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Background: Surgical or endoscopic myotomy are good options for treating achalasia, as >80% of patients continue to report no symptoms at medium-term follow-up. Little is known about the long-term natural history of patients who have undergone myotomy, however, in terms of symptom control, need for retreatment, and complications. In this review we examined the long-term results at least 5 years after surgical or endoscopic myotomy. Methods: A narrative review of all studies reporting the results of surgical or endoscopic myotomy with a follow-up of 5 years or more was conducted. The main focus was on symptom relief, the incidence of GERD, and the need for retreatment. Results: Transthoracic or laparotomic approaches to Heller myotomy were mainly used in the last century, with long-term studies reporting symptom relief in the range of 73% to 95%, and a 4.4% to 45.5% incidence of GERD. The laparoscopic approach has been the gold standard for the last 20 years, eliminating dysphagia symptoms in 65% to 95% of patients. Per-oral endoscopic myotomy (POEM) is a valid method that achieves long-term symptom relief in up to 92% of patients. GERD remains an issue as it’s incidence after POEM exceeds that reported after laparoscopic myotomy. Conclusion: Surgical and endoscopic myotomy both achieve symptom control that persists for more than 5 years and can be accepted as an effective primary treatment for achalasia. However, the real role of the higher incidence of postoperative reflux carried by POEM should not be underestimated.

Background Esophageal achalasia (EA) is a rare primary motility disorder in any age group, and particularly rare in the pediatric population, with a reported incidence of 0.18 per 100,000 children a year. EA in pediatric age is currently treated in the same way as in adults, but this approach is based on only a few studies on small case series. The aim of this retrospective study was to assess the long-term outcome of the laparoscopic Heller–Dor (LHD) procedure when performed in pediatric patients with EA at our university hospital. Materials and Methods We considered children and adolescents younger than 16 years old diagnosed with EA and treated with LHD between 1996 and 2022. Clinical data were prospectively collected in an ongoing database. Symptoms were recorded and their severity was calculated using the Eckardt score. Barium swallow, esophageal manometry (conventional or high-resolution), and endoscopy were performed before and after the surgical procedure. Results During the study period, 40 children with a median age of 14 years (interquartile range [IQR]: 11–15) underwent LHD. At a median follow-up of 10.5 years (IQR: 4.5–13.9), a good outcome was achieved in 36/40 patients (90%). Two of the four patients whose surgical procedure failed underwent complementary pneumatic dilations successfully, thus increasing the overall success rate to 95%. A previous endoscopic treatment (in five patients) did not affect the final outcome (p = 0.49). An intraoperative mucosal lesion was detected in only one patient (2.5%) and was repaired at the time without further consequences. During the follow-up, 22 patients underwent endoscopy, and 17 had pH monitoring as well: only 2 of these patients showed reflux esophagitis at endoscopy (one of them with abnormal findings on pH monitoring), amounting to a 9.1% rate of instrumentally confirmed postoperative reflux. Conclusion LHD is a safe and persistently effective treatment for EA in pediatric age, with a success rate comparable with what is usually obtained in adults, and better than what has been reported to date in the pediatric literature. Adding a fundoplication certainly helps ensure an optimal long-term control of any gastroesophageal reflux induced by the myotomy.

Summary Esophageal resection is a high-risk and technically demanding procedure, with a long proficiency-gain curve. The European Society Diseases of the Esophagus (ESDE)-Minimally Invasive Esophagectomy (MIE) training program was launched in 2018 for European surgeons willing to train and to begin a career undertaking MIE. The aim of this study was to evaluate the first experience of the ESDE-MIE fellowship and relate this to the initially predetermined core principles and objectives of the program. Between October 2021 and May 2022, the participating fellows, in collaboration with the ESDE Educational Committee, initiated a survey to assess the outcome and experience of these fellowships. Data from each individual fellowship were analysed and reported in a descriptive manner. Between 2018 and 2022, in total, five fellows have completed the ESDE-MIE fellowship program. Despite the COVID-19 outbreak just the year after its launch, predetermined clinical and research goals were achieved in all cases. Each of the fellows were able to assist in a median of 40 (IQR 27–69) MIE and/or Robot assisted (RA)MIE procedures, of a total median of 115 (IQR 83–123) attended Upper GI cases. After the fellowship, MIE has been fully adopted by the fellows who returned to their home institutions as Upper GI surgeons. The fellowship was concluded by the European Union of Medical Specialists (UEMS) Multidisciplinary Joint Committee (MJC) certification in Upper GI Surgery, which was successfully obtained by all who took part. Based on the experience of the first five fellows, the ESDE-MIE training fellowship meets with the expected needs even despite the COVID-19 outbreak in 2019. Furthermore, these fellows have returned home and integrated MIE into their independent surgical practice, affirming the ability of this program to train the next generation of MIE surgeons, even in the most challenging of circumstances.

Die perioperative oder neoadjuvante Therapie ist in Europa die tragende Saule der Behandlung des lokal fortgeschrittenen Magenkarzinoms, jedoch fehlen Daten fur eine mogliche Anpassung der chirurgischen Strategie in Abhangigkeit des Ansprechens auf die praoperative Behandlung. Dieses Review erfolgte auf Basis einer Recherche der relevanten aktuellen wissenschaftlichen Literatur zur neoadjuvanten oder perioperativen Behandlung des Adenokarzinoms des Magens und Implikation des Tumoransprechens auf die nachfolgende chirurgische Behandlung. Die aktuellen randomisierten Studien zeigen einen Uberlebensvorteil nach perioperativer bzw. neoadjuvanter Behandlung des Magenkarzinoms. Aufgrund des unterschiedlichen Ansprechens auf den praoperativ verabreichten Teil der Therapie, inklusive „complete response“, liegt es nahe, einen individuellen chirurgischen Ansatz zu entwickeln. Allerdings ist die Aussagekraft der Ergebnisse aufgrund der unterschiedlichen Qualitat der chirurgischen Resektion in diesen Studien begrenzt und die Ansprechrate auf die praoperative Behandlung limitiert. Daruber hinaus ist die Zuverlassigkeit des klinischen Restagings nach praoperativer Behandlung ebenfalls eingeschrankt. Auf der anderen Seite gibt es aktuelle Evidenz, die partielle Gastrektomien durch Neubewertung der notwendigen Resektionsabstande mithilfe intraoperativer Schnellschnittmethoden sowie neuartiger Rekonstruktionen auch beim fortgeschrittenen Magenkarzinom unterstutzt. Die aktuelle Evidenz unterstutzt nicht die Umsetzung einer vollstandigen Magenerhaltung mit aktiver Nachsorge des Magenkarzinoms. Allerdings konnten zukunftig auch beim lokal fortgeschrittenen Magenkarzinom zunehmend partiell magenerhaltende Operationstechniken zur Anwendung kommen.

Background Laparoscopic Heller myotomy (HM) has gained acceptance as the gold standard of treatment for achalasia. However, 10–20% of the patients will experience symptom recurrence, thus requiring further treatment including pneumodilations (PD) or revisional surgery. The aim of our study was to assess the long-term outcome of laparoscopic redo HM. Methods Patients who underwent redo HM at our center between 2000 and 2019 were enrolled. Postoperative outcomes of redo HM patients (redo group) were compared with that of patients who underwent primary laparoscopic HM in the same time span (control group). For the control group, we randomly selected patients matched for age, sex, FU time, Eckardt score (ES), previous PD, and radiological stage. Failure was defined as an Eckardt score > 3 or the need for re-treatment. Results Forty-nine patients underwent laparoscopic redo HM after failed primary HM. A new myotomy on the right lateral wall of the EGJ was the procedure of choice in the majority of patients (83.7%). In 36 patients (73.5%) an anti-reflux procedure was deemed necessary. Postoperative outcomes were somewhat less satisfactory, albeit comparable to the control group; the incidence of postoperative GERD was higher in the redo group (p < 0.01). At a median 5-year FU time, a good outcome was obtained in 71.4% of patients in the redo group; further 5 patients (10.2%) obtained a long-term symptom control after complementary PD, thus bringing the overall success rate to 81.6%. Stage IV disease at presentation was independently associated with a poor outcome of revisional LHD (p = 0.003). Conclusions This study reports the largest case series of laparoscopic redo HM to date. The procedure, albeit difficult, is safe and effective in relieving symptoms in this group of patients with a highly refractory disease. The failure rate, albeit not significantly, and the post-operative reflux are higher than after primary HM. Patients with stage IV disease are at high risk of esophagectomy.

Summary Minimally invasive Ivor-Lewis Esophagectomy (MIE) is widely accepted as a surgical treatment of resectable esophageal cancer. Aim of this paper is to describe the surgical details of our standardized MIE technique and its safety. We also evaluate the esophageal mobilization in semiprone compared to the left lateral position. A retrospective analysis of 141 consecutive patients who underwent Ivor-Lewis esophagectomy for cancer, from February 2016 to September 2021, was conducted. All the procedures were performed by totally thoraco-laparoscopic with an intrathoracic end-to-side circular stapled anastomosis. Thoracic phase was performed in left lateral position (LLP-group, n=47) followed by a semiprone position (SP-group, n=94). The intraoperative and postoperative outcomes were prospectively collected and analyzed. The procedure was completed without intraoperative complication in 94.68% of cases in SP-group and in 93.62% of cases in LLP-group (P=0.99). The total operative time and thoracic operative time were significantly shorter in SP-group (P=0.0096; P=0.009). No statistically significant differences were detected in postoperative outcomes between the groups, except for anastomotic strictures (higher in LLP-group, P=0.02) and intensive care unit stay (longer in LLP-group, P=00.1). No reoperation was needed in any cases. Surgical radicality was comparable; the median of harvested lymph nodes was significantly higher in SP-group (P The present semiprone technique of thoraco-laparoscopic Ivor-Lewis esophagectomy is safe and feasible but may also provide some advantages in terms of lymph nodes harvested and total operation time.

Background The treatment of esophagogastric junction outflow obstruction (EGJOO) currently mirrors that of achalasia, but this is based on only a few studies on small case series. The aim of this prospective, controlled study was to assess the outcome of laparoscopic Heller-Dor (LHD) in patients with EGJOO, as compared with patients with esophageal achalasia. Materials and Methods Between 2016 and 2019, patients with manometric diagnosis of idiopathic EGJOO and patients with radiological stage I achalasia, both treated with LHD, were compared. The achalasia group was further analyzed by subgrouping the patients based on the manometric pattern. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score > 3 or the need for retreatment. Results During the study period, 150 patients were enrolled: 25 patients had EGJOO and 125 had radiological stage I achalasia (25 pattern I, 74 pattern II, and 26 pattern III). The median follow-up was 24 months (IQR: 34–16). Treatment was successful in 96% of patients in the EGJOO group and in 96% of achalasia patients with pattern I, 98.7% in those with pattern II, and 96.2% of those with pattern III (p=0.50). High-resolution manometry showed a reduction in the LES resting pressure and integrated relaxation pressure for all patients in all 4 groups (p Conclusion This is the first comparative study based on prospective data collection to assess the outcome of LHD in patients with EGJOO. LHD emerged as an effective treatment for EGJOO, with an excellent success rate, comparable with the procedure’s efficacy in treating early-stage achalasia.

Study Design: Case series and systematic review of the Literature. Objectives: Pharyngo-esophageal perforation (PEP) is a rare, life-threatening complication of anterior cervical spine surgery (ACSS). Best management of these patients remains poorly defined. The aim of this study is to present our experience with this entity and to perform a systematic Literature review to better clarify the appropriate treatment of these patients. Methods: Patients referred to our center for PEP following ACSS (January 2002-December 2018) were identified from our database. Moreover, an extensive review of the English Literature was conducted according to the 2009 PRISMA guidelines. Results: Twelve patients were referred to our Institution for PEP following ACSS. Indications for ACSS were trauma (n = 10), vertebral metastases (n = 1) and disc herniation (n = 1). All patients underwent hardware placement at the time of ACSS. There were 6 early and 6 delayed PEP. Surgical treatment was performed in 11 patients with total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement, anatomical suture of the fistula and suture line reinforcement with myoplasty. Complete resolution of PEP was observed in 6 patients. Five patients experienced PEP persistence, requiring further surgical management in 2 cases. At a median follow-up of 18.8 months, all patients exhibited permanent resolution of the perforation. Conclusions: PEP following ACSS is a rare but dreadful complication. Partial or total removal of the fixation devices, direct suture of the esophageal defect and coverage with tissue flaps seems to be an effective surgical approach in these patients

Background: Achalasia is currently classified in three manometric patterns. Pattern III is the least common pattern, and reportedly correlated with the worst outcome after all available treatments....

Symptoms of Zenker diverticulum can recur whatever the type of primary treatment administered. A modified transoral stapler-assisted septotomy (TS) was introduced in clinical practice a few years ago to improve the results of this mini-invasive technique. The aim of this prospective, controlled study was to assess the outcome of TS in patients with recurrent Zenker diverticulum (RZD), as compared with patients with treatment-naïve Zenker diverticulum (NZD). Patients diagnosed with NZD or RZD, and treated with TS between 2015 and 2021 were compared. Symptoms were recorded and scored using a detailed questionnaire. Barium swallow and endoscopy were performed before and after the TS procedure. In sum, 89 patients were enrolled during the study period: 68 had NZD and 21 had RZD. The patients’ demographic and clinical data were similar in the two groups. Three mucosal lesions were detected intra-operatively, and one came to light at post-operative radiological assessment in the NZD group. No mucosal lesions were detected in the RZD group. The median follow-up was 36 months (interquartile range 23–60). The treatment was successful in 97% NZD patients and 95% of RZD patients (P = 0.56). This is the first comparative study based on prospectively collected data to assess the outcome of TS in patients with RZD. Traction on the septum during the procedure proved effective in the treatment of RZD, achieving a success rate that was excellent, and comparable with the outcome in treating NZD.

Pancreatic metastases from other neoplasms are rare. The role of surgery for this clinical entity is unclear. The aim of this study was to investigate the role of resection in patients with pancreatic secondary lesions. We observed 44 patients with pancreatic metastases from other tumors. Renal cell carcinoma was the most common primary tumor (n = 19, 43.2%). Thirty-seven patients underwent surgery, and pancreatic resection with curative intent was feasible in 35 cases. Fifteen patients (43.2%) experienced major postoperative complications (Clavien-Dindo > 2), and postoperative mortality rate was 5.4%. The median overall survival and disease-free survival were 38 (range 0–186) and 11 (range 0–186) months, respectively. Overall survival and disease-free survival were significantly longer for pancreatic metastases from renal cell carcinoma when compared to other primary tumors. Multivariate analysis confirmed a pathological diagnosis of metastasis from RCC as an independent prognostic factor for overall survival (OR 2.48; 95% CI, 1.00–6.14; p = 0.05). In conclusion, radical resection of metastases to the pancreas is feasible and safe, and may confer a survival benefit for selected patients. There is a clear benefit of metastasectomy in terms of patient survival for metastases from renal cell carcinoma, while for those with other primary tumors, surgery seems to be mainly palliative.

Esophageal submucosal tumors (SMTs) are rare heterogenous clinical entities. The surgical resection can be performed in different surgical approaches. However, the robotic surgical strategy is poorly documented in the treatment of SMTs. We present our series of operated esophageal SMTs approached via robotic-assisted surgery. Six patients with symptomatic esophageal submucosal tumors underwent robotic surgery within a 3-year period. The performed procedures were robotic-assisted enucleation, robotic esophagectomy (RAMIE) and reverse hybrid robotic esophagectomy. Patients’ clinical data, intra/postoperative outcomes, and histopathological features were retrieved from the institution’s prospective database. Five of six patients were scheduled for upfront surgery: four underwent robotic enucleation (three leiomyoma and one suspected GIST) and one underwent reverse hybrid robotic esophagectomy (suspected GIST). One patient, diagnosed with GIST, was treated with neoadjuvant Imatinib therapy, before undergoing a RAMIE. No major intra-operative complications were recorded. Median length of stay was 7 days (6–50), with a longer post-operative course in patients who underwent esophagectomy. Clavien–Dindo > 3a complications occurred in two patients, aspiration pneumonia and delayed gastric emptying. The final histopathological and immuno-histochemical diagnosis were leiomyoma, well-differentiated GIST, low-grade fibromyxoid sarcoma and Schwannoma. Robotic-assisted surgery seems to be a promising option for surgical treatment strategies of benign or borderline esophageal submucosal tumors.

Perioperative or neoadjuvant therapy is the mainstay of treatment for locally advanced gastric cancer in Europe; however, data regarding possible modifications in the surgical strategy depending on the response to preoperative treatment are lacking.This review was carried out based on a search of the relevant contemporary literature regarding neoadjuvant or perioperative treatment for gastric adenocarcinoma and the implications of tumor response for the subsequent surgical treatment.The most recent randomized trials showed a survival benefit after perioperative or neoadjuvant treatment for gastric cancer. Due to the variable response to the preoperatively administered part of the therapy, including complete response, it appears reasonable to develop an individualized surgical approach; however, scientific results supporting this approach are limited due to the variable quality of the surgical resection provided in these studies and the limited rate of complete response to preoperative treatment. Moreover, the reliability of clinical restaging after preoperative treatment is also limited. On the other hand, there is currently evidence that supports a re-evaluation of the necessary resection margins for partial gastrectomy in advanced gastric cancer with the help of intraoperative frozen sections and new reconstruction methods.The current evidence does not support the implementation of a complete organ-sparing strategy with active follow-up surveillance for gastric cancer.; however, stomach-preserving partial gastrectomy techniques could be applied for advanced disease more often in the future.HINTERGRUND: Die perioperative oder neoadjuvante Therapie ist in Europa die tragende Säule der Behandlung des lokal fortgeschrittenen Magenkarzinoms, jedoch fehlen Daten für eine mögliche Anpassung der chirurgischen Strategie in Abhängigkeit des Ansprechens auf die präoperative Behandlung.Dieses Review erfolgte auf Basis einer Recherche der relevanten aktuellen wissenschaftlichen Literatur zur neoadjuvanten oder perioperativen Behandlung des Adenokarzinoms des Magens und Implikation des Tumoransprechens auf die nachfolgende chirurgische Behandlung.Die aktuellen randomisierten Studien zeigen einen Überlebensvorteil nach perioperativer bzw. neoadjuvanter Behandlung des Magenkarzinoms. Aufgrund des unterschiedlichen Ansprechens auf den präoperativ verabreichten Teil der Therapie, inklusive „complete response“, liegt es nahe, einen individuellen chirurgischen Ansatz zu entwickeln. Allerdings ist die Aussagekraft der Ergebnisse aufgrund der unterschiedlichen Qualität der chirurgischen Resektion in diesen Studien begrenzt und die Ansprechrate auf die präoperative Behandlung limitiert. Darüber hinaus ist die Zuverlässigkeit des klinischen Restagings nach präoperativer Behandlung ebenfalls eingeschränkt. Auf der anderen Seite gibt es aktuelle Evidenz, die partielle Gastrektomien durch Neubewertung der notwendigen Resektionsabstände mithilfe intraoperativer Schnellschnittmethoden sowie neuartiger Rekonstruktionen auch beim fortgeschrittenen Magenkarzinom unterstützt.Die aktuelle Evidenz unterstützt nicht die Umsetzung einer vollständigen Magenerhaltung mit aktiver Nachsorge des Magenkarzinoms. Allerdings könnten zukünftig auch beim lokal fortgeschrittenen Magenkarzinom zunehmend partiell magenerhaltende Operationstechniken zur Anwendung kommen.

Low muscle mass is associated with reduced survival in patients with different cancer types. The interest in preoperative sarcopenia and pancreatic cancer has risen in the last decade as muscle mass loss seems to be associated with poorer survival, higher postoperative morbidity, and mortality. The aim of the present study was to review the literature to compare the impact of low muscle mass on the outcomes of patients undergoing surgery for pancreatic adenocarcinoma. An extensive literature review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and 10 articles were analyzed in detail and included in the meta-analysis. Data were retrieved on 2811 patients undergoing surgery for pancreatic cancer. Meta-analysis identified that patients with low muscle mass demonstrated a significantly reduced OS when compared to patients without alterations of the muscle mass (ROM 0.86; 95% CI: 0.81–0.91, p < 0.001), resulting in a 14% loss for the former. Meta-analysis failed to identify an increase in the postoperative complications and length of stay of patients with low muscle mass. Our analysis confirms the role of low muscle mass in influencing oncologic outcomes in pancreatic cancer. Its role on surgical outcomes remains to be established.

Staging is inaccurate for cT2N0 esophageal cancer, and patients often are clinically mis-staged. This study aimed to evaluate the outcome after upfront surgery or neoadjuvant therapy, considering the impact of clinical "mis-staging."This study reviewed patients with squamous cell carcinoma (SCC) or adenocarcinoma (ADK) of the esophagus who underwent upfront surgery (S group) or neoadjuvant treatment (chemoradiotherapy [CRT] group) for cT2N0 cancer. Overall survival (OS), disease-free survival (DFS), morbidity, and mortality were evaluated. Correctly staged (cTNM = pTNM), understaged (cTNMpTNM), and overstaged (cTNMpTNM) patients in the S group and the CRT group were analyzed. Risk factors for unexpected lymph-node involvement were identified in the S group and for cancer-related death in the whole study cohort.The study enrolled 229 patients with cT2N0 esophageal cancer. The 5-year OS rate was 34.2% in the S group versus 55.7% in the CRT group (p = 0.0088). The DFS also was significantly higher (p = 0.01). The morbidity and mortality rates were similar. In the S group, the cTNM was correctly staged for 21.4% and understaged for 63.4% of the patients, with 48.7% of the patients showing unexpected nodal involvement. A tumor length of 3 cm or more was an independent predictor of nodal metastases in SCC (p = 0.03), as was lymphovascular invasion (LVI) in ADK (p0.01). Cancer-related mortality was independently associated with lymph-node metastases (p = 0.03) and treatment by upfront surgery (p = 0.01).Given the high rate of understaged patients in this study (63.4%), the authors advocate for combining the induction therapy with surgery in cT2N0, achieving better survival with similar morbidity and mortality.

Radiation-induced esophageal cancer (RIEC) is a rare but severe late consequence of radiotherapy. The literature regarding this topic is predominately limited in describing the risk of this disease. Tumor behavior, treatment strategies, and prognosis of this cancer remain poorly defined.We collected data of patients who were referred to our unit between 2000 and 2020 for RIEC. After tumor board discussion, upfront surgery or neoadjuvant therapy and surgery were indicated as the main treatment. Preoperative characteristics, long-term and short-term postoperative outcomes of RIEC patients were compared with a 1:1 clustering-matched cohort of patients affected by primary esophageal cancer (PEC).At pre-matching, 54 RIEC and 936 PEC patients were enrolled. The median time between primary irradiation and diagnosis of RIEC was 13.5 years, and the median primary radiation dose was 60 Gy. Compared to the unmatched cohort of PECs, RIEC patients were more frequently female (p = 0.0007), had earlier detection of disease (p = 0.03) and presented more frequently with upper esophageal cancers (p 0.0001). Neoadjuvant treatment was used less frequently in RIEC patients (p 0.0001). After matching, the 51 RIEC and 50 PEC patients showed comparable results in terms of exposure to neoadjuvant treatment, surgical radicality and survival outcomes. RIEC patients had more severe postoperative complications (p = 0.04) and a higher proportion of pulmonary complications (p = 0.04).Curative treatments are feasible for RIEC. Neoadjuvant chemotherapy or chemoradiation can be used in this subgroup, treatment response and long-term outcomes are comparable to those of PEC. The risk of postoperative complications is probably related to the detrimental effect of primary irradiation on lung function.

Since its introduction in 1993, Laparoscopic Heller-Dor (LHD) operation has been the gold standard treatment for esophageal achalasia. Little is known, however, of the natural story of the operated patients in the long run. The aim of this study was to assess the long-term outcome of patients who underwent LHD more than 20 years ago, in order to provide benchmark data to which new techniques should compare. Methods All the patients who underwent LHD from 1992 to 1999 at our Institution were evaluated. Patients with previous endoscopic treatment with pneumatic dilations (PD) or Botox were included, whereas patients with previous myotomy were ruled out. Symptoms were prospectively collected and scored using a detailed questionnaire. Barium swallow, endoscopy and manometry were performed before and 6–12 months after the operation, when also pH-metry was performed. Endoscopy was then suggested every 2 years. Treatment failure was defined as a postoperative symptom score > 10th percentile of the preoperative score (i.e. > 8) or the need for further treatment. Results Eighty-seven patients with a minimum 10-year follow-up were evaluated (median f/u 20 years). One patient died for esophageal cancer 11.5 years after LHD; 8 patients died 11–24 years after LHD for unrelated causes. All were highly satisfied with the results of the operation. Symptoms recurred in 23 patients (26.4%) 1 month to 13.5 years after LHD: all received 1 to 6 PD, effective in 16: 3 required revisional myotomy and 3 need periodic PD. Good long-term outcome was recorded in 73.6% of patients, and in 92% with combined treatment. Post-operative reflux (pH and/or endoscopy-proven) developed in 10 patients only (11.5%). Conclusion LHD can durably relieve symptoms in the majority of patients, though some of them may require complementary PD to maintain effective symptom control. LHD confirms to be an excellent long-term treatment for achalasia and these results represent the reference point for all other treatments.

Objective Immune thrombocytopenia (ITP) is an acquired disorder, characterized by immune-mediated platelet destruction. The spleen plays a key pathogenic role in ITP and splenectomy is a valuable second-line therapy for this disease. Little is known on ITP spleen histology and response to splenectomy is unpredictable. This study aims to characterize ITP spleen histology and assess possible predictors of splenectomy outcome. Methods A series of 23 ITP spleens were retrospectively assessed for the following histological parameters: density of lymphoid follicles (LFs), marginal zones (MZs), T helper and cytotoxic T cells; presence of reactive germinal centers (GCs); width of perivascular T cell sheaths; and red pulp features. Clinical and histological data were matched with postsplenectomy platelet counts to assess their prognostic relevance. Results Three histological patterns were documented: a hyperplastic white pulp pattern, a non-activated white pulp pattern (lacking GCs), and a white pulp-depleted pattern. Poor surgical responses were associated with presplenectomy high-dose steroid administration, autoimmune comorbidities and low T follicular helper cell density. The combination of such parameters stratified patients into different splenectomy response groups. The removal of accessory spleens was also associated with better outcome. Conclusion ITP spleens are histologically heterogeneous and clinical-pathological parameters may help predict the splenectomy outcome.

Background During the COVID-19 pandemic, surgical departments were forced to re-schedule their activity giving priority to urgent procedures and non-deferrable oncological cases. There is a lack of evidence-based literature providing clinical and organizational guidelines for the management of a general surgery department. Aim of our study was to review the available recommendations published by general Surgery Societies and Health Institutions and evaluate the underlying Literature. Materials and Methods A review of the English Literature was conducted according to the AMSTAR and to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Results After eligibility assessment, a total of 22 papers and statements were analyzed. Surgical societies have established criteria for triage and prioritization in order to identify procedures that can be postponed after the pandemic and those that should not. Prioritization among oncologic cases represents a difficult task: clinicians have to balance a possible delay in cancer diagnosis or treatment against the risk for a potential COVID-19 exposure. There is broad agreement among guidelines that indication to proceed with surgery should be discussed in virtual Tumor Boards taking into consideration alternative therapeutic approaches. Several guidelines deal with the role of laparoscopic surgery during the pandemic: a tailored approach is currently suggested, with a case-by-case evaluation provided that appropriate personal protective equipment is available in order to minimize the potential risk of transmission. Finally, there is a considerable agreement in the published Literature concerning the management of the personnel during the peri- and intraoperative phase and on the technical advices regarding the induction, operative and recover maneuvers in COVID-19 cases. Conclusions During COVID-19 pandemic, it is of paramount importance to face the emergency in the most effective and efficient manner, retrieving resources from non-essential settings and, at the same time, providing care to high priority non-COVID-19 related diseases., Highlights • The COVID-19 pandemic has forced surgical departments to reschedule their activity. • The development of a surgical plan with criteria for elective cases prioritization is necessary. • It is essential to ensure emergency surgery care, preferring non operative management if feasible and safe. • All patients (acute and elective) should be considered COVID-19 suspected cases until proven otherwise: appropriate use of personal protective equipment and organization of the surgical spaces are fundamental.

Mesenteric vein thrombosis (MVT) is a rare condition, often misdiagnosed due to its vague and misleading clinical presentation. It can cause intestinal infarction, peritonitis, and consequently necessitate bowel resection. CT scanning with intravenous contrast enhancement is the gold standard for its diagnosis. Radiologists have an important role in defining the extent of thrombosis and identifying any signs of intestinal infarction influencing the decision whether or not to operate. In patients with no clinical signs of peritonitis or radiological evidence of intestinal infarction, the treatment can be exclusively medical, based on full anticoagulation (initially with low molecular weight heparin, followed by vitamin K antagonists or direct acting oral-anticoagulants). The duration of medical treatment depends on radiological evidence of resolution of thrombosis and the identification of pro-coagulant risk factors.

It is currently unclear if the three manometric patterns of esophageal achalasia represent distinct entities or part of a disease continuum. The study's aims were: a) to test the hypothesis that the three patterns represent different stages in the evolution of achalasia; b) to investigate whether manometric patterns change after Laparoscopic-Heller-Dor (LHD).We assessed the patients diagnosed with achalasia who underwent LHD as their first treatment from 1992 to 2016. Their symptoms were scored using a detailed questionnaire for dysphagia, food-regurgitation, and chest pain. Barium-swallow, endoscopy, and esophageal-manometry were performed before and 6 months after surgery.The study population consisted of 511 patients (M:F=283:228). Patients' demographic and clinical data showed that those with pattern III had a shorter history of symptoms, a higher incidence of chest pain, and a less dilated gullet (p0.001). All patients with a sigmoid-shaped mega-esophagus had pattern I achalasia. One patient with a diagnosis of pattern III achalasia developed pattern II at a follow-up manometry before surgery. At a median follow-up of 30 months (IQR 12-56), the outcome of surgery was positive in 479 patients (91.7%). All patients with pattern I preoperatively had the same pattern after LHD, whereas more than 50% of patients with pattern III before treatment showed pattern I or II after surgery.This study supports the hypothesis/theory that the different manometric patterns represent different stages in the evolution of the disease-where pattern III is the earliest stage, pattern II an intermediate stage, and pattern I the final stage.

An alternative approach to the treatment of gastroesophageal reflux disease (GERD) has recently been introduced in clinical practice, involving the implantation of a magnetic sphincter augmentation device (MSAD). This "magnetic ring" is implanted laparoscopically around the lower esophageal sphincter to improve its barrier function. The literature is still limited on the midterm results achieved in controlling reflux because the MSAD is a very new procedure. So far, only a few cases of the MSAD causing erosion of the esophagus have been reported.We report on two cases of progressive and severe dysphagia after the implantation of an MSAD elsewhere. In both cases, the symptoms were caused by the migration of the device into the esophagus.The devices were removed endoscopically in a single step in both cases, using the Olympus cutter. After 3 months, the first patient had a laparoscopic Nissen fundoplication without any complications and with a good final reflux control. The second only underwent removal of the device, using the same endoscopic approach and again without any complications.Judging from the literature, MSAD implantation may be an effective way to control GERD, but the method can carry major complications, such as migration of the device into the esophagus (as in the two cases reported here). Endoscopic removal of a device possibly penetrating inside the esophagus is feasible and safe, and may later be followed up with a laparoscopic antireflux procedure without any particular difficulty.

Background Transoral Diverticulostomy/Septotomy has become a popular treatment for patients with Zenker Diverticulum (ZD) because of the low complication rates, reduced procedure time, and shorter hospital stay. However, the outcome of this procedure is not, so far, as positive as the open techniques. In order to improve the results of transoral septotomy (TS), a modification of the technique by tractioning the septum with stiches, has been introduced. In this study we aimed to compare the final outcome of a Modify Transoral Septotomy (MTS) with those of the Traditional Transoral Septotomy (TTS) in patients with ZD. Methods Seventy-seven consecutive patients with ZD underwent Transoral Septotomy between 2010-2019. Patients who had already been treated with surgical or endoscopic procedures were excluded. TTS was performed with the classic technique. Since 2015, we adopted a MTS, by positioning 2 sutures at the lateral edges of the septum, for traction. Symptoms were collected and scored using a detailed questionnaire; barium-swallow (to assess the size of the pouch), endoscopy and manometry were performed before and after surgical treatment. Failures were defined when a patient needed an additional procedure for recurrent symptoms. Results Of the 52 patients representing the study population (M:F=49:28), 25 had TTS and 52 had MTS. The patients’ demographic and clinical parameters (sex, age, symptom-score, duration of symptoms, diverticulum size) were similar in both groups. Only two intraoperative mucosal lesions were detected and mortality was nil. The median time of the procedure was 25 min (IQR:22-35) in the TTS and 30 min (IQR:25-36) in the MTS (p At the univariate and multivariate analyses, the surgical procedure was the only factor predictive of a positive final result. Conclusions Transoral Septotomy improves the final outcome of this treatment in patients with ZD.

Background: The circular stapled (CS) technique with transoral placement of the anvil is commonly used to perform the esophagogastric anastomosis during minimally invasive esophagectomy (MIE). The procedure is safe, efficient, and highly reproducible; however, the intersection between the circular plane of the stapler and the linear staple line of the esophageal stump can expose the anastomosis to the formation of dog-ears and, therefore, increase the risk of anastomotic leak (AL). We describe a simple modification of the CS technique that consists of folding the linear esophageal transection line with a stitch around the anvil shaft, to include the staple line in the resection during the EEA™ firing. Methods: We prospectively collected data on a small group of patients who underwent MIE for cancer using our modified CS technique. Feasibility has been evaluated as the percentage of cases in which the modified anastomosis technique has been carried out successfully with the formation of a complete anastomotic ring. Safety has been defined as the absence of procedure-related complications. Results: MIE was performed in 10 patients using our modified CS technique. All the procedures were successfully completed with complete resection of the linear esophageal staple line and no intraoperative complications. Only one patient developed a postoperative AL that was only detected by barium swallow and did not cause any symptom or clinical sign. Conclusion: Our modified CS technique is feasible and did successfully prevent the occurrence of clinically relevant ALs in this small case series of patients.

POEM has recently had a widespread diffusion, aiming at being the treatment of choice for esophageal achalasia. The results of ongoing RCTs against laparoscopic myotomy are not available, yet. We, therefore, designed this propensity score (PS) case-control study with the aim of evaluating how POEM compares to the long-standing laparoscopic Heller myotomy + Dor fundoplication (LHD) and verifying if it may really replace the latter as the first-line treatment for achalasia.Two groups of consecutive patients undergoing treatment for primary achalasia from January 2014 to November 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous endoscopic treatment were included, whereas patients with previous LHD or POEM were excluded. A total of 140 patients in both centers were thus matched. LHD and POEM were performed following established techniques. The patients were followed with clinical (Eckardt score), endoscopic, and pH-manometry evaluations.The procedure was successfully completed in all the patients. POEM required a shorter operation time and postoperative stay compared to LHD (p0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (five mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p = 0.33). Two patients in the POEM group and one in the LHD were lost to follow-up. One patient in both groups died during the follow-up for unrelated causes. At a median follow-up of 24 months [15-30] for POEM and 31 months [15-41] for LHD (p0.05), 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p0.12). Four years after the treatment, the probability to have symptoms adequately controlled was90% for both groups (p = 0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; 24-h pH-monitoring showed however an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p0.05).POEM provides the same midterm results as LHD. This study confirms, however, a higher incidence of postoperative GERD with the former, even if its real significance needs to be further evaluated.

The aim of this study was to assess the long-term outcome of laparoscopic Heller-Dor (LHD) myotomy to treat achalasia at a single high-volume institution in the past 25 years. Patients undergoing LHD from 1992 to 2017 were prospectively registered in a dedicated database. Those who had already undergone surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium swallow, endoscopy, and manometry were performed before and after surgery; and 24-h pH monitoring was done 6 months after LHD. One thousand one patients underwent LHD (M:F = 536:465), performed by six staff surgeons. The surgical procedure was completed laparoscopically in all but 8 patients (0.8%). At a median of follow-up of 62 months, the outcome was positive in 896 patients (89.5%), and the probability of being cured from symptoms at 20 years exceeded 80%. Among the patients who had previously received other treatments, there were 25/182 failures (13.7%), while the failures in the primary treatment group were 80/819 (9.8%) (p = 0.19). All 105 patients whose LHD failed subsequently underwent endoscopic pneumatic dilations with an overall success rate of 98.4%. At univariate analysis, the manometric pattern (p

OBJECTIVE Transoral diverticulostomy/septotomy has become a popular treatment for patients with Zenker diverticulum (ZD). To improve the results of transoral stapler-assisted septotomy, a modification of the technique has been introduced. In this study, we aimed to compare the final outcome of such a modified transoral septotomy (MTS) with the results of traditional transoral septotomy (TTS) in patients with ZD. METHODS Fifty-two consecutive patients with ZD underwent transoral stapler-assisted septotomy between 2010 and 2018. Symptoms were recorded and scored using a detailed questionnaire. Barium swallow, endoscopy, and manometry were performed before and after the procedure. RESULTS Of the 52 patients forming the study population (male:female = 35:17), 25 had TTS and 27 had MTS. The patients' demographic and clinical parameters were similar in the two groups. No intraoperative mucosal lesions were detected, and the mortality was nil. The median time taken to complete the procedure was 25 minutes (interquartile range [IQR]: 22-35) for TTS, and 30 minutes (IQR: 25-36) for MTS (P < 0.07). The median follow-up was 69 months (IQR: 46-95) in the TTS group and 30 months (IQR: 25-35) in the MTS group. All patients in both groups had an improvement in their symptom score after the procedure, but the failure rates were 32% (8 of 25) after TTS and 3.7% (1 of 27) after MTS (P < 0.02). At univariate and multivariate analyses, the procedure was the only predictor of a positive final outcome. CONCLUSION Albeit with the intrinsic limitations of the study (retrospective, different time window, and different follow-up), traction on the septum during transoral septotomy improves the final outcome of this treatment in patients with ZD. LEVEL OF EVIDENCE 4 Laryngoscope, 130:637-640, 2020.

Wireless pH monitoring of the esophagus has been widely used to detect GERD for more than a decade. It is generally well tolerated and accepted by patients, but it is still unclear whether prolonging a recording beyond the usual 48 hours can improve the test's diagnostic value. The aim of this study is to examine the diagnostic yield of 96-hour pH monitoring vis-a-vis 24- and 48-hour tests, and to ascertain whether any gain in diagnostic terms was of genuine clinical utility. Patients with suspected GERD underwent 4-day PPI-off wireless pH monitoring of the distal esophagus. The capsule was inserted under endoscopic control, 6 cm above the squamocolumnar junction. Average acid exposure time was calculated after 24, 48, and 96 hours of recording. Ninety-nine patients completed the 96 hour test, and formed the study sample. The wireless test method was used in 42 patients (42.4%) unable to tolerate the traditional pH-monitoring catheter, and in 57 (57.6%) with a previous negative pH study despite symptoms suggestive of GERD. On complete analysis, 47 patients (47.5%) had a pathological test result: 19 patients within the first 24 hours (19.2%, 24 hour group); another 16 after 48 hours (+16.2%, 48 hour group), and a further 12 (+12.1%, 96 hour group) only after 96 hours of monitoring. All 47 patients with an abnormal acid exposure were offered and accepted surgery (10 patients) or medical therapy (37 patients). Clinical follow-up was obtained in all patients with a positive Bravo test result after a median 67 months (IQR: 38-98) using a validated symptom questionnaire. A good outcome after fundoplication or medical therapy was achieved in 73.7% of patients in the 24 hour group, in 62.5% of those in the 48 hour group, and in only 25% of those in the 96 hour group, P = 0.02. Long-term wireless pH monitoring enables an increase in the diagnostic yield over traditional 24- and 48-hour pH studies, but prolonging the test may constitute an unwanted bias and prompt the recruitment of more complex patients, in whom the outcome of surgical or medical therapy may prove less than satisfactory. These findings should be taken into account when establishing the guidelines for assessing GERD with such long-term pH monitoring methods.