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Objective The present study sought to: 1) assess the prevalence of Binge Eating Disorder (BED) and abnormal eating behaviors in bariatric surgery candidates; 2) compare patients with and without BED as regards to eating disturbances, psychological characteristics, and health status; 3) individuate which factors were significantly related to binge eating severity. Methods Sixty-three preoperative patients (17 males and 46 females) were screened by means of an ad hoc socio-demographic schedule, the Rosenberg Self-Esteem Scale, the Eating Disorders Inventory-3, the Binge Eating Scale, and the General Health Questionnaire-28. BED diagnosis was performed through a clinical interview. Results BED and disordered eating, such as episodes of binge eating, sense of lack of control over eating and inappropriate compensatory behaviors, appear common in patients undergoing weight loss surgery. Significant differences between BED and non-BED subjects in relation to eating disturbances and psychological characteristics emerged. Multiple regression analysis revealed that only emotional dys-regulation significantly predicted binge eating vulnerability. Conclusion The recognition of factors involved in the development and maintenance of disordered eating in bariatric patients may support the choice of particular therapeutic strategies and improve bariatric surgery outcome. Further studies on this issue would be useful.

Background/aim Colorectal cancer is frequently associated with metabolic diseases. Adiponectin (APN) is an insulin-sensitizing adipokine circulating as low molecular weight (LMW), medium molecular weight (MMW) and high molecular weight (HMW) oligomers; the latter are the most bio-active oligomers. APN, through AdipoR1, AdipoR2 and T-cadherin receptors, regulates inflammation, and proliferation. Considering the anti-proliferative and anti-inflammatory properties of APN, we investigated the involvement of the "APN system" in colorectal cancer. Materials and methods A total of 44 colorectal cancer patients and 51 healthy controls were recruited. We analysed APN and HMW oligomers in sera, AdipoR1, AdipoR2 and T-cadherin expression in non-cancerous and cancerous colon tissues. Results we found statistically lower levels of APN in patients compared to controls, with a specific decrease of HMW oligomers. Importantly, APN correlated to cancer grade. AdipoR1 was found overexpressed in cancerous compared to non-cancerous tissues while AdipoR2 and T-cadherin were down-regulated. Conclusion The deregulated expression of the "APN system" in colorectal cancer with a specific correlation to tumor grade suggests APN as a promising biomarker in colorectal cancer.

In the surgical management of large incisional hernias, the main target is the closure of the abdominal wall defect on the midline without a dangerous increase in the intraabdominal pressure. In this setting, new intraperitoneal prosthesis and components separation techniques were proposed to solve this problem. Both solutions present some critical issues. A new surgical approach with a free lateral double layer prosthesis totally in polypropylene both sides (FLaPp (R)) is proposed to overcome this problem. This is a retrospective cohort analysis study with a prospectively collected database from two different Italian hospitals. Twenty-nine patients operated from April 2010 to December 2015 were treated using the new prosthesis. Four patients developed postoperative complications: one (3.4%) presented wound infection, two (6.9%) experienced seroma, and one had a hematoma (3.4%). No deaths were recorded. At a median follow-up of 28.5 months (IQR 22-36), no hernia relapse occurred. The application of FLaPp (R) mesh is a safe and feasible option that can be employed to manage Rives repair in cases of abdominal wall defects with difficult closure of the posterior plan when the conventional prosthetic meshes could be unsuitable.

Background The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. Methods The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. Results The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. Conclusion The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.

Introduction Aim of this study is to determine whether quality of life (QoL) assessment in association with instrumental evaluation can help to identify factors predictive of outcome both in surgically and medically treated GERD patients. Methods Between January 2005 and June 2010, 301 patients affected with GERD were included in the study. QoL was evaluated by means of GERD-HRQL and SF-36 questionnaires administered before treatment, at 6 months, at 1 year follow-up and at the end of the study. The multivariate analysis was used to detect if variables such as sex, age, heartburn, acid regurgitation, dysphagia, presence of esophagitis, percentage of total time at pH < 4, symptom index score (SI), the SF-36 and HRQL scores before treatment, at 6 months and 1 year could affect the QoL questionnaires scores at the end of the study. Results One hundred forty-seven patients were included in the surgical group and 154 in the medical group. No differences with regard to gender, age, mean SF-36 and HRQL scores before treatment were documented. At the end of the study, quality of life was significantly improved for SF-36 and HRQL scores, either for surgical or medical group. The multivariate analysis showed no factors individually affected the SF-36 and the HRQL scores, but symptom index score (SI) and QoL questionnaires scores at 6 months and 1 year follow-up. Conclusions The combined use of pHmetry with evaluation of SI and QoL questionnaires can predict the outcome of GERD patients managed either by medical or surgical therapy.

Objective: The ultrasonic scalpel is a surgical shear that uses high-frequency mechanical energy to enable simultaneous vessel sealing and tissue coagulation at the same time. We conducted a prospective study to compare the outcome of total thyroidectomy using the ultrasonic scalpel versus the device Ligasure in terms of safety, operative time, overall drainage volume, complications, hospital stay. Methods: Between January 2008 and December 2013,400 patients (260 women, 140 men; mean age 46 years) undergoing thyroidectomy were randomized into two groups: group A, where Ultracision were used, and group B, where the Ligasure device was used. Results: There was no significant differences between the two groups in terms of age, gender, indication for thyroidectomy, thyroid gland weight and diameter, histopathologic diagnosis, preoperative and postoperative serum calcium levels, postoperative complications and reoperative thyroid surgery, time of operation and amount of drainage. Conclusions: The ultrasonic scalpel and the Ligasure ares safe, effective, useful, and time-saving alternative to the traditional suture ligation technique for thyroid surgery. They simplified total thyroidectomy, eliminating the need for clamp-and-tie maneuvers while achieving efficient hemostasis.

Background and Aims: While in the past, thoracotomy represented the traditional surgical approach for the treatment of epiphrenic diverticula, actually mini-invasive approach seems to be the preferred treatment as many series have been published in the recent years. This article describes the authors’ experience with the laparoscopic approach for performing diverticulectomy, myotomy, and Nissen–Rossetti fundoplication. Material and Methods: From 1994 to 2010, 21 patients (10 men and 11 women), mean age 58.5 years (range 45–74 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy and Nissen–Rossetti fundoplication. Results: The mean operative time was 135 min (range = 105–190 min). Mean hospital stay was 14.2 days (range = 7–25 days). In 5 patients (23.8%), a partial suture staple line leak was observed. Conservative treatment achieved leak resolution in all the cases. One patient (4.8%) died of a myocardial infarction in the postoperative period. After a mean clinical follow-up period of 78 months (range = 6–192 months), excellent or good outcome was referred with no dysphagia in 16 patients (80%) and only mild occasional dysphagia in 4 patients (20%). Conclusions: Surgical treatment of epiphrenic diverticula remains a challenging procedure also by mini-invasive approach, with major morbidity and mortality rates. For this reason, indications must be restricted only to selected and symptomatic patients in specialized centers.

BACKGROUND: At present, prospectively collected data on rhabdomyolysis (RML) after bariatric surgery are limited. OBJECTIVES: To evaluate the incidence, risk factors, and therapeutic strategy of RML in different bariatric procedures. SETTING: University hospitals, Italy. METHODS: Obese patients were prospectively enrolled. Preoperative demographic characteristics and clinical data, as well as type of anesthesia and type and total duration of surgery, were recorded as potential risk factors for RML. RML was defined as postoperative creatine kinase (CK)>1000 U/L. Incidence, possible risk factors, and therapeutic outcome of RML were assessed and compared with comparative groups. RESULTS: Four hundred eighty obese patients were included in the study. After surgery, RML was diagnosed in 62 (12.9%) patients. Muscular pain was present in 12 patients (19.3%). In RML patients, mean CK value was 1346±2132.5 U/L (range 1191-37,400). Only duration of surgery was identified as an independent risk factor for RML (P230 minutes. CK testing should be performed in all patients after bariatric surgery to make an early diagnosis and properly start fluids and diuretics.

Objective To define the frequency and predictors of short esophagus in a case series of patients undergoing antireflux surgery. Method An observational prospective study from September 10, 2004, to October 31, 2006, was performed at 8 centers. The distance between the esophagogastric junction as identified by intraoperative esophagoscopy and the apex of the diaphragmatic hiatus was measured intraoperatively before and after esophageal mediastinal dissection; a distance of 1.5 cm was arbitrarily determined to categorize cases as long (>1.5 cm) or short (≤1.5 cm). Results One hundred eighty patients were enrolled; the mean age of patients was 49.3 ± 15.3 years. At the first measurement (after isolation of the esophagogastric junction), the median distance between the esophagogastric junction and the apex of the hiatus was equal to or shorter than 1.5 cm in 68 (37.7%) patients; at the second measurement (after full mediastinal isolation), the measurement of the distance was still shorter than 1.5 cm in 34 (18.8%) patients and between 1.5 and 2.5 cm in 24 (13.4%) patients. The median length of the mediastinal esophageal dissection was 6 cm (range 1–12 cm). An esophageal lengthening procedure was performed in 26 (14.4%) patients. The duration of symptoms ( P = .047), the General Health domain of the SF-36 questionnaire ( P = .001), and an x-ray barium swallow ( P = .000) are predictive factors for a “true” short esophagus. Conclusions True short esophagus is present in about 20% of patients undergoing routine antireflux surgery. Radiology, severity, and duration of symptoms are predictors of true foreshortening.

BACKGROUND: Studies have demonstrated that Nissen fundoplication controls acid gastroesophageal reflux (GER). Combined 24-h pH and multichannel intraluminal impedance (MII-pH) allows detection of both acid and nonacid GER. Antireflux surgery is considered for any patient whose medical therapy is not efficient, particularly patients with nonacid gastroesophageal reflux disease (GERD). Nevertheless, fundoplication used to control nonacid reflux has not been reported to date. METHODS: In this study, 15 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-pH both before and after the surgical procedure. The numbers of acid and nonacid GER episodes were calculated with the patient in both upright and recumbent positions. RESULTS: The 24-h pH monitoring confirmed the postoperative reduction of exposure to acid (p < 0.05). Postoperatively, the total, acid, and nonacid numbers of GER episodes were reduced (p < 0.05). CONCLUSION: According to the findings, MII-pH is feasible and well tolerated. It provides an objective means for evaluating the effectiveness of Nissen-Rossetti fundoplication in controlling both acid and nonacid GER

In this paper we describe a case of a 71-year-old man affected by left hemidiaphragm agenesis who presented an extensive enterothorax after an asymptomatic history for many years. The patient had late development of severe constipation and occasional episodes of bowel obstruction and vomiting. The surgical correction of this congenital anomaly consisted of restoring the continuity of the diaphragmatic barrier with a 2-mm-thick expanded polytetrafluoroethylene soft tissue patch(Gore-Tex®) after the herniated viscera have been replaced into the abdominal cavity. At 26 months' follow-up no recurrence has been observed. We would suggest that this is the first known elderly patient surgically treated and the eighth case reported in the literature. The use of a single-layer ePTFE mesh allows a good anatomical and functional repair. An overview of the literature is also reported. © Springer-Verlag 2007.

Background: The purpose of this study was to evaluate the feasibility of primary inguinal repair with open tension-free and sutureless technique using a new polypropylene ‘‘patch and plug system’’ (Prolene 3D patch), and the quality of the treatment in terms of reduction of postoperative discomfort. Methods: Fifty-six consecutive patients, mean age 54.5 – 11.2 years, with primary unilateral uncomplicated inguinal hernia, were treated in a day-surgery setting. Collected data included: pain scores at 24 hours, 72 hours, and 7, 15, and 30 days after operation, analgesic medications, return to work and to heavy house and/or moderate sporting activities, and quality of life as measured by Short Form 36 health survey questionnaire (SF-36) before the operation and at 6 months follow-up. Results: Postoperative pain was low: the mean visual analog scale (VAS) scores were 2.8 at 24 h, 1.8 at 72 h, and 0.9, 0.3, and 0.04 at 7, 15, and 30 days, respectively. Analgesic drugs were not used by 66.0% (n = 37) of the patients. The mean global time to return to work and to heavy activities was 9.9 – 4.6 and 14.6 – 7.0, days, respectively. Patient satisfaction showed a significant improvement in all SF-36 domain scores at 6 months follow-up (P < 0.001). There were no major complications, recurrences, or mortality. Conclusions: The new mesh seems to satisfy all requirements of a feasible, reliable, and effective device for repairing primary inguinal hernia with high patient comfort.

In October 2012, a 29-year-old woman affected by chronic constipation underwent surgery for a laparoscopic total colectomy with ileal j-pouch-rectal anastomosis. After a precise instrumental work-up, the patient was selected as a potential candidate for the surgical treatment after failing to respond to all other medical treatment. During the first three months following the surgery, the patient recorded 3 - 4 daily evacuations of soft stool. After the third month, the number of evacuations stabilised at 2 - 3 a day, with formed stool, and no mention of incontinence or abdominal pain. Although the laparoscopic total colectomy with ileorectal anastomosis (TC with IRA) and the laparoscopically assisted subtotal colectomy with cecorectal anastomosis (SC with CRA) are the most frequently practiced procedures in the surgical treatment of chronic constipation, the laparoscopic colectomy with ileal j-pouch has shown in our experience to be a feasible and effective procedure, with similar results to the two aforementioned procedures in terms of morbidity, mortality and quality of life. In fact, like the first two, the total colectomy with ileal j-pouch has demonstrated the advantages of laparoscopic surgery: low invasiveness, less post-operative pain or ileus, respect of parietal integrity, reduced hospitalization and, lastly, a better cosmesis.

Introduction: The aim of the present study was to critically review the incidence of venous thromboembolism and postoperative hemorrhage in patients undergoing total thyroidectomy without preoperative prophylaxis. Methods: A prospective electronic database of all patients undergoing total thyroidectomy over a six eyear period within August 2013 in our medical unit was analyzed. The incidence of postoperative bleeding and Venous thromboembolism (VTE) was reviewed by subgrouping all patients according to a risk factor score (RFS) for VTE as outlined in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Best Practice Guidelines. Results: An overall 1018 consecutive patients [244 men (24%, mean age 46 ± 13 years), 778 women (76%, mean age 44 ± 17 years)] underwent total thyroidectomy. Postoperative bleeding occurred in 8/1018 patients (0.8%). One out of 1018 (0.1%) patients also subcategorized according to the RFS had VTE. The incidence of VTE complication in the entire population was lower than the risk of postoperative bleeding (P < .0001). Conclusion: The risk of developing VTE in patients who undergo total thyroidectomy for benign and malignant diseases without preoperative prophylaxis is roughly 8-fold less than developing a potentially life threatening complication as postoperative bleeding. Until large well conducted prospective studies on the impact of preoperative prophylaxis on postoperative VTE and bleeding will clarify the issue, it is conceivable to propose the use of stockings and/or anticoagulants according to the individual patient risk factors. © 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Background: To date, few studies of preoperative chemotherapy or chemoradiotherapy (crt) in gastroesophageal junction (gej) cancer have been statistically powered; indeed, gej tumours have thus far been grouped with esophageal or gastric cancer in phase iii trials, thereby generating conflicting results. Methods: We studied 41 patients affected by locally advanced Siewert type i and ii gej adenocarcinoma who were treated with a neoadjuvant crt regimen [folfox4 (leucovorin–5-fluorouracil–oxaliplatin) for 4 cycles, and concurrent computed tomography–based threedimensional conformal radiotherapy delivered using 5 daily fractions of 1.8 Gy per week for a total dose of 45 Gy], followed by surgery. Completeness of tumour resection (performed approximately 6 weeks after completion of crt), clinical and pathologic response rates, and safety and outcome of the treatment were the main endpoints of the study. Results: All 41 patients completed preoperative treatment. Combined therapy was well tolerated, with no treatment-related deaths. Dose reduction was necessary in 8 patients (19.5%). After crt, 78% of the patients showed a partial clinical response, 17% were stable, and 5% experienced disease progression. Pathology examination of surgical specimens demonstrated a 10% complete response rate. The median and mean survival times were 26 and 36 months respectively (95% confidence interval: 14 to 37 months and 30 to 41 months respectively). On multivariate analysis, TNM staging and clinical response were demonstrated to be the only independent variables related to long-term survival. Conclusions: In our experience, preoperative chemoradiotherapy with folfox4 is feasible in locally advanced gej adenocarcinoma, but shows mild efficacy, as suggested by the low rate of pathologic complete response.

Introduction Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation. Methods 40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in not dominant forearm. iPTH were analyzed 24 hours, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo- (< 1.08), aparathyroidism (0) and persistence or relapse ( > 6.99) of disease were determined. Results In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed. Discussion Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience. Conclusions Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications. Introduction: Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation.Methods: 40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in notdominant forearm. iPTH were analyzed 24 h, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo-(< 1.08), aparathyroidism (0) and persistence or relapse (>6.99) of disease were determined.Results: In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed.Discussion: Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience.Conclusions: Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications. (C) 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

ntroduction: Although its excellent results, laparoscopic sleeve gastrectomy (LSG) presents major complications ranging from 0% to 29%. Among them, the staple line leak presents an incidence varying from 0% to 7%. Many trials debated about different solutions in order to reduce leaks??? incidence. No author has investigated the role of gastric decompression in the prevention of this complication. Aim of our work is to evaluate if this procedure can play a role in avoiding the occurrence of staple line leaks after LSG. Materials and Methods: Between January 2008 and November 2012, 145 patients were prospectively and randomly included in the study. Seventy patients composed the group A, whose operations were completed with placement of nasogastric tube; the other 75 patients were included in the group B, in which no nasogastric tube was placed. Results: No statistical differences were observed between group A and group B regarding gender distribution, age, weight, and BMI. No intraoperative complications and no conversion occurred in both groups. Intraoperative blood loss (50.1 ± 42.3 vs. 52.5 ± 37.6 ml, respectively) and operative time (65.4 ± 25.5 vs. 62.6 ± 27.8 min, respectively) were comparable between the two groups (p: NS). One staple line leak (1.4%) occurred on 6th postoperative day in group A patients. No leak was observed in group B patients. Postoperative hospital stay was significantly longer in group A vs. group B patients (7.6 ± 3.4 vs. 6.2 ± 3.1 days, respectively, p: 0.04). Conclusions: Routine placement of nasogastric tube in patients operated of LSG seems not useful in reducing leaks??? incidence.

Transmural migrated retained sponges usually impact at the level of the ileo-cecal valve leading to a small bowel obstruction. Once passed through the ileo-cecal valve, a retained sponge can be propelled forward by peristaltic activity and eliminated with feces. We report the case of a 52-year-old female with a past surgical history and recurrent episodes of abdominal pain and constipation. On physical examination, a generalized resistance was observed with tenderness in the right flank. Contrast-enhanced multi-detector computed tomography findings were consistent with a perforated right colonic diverticulitis with several out-pouchings at the level of the ascending colon and evidence of free air in the right parieto-colic gutter along with an air-fluid collection within the mesentery. In addition, a ring-shaped hyperdense intraluminal material was also noted. At surgery, the ascending colon appeared irregularly thickened and folded with a focal wall interruption and a peri-visceral abscess at the level of the hepatic flexure, but no diverticula were found. A right hemi-colectomy was performed and on dissection of the surgical specimen a retained laparotomy sponge was found in the bowel lumen. © 2014 Baishideng Publishing Group Co., Limited. All rights reserved.

Actually, achalasia can be defined as a primary esophageal motor disorder characterized by esophageal aperistalsis and abnormal post-deglutitive lower esophageal sphincter (LES) relaxation. Its incidence varies from 0.03 to 1.63 cases per 100,000 people per year and increases with age, while the prevalence is almost 10/100,000 with no difference between the sexes. Regarding etiology, the most frequent histologic alteration is represented by the loss of the myenteric nerve fibers regulating inhibitory nitrergic neurotransmission in the LES, with the presence of a lymphocytic infiltrate and collagen deposition. The cause of this loss remains unclear. Among the theories proposed, the infectious, hereditary and autoimmune etiologies have been widely investigated. The only infectious agent identified as a cause of achalasia is Trypanosoma Cruzi, responsible of Chagas' disease. Regarding hereditary component, in rare cases achalasia presents as part of a genetic syndrome such as Down syndrome, Allgrove syndrome and familial visceral neuropathy. Although, no disease-specific gene has been identified. The autoimmune hypothesis has focused on the association of specific HLA classes with achalasia. However, no consistent association has been observed across studies. Despite increasing understanding of the physiopathology of achalasia, its etiology remains largely unknown. The onset of the disease is characterized by chronic inflammation of the myenteric plexus of the esophagus secondary to an environmental insult. Probably, genetic factors are involved in the development of achalasia, although the precise molecular basis of the disease has not been identified.

Esophageal cancer (EC) is an aggressive malignancy with increasing incidence worldwide. Surgery is still the most effective treatment, however, both the high rate of local and distant recurrences and surgery-related complications led us to investigate new preoperative strategies. In this review, we discuss the role of neoadjuvant therapy for locally advanced EC with a focus on preoperative chemoradiation (trimodality treatment). Furthermore, the last fifteen years of published literature and our experience have been also reviewed. In the preoperative setting, few trials have reported a significant benefit with fluoropyrimidine and platinum compound-based neoadjuvant chemotherapy, compared to surgery alone. A large number of phase III trials and meta-analyses have demonstrated improved outcomes with preoperative chemoradiation vs. neoadjuvant chemotherapy or surgery alone. Therefore, trimodality therapy can be considered the most effective option in the management of locally advanced EC. Addition of drugs targeting VEGF or HER2 to standard chemotherapy appears to be feasible but needs to be explored more accurately. FDG-PET may predict both response to neoadjuvant treatments and prognosis.

Extra Ovarian Primary Peritoneal Carcinoma (EOPPC) is a rare type of adenocarcinoma of the pelvic and abdominal peritoneum. The objective examination and the histological aspect of the neoplasia virtually overlaps with that of ovarian carcinoma. The reported case is that of a 72 year-old patient who had undergone a total hysterectomy with bilateral annessiectomy surgery 20 years earlier subsequently to a diagnosis for uterine leiomyomatosis. The patient came to our attention presenting recurring abdominal pain, constipation, weight loss, severe asthenia and fever. Her blood test results showed hypochromic microcytic anemia and a remarkable increase CA125 marker levels. Instrumental diagnostics with Ultrasound (US) and CT scans indicated the presence of a single peritoneal mass (10-12 cm diameter) close to the great epiploon. The patient was operated through a midline abdominal incision and the mass was removed with the great omentum. No primary tumor was found anywhere else in the abdomen and in the pelvis. The operation lasted approximately 50 minutes. The post-operative course was normal and the patient was discharged four days later. The histological exam of the neoplasia, supported by immunohistochemical analysis, showed a significant positivity for CA 125, vimentin and cytocheratin, presence of psammoma bodies, and cytoarchitectural pattern resembling that of a serous ovarian carcinoma even in absence of primitiveness, leading to a final diagnosis of EOPPC. The patient later underwent six cycles of chemotherapy with paclitaxel (135 mg/m2/24 hr) in association with cisplatin (75mg/m2). At the fourth year follow-up no sign of relapse was observed. © 2013, CIC Edizioni Internazionali, Roma.

The Authors present their experience with laparoscopic total or subtotal colectomy (TC or SC) in three patients operated for intractable chronic slow transit constipation (STC), together with a review of literature.From July 2005 to July 2009 three young patients affected by STC, after meticulous preoperative instrumental work-up and after failure of medical treatment, were submitted to laparoscopic TC and ideo rectal anastomosis (IRA) in two cases and to laparo assisted SC followed by Ceco Rectal Anastomosis (CRA) in one case. Number of daily bowel motions, urgency soiling, incontinence, abdominal pain, bloating with special regard to patient's quality of life, were analyzed.All the interventions were completed via laparoscopic approach. No postoperative morbidity or mortality were observed. After twelve months, the patients referred two-three daily evacuation of soft stool, with a good continence and disappearance of abdominal pain and other relatives symptoms. They reported excellent satisfaction with the surgical results and a significant improvement of their quality of life.TC with IRA and CRA after SC represent the most effective and widely used surgical operations in the treatment of STC, in well selected patients, after failure of conservative treatment. According to Literature data, and in our experience, no significant differences in terms of postoperative morbidity or mortality neither in quality of life were observed between the two operations. It is well demonstrated the feasibility of the laparoscopic approach in treatment of colorectal pathologies with typically advantages of less invasive surgery, respect of parietal integrity, less postoperative pain and ileus, fewer postoperative adhesions, a reduced hospitalisation and finally a better cosmesis.Laparoscopic TC and IRA and CRA after laparo assisted SC represent efficacious operations in the treatment of STC offering a good postoperative quality of life and reduced morbidity compared to open surgery.

"\"Abstract. INTRODUCTION:. The Authors present their experience with laparoscopic total or subtotal colectomy (TC or SC) in three patients operated for intractable chronic slow transit constipation (STC), together with a review of literature.. MATERIAL AND METHODS:. From July 2005 to July 2009 three young patients affected by STC, after meticulous preoperative instrumental work-up and after failure of medical treatment, were submitted to laparoscopic TC and ideo rectal anastomosis (IRA) in two cases and to laparo assisted SC followed by Ceco Rectal Anastomosis (CRA) in one case. Number of daily bowel motions, urgency soiling, incontinence, abdominal pain, bloating with special regard to patient's quality of life, were analyzed.. RESULTS:. All the interventions were completed via laparoscopic approach. No postoperative morbidity or mortality were observed. After twelve months, the patients referred two-three daily evacuation of soft stool, with a good continence and disappearance of abdominal pain and other relatives symptoms. They reported excellent satisfaction with the surgical results and a significant improvement of their quality of life.. DISCUSSION:. TC with IRA and CRA after SC represent the most effective and widely used surgical operations in the treatment of STC, in well selected patients, after failure of conservative treatment. According to Literature data, and in our experience, no significant differences in terms of postoperative morbidity or mortality neither in quality of life were observed between the two operations. It is well demonstrated the feasibility of the laparoscopic approach in treatment of colorectal pathologies with typically advantages of less invasive surgery, respect of parietal integrity, less postoperative pain and ileus, fewer postoperative adhesions, a reduced hospitalisation and finally a better cosmesis.. CONCLUSIONS:. Laparoscopic TC and IRA and CRA after laparo assisted SC represent efficacious operations in the treatment of STC offering a good postoperative quality of life and reduced morbidity compared to open surgery.\""

Purpose To investigate pain and other complications following inguinal hernioplasty performed by the Lichtenstein technique with mesh fixation by fibrin glue or sutures. Methods Five hundred and twenty patients were enrolled in this 12-month observational multicenter study and received either sutures or fibrin glue (Tissucol/Tisseel) based on the preference of the surgeon. Pain, numbness, discomfort, recurrence, and other complications were assessed postoperatively and at 1, 3, 6, and 12 months. Pain intensity was assessed by a visual analog scale VAS; 0 [no pain] to 10 [worst pain]). Results One hundred and seventy-one patients received sutures and 349 received fibrin glue. During the early postoperative phase, 87.4% of patients in the fibrin glue group and 76.6% of patients in the sutures group were complication-free (P = 0.001). Patients who received fibrin glue were also less likely to experience hematoma/ecchymosis than those in the suture group (both P = 0.001). The mean pain score was significantly lower in the fibrin group than the sutures group (2.5 vs. 3.2, P

Background Extraovarian Primary Peritoneal Carcinoma (EOPPC) was first described by Swerdlow in 1959 [1]. Basically, EOPPC is a malignancy that spreads widely inside the peritoneal cavity involving mostly the omentum with minimal or no ovarian involvement. Most of the EOPPC cases reported have been of serous histology; histopathological, immunohistochemical, and clinical similarities have been observed between EOPPC and Epithelial Ovarian Cancer (EOC).

Introduction Although laparoscopic Nissen fundoplication has been recognized as the standard of care for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty have been reported as a common mechanism of failure after primary repair. Different surgical techniques for diaphragmatic pillars closure have been proposed, but the problem remains unsolved. The authors hypothesized that ultrastructural illness may be implicated in this recurrence. The aim of this study was to investigate the presence of changes at esophageal hiatal area in patients with and without HH. Materials and Methods One hundred and thirty-two laparoscopic samples from phrenoesophageal membrane and diaphragmatic crura were collected from 33 patients with gastroesophageal reflux disease and HH (HH group) and 60 samples from 15 patients without HH enrolled as the control group (NHH group). All specimens were processed and analyzed by transmission electron microscopy. Results Muscular and connective samples from the NHH group showed no ultrastructural alterations; similar results were found in phrenoesophageal ligament samples from the HH group. In contrast, 94% of the muscular samples obtained from the crura of the HH group have documented four main types of alterations. In 75% of HH patients, the pillar lesions were severe. Conclusion Patients with hiatal hernia have ultrastructural abnormalities at the muscular tissue of the crura that are not present in patients with a normal gastroesophageal junction. There is no difference in the microscopic damage at the connective tissue of the phrenoesophageal membrane surrounding the esophagus of the two groups of patients. The outcome of antireflux surgery could depend not only on the adopted surgical technique but also on the underlying status of the diaphragmatic crura.

A 71-year-old man affected by left hemidiaphragmatic agenesis developed late severe constipation and occasional episodes of bowel obstruction. At left subcostal laparotomy, the stomach, transverse colon, splenic flexure, and spleen were located in the left hemithorax. Repair was performed with a 2-mm-thick expanded polytetrafluoroethylene (Gore-Tex) patch secured in place circumferentially as a new diaphragmatic dome. No early major complications and no recurrence at 34 months' follow-up were observed. To the best of our knowledge, this is the oldest treated patient with a true hemidiaphragmatic agenesis and is the eighth case reported in the literature. The use of the ePTFE soft tissue patch, thanks to its strength and pliability, affords good anatomical and functional repair.

Incisional hernia (IH) is an abdominal hernia that occurs after previous surgery [1]. It is one of the most frequent surgical problems, as the incidence following laparotomy is 10–20% [2, 3, 4, 5]. Surgical treatment of incisional hernia involves either direct suture in patients with primary defects >3 cm in diameter, or a rather complex operation in patients with large defects that involve loss of wall substance and impairment of ventilation and cardiac circulation.

BACKGROUND: Several different ways of fashioning a total fundoplication lead to different outcomes. This article addresses the technical details of the antireflux technique we adopted without modifications for all patients with GERD beginning in 1972. In particular it aims to discuss the relation between the mechanism of function of the wrap and the physiology of the esophagus. METHODS: The study population consisted of 380 patients affected by GERD with a 1-year minimum of follow-up who underwent laparoscopic Nissen-Rossetti fundoplication by a single surgeon. RESULTS: No conversion to open surgery and no mortality occurred. Major complications occurred in 4 patients (1.1%). Follow-up (median 83 months; range: 1-13 years) was achieved in 96% of the patients. Ninety-two percent of the patients were satisfied with the results of the procedure and would undergo the same operation again. Postoperative dysphagia occurred in 3.5% of the patients, and recurrent heartburn was observed in 3.8%. CONCLUSIONS: Laparoscopic Nissen-Rossetti fundoplication with the routine use of intraoperative manometry and endoscopy achieved good outcomes and long-term patient satisfaction with few complications and side-effects. Appropriate preoperative investigation and a correct surgical technique are important in securing these results

Background The study was conducted on a population of 74 patients undergoing surgery for rectal adenocarcinoma with 5-year follow-up. The aim is to evaluate the survival and Quality of Life (QoL) in two groups of patients: Y group with age

Background Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results. Methods Thirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel. Results Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group. Conclusions Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.

44 patients with advanced breast cancer were treated with high-dose epirubicin (130 mg/sqm), because of its steep dose-response curve. Lonidamine and alpha interferon were administered as well with the aim of increasing epirubicin uptake and overcoming drug resistance. Granulocyte-colony stimulating factor support was provided. 14 complete responses and 22 partial responses were observed in 40 evaluable patients for a 90% overall response rate. Median duration of response was 12 months for complete responders, 7 months for partial responders. In two cases the complete response has lasted for more than two years. Myelosuppression, infection, and cardiac toxicity were the main treatment-related toxic effects. These results are encouraging enough to justify a randomized comparison of our chemotherapy program with standard regimens used in advanced breast cancer.

Background: Laparoscopic fundoplication for gastroesophageal reflux disease (GERD) and hiatal hernia has been validated worldwide in the past decade. However, hiatal hernia recurrence still represents the most frequent long-term complication after primary repair. Different techniques for hiatal closure have been recommended, but the problem remains unsolved. The authors theorized that ultrastructural alterations may be implicated in hiatal hernia. Thus, this study was undertaken to investigate the presence of these alterations in patients with or without hiatal hernia. Methods: Samples from Laimer–Bertelli connective membrane and muscular crura at the esophageal hiatus were collected from 19 patients with GERD and hiatal hernia (HH group), and from 7 patients without hiatal hernia enrolled as the control group (NHH group). Specimens were processed and analyzed by transmission electron microscopy. Results: Muscle and connective samples from the NHH group did not present any ultrastructural alteration that could be detected by transmission electron microscopy. Similarly, connective samples from the HH group showed no ultrastructural alterations. In contrast, all muscle samples from the HH group exhibited sarcolemmal alterations, subsarcolemmal vacuolar degeneration, extended disruption of sarcotubular complexes, increased intermyofibrillar spaces, and sarcomere splitting. Conclusion: The evidence of ultrastructural alterations in all the patients in the HH group raises the suspicion that the long-term outcomes of antireflux surgery depend not only on the surgical technique, but also on the underlying muscular diaphragmatic illness.

Introduction Among the surgical procedures for treatment of morbid obesity, laparoscopic sleeve gastrectomy has known widespread diffusion in the last years, although it is not free from significant morbidity rates. Aim of this work is to evaluate the incidence of Helicobacter pylori (HP) infection on the postoperative outcome of patients undergoing laparoscopic sleeve gastrectomy. Methods Between January 2008 and December 2013, 184 patients (65 males, 119 females), mean age 35.8 ± 5.7 years, affected with morbid obesity, mean BMI 46.6 ± 6.7, underwent laparoscopic sleeve gastrectomy. All the specimens at the end of the operation were analysed by the same pathologist. Histological grading was based on the Sidney classification. Results Seventy-two of the patients (39.1%) were HP positive, while 112 (60.9%) were negative. No significant differences were observed between the HP+ and HP− group in terms of age, sex, weight, BMI, incidence of comorbidities and duration of follow-up. All the operations were completed via laparoscopic approach. No mortality was observed. Postoperative complications occurred in 5 patients (2.7%): three leaks (1.6%), all in the HP- group and two bleedings (1.1%), one in the HP+ and one in the HP− group. In two cases a reintervention was necessary. No significant differences were observed in the morbidity rates between the two groups. Overall mean excess weight loss at 6 months, 12 months and 24 months was respectively 47.4 ± 11.3%, 61.1 ± 12.4% and 68.4 ± 13.5%, with no significant differences between the HP+ and HP− groups. Conclusions HP infection seems not to influence postoperative outcome of patients operated of laparoscopic sleeve gastrectomy.

Introduction: Lymph nodal involvement in papillary thyroid cancers is very common, but the role of lymph node dissection is still controversial. Surgeons are consequently divided between opposed to and in favor of routine central neck dissection associated with total thyroidectomy. Methods: Clinical records of 210 patients undergoing from January 2000 to December 2006 total thyroidectomy without routine lymph node dissection were retrospectively evaluated. One hundred and ninety eight patients (94.2%) underwent radioiodine ablation as well, followed by Thyroid Stimulating Hormone suppression therapy. In patients with loco regional lymph nodal recurrence, central (VI) and ipsilateral (III-IV) lymph node dissection was performed. Results: Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent vocal fold paralysis were respectively 1.4% and 1.9%. After an 8-year mean follow-up, the rate of loco regional recurrence was 4.2%-9/210 patients. In these cases selective lymph node dissection was carried out without complications. Discussion: The role of neck dissection in papillary thyroid cancer management, is still subject of research and controversial regarding routine or therapeutic indications, surgical extension, its impact on local recurrence and survival. Conclusion: A low loco regional recurrence rate may be observed after total thyroidectomy without prophylactic lymph node dissection. Lymph nodal recurrences were more frequent in young male patients, sometime affected by follicular variant, in each case less than 2 cm. There is a general agreement about the extension of therapeutic lymph node dissection, while routine central neck dissection is still controversial and may be indicated in high risk patients.

Liposarcoma is the second most common soft tissue sarcoma in adults. These neoplasms take their origin from primitive mesenchymal cells and are rarely encountered in fat rich areas, such as subcutaneous tissue and/or the subserosa of the intestinal tract which, on the contrary, are the two most common sites of lipomas. The two major locations of liposarcomas are the extremities and the retroperitoneum followed with much less frequency by the inguinal region. Other sites are uncommon, particularly the mesentery (9 cases to date in the literature) and, even more so, the mesocolon (only 3 cases of primary sarcoma of the mesocolon reported to date). This paper reports on the case of a well differentiated 'lipoma-like' liposarcoma of the sigmoid mesocolon, associated with multiple lipomatosis of the recto-sigmoid colon in a 75 year-old female patient. Surgical treatment consisted of a trans-anal extra-peritoneal anterior resection by CEEA 28 stapler under endoscopic vision. The patient has been followed up for the last 2 years and is still disease-free and well. The peculiarity of the case consists in the contemporaneous presence in close contiguity of two different rare neoplasms whose association is not yet known.

AIM: Laparoscopic Nissen fundoplication represents the gold standard in GERD therapy, although, a frequent failure of this primary repair is represented by the breakdown of the hiatoplasty. Aim of our work is to evaluate if ultrastructural alterations of the diaphragmatic pillars in patients with hiatal hernia, can explain the physiopathology of hernia recurrence. MATERIAL OF STUDY: The patients were divided into two groups: group A comprised 51 patients affected by hiatal hernia and group B (control) included 30 patients not affected by hiatal hernia.. Each patient underwent four biopsies, two from the phrenoesophageal membrane and two from the diaphragmatic pillars during laparoscopic procedures. Three hundred and twenty-four specimens, 204 from the group A and 120 from the group B, were processed and analyzed by transmission electron microscopy. RESULTS: No alterations were found in the phrenoesophageal membrane in both groups; samples from the diaphragmatic pillars showed no alteration in the group without hiatal hernia (group B). Instead, 90,2% of the muscular samples from the crura of group A patients presented ultrastructural alterations: in almost 75% of the cases the lesions were considered severe with extended disruption-degeneration of the muscle architecture. DISCUSSION: Patients with hiatal hernia have ultrastructural abnormalities of the muscular tissue of the diaphragmatic pillars that are absent in patients with normal gastroesophageal junction. CONCLUSIONS: The outcome of GERD surgery could depend not only on a correct technique but also on the underlying status of the diaphragmatic crura.

BACKGROUND In this prospective non-randomized observational cohort study we evaluated: the feasibility and effectiveness of primary umbilical hernia repair with open tension-free and sutureless technique using a porcine small intestinal submucosa (Surgisis) prosthesis, the quality of the treatment in terms of reduction of postoperative discomfort and the complications at early and long-term follow-up. METHODS Thirty-six consecutive patients, mean age 45.25 +/- 12.19 years, affected by primary umbilical uncomplicated hernia with a defect size < or = 3 cm, were treated in a day-surgery setting. A tailored flat Surgisis graft was used to ensure an overlap of at least 2 cm; in all patients the mesh was fixed by fibrin glue. Collected data included: visual analogic scale (VAS) pain scores at 24 hours, 72 hours, and 7, 15, and 30 days and number of analgesic medications after operation, complications rate, the quality of life measured by Short Form 36 health survey questionnaire (SF-36) before the operation and at long term follow-up. RESULTS The mean follow-up time was 5.6 +/- 1.4 years. Postoperative pain was low: the mean visual analogic scale (VAS) scores were 2.8 at 24 h, 1.8 at 72 h, and 0.9, 0.3, and 0.04 at 7, 15, and 30 days, respectively. 77.8% of the patients (28/36) did not use any analgesic drugs. Seroma was reported in 13.8% of the patients (5/36); there were no hematomas, infection, chronic pain and no major complications or mortality (< or = 30 days). Recurrence rate was 2.8% (1/36). Patient satisfaction showed a significant improvement in all SF-36 domain scores (P < 0.001). CONCLUSIONS The biologic mesh seems to be a safe and reliable device for repairing primary umbilical hernia with high patient comfort, even if not yet an alternative to synthetic mesh.

A case of acute aperistaltic megaesophagus which arose after Nissen fundoplication for sliding hiatal hernia, is reported. The resolution of the clinical and instrumental picture with cholinergic drugs leads to the conclusion that the phenomenon observed is of vagal origin. This may be an extreme picture of the mild esophageal dilatation and transitory dysphagia that sometimes occur after Nissen fundoplication.

Background: In this prospective non randomized observational cohort study we have evaluated the influence of age on outcome of laparoscopic total fundoplication for GERD. Methods: Six hundred and twenty consecutive patients underwent total laparoscopic fundoplication for GERD. Five hundred and twenty-four patients were younger than 65 years (YG), and 96 patients were 65 years or older (EG). The following parameters were considered in the preoperative and postoperative evaluation: presence, duration, and severity of GERD symptoms, presence of a hiatal hernia, manometric and 24 hour pH-monitoring data, duration of operation, incidence of complications and length of hospital stay. Results: Elderly patients more often had atypical symptoms of GERD and at manometric evaluation had a higher rate of impaired esophageal peristalsis in comparison with younger patients. The duration of the operation was similar between the two groups. The incidence of intraoperative and postoperative complications was low and the difference was not statistically significant between the two groups. An excellent outcome was observed in 93.0% of young patients and in 88.9% of elderly patients (p = NS). Conclusions: Laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients, warranting low morbidity and mortality rates and a significant improvement of symptoms comparable to younger patients.

Background Postoperative complications such as failure or disruption of the crura repair and intrathoracic migration of the wrap are the most common anatomic reasons for the failure of Laparoscopic Nissen Fundoplication. The authors hypothesized that ultrastructural illness may be implicated in this recurrence. The aim of this study was to investigate the presence of changes at esophageal hiatal area in patients with and without HH and to shed some light on the use of mesh in this surgery.

Retroperitoneal schwannomas are rare tumours originating from Schwann cells of peripheral nerve sheaths. Their clinical presentation is often delayed as they grow to a large size in a non-restrictive space, such as the retroperitoneum, before any clear symptomatology is manifested. Furthermore, the symptoms may mimic different diseases and be aspecific. The preoperative diagnosis is often unclear as no pathognomonic radiological features are known. Fine needle biopsy is not diagnostic due to tumour cell pleomorphism. We report the case of a 51-year-old woman presenting with unusual symptoms such as severe constipation, bowel distension, excess flatus, postprandial fullness and abdominal pain due to left colon compression by a large retroperitoneal tumour. A complete resection of the mass combined with sparing of the surrounding tissues was carried out through a midline laparotomy. Microscopic evaluation and immunohistochemistry documented a benign retroperitoneal schwannoma. Postoperatively, complete resolution of abdominal symptoms and no major complications were observed. At 28 months' follow-up no local recurrence was found. To the best of our knowledge, this is a rare case of retroperitoneal schwannoma with definite abdominal symptoms and with sudden onset of severe constipation.