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Background: Several reports demonstrated a strong association between the level of adherence to the protocol and improved clinical outcomes after surgery. However, it is difficult to obtain full adherence to the protocol into clinical practice and has still not been identified the threshold beyond which improved functional results can be reached. Methods: The ERCOLE (ERas and COLorectal Endoscopic surgery) study was as a cohort, prospective, multi-centre national study evaluating the association between adherence to ERAS items and clinical outcomes after minimally invasive colorectal surgery. The primary endpoint was to associate the percentage of ERAS adherence to functional recovery after minimally invasive colorectal cancer surgery. The secondary endpoints of the study was to validate safety of the ERAS programme evaluating complications' occurrence according to Clavien-Dindo classification and to evaluate the compliance of the Italian surgeons to each ERAS item. Results: 1138 patients were included. Adherence to the ERAS protocol was full only in 101 patients (8.9%), > 75% of the ERAS items in 736 (64.7%) and > 50% in 1127 (99%). Adherence to > 75% was associated with a better functional recovery with 90.2 ± 98.8 vs 95.9 ± 33.4 h (p = 0.003). At difference, full adherence to the ERAS components 91.7 ± 22.1 vs 92.2 ± 31.6 h (p = 0.8) was not associated with better recovery. Conclusions: Our results were encouraging to affirm that adherence to the ERAS program up to 75% could be considered satisfactory to get the goal. Our study could be considered a call to simplify the ERAS protocol facilitating its penetrance into clinical practice. [ABSTRACT FROM AUTHOR]

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

Background: Laparoscopic sleeve gastrectomy (LSG) is the most widespread bariatric procedure due to its safety and efficacy. Despite continuous refinement, achieving a globally standardized procedure remains challenging. Moreover, due to its wide adoption, numerous studies have focused on complications associated with the technique, such as gastroesophageal reflux disease (GERD). This study evaluates the impact of antrum size (wide antrectomy versus small antrectomy) in LSG on long-term anthropometric outcomes and complications in patients with morbid obesity. Methods: Body mass index (BMI), percentage of excess weight loss (%EWL) at a 5-year follow-up, GERD Health-Related Quality-of-Life (GERD-HRQL) scores, and obesity-related diseases of patients undergoing LSG with gastric resections starting 2 cm and 6 cm from the pylorus were retrospectively evaluated. Results: Between January 2015 and November 2019, 597 patients who met the criteria for LSG were included in the study. Group A (241 patients) underwent wide antrectomy, while Group B (356 patients) underwent small antrectomy. Weight, BMI, %EWL, and %TWL significantly improved at 6 and 12 months in the wide-antrectomy group. However, these differences diminished by 24 months, with no significant long-term differences in weight loss outcomes between the two groups at 5 years. Conversely, GERD-HRQL scores were significantly better in the small-antrectomy group until 24 months; thereafter, results were comparable between groups over the long term. Conclusions: Therefore, while wide antrectomy may offer superior short-term anthropometric outcomes, both techniques yield similar long-term results regarding weight management and GERD incidence. Larger prospective studies are needed to further address this issue.

Laparoscopic Heller myotomy with antireflux procedure seems the procedure of choice in the treatment of patients with esophageal achalasia. Persistent or recurrent symptoms occur in 10% to 20% of patients. Few reports on reoperation after failed Heller myotomy have been published. No author has reported the realization of a total fundoplication in these patient groups. The aim of this study is to evaluate the efficacy of laparoscopic reoperation with the realization of a total fundoplication after failed Heller myotomy for esophageal achalasia. From 1992 to December 2007, 5 out of a series of 242 patients (2.1%), along with 2 patients operated elsewhere, underwent laparoscopic reintervention for failed Heller myotomy. Symptoms leading to reoperation included persistent dysphagia in 3 patients, recurrent dysphagia in another 3, and heartburn in 1 patient. Mean time from the first to the second operation was 49.7 months (range, 4-180 months). Always, the intervention was completed via a laparoscopic approach and a Nissen-Rossetti fundoplication was realized or left in place after a complete Heller myotomy. Mean operative time was 160 minutes (range, 60-245 minutes). Mean postoperative hospital stay was 3.1 +/- 1.5 days. No major morbidity or mortality occurred. At a mean follow-up of 16.1 months, reoperation must be considered successful in 5 out of 7 patients (71.4%). The dysphagia DeMeester score fell from 2.71 +/- 0.22 to 0.91 +/- 0.38 postoperatively. The regurgitation score changed from 2.45 +/- 0.34 to 0.68 +/- 0.23. Laparoscopic reoperation for failed Heller myotomy with the realization of a total fundoplication is safe and is associated with good long-term results if performed by an experienced surgeon in a center with a long tradition of esophageal surgery.

There are different surgical possibilities for the treatment of oesophageal achalasia ranging from a short extramucosal oesophagomyotomy to an extended esophago-gastric myotomy combined with a partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to oesophageal emptying. The aim of this study was to evaluate the role and efficacy of total 360 degrees laparoscopic Nissen-Rossetti fundoplication after oesophago gastric myotomy in the treatment of oesophageal achalasia. From 1992 to January 2008, a total of 245 patients (112 males, 133 females), mean age 45.1 years (range: 12-79), were submitted to laparoscopic Nissen-Rossetti fundoplication after a Heller myotomy with endoscopic and manometric intraoperative monitoring. In 3 patients (1.2%), conversion to laparotomy was necessary. Mean operative time was 60 +/- 15 minutes. No mortality was observed. The overall morbidity rate was 1.6%. The mean postoperative hospital stay was 3.5 +/- 1.0 days (range: 1-12 days). A mean clinical follow-up of 100.2 +/- 7 months (range: 3-177) was possible for 228 patients (93.1%), and an excellent or good outcome was observed in 209 patients (91.7%) (DeMeester dysphagia score 0-1). No improvement in dysphagia was observed in 5 (2.2%) patients. Pathological gastro-oesophageal reflux was absent in all patients. Laparoscopic Nissen-Rossetti fundoplication after a Heller myotomy is a safe, effective treatment for oesophageal achalasia with excellent results in terms of dysphagia resolution, affording total protection from the onset of gastrooesophageal reflux.

After esophagectomy, the stomach is usually used to restore digestive continuity. To prevent postoperative delayed gastric emptying, most authors perform a gastric drainage procedure or transpose a tubulized stomach. The aim of our work is to evaluate the emptying of a transposed whole stomach without performing a pyloromyotomy or a pyloroplasty. From 1996 to January 2004, 45 patients underwent total esophagectomy for cancer or for caustic stenosis. Reconstruction of digestive continuity was realized through transposition of the whole stomach without performing a pyloric drainage procedure. At 12 months after the intervention, 35 patients (77.8%; 20 men and 15 women) were submitted to a gastric emptying scintigraphic study by means of ingestion of a mixed meal labeled with 37 MBq 99mTc-sulfur colloid. Mean half-emptying time was 71.4 minutes (range, 15-90 minutes; reference range, 83 +/- 34 minutes): all the patients were in the normal range except one. No patient complained of delayed gastric emptying symptoms. After esophagectomy, the transposition of the whole stomach without a pyloric drainage procedure seems to be an interesting option, and is not associated with delayed gastric emptying.

Stromal tumours of the gastrointestinal tract can be defined by endoscopic ultrasonography as "hypoechoic intramural tumours" on the basis of their echostructure. Unfortunately, this definition is inadequate for distinguishing between the biological behaviour patterns of different types of stromal tumour. One hundred and twelve hypoechoic intramural tumours observed from 1998 to 2005 were classified in 4 distinct groups (leiomyomas, gastrointestinal stromal tumours, gastrointestinal stromal tumours suspected of malignancy, and malignant stromal tumours) according to more detailed endoscopic ultrasonography criteria in order to better plan the surgical treatment. The endoscopic ultrasonography diagnosis was compared with histology and immunochemistry findings in 33 patients who were operated on. The overall accuracy was 78.6% for the diagnosis of leiomyoma (sensitivity, specificity, positive predictive value, and negative predictive value were 92.3%, 90.0%, 85.7% and 94.7%, respectively). The corresponding data for the diagnosis of malignant stromal tumours were 80.0%, 95.2%, 88.9% and 91.7%. Endoscopic ultrasonography seemed to be less reliable only in relation to the diagnosis of gastrointestinal stromal tumours (specificity 80.9%, positive predictive value 75.0%). The surgical procedures planned on the basis of the endoscopic ultrasonography diagnosis proved adequate in 31 out of 33 cases.

Oesophageal perforations are a catastrophic event with a 10-40% mortality rate. The decisive prognostic factor is the time from the event to the diagnosis, while there is no agreement as to the therapeutic options. The aim of this study was to present our ten-year experience in the treatment of oesophageal perforations together with an evaluation of the prognostic factors. From January 1995 to January 2005, 18 patients (11 M, 7 F), mean age 49.3 years (range: 22-79), with oesophageal perforations were treated in our department. They were classified according to the cause and localization of the perforation and the time elapsing since the event. The perforation was localised in the cervical oesophagus in 4 patients (22.2%), in the abdominal oesophagus in 4 patients (22.2%) and in the thoracic oesophagus in 10 patients (55.5%). It was spontaneous in 4 patients (22.2%), traumatic in 4 (22.2%) and iatrogenic in the remaining 10 (55.5%). In 7 patients (38.9%), the treatment was started during the first 24 hours from the event, while the remaining 11 (61.1 %) were referred to us more than 24 hours after the perforation occurred. The overall mortality was 27.8% (5 patients). The only decisive prognostic factor was the time of observation: only 1 patient (14.3%) died in the group observed in the first 24 hours, while the remaining 4 who died (36.4%) were in the group treated more than 24 hours after the event (p < 0.05). Our series confirms that the time elapsing from the event to the diagnosis is the only decisive prognostic factor in the treatment of oesophageal perforations. There is no therapeutic option of choice since there is no significant influence of either cause or localisation of the perforation on outcome.

The incidence of gastroesophageal junction adenocarcinoma is increasing. About 30% of the tumors cannot be completely resected, and 40% of the patients relapse after complete resection. There is much controversy over the role of neoadjuvant therapy, the approach route, lymphadenectomy, and the extent of esophageal resection. The aim of our study was to report our experience in the treatment of gastroesophageal junction adenocarcinoma. From January 1987 until February 2005, 157 patients (125 men, 32 women), mean age 72.1 +/- 3.2 years, came for observation. One hundred sixteen patients underwent curative intervention. Mean operative time was 185 +/- 45 minutes. Mean postoperative hospital stay was 16.4 +/- 6.1 days. Postoperative complications were observed in 25 patients (21.6%); 6 patients (5.2%) died during the postoperative period. Overall survival was 36.2% and 27.6% at 3- and 5-year follow-up, respectively. Five-year survival rate was significantly lesser in R1/R2 versus R0 resections (0% versus 33.7%), N+ versus N- patients (11.3% versus 53.3%), and worsened with progression of pT histological staging (T1, 100%; T2, 24.1%; T3, 15.1%; T4, 0%). Determining prognostic factors are the radicality of resection, lymph nodal invasion, and histological staging.