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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. [ABSTRACT FROM AUTHOR]

This study aims to evaluate by the use of 24-hour combined multichannel intraluminal impedance and pH monitoring (MII-pH) the efficacy of the Nissen fundoplication in controlling both acid and nonacid gastroesophageal reflux (GER) in patients that underwent Heller myotomy for achalasia. It has been demonstrated that fundoplication prevents the pathologic acid GER after Heller myotomy, but no objective data exists on the efficacy of this antireflux surgery in controlling all types of reflux events. The study population consisted of 20 patients that underwent laparoscopic Heller myotomy and Nissen fundoplication for achalasia. All patients were investigated with manometry and MII-pH. MII-pH showed no evidence of postoperative pathologic GER. The overall number of GER episodes was normal in both the upright and recumbent position. This reduction was obtained because of the postoperative control of both the acid and nonacid reflux episodes. The Nissen fundoplication adequately controls both acid and nonacid GER after extended Heller myotomy. Further controls with MII-pH are warranted to check at a longer follow-up for the efficacy of this antireflux procedure in achalasic patients. [ABSTRACT FROM AUTHOR]

Aim: To determine the impact of total fundoplication on the spontaneous esophageal clearance, known as secondary peristalsis. Background: Although there is general agreement that total fundoplication is not an obstacle to bolus swallowing (primary peristalsis), whether it is an obstacle to spontaneous esophageal clearance (secondary peristalsis) is still not clear. Based on 24-hour monitoring, multichannel intraluminal impedance was used to calculate the time of spontaneous bolus clearance (BCT). Methods: Mean BCT was prospectively calculated in 15 consecutive patients before and after total fundoplication. BCT was calculated in seconds including all the gastroesophageal reflux episodes, whereas bolus swallows (solid meals and liquid swallows) were excluded from the analysis. Results: BCT was extrapolated from 1,057 episodes in the 623 h of study. Overall, BCT did not change after surgery (13.6 ± 4 vs. 15.2 ± 10 s; p = nonsignificant) and in the upright (12.2 ± 3 vs. 16.5 ± 7 s; p = nonsignificant) and recumbent position (22.9 ± 9 vs. 23.0 ± 9 s; p = nonsignificant). Conclusions: In this study total fundoplication did not affect the BCT by combined 24-hour ph monitoring and multichannel intraluminal impedance. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The aims of this study were to evaluate several clinical and instrumental parameters in a large number of patients with constipation and incontinence as well as in healthy controls and discuss their potential implications in the functional aspects of these disorders. Eighty-four constipated and 38 incontinent patients and 45 healthy controls were submitted to a protocol based on proctologic examination, clinico-physiatric assessment, and instrumental evaluation. Constipated and incontinent patients had significantly worse lumbar lordosis as well as lower rate in the presence of perineal defense reflex than controls. Constipated but not incontinent patients had a lower rate of puborectalis relaxation than controls. Furthermore, worse pubococcygeal tests and a higher rate of muscle synergies presence, either agonist or antagonist, were observed in both constipated and incontinent patients compared to controls. This study has demonstrated strong correlations between physiatric disorders and the symptoms of constipation and incontinence. Further studies designed to demonstrate a causal relationship between these parameters and the success of a specific treatment of the physiatric disorders on the proctology symptoms are warranted. [ABSTRACT FROM AUTHOR]

The aim of this study is to evaluate if esophageal dysmotility can influence the outcome of laparoscopic total fundoplication for gatro-esophageal reflux disease (GERD). The advent of laparoscopic fundoplication has greatly reduced the morbidity of antireflux surgery and by now, it should be considered the surgical treatment of choice for GERD. Some authors assert that total versus partial fundoplication should improve the rate of postoperative dysphagia or gas bloat syndrome, particularly in patients with esophageal dysmotility. From September 1992 to December 2005, 420 consecutive patients 171 male and 249 female, mean age 42.8 years (range 12–80) underwent laparoscopic Nissen-Rossetti fundoplication. At manometric evaluation, we divided patients into two groups: group A (163/420; 38.8%) with impaired esophageal peristalsis (peristaltic waves with a pressure < 30 mmHg), and group B (257/420; 61.2%) without impaired peristalsis. We followed up clinically 406 out of 420 (96.7%) patients, 156/163 patients (95.7%) in group A and 250/257 patients (97.3%) in group B. An excellent outcome was observed in 143/156 (91.7%) group A patients and in 234/250 (93.6%) group B patients ( P = NS). Both groups showed significant improvement in clinical symptom score with no statistically significant difference between patients with normal and impaired peristalsis. Thus, preoperative defective esophageal peristalsis is not a contraindication to total laparoscopic fundoplication. [ABSTRACT FROM AUTHOR]

Highlights from the article: We have read with great interest the article "Pelvic floor rehabilitation for defecation disorders" by Bocchini et al. [[1]]. We congratulate the journal and the authors for the publication of a paper on the indications and modality of pelvic floor rehabilitation treatment in patients with defecation disorders. Clinical data collected and quantified using the scores mentioned by Bocchini et al. are important for patient evaluation, even if they play a minor role in identifying the indications for rehabilitation treatment.

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. [ABSTRACT FROM AUTHOR]

Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal–vaginal–dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls. Ninety-two consecutive patients (77 women; mean age 51 years; range 21–71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated. The incidence of anismus resulted significantly higher ( P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam ( P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values. Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

1 Alterations in patients affected by pelvic floor dyssynergia. Therefore, all patients with pelviperineal disorders who are candidates for pelvic floor rehabilitation need to have proper abdominal breathing. This suggests that dyssynergiais in fact just "the tip of the iceberg", careful pre-rehabilitation assessment of patients with pelvic floor disorders is necessary. [Extracted from the article]

Background: The aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for disorders of the adrenal gland in terms of feasibility, safety, and length of hospitalization.Methods: Twenty consecutive patients with benign lesions of adrenal gland were randomized into two groups: Patients in the laparoscopic group underwent traditional laparoscopic adrenalectomy (LAP), whereas those in the robotic group underwent robot-assisted adrenalectomy (ROBOT) using the da Vinci robotic system.Results: There was no significant difference between the groups in terms of age, sex, body mass index, and size or locations of lesions. Operative times were significant longer in the ROBOT group (total operative time, 169.2 min [range, 136-215] vs 115.3 min (range, 95-155) p < 0.001. Skin-to-skin time was 107 m (range, 77-154) vs 82.1 min (range, 55-120) (p < 0.001). There were no conversions to open surgery. However, conversion to standard laparoscopic surgery was necessary in four of 10 ROBOT patients (40%; left, one right). Perioperative morbidity was higher in the ROBOT group (20% vs 0%). There was no difference in length of hospital stay. In the following ROBOT group, hospital stay was 5.7 days (range, 4-9) vs 5.4 days (range, 4-8) in the LAP group (p = NS). The total cost of the ROBOT procedure ($3,467) was significantly higher than that for LAP ($2,737) (p < 0.01).Conclusion: Laparoscopic adrenalectomy is superior to robot-assisted adrenalectomy in terms of feasibility, morbidity, and cost. [ABSTRACT FROM AUTHOR]

Background: Esophageal cancer is associated with a poor long-term prognosis. Only a 10% 5-year survival rate is reported. This article aims to evaluate the feasibility and efficacy of laparoscopic esophagectomy for the palliative treatment of advanced esophageal cancer (T3-T4 Nx-N1) after neoadjuvant therapy.Methods: From March 1998 to July 2002, 35 patients (mean age, 64.6 years; range, 35-72 years) affected by advanced cancer of the middle lower third of the esophagus came to the authors' observation. All received neoadjuvant radiochemotherapy. Of the 35 patients, 22 (62.9%) showed a positive response to treatment (>or=50% reduction of maximal cross-sectional area of the tumor), and surgical intervention was performed 4 weeks after the end of the therapy. The operations were accomplished through the laparoscopic approach and left lateral cervicotomy.Results: The mean operative time was 160 min (range, 120-260 min). One patient (4.5%) experienced a cervical anastomotic leak. Three patients (13.6%) died in the postoperative period: one of myocardial infarction and two of acute respiratory failure. The mean postoperative hospital stay was 12.1 days (range, 9-23 days). After a mean follow-up period of 20.2 months (range, 10-40 months), 13 patients (68.4%) were alive.Conclusions: The laparoscopic approach seems to be effective for the palliative treatment of advanced esophageal cancer. Further trials will be necessary to evaluate the advantages of this technique. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for disorders of the adrenal gland in terms of feasibility, safety. and length of hospitalization. Methods: Twenty consecutive patients with benign lesions of adrenal gland were randomized into two groups: Patients in the laparoscopic group underwent traditional laparoscopic adrenalectomy (LAP), whereas those in the robotic group underwent robot-assisted adrenalectomy (ROBOT) using the da Vinci robotic system. Results: There was no significant difference between the groups in terms of age. sex, body mass index, and size or locations of lesions. Operative times were significant longer in the ROBOT group (total operative time. 169.2 mm [range, 136 215] vs 115.3 mm (range. 95 155) p < 0.001. Skin-to-skin time was 107 m (range. 77 154) vs 82.1 mm (range, 55 120) (p < 0.001). There were no conversions to open surgery. However, conversion to standard laparoscopic surgery was necessary in four of 10 ROBOT patients (40%; left, one right). Perioperative morbidity was higher in the ROBOT group (20% vs 0%). There was no difference in length of hospital stay. In the following ROBOT group. hospital stay was 5.7 days (range, 4-9) vs 5.4 days (range. 4 8) in the LAP group (p NS). The total cost of the ROBOT procedure ($3,467) was significantly higher than that for LAP (S2,737) (p C 0.01). Conclusion: Laparoscopic adrenalectomy is superior to robot-assisted adrenalectomy in terms of feasibility. morbidity. and cost. [ABSTRACT FROM AUTHOR]

Background: Only recently has the spleen been perceived as an organ with a major immune function. This raised an interest in spleen salvage after spleen trauma and pancreatic tail resection, for the treatment of hematologic disorders and inducement tolerance for allogenic transplants. The purpose of this study was to evaluate the feasibility of a new technique for spleen transplantation: laparoscopic spleen autotransplantation in a large animal model.Methods: Ten 35-kg pigs were used for this study. A laparoscopic hand-assisted splenectomy was first performed. The spleen was extracted through the handport to be flushed with a 4 degrees C saline solution and prepared extracorporeally. The graft was then reintroduced into the same animal's abdominal cavity, and a splenic-to-common iliac artery and vein bypass was performed laparoscopically using a 7-0 polytetrafluoroethylene running suture. The animal was killed 1 week postoperatively for histologic examination.Results: All 10 animals tolerated the procedure well. No conversion to open surgery was required. The mean operative time was 253 +/- 45 min. The mean time needed to create the artery and vein anastomoses was 116 +/- 165 min, and the mean blood loss was 190 +/- 120 ml. There was no intra- or postoperative death. Intraoperative complications included two stenosed vascular anastomoses, which were taken down and revised. Seven of the 10 spleens were histologically viable 1 week after surgery. The nonviable transplantations were attributable to a thrombosis of the common iliac artery (n = 1) or the transplant artery (n = 2).Conclusions: Hand-assisted laparoscopic spleen autotransplantation is feasible in an animal model. This procedure could constitute an option when spleen resection is necessary for pancreatic tail resection, or when spleen preservation is important to the maintenance or restoration of an immune function. [ABSTRACT FROM AUTHOR]

Background: Thoracotomy represents the traditional surgical approach for the treatment of epiphrenic diverticula. A mini-invasive procedure has been reported in only few series. This article describes the authors experience with the laparoscopic approach for performing diverticulectomy, myotomy and Nissen-Rossetti fundoplication.Methods: From 1994 to 2002, 13 patients (6 men and 7 women), mean age 57 years (range 45-71 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy, and Nissen-Rossetti fundoplication.Results: The mean operative time was 145 min (range 110-180 min). No operative mortality was observed. The mean hospital stay was 13.9 days (range 7-25 years). The first three patients (23.1%) who underwent surgery experienced a partial disruption of the suture staple line. One patient (7.7%) died of a myocardial infarction. After a mean clinical follow-up period of 58 months (range 3-96 months), all the patients were symptom free.Conclusions: Laparoscopic management of epiphrenic diverticula seems to be as safe and effective as the traditional approach, although a longer follow-up period is necessary to confirm the study results. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about the use of the term mesorectum.

Background: The purpose of our study was to evaluate the impact of laparoscopic adrenalectomy on patients with incidentalomas. We analyzed the results of a multi-centre trial that was performed to evaluate the effectiveness of imaging (computed tomography and magnetic resonance imaging) to obtain a correct preoperative diagnosis.Methods: We obtained our data from the results of a questionnaire that was distributed by mail or email in May 2005 to several surgical units operating in the Campania Region, Italy. Lap Club, a collaborative laparoscopic surgery study group founded in Naples in 1995, distributed the questionnaire. Thirteen centres participated in the audit. In all, we analyzed 255 adrenalectomies performed on 250 patients. We performed statistical analysis using SPSS software.Results: The distribution of pathologic findings demonstrates that the number of lesions caused by cancer discovered from a preoperative indication of incidentaloma has been even smaller (1/114, 0.8%) than the previous numbers reported in the literature. Moreover, whereas most patients with adrenal cancer had lesions larger than 6 cm (7/8, 87.5%), the majority of patients with adrenal metastases had lesions 6 cm or smaller (10/12, 83.3%). Different indications for adrenalectomy emerged on comparison of endocrine surgery units with general surgery units. This difference appears to be significant (p < 0.001), especially on evaluation of the number of nonfunctioning adenomas and the number of endocrine lesions that were observed and treated.Conclusion: Laparoscopy remains the gold standard method for adrenalectomy, but its availability must not obligate physicians to treat with surgery when an incidentaloma is detected through imaging. Adrenal malignancies when metastatic are often 6 cm or smaller. If they are single and they originated from a non-small lung cancer, they must be removed. The endocrine surgery unit remains the best setting to evaluate and treat adrenal gland surgical pathology. [ABSTRACT FROM AUTHOR]

A correction to the article "Laparoscopic Hand-Assisted Spleen Autotransplantation" published in the January 19, 2006 issue is presented.