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Chicago classification version 4.0 (CCv4.0) introduced stringent diagnostic criteria for oesophagogastric junction outflow obstruction (EGJOO), in order to increase the clinical relevance of the diagnosis, although this has not yet been demonstrated.To determine the prevalence of EGJOO using CCv4.0 criteria in patients with CCv3.0-based EGJOO, and to assess if provocative manoeuvres can predict a conclusive CCv4.0 diagnosis of EGJOO.Clinical presentation, high resolution manometry (HRM) with rapid drink challenge (RDC), and timed barium oesophagogram (TBE) data were extracted for patients diagnosed with EGJOO as per CCv3.0 between 2018 and 2020. Patients were then re-classified according to CCv4.0 criteria, using clinically relevant symptoms (dysphagia and/or chest pain), and abnormal barium emptying at 5 min on TBE. Receiver operating characteristic (ROC) analyses identified HRM predictors of EGJOO.Of 2010 HRM studies, 144 (7.2%) fulfilled CCv3.0 criteria for EGJOO (median age 61 years, 56.9% female). Upon applying CCv4.0 criteria, EGJOO prevalence decreased to 1.2%. On ROC analysis, integrated relaxation pressure during RDC (RDC-IRP) was a significant predictor of a conclusive EGJOO diagnosis by CCv4.0 criteria (area under the curve: 96.1%). The optimal RDC-IRP threshold of 16.7 mm Hg had 87% sensitivity, 97.1% specificity, 95.7% negative predictive value and 91.3% positive predictive value for a conclusive EGJOO diagnosis; lower thresholds (10 mmHg, 12 mmHg) had better sensitivity but lower specificity.CCv4.0 criteria reduced the prevalence of EGJOO by 80%, thereby refining the diagnosis and identifying clinically relevant outflow obstruction. Elevated RDC-IRP can predict conclusive EGJOO per CCv4.0.

Background: Ulcerative colitis may impair anorectal function, causing disabling symp-toms such as incontinence and/or increase in the stool frequency, urgency and tenesmus. Data on anorectal function in these patients evaluated by conventional anorectal manometry are conflicting. Objectives: The aim of this prospective study was to assess by means of high resolution anorectal manometry the anorectal function in patients with mild-to-moderate ulcerative colitis at presentation and after remission. Anorectal function of ulcerative colitis patients was compared to that observed in healthy volunteers. Methods: 20 patients with mild to moderate left-sided ulcerative colitis or proctitis and 20 healthy volunteers were prospectively enrolled. All ulcerative colitis patients underwent high resolution ano-rectal manometry before treatment and after clinical remission. Results: Ulcerative colitis patients showed similar values for anal sphincter function as healthy vol-unteers, whereas rectal threshold volume for the first sensation, desire to defecate, urgency to defecate and maximum discomfort were significantly lower than in healthy volunteers (p Conclusions: Ulcerative colitis patients show altered rectal function, with increased rectal sensitivity and lower compliance, compared to controls. This altered function is restored after successful treat-ment of the underlying inflammatory process. Finally high resolution anorectal manometry provides useful information on anorectal functionality and, in our opinion, should be preferred over conven-tional manometry.

Eosinophilic oesophagitis (EoE) may lead to severe complications if not promptly recognised.To assess the diagnostic delay in patients with EoE and to explore its risk factors.EoE patients followed-up at eight clinics were included via retrospective chart review. Diagnostic delay was estimated as the time lapse occurring between the appearance of the first likely symptoms indicative of EoE and the final diagnosis. Patient-dependent and physician-dependent diagnostic delays were assessed. Multivariable regression models were computed.261 patients with EoE (mean age 34±14 years; M:F ratio=3:1) were included. The median overall diagnostic delay was 36 months (IQR 12-88), while patient- and physician-dependent diagnostic delays were 18 months (IQR 5-49) and 6 months (IQR 1-24). Patient-dependent delay was greater compared to physician-dependent delay (95% CI 5.1-19.3, p0.001). A previous misdiagnosis was formulated in 109 cases (41.8%; gastro-oesophageal reflux disease in 67 patients, 25.7%). The variables significantly associated with greater overall diagnostic delay were being a non-smoker,1 episode of food impaction, previous endoscopy with no biopsies, regurgitation, and ≥2 assessing physicians. Being single was significantly associated with lower overall and patient-dependent diagnostic delay.EoE is burdened by substantial diagnostic delay, depending on both patient-related and physician-related factors.

Stapler-less laparoscopic sleeve gastrectomy (LSG) is emerging as a new potential affordable cost-effective alternative procedure. However, no pre-clinical data are currently available on human tissue. We aimed to evaluate whether traditionally suturing without the use of surgical stapling may produce a comparable bursting pressure on human gastric tissue. A prospective cohort of consecutive patients undergoing LSG was divided in two groups to compare a barbed extra-mucosal running suture (stapler-less) versus a standard stapler line. A burst pressure test was applied to the gastric specimen employing high-resolution manometric catheter. Type, location and features of the leak were described. We enrolled a total of 40 obese patients, 20 patients for each group. Median burst pressures of the stapler-less group resulted statistically significant increased (p p = N.S.), more often at the proximal stomach (p

The most recent iteration of the classifications for functional esophageal disorders, Rome IV, proposed relevant modifications of the previous definitions for Rome III. They specifically considered increased esophageal acid exposure as the marker of gastroesophageal reflux disease (GERD), including the remaining part of non-erosive reflux disease patients with normal acid in the group with functional alterations, considering both reflux hypersensitivity and functional heartburn. However, recent pathophysiological and therapeutic data suggest the need for a return to including reflux hypersensitivity in the GERD spectrum. Indeed, physiologic alterations in esophageal mucosal integrity and chemical clearance, the presence of microscopic esophagitis, and strict symptom-reflux association support the concept that reflux hypersensitivity pertains to GERD. Surgical anti-reflux therapy has resulted in positive outcomes, even in the long term, in patients with reflux hypersensitivity and not in those with functional heartburn. Moreover, clinical trials using neuromodulators have been scarce and provided conflicting results. As a result, the real progress of the Rome IV classifications is in dispute. This article aims to summarize the most recent knowledge of non-erosive reflux disease and reflux hypersensitivity to discuss the utility of Rome IV criteria in the identification and management of functional esophageal disorders.

Background. We aim to evaluate morphofunctional changes of the sphincter complex after GateKeeper (GK) and SphinKeeper (SK) procedures and correlate these with symptom improvement. Methods. Ten consecutive females undergoing SK implant were age-matched with a cohort of 10 females who previously underwent the GK procedure. Patients in the SK and GK groups underwent implantation of 10 and 6 prostheses, respectively. Muscle tension ( Tm), expressed in millinewtons per centimetre squared, mN (cm2)−1, was calculated using the equation Tm = P( r i)( tm)−1, where P is the average maximum squeeze pressure and r i and tm the inner radius and thickness of the external anal sphincter, respectively. The pre- and postimplant changes in Tm and Cleveland Clinic Fecal Incontinence Score (CCFIS) were tested by linear and Poisson regression models, respectively. Results. The CCFIS significantly improved in both groups at 12-month postimplantation. Although not reaching statistical significance, symptom improvement after SK was 33% above that observed after GK ( P = .088). Compared to the baseline, a significant increase in Tm was observed in both groups at 12 months (GK, 508.1 [478.8-568.0] vs 864.4 [827.0-885.8] mN (cm2)−1; SK, 528.0 [472.7-564.0] vs 858.6 [828.0-919.6] mN (cm2)−1, P = .005). Compared to the GK group, Tm was significantly higher in patients after SK implant (158.3 mN (cm2)−1 [95% confidence interval, 109.6-207.0]; P < .001), after controlling for baseline values, at 12-month postimplantation. Conclusions. GK and SK are safe and effective treatments for FI with good short-term clinical outcomes. Comparative analysis showed superiority of SK over GK in terms of gain in Tm, with borderline significantly better improvement in symptoms. Larger studies are needed to confirm these findings.

The use of one anastomosis gastric bypass (OAGB) is rapidly spreading. Concerns about biliary reflux and malabsorption with consequent nutritional deficits exist, so studies on biliopancreatic limb (BPL) adequate length in OAGB are required to balance excess weight loss in percentage (% EWL), resolution of comorbidities, and nutritional deficit. The purpose was to evaluate, at 2 years after OAGB, the effects of BPL length on weight loss, resolution of comorbidity, and nutritional deficiencies in patients. From January 2015 to January 2017, 180 patients were collected into three groups based BPL length: group A, 150 cm; group B, 180 cm; and group C, 200 cm. Aims were to compare %EWL, co-morbidity resolution rates, nutritional parameters, and morbidity/mortality in the three groups. The total number of patients was 180: 60 for each group. One hundred seventy-two (95%) patients attended the 1-year follow-up (group A = 58; group B = 58, group C = 56). One hundred fifty-seven (87%) patients attended the 2-year follow-up (group A = 52 (87%); group B = 53 (88%); group C = 52 (87%)). There was no statistically significant difference in %EWL, %TWL, T2DM, and hypertension resolution rates among the groups. About vitamin deficiency, differences were not statistically significant. Iron and ferritin deficiency rate were statistically significant only between A and C groups. According to our evidence, standardization of BPL length shorter than 200 cm is suggested, potentially minimizing malnutrition-related outcomes. Our study seems to show that a BPL of 150–180 cm is safe and effective in terms of EWL and comorbidity improvement with low malnutrition effects even in BMI > 50.

Background: A worrying increase of gastroesophageal reflux disease (GERD) and Barrett esophagus has been reported after sleeve gastrectomy (SG). Recent reports on combined fundoplication and SG seem to accomplish initial favorable results. However, no study included manometry or pH monitoring to evaluate the impact of fundoplication in SG on esophageal physiology. Method: In this study, 32 consecutive bariatric patients with GERD and/or esophagitis had high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) before and after laparoscopic sleeve gastrectomy associated to anterior fundoplication (D-SLEEVE). The following parameters were calculated at HRiM: lower esophageal sphincter pressure and relaxation, peristalsis, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH, symptom index association (SI), and symptom-association probability (SAP) were also analyzed. Results: At a median follow-up of 14months, HRiM showed an increased LES function, and MII-pH showed an excellent control of both acid exposure of the esophagus and number of reflux events. Bariatric outcomes (BMI and EWL%) were also comparable to regular SG (p = NS). Conclusion: D-SLEEVE is an effective restrictive procedure, which recreates a functional LES pressure able to control and/or prevent mild GERD at 1-year follow-up.

The clinical diagnosis of gastro-esophageal reflux disease (GERD) is based on the presence of typical esophageal troublesome symptoms. In clinical practice, heartburn relief following a proton pump inhibitor (PPI) trial or endoscopy can confirm a diagnosis of GERD. In cases of diagnostic uncertainty or before anti-reflux interventions, combined impedance-pH monitoring (MII-pH) provides a comprehensive assessment of both physical and chemical properties of the refluxate, allowing to achieve a conclusive diagnosis of GERD. Recently, the Lyon Consensus proposed the use of mean nocturnal baseline impedance (MNBI) and post-reflux swallow-induced peristaltic wave index (PSPW-I) as novel MII-pH metrics to support the diagnosis of GERD. The calculation of MNBI and PSPW-I currently needs to be performed manually, but artificial intelligence systems for the automated analysis of MII-pH tracings are being developed. Several studies demonstrated the increased diagnostic yield MNBI and PSPW-I for the categorization of patients with GERD at both on- and off-PPI MII-pH monitoring. Accordingly, we performed a narrative review on the clinical use and diagnostic yield of MNBI and PSPW-I when the diagnosis of GERD is uncertain. Based on currently available evidence, we strongly support the evaluation of PSPW-I and MNBI as part of the standard assessment of MII-pH tracings for the evaluation of GERD, especially in patients with endoscopy-negative heartburn.

Purpose: Bariatric surgery (BS) is considered the most efficient treatment for severe obesity. International guidelines recommend multidisciplinary approach to BS (general practitioners, endocrinologists, surgeons, psychologists, or psychiatrists), and access to BS should be the final part of a protocol of treatment of obesity. However, there are indications that general practitioners (GPs) are not fully aware of the possible benefits of BS, that specialty physicians are reluctant to refer their patients to surgeons, and that patients with obesity choose self-management of their own obesity, including internet-based choices. There are no data on the pathways chosen by physicians and patients to undergo BS in the real world in Italy. Methods: An exploratory exam was performed for 6 months in three pilot regions (Lombardy, Lazio, Campania) in twenty-three tertiary centers for the treatment of morbid obesity, to describe the real pathways to BS in Italy. Results: Charts of 2686 patients (788 men and 1895 women, 75.5% in the age range 30–59 years) were evaluated by physicians and surgeons of the participating centers. A chronic condition of obesity was evident for the majority of patients, as indicated by duration of obesity, by presence of several associated medical problems, and by frequency of previous dietary attempts to weight loss. The vast majority (75.8%) patients were self-presenting or referred by bariatric surgeons, 24.2% patients referred by GPs and other specialists. Self-presenting patients were younger, more educated, more professional, and more mobile than patients referred by other physicians. Patients above the age of 40 years or with a duration of obesity greater than 10 years had a higher prevalence of all associated medical problems. Conclusions: The majority of patients referred to a tertiary center for the treatment of morbid obesity have a valid indication for BS. Most patients self-refer to the centers, with a minority referred by a GP or by specialists. Self-presenting patients are younger, more educated, more professional, and more mobile than patients referred by other physicians. Older patients and with a longer duration of obesity are probably representative of the conservative approach to BS, often regarded as the last resort in an endless story. Graphical abstract: [Figure not available: see fulltext.]

A hierarchical approach for gastro-oesophageal reflux disease (GERD) diagnosis by impedance-pH monitoring was proposed by the Lyon Consensus, based on acid exposure time (AET) and supportive impedance metrics.To establish the clinical value of Lyon Consensus criteria in the work-up of patients with proton pump inhibitory (PPI)-refractory heartburn.Expert review of off-therapy impedance-pH tracings from unproven GERD patients with PPI-refractory heartburn prospectively evaluated at referral centers. Impedance metrics, namely total reflux episodes, postreflux swallow-induced peristaltic wave index, and mean nocturnal baseline impedance, were assessed. Expert review of on-therapy preoperative impedance-pH tracings from a separate cohort of surgically treated erosive/nonerosive GERD cases.Off-therapy, normal, inconclusive, and abnormal AET was found in 59%, 17%, and 23% of 317 cases. Supportive evidence of GERD was provided by abnormal impedance metrics in up to 22% and 62% of cases in the normal and inconclusive AET groups, respectively. Adding the cases with inconclusive AET and abnormal impedance metrics to the abnormal AET group, a significant increase in GERD evidence was observed (from 23% to 37% of cases, p 0.0002). At the on-therapy presurgical evaluation, abnormal/inconclusive AET and supraphysiological values of impedance metrics showed ongoing reflux in 21% and 90% of 96 cases, respectively (p 0.00001); a relationship between on-therapy ongoing reflux and PPI-refractory heartburn was confirmed by the favorable surgical outcome at 3-year follow-up, 88% of cases being in persistent off-PPI heartburn remission.Impedance-pH monitoring, off- and on-therapy, is of high clinical value in the work-up of patients with PPI-refractory heartburn.

OBJECTIVE: High-resolution manometry (HRM) is the current standard for characterization of esophageal body and esophagogastric junction (EGJ) function. We aimed to examine the prevalence of abnormal esophageal motor patterns in health, and to determine optimal thresholds for software metrics across HRM systems. DESIGN: Manometry studies from asymptomatic adults were solicited from motility centers worldwide, and were manually analyzed using integrated relaxation pressure (IRP), distal latency (DL), and distal contractile integral (DCI) in standardized fashion. Normative thresholds were assessed using fifth and/or 95th percentile values. Chicago Classification v3.0 criteria were applied to determine motor patterns across HRM systems, study positions (upright vs supine), ages, and genders. RESULTS: Of 469 unique HRM studies (median age 28.0, range 18-79 years). 74.6% had a normal HRM pattern; none had achalasia. Ineffective esophageal motility (IEM) was the most frequent motor pattern identified (15.1% overall), followed by EGJ outflow obstruction (5.3%). Proportions with IEM were lower using stringent criteria (10.0%), especially in supine studies (7.1%-8.5%). Other motor patterns were rare (0.2%-4.1% overall) and did not vary by age or gender. DL thresholds were close to current norms across HRM systems, while IRP thresholds varied by HRM system and study position. Both fifth and 95th percentile DCI values were lower than current thresholds, both in upright and supine positions. CONCLUSIONS: Motor abnormalities are infrequent in healthy individuals and consist mainly of IEM, proportions of which are lower when using stringent criteria in the supine position. Thresholds for HRM metrics vary by HRM system and study position.

Sacrococcigeal pilonidalis disease (SPD) recurrence is a major factor influencing surgical outcomes. Several different surgical treatments have been reported, however, there is a lack of long-term data on reoperation. Aim of this study was to analyze outcomes of a single center adopting a standardized off-midline asymmetric procedure (D-shape). Analytic longitudinal assessment of 83 patients (median age 35years, range 23–59years) with recurrent SPD that completed the 5-year study design following D-shape reoperation. Among a cohort of 607 patients, we enrolled 83 recurrent SPD. After D-shape reoperation, second recurrence rate was 9.6% (8/83). Second recurrence rate was not statistically significantly different among patients undergone D-shape as first surgery compared to patients of symmetric excision group (11.8% vs. 7.4%, p = 0.57). Similarly, there was no statistical difference among patients who underwent D-shape as first surgery compared to patients who underwent symmetric excision elsewhere (11.8% vs. 9.1%, p =.75). D-shape is a safe and effective when adopted as revisional surgery at a long-term follow-up. Comparative evaluation is warranted to establish the potential superiority over different surgical surgery in case of recurrence.

Background Proton pump inhibitors (PPIs) are effective therapies for eosinophilic oesophagitis (EoE), but the mechanism of action is uncertain. At on-PPI impedance-pH monitoring, improvement in oesophageal chemical clearance assessed with post-reflux swallow-induced peristaltic wave (PSPW) index characterises PPI-responsive EoE and reflux disease. Off-PPI, higher efficacy of the oesophago-salivary reflex as measured with PSPW-associated pH increments characterises PPI-responsive reflux disease and could typify PPI-responsive EoE as well. Aim To establish whether PPI responsiveness in EoE is associated with higher efficacy of the oesophago-salivary reflex. Methods Prospective multicentre study in EoE patients investigated with impedance-pH monitoring before starting PPI. Impedance-pH parameters in PPI-responsive and PPI-refractory cases were compared. PPI response was defined histologically. Results Considerable PSPW-associated pH increments (median 1.4 units) were found in 80 EoE patients, with significantly higher values in 48 PPI-responsive than in 32 PPI-refractory cases (1.8 vs 1.0, P = 0.02). Mucosal integrity, as measured with mean nocturnal baseline impedance was more severely impaired in the distal oesophagus in PPI-responsive cases, the gradient between mid and distal oesophagus being significantly higher (546 vs 137 Ω, P = 0.0002). PSPW-associated pH increments and the baseline impedance gradient between mid and distal oesophagus were independently associated with histological response at multivariable logistic regression; at receiver operating characteristic analysis, the area under the curve of PPI response calculated by combined assessment was 0.88. Conclusion Higher efficacy of oesophago-salivary reflex and more severe mucosal damage in the distal oesophagus are associated with EoE response to PPIs, implying an anti-reflux mechanism of action as most likely.

BACKGROUND Following acid perfusion, esophageal pH is restored by swallowed bicarbonate-containing saliva secreted in response to a vagal esophago-salivary reflex. At impedance-pH monitoring, the post-reflux swallow-induced peristaltic wave (PSPW) index puts into relationship timely post-reflux swallows with the number of reflux events: Low values typify reflux-related heartburn (RRH) and lack of on-therapy improvement characterizes proton pump inhibitor (PPI) failure. Considerable esophageal pH increments associated with PSPWs could demonstrate the occurrence of esophago-salivary reflex in clinical setting, while its relevance could be shown by lower esophageal pH increments in PPI-refractory RRH. METHODS Prospective multicenter study in patients with PPI-refractory or PPI-responsive RRH evaluated with off-PPI impedance-pH monitoring. Increments in pH associated with PSPWs were measured and the mean calculated to obtain the PSPW-associated ∆pH. KEY RESULTS The mean PSPW-associated ∆pH in 294 RRH patients was 1.2 ± 0.7 and was lower in 137 PPI-refractory (1.0 ± 0.6) than in 157 PPI-responsive (1.5 ± 0.6) cases (p

After the initial widespread diffusion, laparoscopic adjustable gastric banding (LAGB) has been progressively abandoned and laparoscopic sleeve gastrectomy (LSG) has become the worldwide most adopted procedure. Nevertheless, recent reports raised concerns about the long-term weight regain after different bariatric techniques. Considering the large LAGB series recorded in our multicentric bariatric database, we analysed the anthropometric and surgical outcomes of obese patients underwent LAGB at a long-term follow-up, focusing on LAGB management. Between January 2008 to January 2018, demographics, anthropometric and post-operative data of obese patients undergone LAGB were retrospectively evaluated. To compare the postoperative outcomes, the cohort was divided in two groups according to the quantity of band filling (QBF): low band filling group (Group 1) with at most 3 ml of QBF, and patients in the high band filling group (Group 2) with at least 4 ml. 699 obese patients were considered in the analysis (351 in Group 1 and 348 in Group 2). Patients in Group 1 resulted significantly associated (p p

Background Esophagogastric junction contractile integral (EGJ-CI) and EGJ morphology are high-resolution manometry (HRM) metrics that assess EGJ barrier function. Normative data standardized across world regions and HRM manufacturers are limited. Methods Our aim was to determine normative EGJ metrics in a large international cohort of healthy volunteers undergoing HRM (Medtronic, Laborie, and Diversatek software) acquired from 16 countries in four world regions. EGJ-CI was calculated by the same two investigators using a distal contractile integral-like measurement across the EGJ for three respiratory cycles and corrected for respiration (mm Hg cm), using manufacturer-specific software tools. EGJ morphology was designated according to Chicago Classification v3.0. Median EGJ-CI values were calculated across age, genders, HRM systems, and regions. Results Of 484 studies (28.0 years, 56.2% F, 60.7% Medtronic studies, 26.0% Laborie, and 13.2% Diversatek), EGJ morphology was type 1 in 97.1%. Median EGJ-CI was similar between Medtronic (37.0 mm Hg cm, IQR 23.6-53.7 mm Hg cm) and Diversatek (34.9 mm Hg cm, IQR 22.1-56.1 mm Hg cm, P = 0.87), but was significantly higher using Laborie equipment (56.5 mm Hg cm, IQR 35.0-75.3 mm Hg cm, P < 0.001). 5(th) percentile EGJ-CI values ranged from 6.9 to 12.1 mm Hg cm. EGJ-CI values were consistent across world regions, but different between manufacturers even within the same world region (P = 0.3) but higher in women (P < 0.001). Conclusions EGJ morphology is predominantly type 1 in healthy adults. EGJ-CI varies widely in health, with significant gender influence, but is consistent within each HRM system. Manufacturer-specific normative values should be utilized for clinical HRM interpretation.

Purpose: Hemorrhoidal disease (HD) is a widespread condition severely influencing patients' quality of life. Recently, the large diffusion of stapled hemorrhoidopexy has revealed a new unexpected pathological entity: the asymmetric mucosal prolapse. We aimed to assess the outcomes of the sectorial longitudinal augmented prolapsectomy (SLAP), a technique dedicated to asymmetric prolapse, in terms of HD symptoms, prolapse recurrence, and rectal stenosis. Methods: Patients affected by III-IV-degree symptomatic HD with asymmetric mucosal prolapse undergone SLAP of 1 or 2 hemorrhoidal columns (SLAP1 or SLAP2) were retrospectively assessed. The severity of hemorrhoid symptoms and fecal continence status were evaluated before and after surgery. Mean outcome was evaluation of medium-long-term outcomes as the occurrence of recurrence and anal or rectal stenosis. Secondary outcome was the evaluation of postoperative bleeding, reoperation rate, length of hospitalization, fecal urgency, and time to return to work. Results: We enrolled 433 patients (277 SLAP1 and 156 SLAP2). Hemorrhoidal symptoms recurrence was reported in 9 patients undergone SLAP1 and 4 patients undergone SLAP2, while prolapse recurrence occurred, respectively, in 4 and 2 patients. No major intraoperative complications occurred. An emergency reintervention for postoperative bleeding occurred in 13 cases undergone SLAP1 and in 5 patients treated with SLAP2. Fecal incontinence occurred in 8 and 4 cases of patients treated with SLAP1 and SLAP2. Conclusions: The combination of a simple hemorrhoidectomy to a mucosal rectal prolapsectomy should be part of every coloproctologist background. Promising and satisfying results can be achieved using SLAP for HD associated with asymmetric prolapse. Keywords: asymmetric prolapse; hemorrhoidal disease; hemorrhoidectomy; hemorrhoidopexy; muco-prolapsectomy.

Background: Wire-guided localization is the gold-standard for the detection of non-palpable breast lesions, although with acknowledged limitations. The aim of this study was to evaluate the combined use of LOCalizerr™ (Hologic, Santa Carla, CA, USA), and intraoperative ultrasound (IOUS) for localization and surgery of non-palpable breast cancer. Patients and Methods: Patients with non-palpable breast lesions underwent localization procedure with LOCalizer™ and IOUS. After the placement of the marker, eight measures were made to guide the excision. LOCalizerr™ Pencil and IOUS were performed to obtain the distance between the dissection plane and the margins of lesions. Results: The procedure was feasible in the five enrolled patients and associated with clear oncological margins in all cases. Moreover, a high satisfaction according to Likert scale for surgeons, radiologists and patients, performing limited and tailored resections, was reported. Conclusion: Combining LOCalizerr™ and IOUS is an effective method for locating non-palpable breast cancer, guarantying excellent oncological and cosmetic results.

Hypercontractile esophagus (HE) is a heterogeneous major motility disorder diagnosed when ≥20% hypercontractile peristaltic sequences (distal contractile integral >8,000 mm Hg*s*cm) are present within the context of normal lower esophageal sphincter (LES) relaxation (integrated relaxation pressure < upper limit of normal) on esophageal high-resolution manometry (HRM). HE can manifest with dysphagia and chest pain, with unclear mechanisms of symptom generation. The pathophysiology of HE may entail an excessive cholinergic drive with temporal asynchrony of circular and longitudinal muscle contractions; provocative testing during HRM has also demonstrated abnormal inhibition. Hypercontractility can be limited to the esophageal body or can include the LES; rarely, the process is limited to the LES. Hypercontractility can sometimes be associated with esophagogastric junction (EGJ) outflow obstruction and increased muscle thickness. Provocative tests during HRM can increase detection of HE, reproduce symptoms, and predict delayed esophageal emptying. Regarding therapy, an empiric trial of a proton pump inhibitor, should be first considered, given the overlap with gastroesophageal reflux disease. Calcium channel blockers, nitrates, and phosphodiesterase inhibitors have been used to reduce contraction vigor but with suboptimal symptomatic response. Endoscopic treatment with botulinum toxin injection or pneumatic dilation is associated with variable response. Per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy in relieving dysphagia, but available data are scant. The presence of EGJ outflow obstruction in HE discriminates a subset of patients who may benefit from endoscopic treatment targeting the EGJ.

BACKGROUND Esophageal chemical clearance has been evaluated with the post-reflux swallow-induced peristaltic wave (PSPW) index. The factors triggering PSPW in Gastro-esophageal reflux disease (GERD) have not yet been investigated. This multicenter study was aimed at evaluating the characteristics of reflux episodes associated with PSPW occurrence in patients with typical GERD symptoms. METHODS Impedance-pH tracings from patients with typical reflux symptoms were analyzed. Sixteen healthy subjects were included for comparison. Multivariate analysis was performed to determine predictors of PSPW events. KEY RESULTS Impedance-pH tracings from 60 patients and 16 healthy subjects were evaluated. A total of 3454 refluxes were recorded. In patients, comparing reflux episodes followed with those not followed by a PSPW, significantly higher proportions of acid (79% vs. 74%, p: 0.02), mixed (47% vs. 32%, p: 0.0001) and proximal refluxes (34% vs. 20%, p: 0.0001) were observed. A multivariate analysis, acid (OR: 1.3, 95% CI: 1.05-1.6), mixed (OR: 2, 95% CI: 1.6-2.3), and proximal (OR: 2.1, 95% CI: 1.7-2.5) refluxes were independently associated with PSPWs. Reflux episodes followed by a PSPW were characterized by a significantly higher bolus clearing time [(mean ± SD) 41 s ± 6 s vs. 30 s ± 5 s, p

ObjectiveTo validate Lyon Consensus criteria for diagnosing gastro-oesophageal reflux disease (GORD) by reflux monitoring.DesignManual review of impedance-pH tracings from patients with proton pump inhibitor (PPI)-dependent heartburn, evaluated off PPI. Acid exposure time (AET) thresholds defined by the Lyon Consensus and impedance parameters were investigated, namely, total refluxes (TRs), postreflux swallow-induced peristaltic wave (PSPW) index and mean nocturnal baseline impedance (MNBI).ResultsThe study included 488 patients, 178 (36%) with normal (6%) AET, alongside with 70 healthy controls. At receiver operating characteristic analysis, area under curve was 0.89, 0.95 and 0.89 for TRs, PSPW index and MNBI, respectively, and threshold values were 40, 50% and 2000 Ω; the 4% physiological AET threshold defined by the Lyon Consensus showed 100% specificity but 63% sensitivity. The thresholds defined for impedance parameters were validated against AET by means of ordered logistic regression, being in concordance with the 4% AET threshold (OR 2.5 for TRs, 18.9 for PSPW index and 5.7 for MNBI). TRs positivity and concordant PSPW index/MNBI positivity were found in 80%–90% of patients in the abnormal AET group, in 73%–74% of cases in the inconclusive AET group and in 28%–40% of cases in the group with normal AET.ConclusionsOur results show the overall validity of the Lyon Consensus approach to GORD diagnosis. Adding evaluation of impedance parameters, namely, TRs, PSPW index and MNBI to AET appraisal, substantially improves the diagnostic yield of reflux monitoring.

Eosinophilic esophagitis (EoE) is a clinicopathological disease defined by symptoms of esophageal dysfunction and 215 eosinophils/HPF after excluding other causes of esophageal eosinophilia. Increasing attention has been paid by clinicians and researchers after its first description in 1978. Many consensuses and guidelines have been issued over the years, as gastroenterologists did not reach an agreement on EoE definition, especially regarding the controversial responsiveness to proton pump inhibitor (PPI) therapy. Of note, recent evidence suggests that the incidence and prevalence of EoE have been increasing through the years: many risk factors have been advocated as possible reasons for this, although further studies are needed. In this brief review, we will first cover the history of EoE in the literature, with a focus on its varying definition throughout the years. Then, we will discuss EoE epidemiology, emphasizing potential risk factors explaining its increasing incidence and prevalence. Last, we will deal with the quality of life of adult and pediatric patients with EoE. (Cite this article as: Frazzoni L, Tolone S. Eosinophilic esophagitis: definition, epidemiology and quality of life. Minerva Gastroenterol 2022;68:60-8. DOI: 10.23736/S2724-5985.20.02798-1)

Introduction Considering the multitude of bariatric procedures performed all over the world, the necessity of revisional surgery increased accordingly. Several authors argued that with the great diffusion of sleeve gastrectomy (SG), the number of patients who experienced a weight regain at long follow-up was congruous and physiologic, even if not negligible. Recent studies showed that one anastomosis gastric bypass (OAGB) was an effective and safe option also as redo surgery. The aim of the study was to evaluate effectiveness of OAGB as redo surgery after SG in term of anthropometric features and remission of comorbidities. Methods Bariatric patients experiencing weight regain and insufficient weight loss after SG and undergoing OAGB as redo surgery were retrospectively analyzed. During post-OAGB outpatient visit weight, %EWL, BMI, comorbidities, and vitamin deficiencies were evaluated. A further visit was scheduled for the evaluation of postoperative esophagitis/gastritis at upper endoscopy. Results Fifty-nine (Reviewer #3-1) patients underwent OAGB as redo-surgery consequently to the worsening of the bariatric outcomes at 29.42 +/- 7.29 months from SG (mean weight, BMI and %EWL were 120.89 +/- 16.79 kg, 43 +/- 4.39 and 19.84 +/- 30.29, respectively). Conversely, at a mean follow-up of 34.32 +/- 1.71 months (Reviewer #3-3) after OAGB, no weight regain or insufficient weight loss cases were recorded (mean weight 71.25 +/- 10.22 kg, mean BMI 24.46 +/- 2.06 kg/m2, mean %EWL 69.49 +/- 14.4, p < 0.0001) (Reviewer #3-2). Conclusion OAGB is a safe and effective bariatric procedure in terms of morbidity, mortality, and %EWL also as revision surgery after SG. Further larger studies are needed to address this issue.

Introduction: Bariatric surgery leads to rapid weight loss, a well-known risk factor for gallstone formation. Postoperative biliary complication rate requiring cholecystectomy is between 0.9 and 7.5% after laparoscopic sleeve gastrectomy and between 6 and 50% after laparoscopic gastric bypass. Several authors recommended ursodeoxycholic acid (UDCA) administration to reduce gallstone formation after diet-induced weight reduction. The aim of this randomized monocentric study is to evaluate gallstone incidence after prophylactic administration of UDCA in patients undergoing one anastomosis gastric bypass (OAGB). Methods: Patients undergoing OAGB were prospectively randomized into 2 groups: the UDCA group receiving oral UDCA 600mg/days for 6months in the immediate postoperative days, and the control group not administered with UDCA. Each group included 95 patients. Abdominal ultrasound, clinical evaluation, and quality of life scoring with Gastrointestinal Quality of Life Index (GIQLI) were performed postoperatively in all patients at 3, 6, and 12months. Results: At 12months of postoperative follow-up, 4 (4.2%) and 24 patients (25.2%) showed gallstones in the UDCA group and control group, respectively (p < 0.05). Among those who developed gallstones, 8 (28.6%) cases were symptomatic whereas 20 (71.4%) did not show any symptom. No statistically significant difference in GIQLI score between the two groups was found. Conclusion: OAGB, as other malabsorbent procedures, appears to have higher rate of cholelithiasis than purely restrictive procedures. In our prospective randomized controlled study, a regular postoperative UDCA intake during the first 6months seems to significantly reduce cholelithiasis incidence after OAGB, with no case of intolerance reported. Further studies are needed to assess this issue.

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

Introduction: The one anastomosis gastric bypass (OAGB) is a widely diffused surgical procedure for morbid obesity. Several studies considered OAGB at risk for biliary reflux and anastomotic ulcers. The aim of the study was to evaluate gastro-esophageal reflux disease (GERD) and esophagitis/gastritis rate after OAGB diagnosed by upper endoscopy (UE), comparing the results with GERD-Health-Related Quality of Life (HRQL) score. Methods: From July 2014 to February 2019, patients underwent OAGB with at least 12-month follow-up were retrospectively evaluated. Clinical evaluation was associated with GERD-HRQL scoring. UE with a mucosal biopsy was also performed. A comparison among clinical scores and endoscopic findings was performed. Results: Two hundred forty-one patients were analyzed in the study. Anthropometric features (BMI, %Excess weight loss, %Total weight loss) were significantly improved. Only 30% of patients with GERD-HQRL>30 showed esophagitis at UE: 11/181 (6.1%) showed grade A erosive esophagitis, 2/181 (1.1%) grade B esophagitis, whereas no patient resulted in grade C/D. Fifty-two patients (28.7%) showed endoscopic remnant gastritis of at least grade 1, with histological gastritis of at least mild grade in 70/181 patients (38.7%). Conclusion: OAGB is a feasible and effective procedure in terms of weight reduction and comorbidities control, but controversies remain about the long-term onset of GERD and bile reflux. The incidence of esophagitis was increased after OAGB. However, the severity and incidence were lower compared to sleeve gastrectomy. Conversely, the incidence of gastritis, ileo-gastric anastomotic inflammation, and HP positivity were not negligible, suggesting the potential benefits of endoscopic surveillance after OAGB.

The pelvic floor is a complex anatomical entity and its neuromuscular assessment is evaluated through debated neurophysiological tests. An innovative approach is the study of pelvic floor through dynamic transperineal ultrasound (DTU). The aim of this study is to evaluate DTU sensitivity in recognizing patients with fecal incontinence and to evaluate its concordance with the results of the motor latency studied via pudendal nerve terminal motor latency (PNTML). Female patients affected by FI addressed to our center of coloproctology were prospectively assessed. After a coloproctological evaluation, comprising the PNTML assessment to identify pudendal neuropathy, patients were addressed to DTU to determine anterior and posterior displacement of puborectalis muscle by a blinded coloproctologist. In order to compare the data, a cohort of female healthy volunteers was enrolled. Sixty-eight subjects (34 patients and 34 healthy volunteers) were enrolled. The sensitivities of anterior displacement, posterior displacement and either anterior or posterior displacement in determining the fecal incontinence were 82%, 67% and 91%, respectively. A further high correlation of either anterior or posterior displacement with PTNML was also noted (88%). DTU is an indirect, painless and reproducible method for the identification of the pelvic floor neuromuscular integrity. Its findings seem to highly correlate with FI symptoms and with PNTML results. In the near future, after larger comparative studies, DTU would be considered a potential reliable non-invasive and feasible indirect procedure in the identification of fecal incontinence by pudendal neuropathy. Trial registration number is NCT03933683.

Introduction: Gastro-esophageal reflux disease (GERD) is a highly prevalent, chronic, relapsing disorder, whose knowledge has increased in last years thanks to the advent of new sophisticated techniques, such as 24-h impedance-pH monitoring and high-resolution manometry, for the study of esophageal functions. Areas covered: This review provides an overview of our advancements in understanding the complex pathophysiology, improving the diagnosis and defining the modern pharmacological therapeutic approach to GERD. Expert opinion: The growing clinical application of impedance-pH testing has allowed us to know the diversity of patients with non-erosive reflux disease (NERD), who nowadays represent about 70% of the whole population with reflux symptoms. We have realized that NERD has to be considered as an umbrella term covering various subgroups with different pathophysiologies. The development of new impedance metrics, in particular mean nocturnal baseline impedance, seems to be promising in the improvement of the diagnostic process of this disease. There are no particularly innovative features in the pharmacological therapy of GERD, unless the interest toward drugsis able to increase the defense properties of esophageal mucosa and/or its protection. These compounds can be of help in combination with proton pump inhibitors in NERD patients with partial response to antisecretory drugs alone.

Laparoscopic sleeve gastrectomy (LSG) is a safe and effective bariatric procedure in terms of excess weight loss. Nevertheless, controversies still exist on several technical and operative aspects of LSG. The aim of this study is to evaluate variations in anthropometric features in subjects with a LSG gastric resection starting from 2 cm or 6 cm from the pylorus. Secondary aim was the evaluation of differences in morbidity, food tolerance, and GERD incidence studied with upper endoscopy (UE) and GERD Health-Related Quality-of-Life score. Patients were prospectively randomized into 2 groups: Group A (at 2 cm proximally to the pylorus) and Group B (at 6 cm proximally to the pylorus). All patients were followed-up at 3, 6, 12, and 24 months. UE was performed in all patients at 12 or 24 months. One hundred and fifty met the inclusion criteria and were enrolled in the study. The anthropometric features (BMI, %EWL, %TWL) resulted statistically different in the first 12 months (24.2 ± 3.4 vs 27.5 ± 4.3, 63.7 ± 14.1 vs 59.6 ± 12.5 and 42.9 ± 7.4 vs 38.2 ± 6.2), in favor of group A. At 24 months the differences disappeared (25.2 ± 4.4 vs 26.2 ± 3.3, 62.8 ± 13.1 vs 61.6 ± 10.5 and 41.9 ± 7.4 vs 40.2 ± 6.2). An increased GERD was found in both groups postoperatively with a higher incidence in group A at 6-month follow-up. Performing the LSG with a radical antrectomy could improve weight loss at 12-month follow-up but expose to lower food tolerance and higher transitory GERD. The differences seem to be reduced to a 24-month.

Pelvic floor rehabilitation aims to address perineal functional and anatomic alterations as well as thoraco-abdominal mechanic dysfunctions leading to procto-urologic diseases like constipation, fecal and urinary incontinence, and pelvic pain. They require a multidimensional approach, with a significant impact on patients quality of life. An exhaustive clinical and instrumental protocol to assess defecation disorders should include clinical and instrumental evaluation as well as several clinical/physiatric parameters. All these parameters must be considered in order to recognize and define any potential factor playing a role in the functional aspects of incontinence, constipation and pelvic pain. After such evaluation, having precisely identified any thoraco-abdomino-perineal anatomic and functional alterations, a pelvi-perineal rehabilitation program can be carried out to correct the abovementioned alterations and to obtain clinical improvement. The success of the rehabilitative process is linked to several factors such as a careful evaluation of the patient, aimed to select the most appropriate and specific targeted rehabilitative therapy, the therapist’s scrupulous hard work, especially as regards the patient’s emotional and psychic state, and finally the patient’s compliance in undertaking the therapy itself, especially at home. These factors may deeply influence the overall outcomes of the rehabilitative therapies, ranging from “real” success to illusion “myth”. RESUMO A reabilitação do assoalho pélvico visa abordar alterações funcionais e anatômicas perineais, bem como disfunções mecânicas torácicas-abdominais que levam a doenças procto-urológicas como prisão de ventre, incontinência fecal e urinária e dor pélvica. Requerem uma abordagem multidimensional, com impacto significativo na qualidade de vida dos pacientes. Um protocolo clínico e instrumental exaustivo para avaliar os transtornos de defecação deve incluir avaliação clínica e instrumental, bem como diversos parâmetros clínicos/fisiátricos. Todos esses parâmetros devem ser considerados para reconhecer e definir qualquer fator potencial desempenhando um papel nos aspectos funcionais da incontinência, prisão de ventre e dor pélvica. Após tal avaliação, tendo identificado com precisão quaisquer alterações anatômicas e funcionais tóraco-abdomino-perineais, um programa de reabilitação pelvi-perineal pode ser realizado para corrigir as alterações acima mencionadas e obter melhora clínica. O sucesso do processo de reabilitação está ligado a diversos fatores, como uma avaliação cuidadosa do paciente, visando selecionar a terapia de reabilitação direcionada mais adequada e específica, além do trabalho árduo e escrupuloso do terapeuta, especialmente no que diz respeito ao estado emocional e psíquico do paciente e, finalmente, a conformidade do paciente em realizar a terapia em si, especialmente em casa. Esses fatores podem influenciar profundamente os resultados globais das terapias de reabilitação, que vão desde o sucesso “real” até o “mito” ilusório.

Background: Hiatal hernia (HH) is common in obese patients undergoing bariatric surgery. Preoperative traditional techniques such as upper gastrointestinal endoscopy (UGIE) or barium swallow/esophagram do not always correlate with intraoperative findings. High-resolution manometry (HRM) has shown a higher sensitivity and specificity than traditional techniques in non-obese patients in the HH diagnosis, whereas there is a lack of data in the morbidly obese population. We aimed to prospectively assess the diagnostic accuracy of HRM in HH detection, in comparison with barium swallow and UGIE, assuming intraoperative diagnosis as a standard of reference. Methods: Forty-one consecutive morbidly obese patients prospectively recruited from a tertiary-care referral hospital devoted to bariatric and metabolic surgery underwent a preoperative evaluation including standardized GERD questionnaires, barium swallow, UGIE, and HRM. The surgical procedures were performed by a single surgeon who was blinded to the results of other investigations. Results: HH was intraoperatively diagnosed in 11/41 patients (26.8%). In 10/11 patients, the preoperative HRM showed an esophagogastric junction suggestive of HH. When compared to intraoperative evaluation, the sensitivity of the HRM was 90.9% and the specificity 63.3%, with a positive predictive value of 47.6% and a negative predictive value of 95.0%. HRM showed a higher sensitivity and specificity compared to barium swallow and UGIE. Conclusions: HRM has a high accuracy of HH detection in morbidly obese patients assuming an intraoperative diagnosis as reference standard. It could therefore be a very useful tool in the preoperative work-up of obese patients undergoing bariatric surgery.

Introduction: Bariatric surgery is increasingly performed. Since there are numerous surgical techniques, the effects of these on the esophageal function are still poorly understood. We aimed at assessing the effect of different techniques on esophagogastric junction (EGJ), esophageal peristalsis and reflux exposure using high-resolution manometry (HRM), and impedance-pH monitoring (MII-pH). Methods: All obese patients underwent symptomatic questionnaires, endoscopy, HRM, and MII-pH before and 1year after surgery. Esophageal function and EGJ were classified according to Chicago Classification V. 3.0. Intragastric pressure (IGP) and gastroesophageal pressure gradient (GEPG) were assessed. Total acid exposure time (AET %), total number of refluxes, and symptom association probability (SAP) were assessed. A group of healthy volunteers (HVs) served as control. Results: One hundred and twelve obese subjects and 15 HVs (normal weight) were studied. Thirteen underwent endoscopic balloon placement (BIB), 12 gastric banding (GB), 26 sleeve gastrectomy (SG), 18 Roux-en-Y gastric bypass (RYGB), 15 mini-gastric bypass (MGB), 16 biliointestinal bypass (BIBP), and 12 biliopancreatic diversion (BPD). IGP and GEPG significantly decreased after RYGP, BPD, and BPBP, whereas they significantly increased after GB and SG. Post-operative greater AET (p < 0.05) and increased total number of reflux (p < 0.001) were present after GB and SG. RYGB and MGB showed a significant decrease in AET (p < 0.05) and total number of reflux (p < 0.001). Conclusions: HRM verified that different bariatric techniques produced different modification of IGP and GEPG, leading to different reflux exposure. Only GB and SG can negatively impact on esophageal function and reflux exposure.

Background: Mean nocturnal baseline impedance (MNBI) and postreflux swallow-induced peristaltic wave (PSPW) index are novel impedance-based markers of reflux, but the effect of bile reflux on these metrics is unknown. The aim of this study was to evaluate bile reflux, MNBI, and PSPW index in patients with endoscopy-negative GERD partially responsive to PPI therapy. Methods: All patients underwent off-PPI endoscopy, esophageal manometry, multichannel intraluminal impedance pH (MII-pH), and bile reflux monitoring. Abnormal esophageal acid exposure time (AET) was required for inclusion. Symptom intensity (using 10-cm visual analog scales), and conventional and novel MII-pH metrics were compared between patients with and without abnormal bile reflux. Key Results: We evaluated 42 NERD patients (29 males, mean age: 53.4±13.years), mean AET 6.1±2%, of which 21 had abnormal bile reflux (Group A, 10.2±4.9%), and 21 had normal bile reflux (Group B, 0.4±0.1%, P&nbsp

Backgrounds. One of the major complications after laparoscopic sleeve gastrectomy (LSG) is represented by leaks along the staple line. Several reinforcement techniques have been proposed, but scarce data about the real strengthening offered are present. Thus, we aimed to evaluate if different reinforcements produced different bursting pressures after LSG, and then to verify if the clinical application of the stronger reinforcement produced a reduction in leakage rate. Methods. We prospectively enrolled all consecutive obese patients that underwent LSG. We tested 3 different types of staple lines, as follows: group 1, no reinforcement; group 2, bioabsorbable buttress reinforcement; group 3, invaginating overrunning barbed suture. A burst pressure test was applied to the gastric specimen by means of high-resolution manometric catheter. After burst pressure tests, a subsequent consecutive series of patients were treated with the most effective reinforcement, and rate of leaks was recorded. Results. We enrolled in total 110 obese patients; 20 patients for each group of staple line reinforcement and then other 50 consecutive patients underwent LSG with the higher burst pressure staple line reinforcement. Median burst pressures were similar in group 1 and group 2; group 3 showed a statistically significant pressure increase ( P < .0001) than group 1 and group 2, with a 5.2-fold value. Other consecutive 50 obese patients underwent LSG with overrunning reinforcement. In none of them a leak was detected. Conclusions. Reinforcement of the SG staple line, with overrunning suture, seems to drastically increase bursting pressures in an ex vivo model and it is promising when reproduced in vivo.

Patients with esophageal symptoms potentially associated with gastroesophageal reflux disease such as heartburn, regurgitation, chest pain, or cough represent one of the most frequent reasons for referral to gastroenterological evaluation. The utility of esophageal reflux monitoring in clinical practice is: (1) to accurately define reflux burden, (2) to segregate patients according to reflux monitoring results as true GERD, reflux hypersensitivity and functional heartburn, and (3) to establish a treatment plan. With this in mind, in the last decade, investigations and technical advances, with the introduction of impedance-pH monitoring and wireless pH capsule, have enhanced our understanding and management of GERD. The following recommendations were discussed and approved after a comprehensive review of the medical literature pertaining to reflux testing techniques and their recent application. This review created under the auspices of the Società Italiana di Gastroenterologia ed Endoscopia Digestiva (SIGE), Società Italiana di Neuro-Gastro-Enterologia e Motilità (SINGEM) and Associazione Italiana Gastroenterologi ed Endoscopisti Digestivi Ospedalieri (AIGO) is intended to help clinicians in applying reflux studies in the most fruitful manner within the context of their patients with esophageal symptoms.

Barrett's esophagus (BE) is the only known precursor of esophageal adenocarcinoma, one of the few cancers with increasing incidence in developed countries. The pathogenesis of BE is unclear with regard to either the cellular origin of this metaplastic epithelium or the manner in which malignant transformation occurs, although recent data indicate a possible junctional origin of stem cells for BE. Treatment of BE may be achieved using endoscopic eradication therapy; however, there is a lack of discriminatory tools to identify individuals at sufficient risk for cancer development in whom intervention is warranted. Reduction in gastroesophageal reflux of gastric contents including acid is mandatory to achieve remission from BE after endoscopic ablation, and can be achieved using medical or nonmedical interventions. Research topics of greatest interest include the mechanism of BE development and transformation to cancer, risk stratification methods to identify individuals who may benefit from ablation of BE, optimization of eradication therapy, and surveillance methods to ensure that remission is maintained after eradication is achieved.

Undifferentiated connective tissue disease at risk for systemic sclerosis (UCTD-risk-SSc), otherwise referred to as very early-early SSc, is a condition characterized by Raynaud's phenomenon with serum SSc marker autoantibodies and/or typical capillaroscopic findings and unsatisfying classification criteria for the disease. The aim of the present study was to assess the prevalence of right (RV) or left ventricular (LV) systolic and/or diastolic dysfunction by standard echocardiography and tissue Doppler imaging (TDI). Thirty patients with UCTD-risk-SSc (28 female, mean age 47 ± 13 years, range 21-70) and 30 age- and sex-matched controls underwent cardiac assessment by standard echocardiography and TDI. UCTD-risk-SSc patients and controls did not show any difference at standard echocardiography. Despite results falling within the respective normal ranges, TDI pointed out a mild impairment of LV and RV diastolic (E m 15 ± 4 vs. 19 ± 5, p = 0.0004; E/E m 6.1 ± 1.7 vs. 4.8 ± 1.2, p = 0.001; E t 14 ± 3 vs. 16 ± 2, p = 0.02; E t/A t 0.9 ± 0.4 vs. 1.3 ± 0.3, p = 0.002; E/E t 3.5 ± 1.2 vs. 4.2 ± 0.9, p = 0.02) and systolic function (S m 13 ± 3 vs. 15 ± 2 cm/s, p

Hemorrhoidal disease (HD) treatment still remains controversial. In fact, despite many surgical progresses, postoperative pain, and discomfort remain the major weaknesses. Laser hemorrhoidoplasty (LHP) is a minimal invasive procedure for HD treatment determining the shrinkage of the hemorrhoidal piles by diode laser. The aim of the current study is to analyze the feasibility and efficacy of LHP in patients with II–III degrees hemorrhoids. Consecutive patients with II–III degree hemorrhoids were enrolled in the study and underwent an LHP treatment using a 1470-nm diode laser. Operative time, postoperative pain and complications, resolution of symptoms, and length of return to daily activity were prospectively evaluated. Recurrence of prolapsed hemorrhoid or symptoms at a minimum follow-up of 6months was evaluated. Fifty patients (28 males and 22 females) were enrolled in the study. No significant intraoperative complications occurred. Postoperative pain score (at 12, 18, and 24h postoperatively), evaluated through visual analogue scale, was extremely low (mean value 2). No postoperative spontaneous bleeding occurred. The 100% of our population came back to daily activity 2 days after surgery. At a mean follow-up period of 8.6months, we reported a recurrence rate of 0%. LHP demonstrated a large efficacy in selected patients. The greatest strength points were low postoperative pain, the presence of slightly significant peri-anal wounds, no special anal hygienic measures and low surgical time. Thus, resulting in a negligible postoperative discomfort, LHP could be considered a painless and minimal invasive technique in the treatment of HD.