Short and long term results of the laparoscopic Heller-Dor myotomy. The influence of age and previous conservative therapies.

AIMS: To evaluate the long-term outcome and quality of life (QoL) data, and to assess the potential influence of age and different conservative procedures on laparoscopic surgery. BACKGROUND: Current therapies for achalasia can palliate dysphagia, but other symptoms may persist, making it difficult to quantify and compare. To understand if they could influence results, we analyzed short- and long-term results and correlated them to age and previous conservative treatments using a specific QoL test. METHODS: Functional examinations (endoscopy, 24-hr pH manometry, upper GI X-rays) and the gastrointestinal quality of life index (GIQLI) were used before and after a laparoscopic Heller-Dor myotomy. Data were analyzed by the Mann-Whitney U test, Wilcoxon signed rank test, and Spearman's rho coefficient for bivariate correlations (p < 0.05). RESULTS: From January 1996 to January 2004, 31 consecutive patients out of 35 diagnosed with achalasia, in clinical stages I-III, were operated on by laparoscopy . Two groups were identified using the break point of 70 years of age, (20 younger and 15 older) and two subgroups according to the conservative therapy performed (20, none; 15, some). Patients underwent a clinical manometry evaluation at six and 12 months, and then yearly, and pH-metry at six, 24, and 60 months. In 78% of patients dysphagia disappeared and the incidence of reflux was 13%. Age and previous treatments did not influence surgical outcome. Patients completed a GIQLI questionnaire before surgery, six months after surgery, and then yearly (for five years). The median preoperative GIQLI score was 78 (range 38-109) out of a theoretical maximum score of 144. At a median follow-up of 49 months (range 24-72 months), the score had significantly improved to 115 (range 71-140). There was no significant statistical difference between the groups. CONCLUSIONS: Laparoscopic Heller-Dor myotomy is an effective palliation for achalasia; the long-term outcome is not significantly affected by preoperative conservative treatments or by the age of the patients. The GIQLI questionnaire is a reliable instrument to compare the impact of achalasia symptoms on health-related QoL before and after surgery.

[Timing and results of the surgical treatment of the diverticular disease of the colon]. / Timing e risultati della terapia chirurgica della malattia diverticolare del colon.

AIMS: To evaluate retrospectively the outcome of the curative open and laparoscopic surgical approach to the diverticular disease according to timed steps based on the pathologic stage. PATIENT AND MATERIAL: From 1989 83 out of 242 outpatients underwent surgery in emergency or after medical failure and at least two acute attacks requiring hospital admittance, or complicated diverticulitis. Modified Hinchey classification staged the disease. Clinic and instrumental criteria, surgical procedures, early and late complications were statistically evaluated (Students t-test and exact Fischer test, p < 0.05) in comparison with the different steps of therapeutic strategy. RESULTS: Twenty nine patients were classified as Hinchey 0, 26 as I, 14 as II, 11 as III, 3 as IV. Clinical characteristics of the lap and open groups overlapped, with higher rate of earlier age in first and advanced stages in the second group. 16 patients (19.3%) underwent surgery at the first attack in emergency or in delayed emergency (5 TC-guided drainages). 30 open and 53 lap procedures were done: 21 two-stage: 18 primary resections + ileostomy and 3 Hartmann; 61 single stage: 49 sigmoidectomy, 12 left colectomy. 4 conversions (7.5%), 12 early (14.5%) and 10 late (12.1%) complications were observed. DISCUSSION: Complications rate was higher in the open group including more advanced stages. Elective surgery performed following conservative therapy, 4 weeks from the first acute attack in younger people (age < 55yrs.) and after two attacks in elder (age > 55yrs.) showed a significant lower complications' incidence (p < 0.05) compared to the 8 weeks delayed operations. CONCLUSION: Surgery of diverticulitis must follow standardized criteria. The laparoscopic approach could be performed in more severe stages, provided that conditions of delayed emergency were achieved.

[Sacral neuromodulation in fecal continence disorders]. / La neuromodulazione sacrale nei disturbi della continenza fecale.

The therapeutic approaches to the impairments of the faecal continence not depending from organic lesions of the anal sphincters or the pelvic floor are often unsuccessful, particularly as far as long distance outcome is concerned. The direct setting to the sacral roots of a magnetic stimulation modulating the reflex activity of the Autonomic Nervous System, firstly applied successfully by the urologist in the bladder incontinence, could correct indefinitely the effects of such a defect implying also a social cost in terms of quality of life and linen clothes expenses. Here details of the Interstim, Medtronic devices are reported, discussing the instrumental and clinical indications and the steps of the protocol of its application, in agreement with the Italian Group of Sacral Neuromodulation (GINS), as well as the most recent data of the literature and the early results of our own experience in the treatment of faecal incontinence. It is stressed the aspect of "work in progress" peculiar to this technique, as clearly shows the difficulty to explain the pathway with which neuromodulation effects on anal sphincters and pelvic floor, and moreover on the colorectal motility, as some ongoing applications to patients with refractory constipation seems to evidence. Data of a long standing follow-up are not yet available but the early and intermediate results are in the main successfully in terms of complete recovery or improvement as clearly show both clinical evidence and subjective evaluation assessing the Quality of Life.