Publications by authors named "Luigi Bonavina"

183 Publications

Falciform Ligament Flap as Crural Buttress in Laparoscopic Hiatal Hernia Repair.

J Laparoendosc Adv Surg Tech A 2021 May 7. Epub 2021 May 7.

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano), Italy.

Crural repair is an essential technical component in laparoscopic hiatal hernia surgery, but there is no consensus regarding the optimal method to prevent postoperative hernia recurrence. Mesh augmentation, especially with permanent materials, is associated with dysphagia and complications. The rotational falciform ligament flap (FLF) has been reported to be effective in reinforcing standard suture closure of the hiatus. Patients with primary or secondary hiatal hernia in whom FLF was used to buttress the hiatus repair were included. The FLF was dissected from the anterior abdominal wall, detached from the umbilical area, and transposed below the left lateral liver segment to buttress the cruroplasty. Indocyanine green fluorescence was used to assess vascularization of the flap before and after mobilization. Eighteen consecutive patients underwent laparoscopic FLF cruroplasty reinforcement between October 2019 and January 2021. Indications were primary hiatal hernia ( = 9), recurrent hiatal hernia ( = 4), postsleeve gastrectomy hernia ( = 1), prophylactic hiatal repair during esophagectomy and gastric conduit reconstruction ( = 2), and postesophagectomy hernia ( = 2). All flaps were well vascularized and covered the entire hiatal area. There was no morbidity. At a median follow-up of 8 months (range 3-15), the symptomatic and quality of life scores significantly improved compared with baseline ( < .001), and no anatomic hernia recurrences were detected. FLF is safe for crural buttress and is a viable alternative to mesh in laparoscopic hiatal hernia surgery.
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http://dx.doi.org/10.1089/lap.2021.0244DOI Listing
May 2021

Intramural duodenal dissection for the treatment of bleeding duodenal ulcer.

Updates Surg 2021 Apr 25. Epub 2021 Apr 25.

Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, Piazza Malan 1, 20097, San Donato Milanese, Milano, Italy.

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http://dx.doi.org/10.1007/s13304-021-01060-0DOI Listing
April 2021

The role of magnetic sphincter augmentation in the treatment of gastroesophageal reflux disease.

Curr Opin Gastroenterol 2021 Apr 20. Epub 2021 Apr 20.

University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, Milan, Italy King Edward VII Hospital, Medical Director RefluxUK, London, UK Medical University of Vienna, Department of General Surgery, Upper-GI-Service, Wien, Austria.

Purpose Of Review: Magnetic sphincter augmentation (MSA) has been designed as a less disruptive and more standardized laparoscopic surgical procedure than fundoplication for patients with early stage gastroesophageal reflux disease (GERD). We analyzed the more recent literature in search of updates regarding indications, technique, perioperative management, and long-term outcomes.

Recent Findings: Over the years, the procedure of MSA has evolved to including full hiatus repair rather than relying on the preservation of the phreno-esophageal ligament. Restoring the mechanical synergy between the lower esophageal sphincter and the crural diaphragm has the potential to further enhance the antireflux barrier. The adoption of this approach has led to expand the indications from early stage disease to different scenarios including patients with high esophageal acid exposure, atypical symptoms, large hiatal hernias, Barrett's esophagus, postbariatric surgery, and previously failed fundoplication.

Summary: MSA has a favorable side-effect profile and is highly effective in reducing typical reflux symptoms, medication dependency, and esophageal acid exposure. Excellent outcomes have been confirmed over a 12-year follow-up, indicating that the operation has the potential to prevent GERD progression. Further studies are needed to confirm the cost-effectiveness of this procedure in patients with more advanced disease-stage and prior gastric surgery. A randomized control trial comparing MSA with fundoplication could raise the level of evidence and the strength of recommendation.
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http://dx.doi.org/10.1097/MOG.0000000000000748DOI Listing
April 2021

The semirecumbent position for high-resolution esophageal manometry. Results of a feasibility study.

Eur J Gastroenterol Hepatol 2021 Apr 9. Epub 2021 Apr 9.

Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy.

Objective: Normative values for high-resolution manometry (HRM) have been obtained with the patient lying supine. The aim of the study was to compare supine, semirecumbent and sitting positions during HRM in terms of variation in normative metrics, diagnostic yield, and patient's comfort.

Methods: A prospective, single-center feasibility study was planned in consecutive patients referred to the esophageal function laboratory. In each of the three positions, 10 consecutive 5 ml water swallows and three 10 ml multiple rapid swallows were administered. Validated reflux questionnaires were administered prior to the test, and a visual analogue scale (VAS) assessing the patient's comfort after the test.

Results: Twenty patients presenting with gastroesophageal reflux symptoms completed the study protocol. The intra-abdominal segment of the lower esophageal sphincter was significantly longer in the sitting position (P = 0.013), and the multiple rapid swallow distal contractile integral was lowest in the supine position (P = 0.012). The VAS comfort score did not significantly differ in the three body positions (P = 0.295). The concordance in the final diagnosis was 80% for semirecumbent vs. sitting (kappa = 0.15; P = 0.001), 70% for supine vs. sitting and 65.0% for semirecumbent vs. supine.

Conclusion: Compared to the supine position, both the semirecumbent and sitting position seems to provide similar advantages. HRM metrics and the final manometric diagnosis may be affected by body position, but complementary maneuvers, such are the rapid drink challenge, can resolve diagnostic discrepancies and improve the overall accuracy of the test.
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http://dx.doi.org/10.1097/MEG.0000000000002143DOI Listing
April 2021

Reference high-resolution manometry values after magnetic sphincter augmentation.

Neurogastroenterol Motil 2021 Mar 27:e14139. Epub 2021 Mar 27.

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy.

Background: Magnetic sphincter augmentation (MSA) is an innovative antireflux procedure that can improve lower esophageal sphincter (LES) competency and reduce symptoms of gastroesophageal reflux disease (GERD). Some patients report postoperative dysphagia. To date, no studies have described reference high-resolution manometry (HRM) values after MSA implantation.

Methods: High-resolution manometry was performed in patients free of dysphagia after MSA with or without concurrent crura repair. Reference values for all parameters of the Chicago Classification were defined as those between the 5th and 95th percentiles. The contribution of concurrent crura repair to LES competency and to reference values was also analyzed.

Key Results: Eighty-four patients met the study inclusion criteria. The upper limit of normality for integrated relaxation pressure (IRP) and intrabolus pressure (IBP) was 20.2 mmHg and 30.3 mmHg, respectively. Both variables were higher after MSA compared to normative Chicago Classification v3.0 values. The Distal Contractile Integral upper limit was in the range of normality. Patients undergoing crura repair had a significantly higher IRP (p = 0.0378) and lower GERDQ-A scores (p = 0.0374) and Reflux Symptom Index (p = 0.0030) compared to those who underwent MSA device implantation alone.

Conclusion & Inferences: This study provides HRM reference values for patients undergoing successful MSA implantation. Crural repair appears to be a key component of LES augmentation and is associated with improved clinical outcomes.
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http://dx.doi.org/10.1111/nmo.14139DOI Listing
March 2021

Commentary: Evaluation of Anterior Phrenoesophageal Ligament Preservation During Hiatus Hernia Repair in Laparoscopic Sleeve Gastrectomy as an Anti-Reflux Measure by Elmaleh

Authors:
Luigi Bonavina

J Laparoendosc Adv Surg Tech A 2021 May 26;31(5):515-516. Epub 2021 Mar 26.

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milano, Italy.

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http://dx.doi.org/10.1089/lap.2021.29036.lbDOI Listing
May 2021

Staging esophageal cancer: low EUS accuracy in t2n0 patients.

Endosc Int Open 2021 Mar 18;9(3):E313-E318. Epub 2021 Feb 18.

Bilio-pancreatic Endoscopy and Endoscopic Ultrasound Unit, San Raffaele Hospital, Milan, Italy.

 Esophageal cancer (EC) is one of the most lethal malignancies worldwide. Staging of EC is performed with computed tomography (CT), positron-emission tomography (PET), and endoscopic ultrasonography (EUS). Patient management mostly depends on lymph node status. Compared to histopathology, the accuracy of EUS for T and N parameters is about 85 % and 75 %, respectively. Errors in staging may change prognosis. The aim of this study was to assess the role of EUS in T2-N0 EC considering the experience of two high-volume digestive endoscopic centers.  Two prospectively collected databases were queried to identify all patients with EC, staged as cT2N0 by EUS, with no distant metastases at CT/PET scan and who underwent transthoracic esophagectomy. Preoperative EUS staging (cTNM) was compared to histopathology of the surgical specimen (pTNM) to evaluate accuracy.  Of 729 consecutive patients with EC between January 2011 and September 2018, 72 (49 men) had cT2N0 disease. CT and PET scans confirmed the absence of distant metastasis. In 43 of 72 patients (60 %), the evaluation was correct, 23 of 72 (31,7 %) were understaged, and six of 72 patients (8,3 %) were overstaged. Among the understaged patients, eight were understaged by tumor depth (35 %), seven by nodal involvement (30 %), and eight by both (35 %). All six patients who were overstaged had T1b-N0 disease. EUS accuracy was 77 % in staging for tumor depth and 82 % in staging for nodal metastases. The positive predictive value (PPV) for cT2N0 EC was 60 % (43 pT2N0 /72 cT2N).  The accuracy of EUS staging of T2N0 EC is low, with only 60 % of patients undergoing appropriate therapy based on histopathology.
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http://dx.doi.org/10.1055/a-1336-2505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7892275PMC
March 2021

Esophageal Rhabdoid-Like Tumor: A Rare Disease With Aggressive Clinical Behavior.

Front Surg 2020 24;7:596010. Epub 2020 Nov 24.

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Italy.

Malignant rhabdoid tumor is a kidney childhood tumor with aggressive clinical behavior and a wide spectrum of histologic, immunophenotypic, and cytogenetic findings. Extra-renal rhabdoid tumors have been reported in the brain, breast, liver, pancreas, bladder, vulva, prostate, and colon. To date, only nine cases of esophageal rhabdoid tumors have been described, all in patients over 50-year old. We add to the current literature the case of an esophageal, poorly differentiated rhabdoid tumor occurring in a young man. A 24-year-old man was referred for progressive dysphagia, retrosternal pain, nausea, and food regurgitation. Esophagogastroduodenoscopy showed an obstructing neoplastic lesion of the distal esophagus associated with Barrett's esophagus. Biopsies revealed undifferentiated esophageal cancer with epithelial morphology and immunohistochemistry positive for CK pan, CK 7 e CK 8-18. Minimally invasive esophagectomy and extended lymphadenectomy was performed. Histopathology showed a poorly differentiated tumor, with morphologic characteristics of rhabdoid tumor, central necrosis and transmural infiltration of the esophageal wall. Definitive immunohistochemistry was positive for vimentin, CD34, synaptophysin, and INI1. Esophageal rhabdoid tumor is extremely rare and highly aggressive, with only few patients alive at 1 year follow-up, according to our review. Immunohistochemistry characterization is critical for diagnosis. Minimally invasive esophagectomy is an appealing and possibly less morbid option compared to open surgery. However, further research is needed to investigate the potential role of targeted immunotherapy.
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http://dx.doi.org/10.3389/fsurg.2020.596010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732554PMC
November 2020

Retroperitoneoscopic Drainage of Psoas Abscess: A Systematic Review.

Surg Laparosc Endosc Percutan Tech 2020 Nov 25;31(2):241-246. Epub 2020 Nov 25.

Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan.

Background: Psoas abscess is a relatively rare clinical condition that can occur worldwide, is difficult to diagnose, and has a severe clinical course. Conventional treatment ranges from antibiotic therapy alone to computed tomography (CT)-guided and/or open surgical drainage. Retroperitoneoscopic drainage represents a minimally invasive and potentially definitive therapeutic option.

Materials And Methods: A systematic review of the literature on minimally invasive extraperitoneal access for drainage of psoas abscess was conducted through PUBMED, EMBASE, and COCHRANE databases, according to the PRISMA statement guidelines. We considered only studies in English and with a full text. The quality of all selected articles was assessed for the risk of methodological bias. Additional literature sources were used to put into context the indications and limits of retroperitoneoscopic drainage.

Results: Seven papers published between 2004 and 2020, including a total of 56 patients, met the eligibility criteria and were included in the qualitative analysis. Causative agents of psoas abscess included Mycobacterium tuberculosis, Klebsiella pneumoniae, Enterobacter aerogenes, Staphylococcus aureus, and Streptococcus spp. Tuberculous abscess was more common than pyogenic abscess (92.8% vs. 7.2%). Main clinical findings were back pain (76.8%) and fever (53.6%). All patients were preoperatively evaluated by CT or magnetic resonance imaging. Only 4 patients (7.1%) had previously undergone CT-guided percutaneous drainage. Retroperitoneoscopic drainage was combined with antibiotic therapy in all cases. No Clavien-Dindo grade >3 complications occurred, and there was no 30-day postoperative mortality. The recurrence rate was 1.8% at a mean follow-up of 21 months.

Conclusion: Retroperitoneoscopic surgical drainage is a safe and effective approach for the treatment of psoas abscess.
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http://dx.doi.org/10.1097/SLE.0000000000000879DOI Listing
November 2020

Impact of COVID-19 outbreak on esophageal cancer surgery in Northern Italy: lessons learned from a multicentric snapshot.

Dis Esophagus 2020 Nov 27. Epub 2020 Nov 27.

General, Esophageal and Gastric Surgery Unit, University Hospital of Verona, Verona, Italy.

Coronavirus Disease-19 (COVID-19) outbreak has significantly burdened healthcare systems worldwide, leading to reorganization of healthcare services and reallocation of resources. The Italian Society for Study of Esophageal Diseases (SISME) conducted a national survey to evaluate changes in esophageal cancer management in a region severely struck by COVID-19 pandemic. A web-based questionnaire (26 items) was sent to 12 SISME units. Short-term outcomes of esophageal resections performed during the lockdown were compared with those achieved in the same period of 2019. Six (50%) centers had significant restrictions in their activity. However, overall number of resections did not decrease compared to 2019, while a higher rate of open esophageal resections was observed (40 vs. 21.7%; P = 0.034). Surgery was delayed in 24 (36.9%) patients in 6 (50%) centers, mostly due to shortage of anesthesiologists, and occupation of intensive care unit beds from intubated COVID-19 patients. Indications for neoadjuvant chemo (radio) therapy were extended in 14% of patients. Separate COVID-19 hospital pathways were active in 11 (91.7%) units. COVID-19 screening protocols included nasopharyngeal swab in 91.7%, chest computed tomography scan in 8.3% and selective use of lung ultrasound in 75% of units. Postoperative interstitial pneumonia occurred in 1 (1.5%) patient. Recovery from COVID-19 pandemic was characterized by screening of patients in all units, and follow-up outpatient visits in only 33% of units. This survey shows that clinical strategies differed considerably among the 12 SISME centers. Evidence-based guidelines are needed to support the surgical esophageal community and to standardize clinical practice in case of further pandemics.
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http://dx.doi.org/10.1093/dote/doaa124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717178PMC
November 2020

Computed tomography-derived myocardial extracellular volume: an early biomarker of cardiotoxicity in esophageal cancer patients undergoing radiation therapy.

Insights Imaging 2020 Nov 23;11(1):120. Epub 2020 Nov 23.

Department of Biomedical Sciences for Health, Università Degli Studi Di Milano, Via Mangiagalli 31, 20133, Milano, Italy.

Objectives: We aimed to assess extracellular volume (ECV) through non-gated, contrast-enhanced computed tomography (CT) before and after radiation therapy (RT) in patients with esophageal cancer (EC).

Materials And Methods: EC patients who had undergone CT before and after RT were retrospectively assessed. Patients with preexisting cardiovascular disease or with heavily artifacted CT were excluded. ECV was calculated using density values for the myocardial septum and blood pool. Data were reported as mean and standard deviation or median and interquartile range according to their distribution; t test or Wilcoxon and Pearson r or Spearman ρ were subsequently used.

Results: Twenty-one patients with stage ≥ IB EC, aged 64 ± 18 years, were included. Mean and maximum RT doses were 21.2 Gy (16.9-24.1) and 42.5 Gy (41.8-49.2), respectively. At baseline (n = 21), hematocrit was 39% ± 4%, ECV 27.9% ± 3.5%; 35 days (30-38) after RT (n = 20), hematocrit was 36% ± 4%, lower than at baseline (p = 0.002), ECV 30.3% ± 8.3%, higher than at baseline (p = 0.081); at follow-up 420 days (244-624) after RT (n = 13), hematocrit was 36% ± 5%, lower than at baseline (p = 0.030), ECV 31.4% ± 4.5%, higher than at baseline (p = 0.011). No patients showed signs of overt cardiotoxicity. ECV early after RT was moderately positively correlated with maximum RT dose (ρ = 0.50, p = 0.036).

Conclusions: In EC patients, CT-derived myocardial ECV was increased after RT and may thus appear as a potential early biomarker of cardiotoxicity.
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http://dx.doi.org/10.1186/s13244-020-00922-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683763PMC
November 2020

Esophageal Lipoma and Liposarcoma: A Systematic Review.

World J Surg 2021 Jan 7;45(1):225-234. Epub 2020 Oct 7.

Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, 20133, Milan, Italy.

Background: Esophageal lipomatous tumors, also reported as fibrovascular polyp, fibrolipoma, angiolipoma, and liposarcoma, account for less than 1% of all benign mesenchymal submucosal tumors of the esophagus. Clinical presentation and therapy may differ based on location, size, and morphology. A comprehensive and updated systematic review of the literature is lacking.

Methods: A systematic review of the literature was performed according to PRISMA guidelines. Pubmed, Embase, Cochrane, and Medline databases were consulted using MESH keywords. Non-English written articles and abstracts were excluded. Sex, age, symptoms at presentation, diagnosis, tumor location and size, surgical approach and technique of excision, pathology, and morphology were extracted and recorded in an electronic database.

Results: Sixty-seven studies for a total of 239 patients with esophageal lipoma or liposarcoma were included in the qualitative analysis. Among 176 patients with benign lipoma, the median age was 55. The main symptoms were dysphagia (64.2%), transoral polyp regurgitation (32.4%), and globus sensation (22.7%). The majority of lipomas (85.7%) were intraluminal polyps, with a stalk originating from the upper esophagus. Overall, 165 patients underwent excision of the mass through open surgery (65.5%), endoscopy (27.9%), or laparoscopy/thoracoscopy (3.6%). Only 5 (3%) of patients required esophagectomy. Of the 11 untreated patients with an intraluminal polyp, 7 died from asphyxia. Overall, liposarcoma was diagnosed in 63 patients, and 12 (19%) underwent esophagectomy.

Conclusion: Esophageal lipomatous tumors are rare but potentially lethal when are intraluminal and originate from the cervical esophagus. Modern radiological imaging has improved diagnostic accuracy. Minimally invasive transoral and laparoscopic/thoracoscopic techniques represent the therapeutic approach of choice.
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http://dx.doi.org/10.1007/s00268-020-05789-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752877PMC
January 2021

Endoscopic stapling versus laser for Zenker diverticulum: a retrospective cohort study.

Eur Arch Otorhinolaryngol 2020 Sep 7. Epub 2020 Sep 7.

Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.

Purpose: Despite the evolution of the endoscopic techniques for the treatment of symptomatic Zenker diverticulum, comparative studies are lacking. Aim of this observational study was to compare safety, efficacy, and outcomes of endoscopic stapling (ES) versus Laser (EL).

Methods: A prospectively collected database of patients who underwent treatment for Zenker diverticulum at a single institution was reviewed. Consecutive patients treated by ES or EL were included in the study. Demographic data, presenting symptoms, diverticulum characteristics, and intra- and postoperative data were analyzed. The Functional Outcome Swallowing Scale (FOSS) and MD Anderson Dysphagia Inventory (MDADI) questionnaires were administered to assess severity of dysphagia and quality of life before and after treatment.

Results: Between March 2017 and September 2018, 36 patients underwent ES or EL. In the TL group (n = 19), the diverticulum size was smaller compared to the EL group (n = 17) (p = 0.002). Two perforations occurred in the EL group, one treated conservatively and the other requiring drainage of a mediastinal abscess. At a median follow-up of 16 months, symptoms improved in both groups but the number of patients with a postoperative FOSS score ≥ 2 significantly decreased only after EL (p < 0.001). The scores of all items of the MDADI questionnaire significantly increased in both groups, but the average delta values were greater in the EL patients (p < 0.001).

Conclusions: Both TL and ES are effective treatment options for Zenker diverticulum. Postoperative quality of life was significantly higher in patients undergoing EL compared to ES.
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http://dx.doi.org/10.1007/s00405-020-06346-4DOI Listing
September 2020

Six to 12-year outcomes of magnetic sphincter augmentation for gastroesophageal reflux disease.

Sci Rep 2020 08 13;10(1):13753. Epub 2020 Aug 13.

Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.

The magnetic sphincter augmentation (MSA) device has been proven safe and effective in controlling typical reflux symptoms and esophageal acid exposure for up to 6-year follow-up. Longer term outcomes have not been reported yet. A prospectively maintained database was reviewed to assess long-term safety and efficacy of the laparoscopic MSA procedure at a single referral center. Gastro-Esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL), use of proton-pump inhibitors (PPI), and esophageal acid exposure were compared to baseline. Favorable outcomes were defined as ≥ 50% improvement of GERD-HRQL total score and PPI discontinuation. Between March 2007 and March 2020, 335 patients met the study inclusion criteria, and 124 of them were followed from 6 to 12 years after surgery (median 9 years, IQR 2). Mean total GERD-HRQL score significantly improved from 19.9 to 4.01 (p < 0.001), and PPI were discontinued by 79% of patients. The mean total percent time with pH < 4 decreased from 9.6% at baseline to 4.1% (p < 0.001), with 89% of patients achieving pH normalization. Independent predictors of a favorable outcome were age at intervention < 40 years (OR 4.17) and GERD-HRQL score > 15 (OR 4.09). We confirm long-term safety and efficacy of MSA in terms of symptom improvement, decreased drug dependency, and reduced esophageal acid exposure.
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http://dx.doi.org/10.1038/s41598-020-70742-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426413PMC
August 2020

Minimally invasive approach to esophageal lipoma.

J Surg Case Rep 2020 Jul 31;2020(7):rjaa123. Epub 2020 Jul 31.

University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, Milano, Italy.

Esophageal lipoma is a rare neoplasm with heterogeneous and sometimes life-threatening clinical presentation. We report the case of two patients, a 77-year-old man and a 69-year-old woman presenting with heartburn and dysphagia, and with recurrent vomiting and asphyxia, respectively. Upper gastrointestinal endoscopy and computed tomography were highly suggestive of the diagnosis of esophageal lipoma and identified an intramural and an intraluminal pedunculated mass originating, respectively, from the distal and the cervical esophagus. The first patient was treated by laparoscopic transhiatal enucleation and the second by transoral endoscopic resection under general anesthesia. Both had an uneventful postoperative course and were discharged home on postoperative day 2. Minimally invasive excision of esophageal lipoma is feasible and effective. It may be life-saving in patients with pedunculated tumors who suffer from intermittent regurgitation of a bulky polypoid mass in the mouth causing asphyxia.
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http://dx.doi.org/10.1093/jscr/rjaa123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394138PMC
July 2020

Ingestion of Caustic Substances.

N Engl J Med 2020 08;383(6):600

Saint-Louis Hospital, Paris, France.

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http://dx.doi.org/10.1056/NEJMc2019467DOI Listing
August 2020

Open versus minimally invasive total gastrectomy after neoadjuvant chemotherapy: results of a European randomized trial.

Gastric Cancer 2021 Jan 31;24(1):258-271. Epub 2020 Jul 31.

Department of Gastro-Intestinal Surgery, Amsterdam University Medical Center, Location VU University, De Boelelaan 1117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands.

Background: Surgical resection with adequate lymphadenectomy is regarded the only curative option for gastric cancer. Regarding minimally invasive techniques, mainly Asian studies showed comparable oncological and short-term postoperative outcomes. The incidence of gastric cancer is lower in the Western population and patients often present with more advanced stages of disease. Therefore, the reproducibility of these Asian results in the Western population remains to be investigated.

Methods: A randomized trial was performed in thirteen hospitals in Europe. Patients with an indication for total gastrectomy who received neoadjuvant chemotherapy were eligible for inclusion and randomized between open total gastrectomy (OTG) or minimally invasive total gastrectomy (MITG). Primary outcome was oncological safety, measured as the number of resected lymph nodes and radicality. Secondary outcomes were postoperative complications, recovery and 1-year survival.

Results: Between January 2015 and June 2018, 96 patients were included in this trial. Forty-nine patients were randomized to OTG and 47 to MITG. The mean number of resected lymph nodes was 43.4 ± 17.3 in OTG and 41.7 ± 16.1 in MITG (p = 0.612). Forty-eight patients in the OTG group had a R0 resection and 44 patients in the MITG group (p = 0.617). One-year survival was 90.4% in OTG and 85.5% in MITG (p = 0.701). No significant differences were found regarding postoperative complications and recovery.

Conclusion: These findings provide evidence that MITG after neoadjuvant therapy is not inferior regarding oncological quality of resection in comparison to OTG in Western patients with resectable gastric cancer. In addition, no differences in postoperative complications and recovery were seen.
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http://dx.doi.org/10.1007/s10120-020-01109-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7790799PMC
January 2021

Achalasia: what to do in the face of failures of Heller myotomy.

Ann N Y Acad Sci 2020 12 26;1481(1):236-246. Epub 2020 Jul 26.

Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea.

Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.
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http://dx.doi.org/10.1111/nyas.14440DOI Listing
December 2020

Three-year clinical experience with magnetic sphincter augmentation and laparoscopic fundoplication.

Surg Endosc 2020 Jul 16. Epub 2020 Jul 16.

Ethicon, Inc., Cincinnati, OH, USA.

Background: Magnetic sphincter augmentation (MSA) is a surgical intervention for gastroesophageal reflux disease (GERD) which has been evaluated in numerous studies and has shown beneficial effects. Long-term effectiveness data for MSA as well as laparoscopic fundoplication (LF) in patients with GERD are needed.

Objective: The objective of this study was to evaluate the 3-year outcomes for MSA and LF in patients with GERD.

Methods: This prospective, multi-center, observational registry study evaluated MSA and LF in clinical practice over 3 years (ClinicalTrials.gov identifier: NCT01624506). Data collection included baseline characteristics, reflux symptoms, medication use, satisfaction and complications. Post-surgical evaluations were collected at yearly intervals.

Results: Between December 2009 and December 2014, 631 patients (465 MSA and 166 LF) were enrolled in the registry. Both MSA and LF resulted in improvements in total GERD-HRQL score (mean reduction in GERD-HRQL from baseline to 3 years post-surgery: MSA 22.0 to 4.6 and LF 23.6 to 4.9) and in satisfaction (GERD-HRQL satisfaction increase from baseline to 3 years: MSA 4.6% to 78.2% and LF 3.7% to 76.5%). Most patients were able to belch as needed with both therapies (MSA 97.6% and LF 91.7% at 3 years). MSA allowed a higher percentage of patients the ability to vomit as needed (MSA 91.2% and LF 68.0% at 3 years). PPI usage declined from baseline to 3 years for both groups after surgery (MSA 97.8% to 24.2% and LF 95.8% to 19.5%). The mean procedure time was shorter for MSA than for LF. Intraoperative and procedure-related complication rates (≤ 2%) were low for both therapies.

Conclusions: This 3-year prospective observational registry study contributes to the mounting evidence for the effectiveness of MSA and LF. Despite the more severe nature of GERD in the LF group, the clinical outcomes for MSA and LF were favorable from an effectiveness and safety standpoint.
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http://dx.doi.org/10.1007/s00464-020-07792-1DOI Listing
July 2020

Retroperitoneoscopic drainage of cryptogenic psoas abscess.

BMJ Case Rep 2020 Jul 8;13(7). Epub 2020 Jul 8.

Department of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milano, Italy

Psoas abscess is a rare and occasionally life-threatening condition. In the past, the major cause of psoas abscess was a descending infection originating from spine tuberculosis (Pott's disease). Subsequently, secondary infection from spondylodiscitis or Crohn's disease has become the prevalent aetiology. Conventional treatment ranges from antibiotic therapy alone to CT-guided and/or surgical drainage. We present the case of a 67-year-old man with a complex history, including pneumonia, sepsis and previous muscle-skeletal trauma. The patient subsequently developed a psoas abscess that was successfully treated with a minimally invasive retroperitoneoscopic approach and antibiotics. Blood cultures and pus yielded Gram-positive sp, and transesophageal echocardiography identified endocarditis as a possible source of sepsis. Postoperative clinical course was complicated by recurrent sepsis that required a change of antibiotic therapy. The patient was eventually discharged to rehabilitation care without further complications. The retroperitoneoscopic approach is safe and effective for the treatment of cryptogenic psoas abscess.
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http://dx.doi.org/10.1136/bcr-2020-235579DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7348476PMC
July 2020

Clinical outcomes and quality of life associated with the use of a biosynthetic mesh for complex ventral hernia repair: analysis of the "Italian Hernia Club" registry.

Sci Rep 2020 07 1;10(1):10706. Epub 2020 Jul 1.

Azienda Ospedaliero-Universitaria, OCB (Ospedale Civile Baggiovara), Modena, Italy.

With the development of newer meshes and approaches to hernia repair, it is currently difficult to evaluate their performances while considering the patients' perspective. The aim of the study was to assess the clinical outcomes and quality of life consequences of abdominal hernia repairs performed in Italy using Phasix and Phasix ST meshes through the analysis of real-world data to support the choice of new generation biosynthetic meshes. An observational, prospective, multicentre study was conducted in 10 Italian clinical centres from May 2015 to February 2018 and in 15 Italian clinical centres from March 2018 to May 2019. The evaluation focused on patients with VHWG grade II-III who underwent primary ventral hernia repair or incisional hernia intervention with a follow-up of at least 18 months. Primary endpoints included complications' rates, and secondary outcomes focused on patient quality of life as measured by the EuroQol questionnaire. Seventy-five patients were analysed. The main complications were: 1.3% infected mesh removal, 4.0% superficial infection requiring procedural intervention, 0% deep/organ infection, 8.0% recurrence, 5.3% reintervention, and 6.7% drained seroma. The mean quality of life utility values ranged from 0.768 (baseline) to 0.967 (36 months). To date, Phasix meshes have proven to be suitable prostheses in preventing recurrence, with promising outcomes in terms of early and late complications and in improving patient quality of life.
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http://dx.doi.org/10.1038/s41598-020-67821-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329869PMC
July 2020

Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis.

J Neurogastroenterol Motil 2020 07;26(3):335-343

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, IRCCS Policlinico San Donato Milanese, Milano, Italy.

Background/aims: According to the Chicago classification version 3.0, high-resolution manometry (HRM) should be performed in the supine position. However, with the patient in the upright/sitting position, the test could more closely simulate real-life behavior and may be better tolerated. We performed a systematic review of the literature to search whether the manometric variables and the final diagnosis are affected by positional changes.

Methods: A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies published in English that compared HRM results in different body positions were included. Moreover, the change in diagnosis of esophageal motility disorders according to the shift of body position was investigated.

Results: Seventeen studies including 1714 patients and healthy volunteers met the inclusion criteria. Six studies showed a significant increase in lower esophageal sphincter basal pressure in the supine position. Integrated relaxation pressure was significantly higher in the supine position in 10 of 13 studies. Distal contractile index was higher in the supine position in 9 out of 10 studies. One hundred and fifty-one patients (16.4%) out of 922 with normal HRM in the supine position were diagnosed with ineffective esophageal motility (IEM) when the test was performed in the upright position ( < 0.001).

Conclusions: Performing HRM in the upright position affects some variables and may change the final manometric diagnosis. Further studies to determine the normal values in the sitting position are needed.
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http://dx.doi.org/10.5056/jnm20010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329148PMC
July 2020

Subtotal laparoscopic cholecystectomy for gangrenous gallbladder during recovery from COVID-19 pneumonia.

Int J Surg Case Rep 2020 13;72:335-338. Epub 2020 Jun 13.

University of Milan, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, Italy. Electronic address:

Introduction: Management of acute abdomen during COVID-19 pandemic may be challenging.

Presentation Of Case: A 42-year old man was hospitalized for Covid-19 pneumonia. Fever, respiratory symptoms and hypoxemia significantly improved over the next 2 weeks, but the patient developed abdominal pain, nausea, and low-grade fever. Computed tomography scan revealed absence of contrast enhancement of gallbladder wall and a micro-perforation of the fundus. At laparoscopy, gallbladder gangrene was confirmed and a subtotal cholecystectomy performed. Special precautions were adopted for patient transportation from the ward to a dedicated operating room, and two teams with adequate personal protective equipment took charge of the procedure. The patient was discharged home on postoperative day 7 under protective lockdown measures for 2 weeks.

Discussion: The pathogenesis of acute acalcolous gangrenous cholecystitis is multifactorial. It is unknown whether a prothrombotic state induced by COVID-19 contributes to wall ischemia and perforation. Percutaneous cholecystostomy should be avoided in patients with gallbladder gangrene. Contraindications to laparoscopy are not evidence-based since aerosolization is produced during both open and laparoscopic surgical procedures. However, personal protective equipment is key for prevention.

Conclusion: Early diagnosis and surgical therapy are critical in patients with gangrenous cholecystitis. Subtotal laparoscopic cholecystectomy for gangrenous gallbladder is safe and effective.
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http://dx.doi.org/10.1016/j.ijscr.2020.06.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293458PMC
June 2020

The Malnutrition Universal Screening Tool can predict malnutrition in patients with esophageal achalasia.

Eur J Gastroenterol Hepatol 2020 09;32(9):1135-1140

Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, Milano.

Background: At present, little research has been done to clarify why some achalasia patients do not lose weight or are even obese and to investigate their nutritional status. The aim of this study was to identify predictive factors of malnutrition in these patients and to assess their response to treatment.

Methods: We conducted a retrospective cohort study on consecutive patients referred to a tertiary-care center for laparoscopic or endoscopic treatment of achalasia. Demographics, anthropometric variables, presenting symptoms, and results of the objective investigation were recorded on a prospectively collected database. The severity of symptoms and the nutritional risk were assessed by the Eckardt score and the Malnutrition Universal Screening Tool (MUST), respectively, before and after treatment.

Results: Between 2013 and 2019, 171 patients met the study inclusion criteria. There were 87 (50.9%) male and the median age was 53.0 (39-66) years. The median Eckardt score was 6 (interquartile range 3). Based on the MUST score, 121 (70.8%) patients were classified at moderate/high risk of malnutrition. Of these, 93 (76.9%) were overweight or obese. Compared to low-risk group, predictive factors of moderate/high risk of malnutrition were higher Eckardt score [odds ratio (OR) 1.63; 95% CI, 1.35-1.99], more severe dysphagia (OR 2.68, 95% CI, 1.66-4.30), and greater absolute weight loss (OR 2.37; 95% CI, 1.77-3.17). The latter was the only independent predictive factor of malnutrition (OR 2.54; 95% CI, 1.69-3.82). After treatment, the measured MUST score was 0 in 96% of patients.

Conclusions: Over 70% of achalasia patients were at moderate/high risk of malnutrition. These individuals may benefit from a perioperative multidisciplinary approach including dietary intervention to stabilize weight and improve their nutritional status.
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http://dx.doi.org/10.1097/MEG.0000000000001798DOI Listing
September 2020

Gangrenous cholecystitis during hospitalization for SARS-CoV2 infection.

Updates Surg 2020 Sep 26;72(3):917-919. Epub 2020 May 26.

Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy.

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http://dx.doi.org/10.1007/s13304-020-00814-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249979PMC
September 2020

Clinical course of gastroesophageal reflux disease and impact of treatment in symptomatic young patients.

Ann N Y Acad Sci 2020 12 8;1481(1):117-126. Epub 2020 Apr 8.

Department of Surgery, University of Washington School of Medicine and VA Puget Sound Health Care System, Seattle, Washington.

In symptomatic young patients with gastroesophageal reflux symptoms, early identification of progressive gastroesophageal reflux disease (GERD) is critical to prevent long-term complications associated with hiatal hernia, increased esophageal acid and nonacid exposure, release of proinflammatory cytokines, and development of intestinal metaplasia, endoscopically visible Barrett's esophagus, and dysplasia leading to esophageal adenocarcinoma. Progression of GERD may occur in asymptomatic patients and in those under continuous acid-suppressive medication. The long-term side effects of proton-pump inhibitors, chemopreventive agents, and radiofrequency ablation are contentious. In patients with early-stage disease, when the lower esophageal sphincter function is still preserved and before endoscopically visible Barrett's esophagus develops, novel laparoscopic procedures, such as magnetic and electric sphincter augmentation, may have a greater role than conventional surgical therapy. A multidisciplinary approach to GERD by a dedicated team of gastroenterologists and surgeons might impact the patients' lifestyle, the therapeutic choices, and the course of the disease. Biological markers are needed to precisely assess the risk of disease progression and to tailor surveillance, ablation, and management.
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http://dx.doi.org/10.1111/nyas.14350DOI Listing
December 2020

Esophageal foreign bodies: observational cohort study and factors associated with recurrent impaction.

Eur J Gastroenterol Hepatol 2020 07;32(7):827-831

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato.

Background And Aim: Esophageal foreign bodies, including food bolus impaction, represent a common clinical problem. The prevalence of underlying esophageal disease depends on study design and degree of suspicion of a structural or functional esophageal abnormality. Aim of this study was to analyze factors associated with recurrent impaction.

Methods: The prospectively collected database at a University Hospital and Swallowing Center was reviewed from January 2012 to June 2019 to identify all patients admitted for esophageal foreign bodies. Patients who underwent an emergency endoscopic procedure represented the final study sample. Patient characteristics, including history of previous esophageal foreign bodies, and type of endoscopic procedure were collected.

Results: Sixty-five patients, 41 males and 24 females with a median age of 59 years, underwent emergency endoscopy for esophageal foreign bodies during the study period. Food bolus was the most common foreign body (n = 43, 66%). Flexible endoscopy was successful in retrieving or pushing the foreign bodies in the stomach in 91% of patients. In 54% of patients, impaction was secondary to an underlying esophageal disorder, which was previously unrecognized in half of them. Recurrent impaction was more common in patients with esophageal disease (P < 0.011). Surgical therapy was required in 4 patients (6.1%).

Conclusions: Food bolus impaction is a common sentinel event in patients with underlying esophageal disease and is associated with recurrent impaction. Diagnostic endoscopy with biopsies should possibly be performed at the first episode of impaction. Patients with negative biopsies should undergo barium swallow study and high-resolution esophageal manometry.
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http://dx.doi.org/10.1097/MEG.0000000000001717DOI Listing
July 2020

Laparoscopic Toupet fundoplication for gastroesophageal reflux disease and hiatus hernia: proposal for standardization using the "critical view" concept.

Updates Surg 2020 Jun 4;72(2):555-558. Epub 2020 Mar 4.

Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy.

Laparoscopic Toupet fundoplication has gained progressive consideration in the management of patients with gastroesophageal reflux disease and hiatus hernia. Previous studies showed equivalent results in terms of reflux control with lower rate of side effects compared to the Nissen fundoplication. However, multiple technical variations may account for the long-lasting reputation of decreased durability and poor long-term reflux control. Inspired by the "critical view" concept, a step-by-step laparoscopic Toupet fundoplication is described and illustrated. During the study period, 2012-2017, 348 consecutive patients underwent laparoscopic Toupet fundoplication according to a standardized procedure. A large hiatus hernia was present in 39% of patients, and 14% had volvulus of the intrathoracic stomach. Sixty-four (18.4%) patients had one or more previously failed antireflux procedures. The median follow-up was 37 months (range 12-61). The Gastroesophageal Reflux Disease Health-Related Quality of Life score significantly improved compared to baseline (p < 0.001), and 77% of patients were off proton-pump inhibitors. The proposed standardization of the Toupet fundoplication based on a "critical-view" concept may help to improve reproducibility, clinical outcomes, and teaching of this procedure.
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http://dx.doi.org/10.1007/s13304-020-00732-7DOI Listing
June 2020