a high incidence of postoperative morbidity. Complications lead to a decreased short-term survival, however the influence of those complications on long-term survival is still unclear. Most of the performed studies are small, single center cohort series with inconclusive or conflicting results. Minimally invasive esophagectomy (MIE) has been shown to be associated with a reduced postoperative morbidity. In this study, the influence of complications on long-term survival for patients with esophageal cancer undergoing a MIE were investigated. Methods Data was collected from the EsoBenchmark database, a collaboration of 13 high-volume centers routinely performing MIE. Patients were included in this database from June 1, 2011 until May 31, 2016. Complications were scored according to the Clavien-Dindo (CD) classification for surgical complications. Major complications were defined as a CD grade ≥ 3. The data were corrected for 90-day mortality to correct for the short-term effect of postoperative complications on mortality. Overall survival was analyzed using the Kaplan Meier, log rank- and (uni- and multivariable) Cox-regression analyses. Results A total of 926 patients were eligible for analysis. Mean follow-up time was 30.8 months (SD 17.9). Complications occurred in 543 patients (59.2%) of which 39.3% had a major complication. Anastomotic leakage (AL) occurred in 135 patients (14.5%) of which 9.2% needed an intervention (CD grade ≥ 3). A significant worse long-term survival was observed in patients with any AL (HR 1.73, 95% CI 1.29–2.32, P Conclusion The occurrence and severity of anastomotic leakage and cardiac complications after MIE negatively affect long-term survival of esophageal cancer patients. Disclosure All authors have declared no conflicts of interest.

Summary Introduction Patients with esophageal carcinoma and concomitant liver cirrhosis carry a high operative risk and may be denied esophagectomy. We performed a systematic review of the literature and meta-analysis to investigate postoperative outcomes in these patients. Methods Studies reporting outcomes after esophagectomy in patients with liver cirrhosis were searched in Medline, Embase, Cochrane Library, ISI Web of Science, and Scopus until June 2017, matching the terms “liver cirrhosis”, “esophageal neoplasm” and/or “esophageal surgery”. Extracted data included study characteristics, demographic and clinical patient characteristics, type of surgical procedure, and postoperative outcomes. A systematic review and Bayesian meta-analysis were performed. Results Five observational, retrospective and single-arm studies with a total of 157 patients were included. The main cause of death was liver failure followed by pneumonia/sepsis and anastomotic leak. Ascites and pleural effusion were the most frequent postoperative complications (pooled rates 36% and 34%, respectively). The pooled morbidity rate was 74% (95% HPD = 46–81%) while the pooled mortality was 18% (95% HPD = 17–27%). Study heterogeneity (τ2) was low, ranging from 0.046 to 0.080. An incidental diagnosis of liver cirrhosis was reported in 15.6% of patients in one series. Five-year survival was similar between cirrhotic and non-cirrhotic patients but was statistically significantly higher in patients with MELD score Conclusions Sound scientific evidence with regard to efficacy and outcomes of esophagectomy in patients with concomitant liver cirrhosis is lacking. There is a need to properly select these frail patients to reduce postoperative morbidity and mortality rates.

Use of the magnetic sphincter augmentation (MSA) device for the laparoscopic treatment of gastroesophageal reflux disease is increasing since the first clinical implant performed a decade ago. The MSA procedure is a minimally invasive and highly standardized surgical option for patients who are partially responders to proton-pump inhibitors, which have troublesome regurgitation or develop progressive symptoms despite continuous medical therapy. The procedure has proven to be highly effective in improving typical reflux symptoms, reducing the use of proton-pump inhibitors, and decreasing esophageal acid exposure. Observational cohort studies have shown that MSA compares well with fundoplication in selected patients and has an acceptable safety profile. The device can be easily removed if necessary, thereby preserving the option of fundoplication in the future. The majority of the removals have occurred within 2 years after implant and have been managed non-emergently, with no complications or long-term consequences. “Expanded” indications to MSA (large hiatal hernia and Barrett’s esophagus) need to be tested in further comparative studies with classic fundoplication procedures.

Background: Laparoscopic surgery has proven safe and effective in the treatment of large hiatus hernia. Differences may exist between objectively assessed surgical outcomes, symptomatic scores, and patient-reported outcomes. Methods: An observational, single-arm cohort study was conducted in patients undergoing primary laparoscopic repair with crura mesh augmentation and Toupet fundoplication for large (> 50% of intrathoracic stomach) type III–IV hiatus hernia. Data were extracted from hospital charts and a prospectively updated research database. The main study outcome was quality of life assessed by the Gastroesophageal reflux disease Health-Related Quality of Life (GERD-HRQL) score and the Short-form 36 (SF-36). Results: Between 2013 and 2016, 37 out of 49 operated patients completed the comprehensive quality-of-life evaluation at the 2-year follow-up. The GERD-HRQL score significantly decreased compared to baseline (p < 0.001). All items of the SF-36 significantly improved compared to baseline (p < 0.05). Both Physical and Mental Component Summary scores were significantly higher than preoperative scores, with a medium Cohen’s effect size (–0.77 and 0.56, respectively). At the 2-year follow-up, symptoms had disappeared in the majority of patients. The use of proton-pump inhibitors significantly decreased compared to baseline (13.5 vs. 86.4%, p < 0.001). Also, the use of antidepressants and benzodiazepines significantly decreased after surgery (8.1 vs. 32.4%, p < 0.001). The overall alimentary satisfaction score was > 8 in 92% of patients. There were no safety issues related to the use of the absorbable synthetic mesh. The incidence of anatomical hernia recurrence was 5.4%, but no patient with recurrent hernia required surgical revision. Conclusions: Laparoscopic repair of large hiatus hernia with mesh and partial fundoplication is associated with symptomatic relief, no side-effects, and a significant improvement in disease-specific and generic quality of life at 2-year follow-up.