prof. alberto del genio hon. oeso, facs professore emerito di chirurgia seconda università degli...
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Prof. ALBERTO DEL GENIO Hon. OESO, FACSProfessore Emerito di Chirurgia Seconda Università degli Studi di Napoli
RECENTI ACQUISIZIONI DI FISIOPATOLOGIA ESOFAGEA
ENDOSCOPIC PRESSURE OF THE WRAP
TOUPETDORNISSEN
Del Genio A
Low HPZ
360° HPZ
Tight wrapFloppy wrap
Total wrapPartial wrap
High HPZ
portion of HPZ
Resting pressure range 20-40mmHg
“SINCE 1972 STANDARDIZED
TECHNIQUE”
LENGHT OFTHE WRAP (2-3 CM)
ANTERIOR FUNDUS
PRESERVATION OF VAGAL BRANCHESAND LESSER OMENTUM
WIDE TRANSHIATALMINIMAL RETROESOPHAGEAL
PRESERVATION SGV
6
HIGH RESOLUTION COMBINED MANOMETRY AND IMPEDANCE (HR-MII)HIGH RESOLUTION COMBINED MANOMETRY AND IMPEDANCE (HR-MII)
INTRAOPERATIVE CONTROL
ESOFAGEAL MOBILIZATION
+ IATOPLASTY+ IATOPLASTY
IATOPLASTY + FIRST STICH NISSEN-
ROSSETTI
IATOPLASTY + SECOND STICH
NISSEN-ROSSETTI
DISTANCE BETWEEN CRURA AND WRAPIATOPLASTY
CORRECTELY FASHIONED FUNDOPLICATIO
IATOPLASTY
Number 524
Male 307
Female 217
M/F 0.96 : 1
Median age 42.3
Age Range 17-78
Nissen-Rossetti Fundoplication
Personal Experience
(Feb 1992 -Nov 2007)
Del Genio, Febbraio 2010
•Hospital stay: 2.3 ± 0.9 days •Mortality: 0• Intraoperative mucosal injuries: 1/524 (0.2%)• Conversions: 1/524 (0.2%)• Early Complications
1 pt (0.2%): esophageal perforation (laparotomy + drainage in II p.o. day)
1 pt (0.2%): splenic injury (splenectomy in I p.o. day)
3 pts (0.4%): hemorrage (reintervention via laparoscopy in
2 pts and via laparotomy in 1 pt)
Peri-operative Results
Del Genio, Febbraio 2010
Autor N pts
FU Success (%)
Morbidity (%)
Mortality (%)
Cowgill ‘07 829 10 aa 80 1.5 0.2
Salminen ’07 49 11 aa 81.8 13.2 0
Lundell ’07 99 7 aa 92.1 2.4 0
Zaninotto ’07 399 6-10 aa 74 5.2 0
Morgenthal ’07
312 11 aa 93.3 - 0
Rosenthal ’06 186 10 aa 82 13 0
Del Genio ‘07 380 7aa 92.6 1.1 0
GERD – Long-term results outcomes from recent series
DEL GENIO WORLD J SURG 2007
META-ANALISI di 9 studi randomizzati (4 Nissen vs Toupet e 5 Nissen/Toupet vs Dor)
better reflux control after Nissen fundoplication
it has been consistently shown that tailoring antireflux surgery according to esophageal motility is not indicatedthere is significance evidence that anterior fundoplication offers less effective long-term reflux control
GERD
POSTOPERATIVE MANOMETRY
PROGRESSION OF THE BOLUS AT IMPEDANCE
PERISTALSIS
NORMAL WRAPRELAXATION
U.E.S.
HIGH RESOLUTION MANOMETRY AND IMPEDANCE (HRiM)HIGH RESOLUTION MANOMETRY AND IMPEDANCE (HRiM)
LES + CRURA
POSTOPERATIVE NISSEN-ROSSETTI
NORMAL WRAPRELAXATION
RESULTS: HRiM
PRE POST
HRiM: LIQUID SWALLOW
HRiM: VISCOUS SWALLOW
Pizza, Del Genio et al. Dis Esoph 2008
INFLUENCE OF ESOPHAGEAL MOTILITY ON LARS SURGERY
6 m FW-UP 330/406 (81%) 12m FW-UP 276/406 (68%)24m FW-UP 260/406 (65%) 48m FW-UP 206/406 (53%)
MANOMETRY
LES PRESSURE
Pizza, Del Genio et al. Dis Esoph 2008
INFLUENCE OF ESOPHAGEAL MOTILITY ON LARS SURGERY
6 m FW-UP 330/406 (81%) 12m FW-UP 276/406 (68%)24m FW-UP 260/406 (65%) 48m FW-UP 206/406 (53%)
MANOMETRY
PERISTALSIS
BOLUS TOTAL TRANSIT TIME (sec.) at HRiM
Del Genio et al. J CLIN GASTROENT 2012
IMPEDANCE
p=N.S.
p=N.S.
p=N.S.Del Genio et al. Eur Surg Res 2007
PERISTALSI SECONDARIA (CLEARANCE)
POSTOPERATIVE PH-MONITORING
AND COMBINED PH-IMPEDANCE
(MII-PH)
Del Genio G et al, World J Surg 2007
standard Ph-MONITORING
Del Genio G et al. Surg Endosc 2008Del Genio G et al. Dis Esophag 2009Del Genio G. et al. Gastroenterol 2010
PH-IMPEDANCE MONITORING
Del Genio G et al. Surg Endosc 2008Del Genio G et al. Dis Esophag 2009Del Genio G. et al. Gastroenterol 2010
PH-IMPEDANCE MONITORING
POSTOPERATIVE OUTCOMES ON PHARYNGEAL REFLUX
PH-IMPEDANCE MONITORING
Tolone, Del Genio. U Surg 2012
SELEZIONE
““IMPEDANCE DRIVEN ANTIREFLUX SURGERY”IMPEDANCE DRIVEN ANTIREFLUX SURGERY”
2010
… ALLORA QUANTO CAMBIA
L’INDICAZIONE ALLA
CHIRURGIA?
Alberto del GenioAlberto del Genio
MII-pH allows identification of 40% of pz with GERD with a
NEGATIVE standard pH-monitoring
COMBINED 24 HOUR PH-IMPEDANCE COMBINED 24 HOUR PH-IMPEDANCE
Del Genio G et al, J Gastrintest Surg 2008
Ref #164, #170, #235
HELLER NISSEN-ROSSETTI
CONCLUSIONCONCLUSION
LA CHIRURGIA FUNZIONALE NON PUO’ PRESCINDERE DA UNA ATTENTO STUDIO FISIOPATOLOGICO. QUESTO VALE SIA PER LA SELEZIONE DEI PAZIENTI CHE PER IL CONTROLLO DELLA CORRETTA FUNZIONE DELL’INTERVENTO NEL TEMPO.
GLI STUDI DI CHIRURGIA FUNZIONALE HANNO A LORO VOLTA COSTITUITO UN VALIDO MODELLO PER UNA AVANZAMENTO DELLA CONOSCENZA DELLA FISOLOGIA E DELLA FISIOPATOLOGIA.