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Early suspicion, diagnosis, and timely treatment of anastomotic leak after esophagectomy is essential. Retrospective studies have investigated the role of C-reactive protein (CRP) as early marker of anastomotic leakage. The aim of this systematic review and meta-analysis was to evaluate the predictive value of CRP after esophageal resection. A literature search was conducted to identify all reports including serial postoperative CRP measurements to predict anastomotic leakage after elective open or minimally invasive esophagectomy. Fully Bayesian meta-analysis was carried out using random-effects model for pooling diagnostic accuracy measures along with CRP cut-off values at different postoperative day. Five studies published between 2012 and 2018 met the inclusion criteria. Overall, 850 patients were included. Ivor-Lewis esophagectomy was the most common surgical procedure (72.3%) and half of the patients had squamous-cell carcinoma (50.4%). The estimated pooled prevalence of anastomotic leak was 11% (95% CI = 8-14%). The serum CRP level on POD3 and POD5 had comparable diagnostic accuracy with a pooled area under the curve of 0.80 (95% CIs 0.77-0.92) and 0.83 (95% CIs 0.61-0.96), respectively. The derived pooled CRP cut-off values were 17.6 mg/dl on POD 3 and 13.2 mg/dl on POD 5; the negative likelihood ratio were 0.35 (95% CIs 0.096-0.62) and 0.195 (95% CIs 0.04-0.52). After esophagectomy, a CRP value lower than 17.6 mg/dl on POD3 and 13.2 mg/dl on POD5 combined with reassuring clinical and radiological signs may be useful to rule-out leakage. In the context of ERAS protocols, this may help to avoid contrast radiological studies, anticipate oral feeding, accelerate hospital discharge, and reduce costs.

IntroductionLaparoscopic sleeve gastrectomy (LSG) has rapidly become popular with excellent results. However, LSG may exacerbate or increase the risk of “de novo” gastroesophageal reflux disease (GERD). Adding a fundoplication has been proposed to increase the lower esophageal sphincter competency. The aim of this study was to examine the current evidence and outcomes of sleeve-fundoplication (Sleeve-F).Materials and MethodsSystematic review and meta-analysis. Web of Science, PubMed, and Embase data sets were consulted.ResultsSix studies (485 patients) met the inclusion criteria. The age of the patient population ranged from 17 to 72 years old and 82% were females. All patients underwent sleeve-fundoplication. Rossetti, Collis-Nissen, and Nissen were the most commonly performed fundoplications. The estimated pooled prevalence of postoperative leak, gastric perforation, and overall complications were 1.0% (95% CI = 0.0–2.0%), 2.9% (95% CI = 0.0–8.3%), and 9.8% (95% CI = 6.7–13.4%), respectively. The pooled reoperation rate was 4.1% (95% CI = 1.3–10%). There was no mortality. At 12-month follow-up, the estimated pooled BMI and %EWL were 29.9 kg/m2 (95% CI = 28.5–31.2) and 66.2% (95% CI = 59.3–71.1), respectively, while esophagitis, PPI consumption, and GERD rates were 8.0% (95% CI 3–21%), 7.8% (95% CI 5–13%), and 11% (95% CI 4–26%).ConclusionsThis systematic review and meta-analysis shows that current evidence for Sleeve-F is limited with high postoperative gastric perforation and overall complication rates. Weight loss and GERD resolution seem promising in the short term; however, further studies are warranted to explore long-term effects with instrumental investigations. Sleeve-F should be considered cautiously while future well-structured randomized trials are warranted.

Background This study aims to evaluate the 12–24-month impact of bariatric surgery on the foremost modifiable traditional risk factors of cardiovascular disease. Methods A systematic review and meta-analysis of prospective interventional studies reporting the most commonly performed laparoscopic surgical procedures, i.e., Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and cardiovascular risk reduction after surgery. Results The bibliographic research conducted independently by two authors yielded 18 records. When looking at RYGB and AGB separately, we observed a relevant heterogeneity ( I 2 index ≥87 %) when BMI reduction was considered as the main outcome. When hypertension, type II diabetes, and hyperlipidemia risk reduction was estimated, a highly significant beneficial effect was found. The risk reduction was 0.33 [0.26; 0.42] for type II diabetes, 0.52 [0.42; 0.64] for hypertension, and 0.39[0.27; 0.56] for hyperlipidemia ( P  < 0.0001 for all outcomes considered). When looking at surgical technique separately, a higher but not statistically significant risk reduction for all outcomes considered was found. Results from the meta-regression approach showed an inverse relation between cardiovascular risks and BMI reduction. Conclusions The present study showed an overall reduction of cardiovascular risk after bariatric surgery. According to our analysis a BMI reduction of 5 after surgery corresponds to a type II diabetes reduction of 33 % (as reported by Peluso and Vanek (Nutr Clin Pract 22(1):22–28, 2007 ); SAS Institute Inc., ( 2000 –2004)), a hypertension reduction of 27 % (as reported by Buchwald and Oien (Obes Surg 23(4):427–436, 2013 ); Valera-Mora et al. (Am J Clin Nutr 81(6):1292–1297, 2005 )), and a hyperlipidemia reduction of 20 %(as reported by Adams et al. (JAMA 308(11):1122–31, 2012 )); Alexandrides et al. (Obes Surg 17(2):176–184, 2007 ). In summary, our study showed that laparoscopic bariatric surgery is an effective therapeutic option to reduce the cardiovascular risk in severe obese patients.

BackgroundThe Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures for surgical weight loss. It has been shown that overweight may be associated with an increased risk of gastric cancer. However, the risk of remnant gastric cancer after RYGB has not been defined yet and the development of neoplasm in the excluded stomach remains a matter of concern.MethodsPubMed, EMBASE, and Web of Science databases were consulted. Articles that described the diagnosis and management of remnant gastric cancer after RYGB were considered.ResultsSeventeen patients were included. The age of the patient population ranged from 38 to 71 years. The most commonly reported symptoms were abdominal pain, nausea/vomiting, and anemia. Abdominal computed tomography was used for diagnosis in the majority of patients. The neoplasm was located in the antrum/pre-pyloric region in 70% of cases and adenocarcinoma was the most common tumor histology (80%). An advanced tumor stage (III–IV) was diagnosed in almost 70% of patients and 40% were considered unresectable. Gastrectomy with lymphadenectomy was performed in 9 cases (53%). Post-operative morbidity was 12%. The follow-up ranged from 3 to 26 months and the overall disease-related mortality rate was 33.3%.ConclusionThe development of remnant gastric cancer after RYGB is rare. Surgeons should be aware of this potential event and the new onset of epigastric pain, nausea, and anemia should raise clinical suspicion. Further epidemiologic studies are warranted to deeply investigate the post-RYGB-related risk of remnant gastric cancer development in high-risk populations.

Background The effect of laparoscopic Toupet fundoplication (LTF) for the treatment of laryngopharyngeal reflux (LPR) is unclear. The purpose of this study is to investigate the feasibility and effectiveness of LTF for the treatment of LPR-related symptoms and disease-specific quality of life (QoL) up to 3-year follow-up. Materials and methods Observational cohort study (2015–2019). Patients suffering from LPR were included. Preoperative evaluation included esophagogastroduodenoscopy, esophageal manometry and 24-h pH/impedance study. Symptoms and QoL were measured with the reflux symptom index (RSI) and the laryngopharyngeal reflux–health-related quality of life (LPR–HRQL) validate questionnaires at baseline and during follow-up. Results Eighty-six patients were included. Twenty-three (27%) patients had pure LPR while 63 (73%) presented with combined LPR/GERD. Cough (89.7%), dyspnea/choking (39.6%) and asthma (25.6%) were the most commonly reported extraesophageal symptoms. The median (interquartile range, IQR) total RSI score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 36.1 (10.3), 9.58 (12.3), 11.8 (10.2), 12.4 (9.6), 12.0 (13.1) and 10.1 (12.0), respectively. The median (IQR) total LPR–HRQL score before operation and at 3-month, 6-month, 1-year, 2-year and 3-year follow-up was 57.4 (22.2), 13.4 (14.9), 15.2 (12.8), 11.4 (10.9) and 11.9 (13.5), respectively. The subscores “voice,” “cough,” “throat” and “swallow” showed a significant improvement after intervention. Compared to baseline, each per-year follow-up pairwise comparison was significantly improved ( p  < 0.001). Conclusions LTF seems feasible, effective and promising for the treatment of LPR with improved symptoms and disease-specific patients’ quality of life perception up to 3-year follow-up.

PurposeEsophageal dysmotility and disorders of the lower esophageal sphincter are well documented in morbidly obese patients. Esophageal achalasia has been reported in up to 1% of obese patients but the development of such esophageal motility disorder after laparoscopic sleeve gastrectomy (LSG) is extremely rare. The purpose of this video was to demonstrate the management of a type II esophageal achalasia diagnosed in a 46-year-old female patient 4-year after LSG.Materials and MethodsAn intraoperative video has been anonymized and edited to demonstrate the feasibility of laparoscopic Heller myotomy and anterior Dor fundoplication on the mentioned patient.ResultsThe operation started with the section of the perigastric adhesions. Proceeding in a clockwise direction, the esophagogastric junction, the anterior esophageal wall, and the His angle were freed. A residual slightly dilated fundus was found and isolated. After mobilization of the distal esophagus and identification of the anterior vagus nerve, a “hockey stick” myotomy was carried out for 6 cm on the esophagus and for 2 cm on the gastric side. An anterior Dor fundoplication was fashioned using the residual gastric fundus.ConclusionEsophageal achalasia in patients that previously underwent LSG is exceptional but should always be suspected in case of pathognomonic symptoms onset. In tertiary referral centers, laparoscopic Heller myotomy and, if technically feasible, an anterior Dor fundoplication seem safe and effective to relieve gastroesophageal outflow obstruction and prevent gastroesophageal reflux.

IntroductionThe development of achalasia after Roux-en-Y gastric bypass (RYGB) is rare. Heller myotomy (HM) is the gold standard treatment while peroral endoscopic myotomy (POEM) is an emerging technique with promising results. The aim of this narrative review was to summarize the current knowledge on the treatment of esophageal achalasia after RYGB.MethodsPubMed, EMBASE, and Web of Science databases were consulted. All articles that described the management of achalasia after RYGB were included in this narrative review.ResultsTwelve studies for a total of 28 patients were included. The age of the patient population ranged from 44 to 70 years old and 80% were females. Overall, 61.5% underwent laparoscopic RYGB while 38.5% underwent open RYBG. The elapsed time from the RYGB to myotomy ranged from 14 months to 14 years. Dysphagia (64%) and regurgitation (60.7%) were the most commonly reported symptoms; type I achalasia was diagnosed in 50% of patients. Surgical HM was performed in 17 patients (61%) while POEM was performed in 11 patients (39%). Postoperative morbidity was 3.6% with no differences comparing surgical HM and POEM (6% vs. 0%, p = 0.43). The follow-up time ranged from 1 to 43 months. The overall recurrence rate requiring reoperation was 7% with no differences comparing surgical HM and POEM (12% vs. 0%; p = 0.25).ConclusionBoth HM and POEM seem feasible, safe, and effective in the management of achalasia after RYGB. The role of POEM in the management algorithm of these patients should be further evaluated.

Introduction: Appendiceal neuroendocrine neoplasms (aNENs) are the most common malignant appendiceal neoplasms. Localized aNENs are typically managed with an appendectomy; however, right colectomy may be necessary in patients with a high risk of nodal disease. However, the role of right hemicolectomy and the optimal surveillance strategy, particularly for tumors between 1 and 2 cm, remains controversial. Material and Methods: This retrospective, observational study evaluated patients diagnosed with aNENs between January 1995 and July 2015 at two tertiary centers in Ireland and Italy. Data were extracted from a prospectively maintained registry and included clinical, pathological, and therapeutic variables, as well as follow-up outcomes. Results: Forty-three patients (41.8% male; median age 27.5 years) were included, with a median follow-up of 49 months. The median tumor size was 6.4 mm (range: 0.6–40 mm). The majority were G1 tumors (58%), and staging distribution was predominantly Stage I (60%). While no significant differences in demographics or tumor features were observed between centers, completion right hemicolectomies were more frequent in the Irish cohort (p = 0.04). Follow-up practices varied, with more intensive imaging and biochemical monitoring observed in the Italian cohort. Overall prognosis was excellent, with a single case of recurrence during the study period. Conclusions: Most aNENs are effectively managed with appendectomy alone, and routine follow-up may be unnecessary in the absence of adverse pathological features. Accurate risk stratification, driven by comprehensive histopathological assessment, is critical for optimizing management and surveillance strategies.

Background Foreign body (FB) impaction accounts for 4% of emergency endoscopies in clinical practice. Flexible endoscopy (FE) is recommended as the first-line therapeutic option because it can be performed under sedation, is cost-effective, and is well tolerated. Rigid endoscopy (RE) under general anesthesia is less used but may be advantageous in some circumstances. The aim of the study was to compare the efficacy and safety of FE and RE in esophageal FB removal. Methods PubMed, MEDLINE, Embase, and Cochrane databases were consulted matching the terms “Rigid endoscopy AND Flexible endoscopy AND foreign bod*”. Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I 2 index and Cochrane Q test. Results Five observational cohort studies, published between 1993 and 2015, matched the inclusion criteria. One thousand four hundred and two patients were included; FE was performed in 736 patients and RE in 666. Overall, 101 (7.2%) complications occurred. The most frequent complications were mucosal erosion (26.7%), mucosal edema (18.8%), and iatrogenic esophageal perforations (10.9%). Compared to FE, the estimated RE pooled success OR was 1.00 (95% CI 0.48–2.06; p  = 1.00). The pooled OR of iatrogenic perforation, other complications, and overall complications were 2.87 (95% CI 0.96–8.61; p  = 0.06), 1.09 (95% CI 0.38–3.18; p  = 0.87), and 1.50 (95% CI 0.53–4.25; p  = 0.44), respectively. There was no mortality. Conclusions FE and RE are equally safe and effective for the removal of esophageal FB. To provide a tailored or crossover approach, patients should be managed in multidisciplinary centers where expertise in RE is also available. Formal training and certification in RE should probably be re-evaluated.

Background and Objectives: Gastric neuroendocrine neoplasms (gNENs) represent rare but increasingly recognized tumors. They are distinguished into three main clinical types (type-1, type-2, and type-3) according to gastrin level and at histological evaluation in well-differentiated G1, G2, or G3 lesions, as well as poorly-differentiated lesions. Small type-1 and type-2 neoplasms with low proliferation indices demonstrated excellent survival without progression during an extended follow-up period, and for these reasons, active endoscopic observation or endoscopic resection are feasible options. On the other hand, surgery is the treatment of choice for more aggressive type-3, G3, or infiltrating neoplasms. The present study aims to comprehensively review and compare the available therapeutic strategies for gNENs. Materials and Methods: A computerized literature search was performed using relevant keywords to identify all of the pertinent articles with particular attention to gNEN endoscopic treatment. Results: In recent years, different endoscopic resective techniques (such as endoscopic mucosal dissection, modified endoscopic mucosal resection, and endoscopic full-thickness resection) have been developed, showing a high rate of complete resection for advanced and more aggressive lesions. Conclusions: Overall, gNENs represent a heterogeneous group of lesions with varying behavior which require personalized management. The non-operative approach for small type-1 gNENs seems to be feasible and should be promoted. A step-up approach with minimally invasive endoscopic therapies might be proposed, particularly for type-1 gNEN. On the other hand, it is important to recognize the negative prognostic factors in order to identify those rare cases requiring more aggressive approaches. A possible therapeutic algorithm for localized gNEN management is provided.