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.