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Roux-en-Y Gastric Bypass on Vertical Banded Gastroplasty (RYGB-on-VBG) , is a technical change of the standard Roux-en-Y Gastric Bypass (RYGB) with the goal to obtain a gastric bypass where it was possible to make the traditional endoscopy and x-ray study of the excluded stomach, conceived in 2002 after a pilot study performed with a functional gastric bypass for the same objective. In the midterm the RYGB-on-VBG procedure reached similar outcomes as standard techniques of gastric bypass, both in terms of weight loss and incidence of surgical complications, and achieved the same good results when performed in other bariatric surgery centres proving therefore to be operator-independent, while enabled traditional diagnostic evaluation of the bypassed stomach and biliary tract. Progressively, outcomes of RYGB-on-VBG have been presented at international meetings and published , also when adopted as conversion after failures of gastric restrictive procedures. This paper reports the long term results of patients who underwent RYGB-on-VBG in a single centre, with up to 12 years clinical follow-up.

Summary: Modified transverse coloplasty pouch: new reconstruction techniques after total mesorectal excision, our experience. r. ruGGIero, G. DocImo, a. BoSco, m. lanzavolPe, G. terraccIano, a. GuBItoSI, l. DocImo Introduction. The Harmonic scalpel (“Focus“ and the new version “Focus+”) is one of the first devices for surgical simultaneous cutting and tissue coagulation which allows to obtain dissection and hemostasis by direct application of ultrasound and allows minimally invasive surgical procedures with minimal lateral thermal spread and, thus, minimal adjacent tissue destruction. The aim of the study is to complete the previous study that we made in 2014, based on the TT performed between January 2008 and December 2013, with new data about TT performed in our Surgical Division between January 2014 and December2016 and compare the outcome using the Ultrasonic scalpel versus the device Ligasure in term of safety, operative time, overall drainage volume, complications, hospital stay. materials and methods. 250 patients were randomized into two groups: Group A where Ultracision were used and Group B where the Ligasure device was used. Results. The results of the group A and of the Group B 2014-2016 have been compared with the results of the previous study and we found that they are similar, but asymptomatic hypocalcaemia increased in the patients of the new study. conclusions. We found that the use of Ultrasonic scalpel and Ligasure is effective both in the hemostasis of all vessels and in dissection of tissues and confirm the results of our first study without significant difference in the rate of post-operative morbidity with these two different energy based devices used.

Background. Permacol paste injection is a novel treatment approach for complex cryptoglandular anal fistulas. This study was performed to evaluate the long-term clinical outcomes of treatment with Permacol paste for complex cryptoglandular fistulas. Methods. Patients with primary or recurrent complex cryptoglandular anal fistulas treated with Permacol paste from 2014 to 2016 were retrospectively analyzed. Results. A total of 46 patients (median age, 41.3 years; 21 female) underwent Permacol paste injection; 20 patients (43%) had previously undergone failed fistula surgery. The patients had experienced anal fistula-related symptoms for a median of 10 weeks (range, 3-50 weeks). All patients had a draining seton in situ for a median of 10 weeks (range, 4-46 weeks). The median follow-up time was 24 months (range, 1-25 months). At the 1-month follow-up, 2 patients had paste extrusion and 2 had anal abscesses. The mean preoperative Continence Grading Scale score was 1.10 ± 1.40, and that at 3 months postoperatively was 1.13 ± 1.39 ( P = .322). There was a significant difference in the preoperative and the 1- and 3-month postoperative pain scores ( P < .001). At the 24-month follow-up, the healing rate was 50% (n = 23). A total of 19 patients (41%) with a recurrent fistula after failed Permacol paste injection required additional operative procedures. The satisfaction rate at the 2-year follow-up was 65%. Conclusion. Permacol paste injection is minimally invasive and technically easy to perform. It can be considered as a viable and reasonable option for the treatment of complex cryptoglandular anal fistulas in patients with fecal continence disorders.

To investigate correlation between rectal wall thickness (RWT) and anorectal pressures, in obstructed defecation syndrome (ODS) patients caused by internal rectal prolapse.ODS patients and healthy volunteers (HVs) underwent 3D endorectal ultrasound (3D-EUS) and high-resolution anorectal manometry (HRAM); RWT, total rectal wall volume (TRWV), pushing endorectal pressure (PEP), recto-anal gradient were determined RESULTS: We enrolled 35 ODS patients and 25 HVs. Patients showed markedly decreased TRWV, PEP, and recto-anal gradient. Linear correlation was found between markedly reduced TRWV and markedly hypotonic PEP.HRAM and 3D-EUS could be performed in ODS assessment, to better understand rectal function.

• Nowadays, there has been an improvement in hospital safety but risk management is still not a priority for academia.

This study aims to investigate pre-clinical esophageal involvement in systemic sclerosis (SSc) by high-resolution impedance manometry (HRiM), its associations with disease features including lung involvement, and its predictivity of esophageal symptoms overtime. Charts of 45 asymptomatic (no heartburn/regurgitation/dysphagia) SSc patients (96% females; mean age 46 years) with at least one follow-up (FU) visit and complete clinical, serological, functional, and radiological assessment, including high-resolution computed tomography (HRCT) of the chest and lung function tests, that had undergone esophageal HRiM were retrospectively evaluated. Esophagogastric junction-contractile integral (EGJ-CI) and esophageal body motility, as evaluated by mean distal contractile integral (DCI), were assessed. SSc patients had a normal esophageal motility in 7/45 cases, a defective EGJ-CI in 28, an ineffective esophageal motility (IEM) in 17, and aperistalsis in 12. Defective EGJ-CI was associated with IEM/aperistalsis in 20 cases, while 9 patients had isolated IEM. Defective EGJ-CI and/or IEM/aperistalsis were associated with a diffusing lung capacity for CO < 80% of predicted value (all p < 0.05), while defective EGJ-CI was also associated with interstitial lung disease on HRCT (p = 0.03). Prevalence of any HRiM abnormality was higher in anti-centromere antibody negative patients (all p < 0.05). IEM/aperistalsis independently increased the risk of esophageal symptoms by 2.3-fold (95% CI 1.1–5.7) and was associated with their higher cumulative incidence with respect to patients with other HRiM patterns at FU (χ2= 4.63; p = 0.03). SSc patients asymptomatic for esophageal involvement can have HRiM abnormalities in up to 84% of cases. A baseline-impaired motility is a risk factor for symptomatic esophageal disease.

Background Undifferentiated connective tissue disease at risk for Systemic Sclerosis (UCTD-risk-SSc), previously referred to as very early SSc, is a condition characterized by Raynaud9s phenomenon (RP) with SSc marker autoantibodies and/or typical capillaroscopic findings and unsatisfying classification criteria for the disease (1). UCTD-risk- SSc patients have been reported to present, in about 40% of the cases, a preclinical vascular internal organ disease as detected by a diffusing lung capacity for CO Objectives Aim of the present study was to assess the prevalence of right (RV) or left ventricle (LV) systolic and/or diastolic dysfunction by standard echocardiography and tissue Doppler imaging (TDI). Methods Thirty patients with UCTD-risk-SSc (28 female, aged 47±13 years, range 21–70) and 30 age- and sex-matched controls underwent cardiac assessment by standard echocardiography and TDI. Results UCTD-risk-SSc patients and controls did not show any difference at standard echocardiographic evaluation. In particular, an inverted E/A ratio was pointed out in 10/30 patients and 7/30 controls (p=ns). TDI showed a mild impairment of LV and RV diastolic (Em15±4 vs 19±5, p Conclusions Our study shows that UCTD-risk-SSc patients present a previously unrecognized, mild biventricular systolic and diastolic dysfunction as compared to controls. The pathophysiologic meaning (i.e.intramyocardial artery disease and/or patchy fibrosis) as well the predictive value of developing overt SScin the short time await to be elucidated. Disclosure of Interest None declared

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.

Gastroesophageal reflux disease (GERD) is a condition, which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. In patients with alarm symptoms or signs or in those refractory to antiacid therapy, it is indicated to perform instrumental tests to correctly diagnose GERD presence. Esophageal manometry is currently considered the gold standard test for the diagnosis of esophageal dysmotility. However, it has shown limited capability in diagnosing GERD. With the advent of high resolution manometry (HRM), more accurate evaluations of esophageal motility are now possible. Furthermore, new metrics have been developed to investigate esophagogastric junction (EGJ) morphology and function. In particular, the antireflux barrier function of EGJ can now be assessed evaluating the contraction integral of the junction. Also, transient lower esophageal relaxations can be defined more precisely with HRM. Provocative tests with multiple swallows can give additional information on peristaltic reserve. Finally, adding impedance measurement to HRM allows to detect retrograde movements (e.g. reflux) in the esophagus and to measure the baseline impedance, a novel promising metric associated to esophageal mucosal integrity. The present review will discuss the recent progresses made in evaluation of GERD patients with HRM and its potential role in diagnosing pathological reflux presence.

This is a retrospective analysis including all of the patients that have undergone anterior resection for rectal cancer from January 1998 to December 2005 in two tertiary referral centers. The study aims to evaluate the long term functional results after low anterior resection and to identify the risk factors of postoperative bowel disorders. Data were collected from the clinical records, and then the low anterior resection syndrome score which is a specific questionnaire to investigate the symptoms after surgery was submitted to the selected patients. Exclusion criteria were intra-abdominal rectal cancer, partial mesorectal excision, permanent stoma, recurrent local disease, and patients who declined the questionnaire. A total of 93 patients were included in the analysis with a median age at the diagnosis of 66 years. The median follow-up was 13.7 years, and low anterior resection syndrome was reported in 44 patients (47.5 %), with major manifestations in 19 patients (20.5 %), and minor symptoms in 25 patients (27 %). Age more than 70 years, tumor distance from the external anal verge, neoadjuvant treatment, and interval time of closing stoma are independent prognostic factors of functional disorders after surgery. Because of its great impact on the quality of life of these patients, it is necessary to early identify the syndrome trying to reduce its manifestations. Moreover, the symptoms seem to remain stable 1 year after surgery; hence, it is important to have an exhaustive, preoperative counseling and an integrated post-operative functional and rehabilitational follow-up in association with the oncologic pathway.

The aim of the study was to evaluate CXCL4 levels in undifferentiated connective tissue disease at risk for SSc (UCTD-SSc-risk) and confirm its increase and investigate its prognostic value. Serum CXCL4 levels were measured in 45 patients and 24 controls. CXCL4 was significantly higher in UCTD-SSc-risk patients than in controls. It resulted higher in patients with a shorter disease duration and in those lacking capillaroscopic alterations. We confirm that CXCL4 levels are increased in UCTD-risk-SSc patients. Further studies are needed to investigate the role of CXCL4 assessment in UCTD-risk-SSc.

Context: Obesity is associated with a low-grade inflammatory state and adipocyte (ADP) hyperplasia/hypertrophy. Obesity inhibits the “browning” of white adipose tissue. Cannabinoid receptor 2 (CB2) agonists reduce food intake and induce antiobesity effect in mice. A common missense CB2 variant, Q63R, causes CB2-reduced function. Objective: To evaluate the influence of CB2 receptor on the modulation of childhood obesity and of ADP activity and morphology. Design: CB2-Q63R variant was analyzed in obese Italian children. The effects of an inflammatory stimulus and those of drugs selectively acting on CB2 were investigated on in vitro ADPs obtained from mesenchymal stem cells of adult healthy donors or from sc adipose biopsies of adult nonobese and obese subjects. Setting: Department of Women, Child and General and Specialist Surgery of the Second University of Naples. Patients or Other Participants: A total of 501 obese Italian children (age 11 ± 2.75). Twelve healthy bone marrow donors (age 36.5 ± 15); and 17 subjects, 7 lean (age 42 ± 10) and 10 obese (age 37.8 ± 12) underwent sc adipose tissue biopsies. Main Outcome Measures: Effects of CB2 stimulation on adipokine, perilipin, and uncoupling protein-1 expression. Results: The less-functional CB2-R63 variant was significantly associated with a high z-score body mass index. CB2 blockade with AM630 reverse agonist increased inflammatory adipokine release and fat storage and reduced browning. CB2 stimulation with JWH-133 agonist reversed all of the obesity-related effects. Conclusion: CB2 receptor is a novel pharmacological target that should be considered for obesity.

Thyroid disease is common in elderly population. The incidence of hypothyroidism and multinodular goiter increases with age. Surgery in elderly patients has been considered to be more hazardous than in a youthful population. Besides the traditional surgical hemostatic techniques, different hemostatic approaches, which further minimize the risk of bleeding and complications during thyroidectomy, have become available. Aim of this study was to review and compare the outcomes of total thyroidectomy (TT) in elderly performed with different energy system. Introduction Thyroid disease is common in elderly population. The incidence of hypothyroidism and multinodular goiter increases with age. Surgery in elderly patients has been considered to be more hazardous than in a youthful population. Besides the traditional surgical hemostatic techniques, different hemostatic approaches, which further minimize the risk of bleeding and complications during thyroidectomy, have become available. Aim of this study was to review and compare the outcomes of total thyroidectomy (TT) in elderly performed with different energy system. Methods A total of 255 patients were eligible for the study and enrolled. One hundred and five patients with age >70 years (median age 76, range 70–90) constituted the elderly group (EG), whereas the young group (YG) was composed by 150 patients (median age 36, range 18–69). Each group was further divided into three subgroups, on the basis of the device used (none, Ligasure Precise/Small Jaw or Harmonic Focus) for performing TT as follows: conventional thyroidectomy in EG (CTE) and YG (CTY), Ligasure thyroidectomy (LTE and LTY) and Harmonic thyroidectomy (THE and HTY). Intra-operative and post-operative data, as well as complications rate, were collected. Results There was no significant difference between the elderly and the young patients treated with total thyroidectomy. Using of Harmonic Focus or Ligasure Precise/Small Jaw allowed a reduction of the duration of surgery (p

Bariatric surgery has proven efficacy in the modulation of a number of gut peptides that can contribute to improvement of diabetes and its associated metabolic changes. In order to evaluate dietary intake, nutritional assessment and plasma levels of gastrointestinal peptides, we enrolled severely obese patients before and after bariatric surgery.We evaluated food intake, plasma levels of peptide YY (PYY), glucagon-like peptide-1/2 (GLP-1/2), ghrelin (GHR), orexin (ORE) and cholecystokinin (CCK), body composition and fecal microbiota in 28 severely obese patients and 28 healthy normal-weight controls. All parameters were evaluated at 0 time and 6 months after bariatric surgery.In obese patients we found a higher intake of nutrients, a decrease of free fat mass and an increase of BMI (body mass index), a significant decrease of GLP-1 and an increase of GLP-2, GHR and PYY with respect to controls, further increase in GLP-2, GHR and PYY, as well as increase over control values of GLP-1 after bariatric surgery. Obese individuals were found to harbor a community dominated by members of the Clostridial clusters XIVa and IV, whereas prominent bands after surgery were identified as Lactobacillus crispatus and Megasphaera elsdenii-related phylotype.The beneficial effects of bariatric surgery may at least in part be accounted for changes in circulating gastrointestinal (GI) peptides and fecal microbiota.

Background Nutrient interaction with the mid-gut may play a role in improving type 2 diabetes mellitus (T2D) after bariatric surgery. However, Roux-en-Y gastric bypass, biliopancreatic diversion, and sleeve gastrectomy include diversion of food from the duodenum and/or partial gastrectomy. Biliointestinal bypass (BIBP) was introduced to eliminate the major side effects of jejunoileal bypass. It does not involve any change to the anatomy of the stomach or the duodenum. A prospective evaluation of the role of BIBP in glycemic control has not been reported. Objectives Longitudinal evaluation of T2D after BIBP. Setting University hospitals in Europe and Canada. Method The effects of BIBP on metabolism and glycemia in 28 consecutive patients with T2D were evaluated over 2 years. Results Decreases (P

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.

Dear Editor: Low transsphincteric fistula (LTF) is a tedious surgical disease and its treatment relies on several conventional strategies among which the most common are fistulotomy and fistulectomy. Fistulotomy consists of leaving the anal wound open but is reported to be associated with prolonged wound healing, anal deformity, and an altered continence. In light of these findings, at the end of the 1980s, authors have described a technique based on the marsupialization of wound edges to leave less raw unepithelialized tissues to heal over. Previous randomized studies have compared the outcomes of marsupialization and open wounds in the treatment of anal fistula. To date, no study has specifically compared postoperative care management and recurrence in patients who underwent fistulotomy with or without marsupialization for LTF. In this letter, we compared shortand long-term outcomes of patients with LTF undergoing fistulotomy with those of patients undergoing fistulotomy with marsupialization in the same period. From December 2007 to October 2013, consecutive patients with a diagnosis of anal fistula referred to our surgical uni t , who underwent f is tulectomy with marsupialization (M) or with open wound (OW) on a 1.5:1 ratio over a 7-year period, were prospectively enrolled. At the baseline, all patients underwent anal manometry and endoanal ultrasound. Low transsphincteric anal fistula was defined as a fistula tract traversing the lower third of the external anal sphincter at preoperative instrumental evaluation and confirmed intra-operatively. Patient follow-up was based on regular outpatient clinic visits every 3 months, and information obtained from medical records, correspondence, and telephone contact. Postoperative pain was evaluated with the visual analogue scale (VAS) 12 and 24 h after surgery. Wound healing was defined by complete re-epithelialization recorded by one independent observer who attended the outpatients’ visits and contacted the patients by phone every day afterwards to plan the final outpatient visit. Local wound care was assessed by recording the daily frequency of dressing change or even need for and frequency of who (Bmy-self^; family; district nurse) performed it . Dressing change was strictly performed only at the three daily dressing assessments (every 8 h–7 a.m., 3 p.m., and 11 p.m.), only in case the dressing appeared moist and not absolutely clean and dry. This was recorded bymeans of diaries the patients were asked to complete. In addition, wound care was monitored during outpatient follow-up visits until the wound was closed or up to 3 months after dismissal from the hospital. Wound infection was defined as the presence of local symptoms of suppuration with or without an isolated pathogenic microorganism. A recurrent fistula was assessed by clinical examination and 3D endoanal ultrasound at the outpatient clinic by a competent observer, independent from the operating team. Recurrence was defined when symptoms of the disease recurred after an interval following complete wound healing. Two hundred and sixty-eight consecutive patients with a diagnosis of anal fistula were admitted in our department. Seventythree of 268 consecutive patients with a low transsphincteric anal fistula entered the study. Forty patients were male (male/female ratio 1:2), and the median age at the time of diagnosis was 41 (31–68) years. Forty-four patients (60.2 %) had a marsupialization (M group) and 29 had an open wound (OW group). The median operating time was higher in the M group (P=0.0001). Wound bleeding was less frequent in the marsupialization group than in the OW group (16 vs. 48%, P= * Paolo Limongelli limpao@libero.it

Introduction and Purpose: Sleeve gastrectomy (SG) is gaining ground in the field of bariatric surgery. Data are scarce on its impact on esophagogastric physiology. Our aim was to evaluate the impact of SG on esophagogastric motility with high-resolution impedance manometry (HRIM) and to assess the usefulness of HRIM in patients with upper gastrointestinal (GI) symptoms after SG. Methods: A retrospective analysis of 53 cases of HRIM performed after SG was conducted. Upper GI symptoms at the time of HRIM were scored. HRIM was analyzed according to the Chicago classification v3.0. A special attention was devoted to the occurrence of increased intragastric pressure (IIGP) after water swallows and reflux episodes as detected with impedance. A measurement of sleeve volume and diameter was performed with CT scan in a subgroup of patients. Results: IIGP occurred very frequently in patients after SG (77 %) and was not associated with any upper GI symptoms, specific esophageal manometric profile, or impedance reflux. Impedance reflux episodes were also frequently observed after SG (52 %): they were significantly associated with gastroesophageal reflux (GER) symptoms and ineffective esophageal motility. The sleeve volume and diameters were also significantly smaller in patients with impedance reflux episodes (p < 0.01). Conclusion: SG significantly modified esophagogastric motility. IIGP is frequent, not correlated to symptoms, and should be regarded as a HRIM marker of SG. Impedance reflux episodes were also frequent, associated with GER symptoms and esophageal dysmotility. HRIM may thus have a clinical impact on the management of patients with upper GI symptoms after SG.

BACKGROUND: Recent data have shown that obesity is an important potential risk factor for atrial fibrillation (AF). The mechanism of development of AF in obesity patients is still unclear and may be related to atrial refractoriness heterogeneity. The aim of our study was to determine the influence of bariatric surgery with a consequent substantial weight loss on P-wave dispersion in morbidly obese population. METHODS: We enrolled in this study 40 severe obese patients, and 40 age-matched non-obese healthy subjects were also recruited as controls. All subjects underwent conventional 12-lead electrocardiography for the analysis of P-wave dispersion. All subjects underwent bariatric surgery and were resubmitted to electrocardiography, biochemical, and anthropometric examination within 12 months after intervention. RESULTS: Severe obese patients had greater values in P-wave duration and dispersion than the normal weight controls. Bariatric surgery reduced significantly P-wave dispersion. There was a significant correlation between decrease of atrial refractoriness heterogeneity and bariatric-surgery-induced weight loss. CONCLUSIONS: In severe obese patients, surgically induced weight loss reduction is associated with significant decreased in P-wave dispersion. The reduction of the atrial refractoriness heterogeneity may be of clinical significance by reducing the risk of atrial fibrillation in morbidly obese subjects.

Weight-stable obese subjects have an increased risk of arrhythmias and sudden death, even in the absence of cardiac dysfunction, and the risk of sudden cardiac death (SCD) with increasing weight is seen in both genders. The mechanism of unexplained deaths in obese patients is still unclear and may be related to ventricular repolarization abnormalities. The aim of this study is to determine the effect of severe obesity on spatial and transmural ventricular repolarization and to clarify the influence of bariatric surgery with a consequent substantial weight loss on arrhythmogenic substrate in the morbidly obese population.For the study, we enrolled 100 severely obese patients; 50 age-matched non-obese healthy subjects were also recruited as controls. All subjects underwent conventional 12-lead electrocardiography for analysis of spatial and transmural ventricular repolarization assessed by corrected QT dispersion (QTc-d), corrected JT dispersion (JTc-d) and transmural dispersion of repolarization, (TDR). All subjects underwent bariatric surgery and were resubmitted to electrocardiographic, biochemical and anthropometric examination 12 months postoperatively.Severely obese patients had greater values in QTc-d, JTc-d and TDR than the normal-weight controls. Bariatric surgery reduced significantly the QTc-d value, JTc-d value and TDR value. There was a significant correlation between decrease of heterogeneity of repolarization indexes (QTd, JTd and TDR) and bariatric surgery-induced weight loss.In severely obese patients, surgically-induced weight loss is associated with significant decrease in the heterogeneity of ventricular repolarization. The reduction of spatial (QTc-d, JTc-d) and transmural dispersion of repolarization (TDR) may be of clinical significance, by reducing the risk of potentially fatal arrhythmias in morbidly obese subjects.

Background: The role of esophagogastric junction contractile integral (EGJ-CI) as assessed by high-resolution manometry (HRM) is unclear. We aimed to correlate the EGJ-CI with impedance-pH findings in gastro-esophageal reflux disease (GERD) patients. Methods: Consecutive patients with GERD symptoms were enrolled. All patients underwent upper endoscopy, HRM, and impedance-pH testing. The EGJ-CI was calculated using the distal contractile integral tool box during three consecutive respiratory cycles. The value was then divided by the duration of these cycles. A value below 13 was considered as a defective EGJ-CI. We also assessed EGJ morphology, esophageal acid exposure time (AET), number of reflux episodes (NRE), and symptom association analysis (SAA). A positive impedance-pH monitoring was considered in case of abnormal AET and/or NRE and/or positive SAA. Key Results: Among 130 patients we enrolled, 91 had GERD (abnormal AET and/or elevated NRE and/or positive SAA) and 39 had functional heartburn (FH) (negative endoscopy, normal AET, normal NRE, and negative SAA). The GERD patients had a lower median value of EGJ-CI (11 [3.1-20.7] vs 22 [9.9-41], p < 0.02) compared to FH patients. Patients with a defective EGJ-CI had, more frequently, a positive impedance-pH monitoring or esophageal mucosal lesions at endoscopy (p < 0.05 and p < 0.05, respectively) than patients with a normal EGJ-CI. An EGJ-CI cut-off value of 5 mmHg cm yielded the optimal performance in identifying GERD at impedance-pH (sensitivity 89%-specificity 63%). Conclusions & Inferences: A defective EGJ-CI at HRM is clearly associated with evidence of GERD at impedance-pH monitoring. Evaluating EGJ-CI may be useful to predict an abnormal impedance-pH testing. Esophagogastric junction (EGJ) plays an important role in defense mechanisms against reflux. Defining EGJ vigor with high-resolution manometry (HRM) may be useful to predict an abnormal impedance-pH testing in reflux disease. This study aims to establish a correlation between EGJ-contractile integral (EGJ-CI) and different reflux parameters, detected during impedance-pH monitoring in GERD patients. Esophagogastric junction contractile integral is calculated at HRM enclosing the upper and lower margins of the EGJ in a DCI toolbox, during three consecutive respiratory cycles and referenced to gastric pressure. The value computed with the DCI tool in mmHg*s*cm is then divided by the duration of the three respiratory cycles (in seconds) yielding EGJ-CI units of mmHg*cm. The value below 13 is established in a series of normal volunteers as a defective EGJ-CI. Reflux parameters determined at impedance-pH monitoring are total number of reflux, total esophageal acid exposure time (AET), and symptom association. Our findings show that, when a defective EGJ-CI is present, a gradual and significant increase IN reflux can be present.

Background: Morbid obesity is a pathologic condition associated to an increased incidence of several chronic conditions associated to increased risk of mortality. Erythrocyte fatty acid composition has been candidate as a biomarker of oxidative stress and consequently on the rate of aging and ultimately lifespan. To our knowledge, no study has investigated the total spectrum of lipid composition of erythrocyte membranes from obese individuals. The aim of this study was to compare the fatty acid composition of erythrocyte membranes derived from morbidly obese patients with healthy matched controls and long-living descendants. Methods: Gas chromatography was employed to determine fatty acid percentage of erythrocyte membranes from investigated groups. Results: Erythrocyte membranes from obese subjects had significantly lower percentage of monounsaturated fatty acids (16.0 ± 0.8 vs. 23.0 ± 4.5, p

Background. Few studies have reported long-term recurrence rates after asymmetric excision with primary closure in the treatment of sacrococcygeal pilonidal disease. Methods. A retrospective analysis of a prospectively maintained database of 550 surgical excisions performed for sacrococcygeal pilonidal disease between 1988 and 2005 was performed. Results. A total of 550 patients with a diagnosis of pilonidal sinus underwent surgical excision over a period of 17 years. Thirty-eight out of the 550 patients (3.5%) were lost at follow-up. At a mean follow up of 11.2 ± 5.3 years, median 11 years (range = 3-22), the recurrence rate was 8.9%. Actuarial 1-, 5-, 10-, and 20-year disease-free survival rates were 98%, 94%, 92%, and 83%, respectively, with a median overall disease-free survival of 10 years (95% confidence interval [CI] = 3-15). When patients were stratified according to several variables known to influence recurrence, an age of less or ≥22 years (odds ratio [OR] = 1.5, 95% CI = 0.3-7.5, P = .001), a family history of sinus (OR = 5.9, 95% CI = 2.7-12, P = .0001), and intraoperative methylene blue use (OR = 6.3, 95% CI = 1.2-31, P = .024) were indicated as independent predictors of disease-free survival rates. Conclusions. D-shape asymmetric excision and scar lateralization, with primary multilayer subcuticular closure, suction drain insertion, and skin closure in patients with sacrococcygeal pilonidal disease is a safe and adequate surgical treatment offering an effective healing rate as well as low recurrence. Several features are likely to predict a better or a worse long-term recurrence rate in patients undergoing surgery for sinus pilonidalis.

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.

To date, therapeutic guidelines and pattern of reflux for patients with no-dysplasia (ND) or low-grade dysplasia (LGD) Barrett's esophagus (BE) remain unclear. We aimed to analyze pattern of reflux and regression of ND- or LGD-BE after medical and surgical treatment. METHODS: We studied a cohort of ND- and LGD-BE patients who underwent laparoscopic total fundoplication and a cohort of ND- and LGD-BE patients managed medically. Patients were matched for age, sex, and disease duration. After 1 year of follow-up at least, all patients underwent upper endoscopy with esophageal biopsies to evaluate any histological changes, as well as manometry and impedance-pH-metry to re-assess reflux patterns. RESULTS: Thirty-seven patients (20 LGD, 17 ND) undergoing laparoscopic fundoplication were enrolled and compared with 25 patients (13 LGD, 12 ND) managed with proton pump inhibitors (PPI). Laparoscopic fundoplication resulted in a better control of both acidic and weakly acidic reflux (P < 0.001) and was associated with a higher probability of reversion for LGD (P < 0.01). Esophageal motility did not differ between surgically and medically treated patients. CONCLUSIONS: In patients with ND- or LGD-BE, laparoscopic fundoplication seems to warrant a better control of all kinds of refluxate and it is associated with a higher likelihood of reversion of both LGD- and ND-BE, compared with PPI therapy.

Sleeve gastrectomy (SG) is currently gaining popularity due to an excellent efficacy combined to minimal anatomic changes. However, some concerns have been raised on increased risk of postoperative gastroesophageal reflux disease (GERD) due to gastric fundus removal, section of the sling muscular fibers of gastroesophageal junction, reduced antral pump function, and gastric volume. We undertook the current study to evaluate by means of high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) the impact of SG on esophageal physiology. METHODS: In this study, 25 consecutive patients had HRiM and MII-pH before and after laparoscopic SG. The following parameters were calculated at HRiM: lower esophageal sphincter (LES) pressure and relaxation, peristalsis, number of complete esophageal bolus transit, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH with the patient in both upright and recumbent positions. RESULTS: At a median follow-up of 13 months, HRiM showed an unchanged LES function, increased ineffective peristalsis, and incomplete bolus transit. MII-pH showed an increase of both acid exposure of the esophagus and number of non-acid reflux events in postprandial periods. CONCLUSIONS: Laparoscopic SG is an effective restrictive procedure that creates delayed esophageal emptying without impairing LES function. A correctly fashioned sleeve does not induce de novo GERD. Retrograde movements and increased acid exposure are probably due to stasis and postprandial regurgitation.

Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter (LES) and usually with an elevated LES pressure, leading to an altered passage of bolus through the esophago-gastric junction. A definitive cure for achalasia is currently unavailable. Palliative treatment options provide only food and liquid bolus intake and relief of symptoms. Endoscopic therapy for achalasia aims to disrupt or weaken the lower esophageal sphincter. Intra-sphincteric injection of botulinum toxin is reserved for elderly or severely ill patients. Pneumatic dilation provides superior results than botulinum toxin injection and a similar medium-term efficacy almost comparable to that attained after surgery. Per oral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and further objective and long-term follow up. This article will review different endoscopic treatments in achalasia, and summarize the short-term and long-term outcomes.

Introduction Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and esophageal erosions. However the relationship between obesity and GERD is still a subject of debate. In fact, if in most cases bariatric surgery can diminish reflux by losing a large amount of fat, on the other hand some restrictive procedure can worsen or cause the presence of GERD. Thus, it is unclear if patients candidate to bariatric surgery have to perform pre-operative reflux testing or not. Aim of the study was to verify the presence of GERD patterns in patients candidate to surgery and the need of pre-operative reflux testing. Methods All patients underwent to a standardized questionnaire for symptoms severity (GERQ), upper endoscopy, high resolution manometry (HRiM) and impedance pH-monitoring (MII-pH). Patients were stratified into: group 1 (negative for both GERQ and endoscopy), group 2 (positive for GERQ and negative for endoscopy), group 3 (positive for both GERQ and endoscopy). A healthy-volunteers group (HV) was assessed. Results One hundred thirty-nine subjects (obese, 124; HV normal weight, 15) were studied. Group 1 showed comparable mean LES pressure, peristaltic function, bolus transport and presence of hiatal hernia than HV. Group 2 showed a reduction of these parameters, while group 3 showed a statistical significant reduction in LES pressure, peristaltic function, bolus transport and increase in presence of hiatal hernia. At MII-pH, Group 1 showed a not significant increase in reflux patterns; group 2 and 3 showed a significant increase in esophageal acid exposure and in number of refluxes (both acid and weakly acid), with group 3 showing the higher grade of reflux pattern. Conclusions Obese subjects with pre-operative presence of GERD symptoms and endoscopical signs could be tested with HRM and MII-pH before undergoing bariatric surgery, especially for restrictive procedures. On the other hand, obese patients without any sign of GERD could not be tested for reflux, showing similar patterns to HV.

INTRODUCTION: Hemostasis during thyroidectomy is essential; however, the safest, most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with combination of harmonic scalpel (HS) and Floseal. METHODS: Patients undergone TT were divided into two groups: HS + Floseal and traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates. RESULTS: Between September 2012 and January 2014, 165 patients were enrolled (100 to HS + Floseal, 65 to standard hemostasis); 80.5% female; mean age 42.3 years. The 24-h drain output was lower in the HS + Floseal group compared with standard TT. HS + Floseal also had a shorter mean surgery time (p < 0.0001) vs standard TT. No differences in post-surgical complications and in hypocalcemiarates between groups. CONCLUSION: combination of Floseal plus the HS is effective and safe for TT and it provides a complementary hemostatic approach.

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.

Introduction Mastectomy for breast cancer may bring the patient to develop long term issues concerning the psychological and physical status. Immediate breast reconstruction (IBR) should be considered and proposed by physicians as an integrated procedure in the surgical approach to breast cancer to reduce further surgery. Acellular dermal matrix (ADM) has been used in revision breast reconstruction for fold malposition, capsular contracture and rippling also, showing good outcomes with low risk of complications. Aim of this study was to verify if the known advantages in using ADM for IBR would led to lower rates of seroma formation, infection, skin flap necrosis and overall complication related to the implant. Methods We performed a prospective study, including all consecutive patients undergone to IBR with biological graft with ADM between January 2012 and January 2013 at our Institution. Data on major issues of the patients and complications were recorded. All patients underwent to IBR with ADM (Tutomesh) implant with or without fibrin sealant positioning. Results A total of 24 patients underwent 28 immediate breast reconstruction with Tutomesh ADM implant. Main postoperative complications included seroma formation in 20.8% (5 pts), infection in 8.3% (2 pts) and hematoma in 4.2% (1 pt). There were any skin flap necrosis in the study. Diabetes was associated in two cases with edema and ecchymosis; hypertension with infection in one case (implant removal) and seroma in one case. First class of obesity (BMI 30–32.7) was associated with seroma in 3 cases, and with infection in one. In patient without fibrin sealant (12 patients – 13 breasts) complications were represented by hematoma (1 pt. 4.2%), infection (1 pt. 4.2%; implant removal) and seroma (4 pts 16.8%). Conclusions The use of Tutomesh ® bovine pericardium for immediate breast is safe and technically useful. Complications rate is not high, except for seroma formation that can be reduced by the contemporary use of fibrin sealant.