INTRODUCTION Gastro-esophageal reflux disease (GERD) is increasingly common worldwide, with a prevalence in Western countries between 10 and 30% of the population. Prevalence could be even underestimated as only typical symptoms (heartburn and regurgitation) are considered in epidemiological studies. At present no questionnaire is universally accepted as the benchmark. Herein we propose a new 15-item questionnaire, named RoRex (Rovereto Reflux), which is intended to be both complete as it considers both typical, atypical and extra-esophageal symptoms, easy to understand, and as objective as possible as it assesses symptom frequency on a numeric scale rather than perceived severity. AIM To validate the RoRex questionnaire. METHODS The RoRex questionnaire was administered via web from April 2021 to October 2023 to volunteers and patients attending specialized gastrointestinal surgical units in two Italian centres, Rovereto (Trento) and Verona. Each individual answered a RoRex version in scientific jargon and in plain language, and two already validated questionnaires, RSI and GERD-HQRL. Internal consistency was assessed by Cronbach’s alpha, questionnaire dimensions were evaluated by exploratory and confirmatory factor analysis, and item responses were related to subjects’ characteristics. RESULTS 213 individuals (149 patients and 64 volunteers) answered the questionnaire. Of these, 60 patients and 29 volunteers were recruited in Rovereto, while 89 patients and 35 volunteers were recruited in Verona. In the exploratory factor analysis (EFA), two factors (esophageal and extra-esophageal symptoms) were identified which accounted for 97.7% and 94.1% of the total variance of the scientific or plain language versions, respectively (Kaiser–Meyer–Olkin [KMO] statistic = 0.9015 form normal item and 0.8803 for easy item). For the plain language version, overall Cronbach’s α of the questionnaire was 0.89, indicating good internal consistency; in detail, Cronbach's α was equal to 0.87 for factor 1 and 0.85 for factor 2. We evaluated the factor correlation matrix of the final exploratory factor analysis to be verified discriminant validity. The correlation between factor 1 and factor 2 was 0.546. The confirmatory factor analysis (CFA) yield similar results. CONCLUSION The RoRex questionnaire seems to be an easy clinical tool, useful to diagnose GERD and evaluate therapy effectiveness, whether medical or surgical.

Background Achalasia is a rare progressive disease for which longitudinal outcomes and optimal follow-up remain poorly defined. We assessed longitudinal reintervention, symptom palliation, and esophageal emptying after Heller myotomy performed in more than 1000 patients over a 25-year period. Methods Between January 1, 1995, and January 1, 2020, a total of 1010 adults underwent Heller myotomy at Cleveland Clinic. The operation was minimally invasive in 937 (93%) patients, with Dor fundoplication in 838 (92%). Esophageal emptying was assessed by timed barium esophagram (TBE), and symptoms were quantified by Eckardt score. Multiphase mixed-effects models and Kaplan-Meier analysis were used to estimate longitudinal symptom palliation, esophageal emptying, and reintervention (pneumatic dilation ≥30 mm, per-oral endoscopic myotomy, repeat Heller myotomy, or esophagectomy). Results Freedom from any reintervention was 75% and freedom from esophagectomy was 96.8% at 10 years postmyotomy. The risk of reintervention was greatest during the first year, with 1 reintervention portending additional reintervention(s). Severe recurrent symptoms were rare, with a probability of freedom from severe dysphagia (daily or every meal) of 74% and probability of an Eckardt score ≤3 of 68% at 10 years. The probability of complete TBE emptying was 55% immediately postmyotomy and decreased to 24% by 10 years. Conclusions Heller myotomy provides long-term symptom palliation and esophageal emptying for patients with achalasia, with a gradually increasing risk of reinterventions over time, highlighting the importance of initial annual follow-up. After 3 years, the follow-up interval may be increased to every 3 years when symptom relief and esophageal emptying remain stable. These findings provide a long-term benchmark for future therapies.

Journal Article Nerve-preserving gracilis transposition and onlay mesh for total abdominal wall functional reconstruction Get access Alessandro Carrara, Alessandro Carrara Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Correspondence to: Alessandro Carrara, Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Corso Verona 4, 38068 Rovereto (Tn)), Italy (e-mail: alessandro.carrara@apss.tn.it) https://orcid.org/0000-0002-9508-335X Search for other works by this author on: Oxford Academic Google Scholar Giovanni Scudo, Giovanni Scudo Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy https://orcid.org/0000-0002-4490-6539 Search for other works by this author on: Oxford Academic Google Scholar Enrico Lauro, Enrico Lauro Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy https://orcid.org/0000-0001-7494-4395 Search for other works by this author on: Oxford Academic Google Scholar Marinella Menegazzo, Marinella Menegazzo Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar Matteo Rivelli, Matteo Rivelli Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar Luca Felicioni, Luca Felicioni Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) Public Hospital, Arco, Italy Search for other works by this author on: Oxford Academic Google Scholar Simone Zanella, Simone Zanella Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar Andrea Zanoni, Andrea Zanoni Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar Enzo Bonadies, Enzo Bonadies Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar Cristian Mazzetti, Cristian Mazzetti Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar ... Show more Federico Accordini, Federico Accordini Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar Valentina Mari, Valentina Mari Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar Daniele Scerrati, Daniele Scerrati Department of General Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar Fabrizio Cortese Fabrizio Cortese Department of Orthopaedic Surgery, APSS (Azienda Provinciale per i Servizi Sanitari Provincia Autonoma di Trento) St Maria Del Carmine Hospital, Rovereto, Italy Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 111, Issue 2, February 2024, znae040, https://doi.org/10.1093/bjs/znae040 Published: 20 February 2024 Article history Received: 27 November 2023 Accepted: 15 January 2024 Published: 20 February 2024

In the presence of great uncertainty and volatility, the valuation of single assets or enterprises can be extremely complicated. Over the last few years, the European Securities and Market Authority (ESMA) has analyzed the potential impacts of these uncertainties on the application of the Impairment of Assets (IAS 36) accounting standards and exhorted firms adopting the IAS/IFRS accounting standards to consider multiple scenarios in forecasting information. This study, adopting a theoretical and conceptual perspective, aimed to analyze the theoretical and practical implications of the shift from single-path to multiple-scenario analysis. This paper contributes to the literature in the following ways: first, it suggests a new perspective of analysis that combines valuation needs with a strategic approach (a robust strategy). Second, it contributes to clarifying the antecedents and consequences of the ESMA recommendations. Furthermore, the paper also has practical implications as it highlights some critical issues associated with every valuation process, including the need to cope with growing uncertainty, the necessity of clarifying the great misunderstanding related to the confusion between the multiple-scenario valuation method and sensitivity analysis, and, last but not least, the importance of the relationship between strategy and the valuation process.

(1) Background: To explore the impact of the degree of inflammation on voriconazole exposure in critically ill patients affected by COVID-associated pulmonary aspergillosis (CAPA); (2) Methods: Critically ill patients receiving TDM-guided voriconazole for the management of proven or probable CAPA between January 2021 and December 2022 were included. The concentration/dose ratio (C/D) was used as a surrogate marker of voriconazole total clearance. A receiving operating characteristic (ROC) curve analysis was performed by using C-reactive protein (CRP) or procalcitonin (PCT) values as the test variable and voriconazole C/D ratio > 0.375 (equivalent to a trough concentration [C-min] value of 3 mg/L normalized to the maintenance dose of 8 mg/kg/day) as the state variable. Area under the curve (AUC) and 95% confidence interval (CI) were calculated; (3) Results: Overall, 50 patients were included. The median average voriconazole C-min was 2.47 (1.75-3.33) mg/L. The median (IQR) voriconazole concentration/dose ratio (C/D) was 0.29 (0.14-0.46). A CRP value > 11.46 mg/dL was associated with the achievement of voriconazole C-min > 3 mg/L, with an AUC of 0.667 (95% CI 0.593-0.735; p < 0.001). A PCT value > 0.3 ng/mL was associated with the attainment of voriconazole C-min > 3 mg/L (AUC 0.651; 95% CI 0.572-0.725; p = 0.0015). (4) Conclusions: Our findings suggest that in critically ill patients with CAPA, CRP and PCT values above the identified thresholds may cause the downregulation of voriconazole metabolism and favor voriconazole overexposure, leading to potentially toxic concentrations.

Objectives: Therapeutic drug monitoring (TDM) may be helpful in tailoring antimicrobial treatment, and expert interpretation of the results may make it more clinically useful.Methods: This study aimed to assess retrospectively the first-year impact (July 2021 to June 2022) of a newly established expert clinical pharmacological advice (ECPA) programme based on TDM results in tailoring therapy with 18 antimicrobials hospital-wide in a tertiary university hospital. All patients hav-ing & GE;1 ECPA were grouped in five cohorts [haematology, intensive care unit (ICU), paediatrics, medical wards and surgical wards]. Four indicators of performance were identified: total ECPAs; total ECPAs rec-ommending dosing adjustments/total ECPAs both at first and at subsequent assessments; and turnaround time (TAT) of ECPAs, defined as optimal ( < 12 h), quasi-optimal (12-24 h), acceptable (24-48 h) or sub-optimal ( > 48 h).Results: A total of 8484 ECPAs were provided for tailoring treatment in 2961 patients, mostly admitted in the ICU (34.1%) and medical wards (32.0%). The proportion of ECPAs recommending dosing adjustments was > 40% at first assessment (40.9% haematology; 62.9% ICU; 53.9% paediatrics; 59.1% medical wards; and 59.7% surgical wards), and decreased consistently at subsequent TDM assessments (20.7% haematol-ogy; 40.6% ICU; 37.4% paediatrics; 32.9% medical wards; and 29.2% surgical wards). The overall median TAT of the ECPAs was optimal (8.11 h).Conclusion: The TDM-guided ECPA programme was successful in tailoring treatment with a wide panel of antimicrobials hospital-wide. Expert interpretation by medical clinical pharmacologists, short TATs, and strict interaction with infectious diseases consultants and clinicians were crucial in achieving this.& COPY; 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

The aim of this retrospective multicenter observational study is to test the feasibility and safety of a combined extracorporeal CO 2 removal (ECCO 2 R) plus renal replacement therapy (RRT) system to use an ultraprotective ventilator setting while maintaining (1) an effective support of renal function and (2) values of pH within the physiologic limits in a cohort of coronavirus infectious disease 2019 (COVID-19) patients. Among COVID-19 patients admitted to the intensive care unit of 9 participating hospitals, 27 patients with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) requiring invasive mechanical ventilation undergoing ECCO 2 R-plus-RRT treatment were included in the analysis. The treatment allowed to reduce V T from 6.0 ± 0.6 mL/kg at baseline to 4.8 ± 0.8, 4.6 ± 1.0, and 4.3 ± 0.3 mL/kg, driving pressure (ΔP) from 19.8 ± 2.5 cm H 2 O to 14.8 ± 3.6, 14.38 ± 4.1 and 10.2 ± 1.6 cm H 2 O after 24 hours, 48 hours, and at discontinuation of ECCO 2 R-plus-RRT (T3), respectively ( p < 0.001). PaCO 2 and pH remained stable. Plasma creatinine decreased over the study period from 3.30 ± 1.27 to 1.90 ± 1.30 and 1.27 ± 0.90 mg/dL after 24 and 48 hours of treatment, respectively ( p < 0.01). No patient-related events associated with the extracorporeal system were reported. These data show that in patients with COVID-19–induced ARDS and AKI, ECCO 2 R-plus-RRT is effective in allowing ultraprotective ventilator settings while maintaining an effective support of renal function and values of pH within physiologic limits.

Gastroesophageal reflux is a very frequent condition and different questionnaires to describe it have been proposed overtime. Nevertheless available questionnaires don’t allow to fully describe all different aspects of the disease. The aim of this study was to validate a new questionnaire (RoRex) on gastroesophageal reflux disease. The RoRex questionnaire was administered via web in two Italian centres, Rovereto and Verona, to patients attending specialized gastrointestinal surgical units, and to volunteers. Up to now, 54 patients and 50 volunteers participated in the study. Median age was 52 years (range 23-75 years) in patients and 47.5 years (range 25-80 years) in volunteers. Women were more prevalent than men in both groups (57% and 56% respectively). The RoRex questionnaire comprises 15 questions, where symptoms are scored on a frequency base: no, sometimes, several times per week, every day. Information on smoking habits, alcohol use, diet was also collected. The two groups largely differed as regards major symptoms. Regurgitation, heartburn, epigastric pain, retrosternal pain, laryngospasm were reported several times per week/every day in 50%, 39%, 30%, 22%, 23% of patients and 9%, 11%, 7%, 7%, 0% of volunteers. Preliminary analysis showed a different pattern in principal components between patients and volunteers. The 1st component, comprising heartburn and epigastric/retrosternal pain, was similar in both groups. The 2nd component comprised reclage, peevish cough, hoarseness in patients, and postnasal drip, hoarseness, dysphagia in volunteers. The 3rd component included regurgitation/laryngospasm in the former and peevish cough/belching in the latter. The new questionnaire, based on symptom frequency, allows to distinguish among major symptoms, i.e. heartburn/pain, upper airways irritation, and regurgitation in patients suffering from gastroesophageal reflux disease. These results, as well as the comparison of RoRex questionnaire with already validated ones and its usefulness as a screening tool in the general population, will be verified in larger samples.

Objectives: The objective of this study was to explore the relationship between pharmacokinetic/pharmacodynamic (PK/PD) target attainment of continuous-infusion (CI) meropenem and microbiological outcome in critical COVID-19 patients with documented Gram-negative superinfections. Methods: Patients receiving CI meropenem for documented Gram-negative infections at the COVID ICU of the IRCCS Azienda Ospedaliero-Universitaria di Bologna and undergoing therapeutic drug monitoring from January 2021 to February 2022 were retrospectively assessed. Average steady-state meropenem concentrations (Css) were calculated and the Css/MIC ratio was selected as a pharmacodynamic parameter of meropenem efficacy. The Css/MIC ratio was defined as optimal if ≥4, quasi-optimal if between 1 and 4, and suboptimal if <1. The relationship between Css/MIC and microbiological outcome was assessed. Results: Overall, 43 critical COVID-19 patients with documented Gram-negative infections were retrieved. Combination therapy was implemented in 26 cases. Css/MIC ratios were optimal in 27 (62.8%), quasi-optimal in 7 (16.3%), and suboptimal in 9 cases (20.9%). Microbiological failure occurred in 21 patients (48.8%), with no difference between monotherapy and combination therapy (43.8% vs. 53.8%; p = 0.53). The microbiological failure rate was significantly lower in patients with an optimal Css/MIC ratio compared to those with a quasi-optimal or suboptimal Css/MIC ratio (33.3% vs. 75.0%; p = 0.01). Conclusion: Suboptimal attainment of meropenem PK/PD targets may be a major determinant impacting on microbiological failure in critical COVID-19 patients with Gram-negative superinfections.

Siewert III cancer, although representing around 40% of esophagogastric junction (EGJ) cancers and being the EGJ cancer with worst prognosis, does not have a homogenous treatment. According to TNM 8th ed., they are considered gastric cancers. Our aim was to consolidate the current literature on the indications and treatment options for Siewert III adenocarcinoma. A review of the literature was performed in order to better delineate treatment indications (according to stage, surgical margins, type of lymphatic spread and lymphadenectomy) and treatment strategy. The treatment of Siewert III cancer requires a total gastrectomy and distal esophagectomy, with 5 cm of clear proximal and distal margins and a D2 abdominal and inferior mediastinal lymphadenectomy. Multimodal treatments are indicated in all locally advanced and node positive Siewert III patients and surgical principles remain unaltered after multimodal treatments. Siewert III cancers are gastric cancers with some peculiarities and require dedicated studies and deserve more consideration in the current literature, especially because their treatment is particularly challenging.

AbstractHiatal hernia is defined as the herniation of the stomach, possibly with other abdominal cavity elements, through the esophageal hiatus of the diaphragm. The most used classification describes four types of hernia: type I is the sliding hiatus hernia; type II the rolling hernia, where the gastric fundus herniate, while the gastroesophageal junction remains in the abdomen; type III the mixed hernia: with elements of both types I and II hernias; type IV is characterized by the presence of organs other than the stomach in the hernia sac. Types II–IV hernias as a group are referred to as paraesophageal hernias. Type I is the most common (95% of the cases), followed by type III, which comprises almost all paraesophageal hernias. Type II and IV are rare. Gastric volvulus is commonly associated with paraesophageal hiatal hernias. During sac reduction, the content is also retracted into the abdomen and the volvulus is automatically derotated. Natural history of hiatal hernias is not really known, but preliminary studies suggest that, like all other types of hernia, they tend to increase in size over time. The anatomic disruption of the gastroesophageal junction, due to hiatal hernia, leads to the disruption of natural anti-reflux mechanisms and hernia size is one of the main determinant of reflux severity [3]. Indeed, symptoms of hiatal hernia can be distinguished into GERD-related and Non-GERD-related. GERD symptoms are described in another chapter. Non-GERD symptoms include all those related to compression of mediastinal structures and to damage of herniated organs. A particular case is that of asymptomatic paraesophageal hernias. In those patients, prophylactic paraesophageal hernia repair is debated among experts. Although there is no consensus, most would agree that very old or debilitated patients should not undergo surgery, while younger and healthier patients, with a life expectancy of at least 10 years, should consider surgery to prevent both the risk of acute complications and potentially progressive symptoms.

Despite several studies highlighting the gap between strategy formulation and strategy implementation, strategy execution continues to be considered one of the greatest challenges in strategic management. Beginning from this premise, the present study explores how the gap between strategy formulation and implementation is perceived by middle-sized Italian companies. The basic idea of this study is to verify whether the difficulties that are widely reported in the strategic literature and empirical research of translating strategy into practice also arise in the context of Italian firms, and to examine which are the greatest barriers to successful strategy implementation. To address the research aims, we conduct a survey analysis of 544 middle-sized firms located in Northeast Italy. The findings of the analysis highlight how the main sources of the gap between strategy formulation and execution can be traced to two main factors: the processes through which the implementation step is conducted and the competences and skills necessary to effectively achieve the execution results. This paper contributes to the existing literature by conducting empirical research on the relevance of strategy execution in the Italian context. The study also has practical implications through its demonstration of the importance of some managerial tools that are highly useful in effective strategy execution.

Several studies have underlined the importance of including sustainability issues in business models, yet little is known on ways in which to embed stakeholders’ influence in defining and executing firm strategies. In light of this gap, this study inductively develops a framework for stakeholder relationship assessment, which suggests methods to evaluate relationships between the firm and stakeholders, with a dual aim: to embed more sustainable strategies in business models and to make strategy execution more effective and less risky. In doing so, a case study is conducted on Science Lab owing to the multiple stakes of its stakeholders. It presents a unique example on how stakeholder relationships were evaluated for making a strategic decision that, in this case, was whether to close (or not) the organization. This study contributes to the existing literature stressing the role of stakeholders in influencing strategy realization and proposes a useful managerial tool to improve the effectiveness of strategy execution through a better understanding of the role played by each stakeholder.

Background: Laparoscopic Incisional and Ventral Hernia Repair (LIVHR) is a safe and worldwide accepted procedure performed using absorbable tacks. The aim of the study was to evaluate recurrence rate in a long term follow-up and whether the results of laparoscopic IVH repair in the elderly (≥65 years old) are different with respect to results obtained in younger patients. Methods: One hundred and twenty-nine consecutive patients (74 women and 55 men, median age 67 years, range = 30-87 years) with ventral (N = 42, 32.5%) or post incisional (N = 87, 67.5%) hernia were enrolled in the study. Patients were divided into two groups according to their age: group A (N = 55, 42.6%) aged <65 years and group B (N = 74, 57.4%) aged ≥65 years. Results: The mean operative time was not significantly different between groups (66.7 ± 37 vs. 74 ± 48.4 min, p = 0.4). To the end of 2016, seven recurrences had occurred (group A = 3, group B = 4, p = 1). Complications occurred in 8 (16%) patients in group A and 21 (28.3%) patients in group B. Conclusion: In conclusion, our results confirm that the use of absorbable tacks does not increase recurrence frequency and laparoscopic incisional and ventral repair is a safety procedure also in elderly patients.

Objectives: The value of routine timed bariumesophagram (TBE) in longitudinal follow-up of achalasia after Heller myotomy is unknown. We prospectively prescribed a yearly follow-up TBE. Purposes were to characterize esophageal emptying over time after myotomy, identify preoperative TBE measures associated with follow-up TBE, and characterize follow-up TBE over time in relationship to reintervention. Methods: From March 1995 to April 2013, 635 patients underwent Heller myotomy for achalasia; 559 had at least 1 follow-up TBE. Temporal trends of 1335 follow-up TBEs in all nonreintervention and reintervention patients were assessed. Multivariable longitudinal analysis identified preoperative TBE measures associated with follow-up TBE. Results: On average, TBE height and width at 1 and 5 minutes decreased approximately 50% and 60%, respectively, at first postoperative follow-up, and remained stable or slightly decreased for up to 5 years. Wider TBE width at 5 minutes was associated with greater follow-up TBE height and width at 1 minute. Of 118 patients undergoing reintervention, 64 (57%) had only 1 reintervention, with follow-up TBE returning to that of nonreintervention patients. Patients whose follow-up TBE remained abnormal underwent a further reintervention, some normalizing on subsequent TBE, and some not. Conclusions: Follow-up TBE is valuable postmyotomy, particularly if there is substantial esophageal dilatation preoperatively. Follow-up TBE reassures patients with stable or decreasing TBE measures, permitting decreased follow-up intensity. Reintervention should not be considered a myotomy failure, because a successful, single, nonsurgical reintervention often results in long-term successful palliation. More than 1 reintervention requires intensification of TBE follow-up, facilitating treatment planning.

Background. Few studies of reintervention after Heller myotomy for achalasia set patients' expectations, assist therapeutic decision making, and direct follow-up. Therefore, we investigated the frequency and type of symptoms and reinterventions after myotomy based on achalasia type. Methods. From January 2006 to March 2013, 248 patients who had preoperative high-resolution manometry and a timed barium esophagram (TBE) underwent Heller myotomy, 62 (25%) for type I, 162 (65%) for type II, and 24 (10%) for type III achalasia. Postoperative surveillance, including TBE, was performed at 8 weeks, then annually. Median follow-up was 36 months. End points were all symptom types and modes of reintervention, endoscopic or surgical. Reintervention was based on both symptoms and objective TBE measurements. Results. Eventually most patients (169 of 218; 69%) experienced at least one symptom after myotomy. Fifty patients underwent 85 reinterventions, 41 endoscopic only, 4 surgical only, and 5 both. Five-year freedom from reintervention was 62% for type I, 74% for type II, and 87% for type III, most occurring within 6 months, although later in type III. At 5 years, number of reinterventions per 100 patients was 72 for type I, 51 for type II, and 13 for type III. After each reintervention, there was approximately a 50% chance of another within 2 years. Conclusions. Patients' expectations when undergoing Heller myotomy for achalasia must be that symptoms will only be palliated, and patients who have worse esophageal function-achalasia type I-may require one or more postoperative reinterventions. Thus, we recommend that patients with achalasia have lifelong annual surveillance after Heller myotomy that includes TBE. (C) 2019 by The Society of Thoracic Surgeons

Siewert III cancers were classified as esophageal cancers by the TNM 7th edition (TNM7), while being defined as gastric cancers by the new TNM 8th edition (TNM8). Aim of this study was to compare previous and present TNM classifications of Siewert III. From 2000 to 2015, 309 patients with Siewert III adenocarcinoma were treated at ten high-volume centers, belonging to the GIRCG (Italian Research Group for Gastric Cancer). We retrospectively analyzed overall survival according to TNM classifications: gastric TNM8 was compared with either gastric TNM7 or esophageal TNM7. Median number of lymph nodes harvested was 31 (interquartile range 22–44). Agreement between gastric TNM7 and TNM8 was very good (weighted kappa 92.3%, IC 95% 90.3–94.1%). Accordingly, stage migration was observed in 54 of 309 patients (17.5%), with 12 patients upstaged (3.9%) and 42 downstaged (13.6%). Cox models including either gastric TNM7 or TNM8 achieved similar goodness-of-fit and c-index. Differences were much larger, when shifting from esophageal TNM7 to gastric TNM8: the agreement was much lower (weighted kappa 69.1%, 65.2–73.2%), with 196 of 309 patients (63.4%) downstaging. The corresponding Cox model presented the lowest goodness-of-fit and discrimination ability. Gastric TNM7 and TNM8 were largely superimposable, so that stage migration was minor and prognostic significance was similar. At variance, stage migration was substantial when shifting from esophageal TNM7 to TNM8. Moreover, survival models with esophageal TNM7 presented the worst goodness-of-fit and the lowest discrimination ability. This further supports placing Siewert III among gastric cancers, as done in TNM8.

Abstract Background Routine timed barium esophagram (TBE), before and after Heller myotomy and Dor funduplication for achalasia, could offer the unique opportunity to objectively measure the outcome of the surgical procedure. In an initial single center experience we aimed at comparing pre-operative and post-operative TBE to objectively measure esophageal emptying and dilation, and to look for possible factors related to surgery results. Methods From 2016 to 2017, 11 patients underwent Heller myotomy and Dor funduplication for achalasia at a single center; all had a pre-operative and post-operative TBE after one month of surgery. TBE measured height and width of barium column at 1 and 5 minutes. All patients were staged according to radiological achalasia staging system: 1 patient was stage 1 (pre-operative esophageal width between 2 and 3 cm), 4 stage 2 (4–6 cm) and 6 stage 3 (> 6 cm). TBE height and width at 1 and 5 minutes were compared between pre-operative and post-operative TBE by the Wilcoxon signed-rank test. Moreover the association between surgery results and possible risk factors was evaluated by Spearman's rho. Results TBE height and width at 1 minute decreased in median by 79% (range 17–100%) and 57% (37–100%), respectively, from pre-operative to post-operative TBE. The decrease was more pronounced at 5 minutes, where it was 85% (40–100%) and 71% (40–100%), respectively. Although all patients reported a significant subjective improvement in symptoms, radiological stage was associated to esophageal emptying: the 4 subjects in stage 2 and the subject in stage 1 had complete or near complete emptying at 5 minutes, while the 6 patients in stage 3 had a median percent decrease at 5 min in height of 75% (40–86%) and in width of 50% (40–71%) (Spearman's rho for height = -0.87, P < 0.001; Spearman's rho for width = -0.88, P < 0.001). Conclusion TBE is essential post myotomy, particularly if a substantial esophageal dilatation occurs pre-operatively (stage 3). Initial stage is associated with surgical outcomes, advanced stages being related to poorer emptying and more dilated esophagus after surgery. TBE is a reliable system to objectively define surgical outcomes and preserved esophageal function after Heller-Dor procedure. Disclosure All authors have declared no conflicts of interest.

Abstract Background Like in gastric cancer, the incidence of signet-ring cell carcinoma (SRCC) is rising also in esophago-gastric junction (EGJ) adenocarcinoma Siewert type I and II. SRCC is much more studied in gastric cancer and WHO classification divides poorly cohesive gastric cancer in two subtypes, depending on the percentage of signet-ring cells: real SRCC (percentage of signet-ring cell more than 50%) and poorly cohesive non-SRCC (less than 50%). Real SRCC seems to have higher chemosensitivity and better prognosis than poorly cohesive non-SRCC. Recently, a new classification for SRCC has been proposed, which subdivides SRCC based on different cut-off percentages of signet ring cells (less than or equal to 90% vs more than 90%). Aim of this study was to compare pathological response in patients with EGJ SRCC treated with neoadjuvant chemotherapy. Methods Study population comprised 11 patients with Siewert I and II EGJ SRCC treated with neoadjuvant chemotherapy and surgery. We analyzed differences in pathological response to therapy between ‘pure’-SRCC (more than 90% of SRC) and ‘non-pure’-SRCC (less than or equal to 90%). Tumor regression grade (TRG) was used to define response to treatment, with TRG 1–2 defining good response to treatment and TRG 3–5 poor or absent response to treatment. Results Among the 11 patients with EGJ SRCC, 6 had ‘pure’-SRCC histology and 5 ‘non-pure’-SRCC. Response to treatment in ‘pure’-SRCC patients was equally splint into good and poor responders: 3 had good response to treatment (TRG 1–2) and 3 poor or absent response (TRG 3–5). On the contrary most of ‘non-pure’-SRCC had poor or absent response: 4 out of 5 patients had TRG 3–5. Conclusion Although the case series was too small to perform statistical analyses, our results suggest that signet-ring cell percentage may influence the outcome of neoadjuvant therapy. Probably a larger case series would allow to better define cut-offs of percentage of signet-ring cell carcinoma of the EGJ. Moreover it would allow to inspect other factors related to response to treatment. This is only a preliminary investigation and further studies are needed to better understand the characteristics of these rising in incidence types of cancer. Disclosure All authors have declared no conflicts of interest.