Gastroesophageal reflux disease has different clinical presentations that require different diagnostic and therapeutic approaches. This paper describes the appropriate use of diagnostic tests before and after treatment. Each diagnostic tool is examined from a practical point of view to determine the information it can provide and its possible pitfalls, and to comment on how it can influence therapeutic choices. Performing a preoperative diagnostic evaluation is especially stressed, so as not to select the wrong patient or the wrong procedure. Finally, failures of surgery are examined to understand their causes and to prevent them. The value of the most relevant examinations for diagnosing the causes of failures and choosing the appropriate solution are discussed.

. Duodenal perforations after laparoscopic cholecystectomies are rarely reported. The aim of this study is to focus on this complication and to suggest ways to reduce its occurrence and avoid diagnostic mistakes and therapeutical delays that could be fatal. We reviewed four personal cases and a number of others reported in the literature. Duodenal perforations are caused by improper use of the irrigator-aspirator device when retracting the duodenum, or by electrosurgical and laser burns. A duodenal perforation should be suspected in cases of bile leakage, peritonitis, intraabdominal or retroperitoneal collections, high serum or drainage amylase concentration, absence of bile leakage from the biliary tree, and the existence of a retroduodenal mass. Diagnosis requires a gastrografin upper GI series. Differential diagnosis is mainly with biliary lesions and other causes of peritonitis. Relaparoscopy may require intraoperative upper GI endoscopy or Kocher's duodenal mobilization to detect the perforation. Early diagnosis allows primary repair, usually by laparoscopy. Perforations of the duodenal cap are easier to diagnose and have a better prognosis than those of the descending duodenum. A lumbar abscess is a frequent complication.

BACKGROUND/AIMS:This study illustrates our experience in treating duodenal ulcers by means of laparoscopy over a period of 6 years and the results after a lengthy careful follow-up.METHODOLOGY:From October 1991 to October 1997 we submitted 35 patients, 28 men and 7 women of an average age of 51 years (range: 22-78), to vagotomy with minimally invasive access: 23 Hill-Barkers, 2 Taylors, 6 thoracoscopic truncal vagotomies, and 4 laparoscopic truncal vagotomies. Of the patients submitted to surgery with the Hill-Barker technique, 8 were resistant to medical therapy, 11 decided not to continue with long-term medical therapy, 3 assumed an irregular medical therapy, and 1 who had been suffering for a long time from an ulcerous disease required vagotomy in association with laparoscopic cholecystectomy. In 16 patients a bleeding complication preceded surgery.RESULTS:In our experience, the average duration of the operation with the Hill-Barker technique is 40 min (range: 30-80 min), with return to normal feeding in 1 day without any disorders and return home on day 3 (range: 2-5). The patients have been followed for 3-54 months. One patient (4.3%) was lost during the follow-up. Twenty-one (91.3%) out of the 23 submitted to anterior superselective and posterior truncal vagotomy were pain and ulcer-free without medical therapy. There was only one relapse (4.3%) after 7 months where the patient underwent left thoracoscopic truncal vagotomy.CONCLUSIONS:In our opinion, as posterior truncal and anterior superselective vagotomy using the Hill-Barker technique guarantees the same excellent results, it is preferable due to the speed and ease of performance and to the low cost compared with other procedures which take more time (e.g., Taylor's section and suture of the anterior gastric wall) and require the use of particularly expensive equipment (e.g., Gomez-Ferrer's mechanical sectioning and suturing).

Background: The aim of this study is to review our experience performing laparoscopic colon surgery and to present the operative technique as used and standardized by us. Methods: From April 1992 to December 1996, 158 consecutive patients underwent laparoscopic colon surgery. There were 92 females and 66 males, whose average age was 66.7 years (range 31 - 92); 134 patients (84.9%) were operated on for carcinoma, and the remaining 24 (14.1%) for benign disease. Results: There were 117 procedures completed laparoscopically out of 158 patients (74%); 103 colon resections (18 for benign disease and 95 for malignant disease), 7 Hartmann procedures, 3 for reversal of Hartmann's procedures, 1 rectopexy, and 3 ileotrasversostomies. Conversions were required in 41 out of 158 cases (25.9%); 19 of these cases, however, were converted to a laparoscopic-facilitated procedure. The most common causes for conversion were the presence of bulky tumors and/or tumors that contaminated adjacent structures (16/158), adhesions due to previous operations (8/158) or patient obesity (5/158). There were 31 complications (19.6%), 9 of which required re-operation. There was only one recurrence (0.9%) that manifested 15 months after the procedure, at both trocar and drainage sites, and with peritoneal carcinomatosis. This occurred in a patient with rectal neoplasia who suffered a perforation of the rectum during dis-section, with bowel spillage. The average number of lymph nodes harvested in resected specimens was 12.8 (range 1-41), whereas the mean distance of the tumor from the proximal margin of resection was 11.5 cm (range 5-35), and from the distal margin 7.5 cm (range 1-25). The average operative time was 165 minutes (range 40-360), and the mean hospital stay was 9.2 days (range 6-40). There were three mortalities out of 158 patients (1.9%). Conclusions: Laparoscopic colon resection for malignant lesions, performed with the highest respect for oncologic principles, has demonstrated that it is difficult to develop a barrier to wall and intraluminal recurrence. Recurrence, in our opinion, is caused by improper surgical technique. Therefore, neoplastic colon laparoscopic surgery must be the prerogative of selected and specialized centers.

Since 1994 until the present day, we have had to surgically re-operate in five cases of failure with laparoscopic operations aimed at correcting gastrooesophageal reflux disease. Two of these cases came from our own patients and three came under our observation from other centers. We applied fundoplication according to Nissen-Rossetti in three cases and the Rossetti-Hell operation in the other cases. One case involved recurrent gastro-oesophageal reflux with a short oesophagus and fundoplication raised into the mediastinum. In one other case, there was recurrent hiatal herniation with a rotary as well as axial component and consequent mediastinal occupation. The other three cases featured persistent post-operative dysphagia caused, in one case, by an error in the creation of the anti-reflux valve (perigastric cuff) and, in the other two, by erroneous choice of the anti-reflux operation: post-operative manometry showed important oesophageal hypo-dyskinesia which should have indicated partial fundoplication. All the patients underwent laparoscopic exploration. The patient with the short oesophagus had to be converted for the performance of a total duodenal diversion, while the remaining four patients underwent a total laparoscopic operation. The patient with recurrent hiatal hernia had the hernia reduced in the abdomen and combined anterior and posterior hiatoplasty. In another three cases, total fundoplication was transformed into partial fundoplication according to Toupet. The post-operative course and clinical results were excellent in all five patients. Stress is placed on the importance of accurate morphological and functional assessment of the oesophagus in the pre-operative stage so as to select the most suitable operation and in the post-operative stage in order to evaluate the causes of failure, the advantages of laparoscopy in terms of exposure of the operative field, the importance of certain technical details that optimize the results of the operation, and the efficacy of the laparoscopic approach also for the correction, of most failures that demand re-operation.

Background: Thirty-three patients were candidates for laparoscopic choledochotomy. The indications for this operation are described.

Data concerning 6,865 laparocholecystectomies have been collected retrospectively from 19 Italian groups. Only 5% of all patients were chosen for open cholecystectomy (OC). Acute cholecystitis was present in 5.6% of laparocholecystectomies (LC). Conversion to laparotomy occurred in 3.1% of patients. Mortality was 0.06%, morbidity 2.53% (general anesthesia complications 0.07%; general complications 0.07%; omphalitis 0.7%; abdominal complications 1.69%). Main duct lesions occurred in 0.26% of the patients, biliary leaks in 0.48%, bleedings in 0.75%, perforations in 0.2%. Data from literature concerning OC are compared to ours: mortality and morbidity have been lowered by LC; general and abdominal-wall complications have been drastically reduced; main duct lesions are not different.

Data concerning 6,865 laparocholecystectomies have been collected retrospectively from 19 Italian groups. Only 5% of all patients were chosen for open cholecystectomy (OC). Acute cholecystitis was present in 5.6% of laparocholecystectomies (LC). Conversion to laparotomy occurred in 3.1% of patients. Mortality was 0.06%, morbidity 2.53% (general anesthesia complications 0.07%; general complications 0.07%; omphalitis 0.7%; abdominal complications 1.69%). Main duct lesions occurred in 0.26% of the patients, biliary leaks in 0.48%, bleedings in 0.75%, perforations in 0.2%. Data from literature concerning OC are compared to ours: mortality and morbidity have been lowered by LC; general and abdominal-wall complications have been drastically reduced; main duct lesions are not different.

Simplified parietal cell vagotomies (Taylor's and Hill-Barker's procedures) were proposed more than a decade ago to make the operation easier and faster. Efficacy and safety have proven to be as good as with proximal gastric vagotomy. The Hill-Barker operation is particularly simplified by the laparoscopic approach, which enables the procedure to be performed very precisely. The limited trauma of minimally invasive vagotomy has increased the interest in peptic ulcer surgery, especially for patients with chronic duodenal ulcer disease who cannot or do not want to take long-term continuous medication, or who are resistant to it. We describe our technique of performing the laparoscopic Hill-Barker procedure. Our initial results with eleven patients show no operative mortality and minimal morbidity with early discharge and ulcer of all patients. Of the 9 cases which are evaluable, 8 are pain-free and one had an ulcer recurrence after incomplete vagotomy.

Our initial experience with four minor resections for one malignant and three benign lesions is reported. Dissection was accomplished by mechanical fragmentation and hydrojet. Coagulation was effectively achieved by the argon beam system. Larger vessels were clipped. Three patients were treated laparoscopically and were rapidly discharged after an uneventful postoperative course. The other patient (small hepatocellular carcinoma in cirrhotic liver) had an intraoperative cardiac arrest, probably due to gas embolism. After restoration of normal cardiac activity, the operation was completed after conversion to an open approach. When using the argon coagulator it is necessary to prevent excessive intra-abdominal pressure due to the flow of argon gas and to avoid injury to the hepatic veins, which may cause gas embolism.

Cholecystectomy causes alterations in bile composition. In particular it rises the proportion of highly detergent bile acids with the possible consequence of the manifestation of dyspepsia in a high percentage of patients: this is the well-known post-cholecystectomy syndrome. In this clinical trial we studied the activity and safety of tauroursodeoxycholic acid--TUDCA--(500 mg/die) in the prevention of dyspepsia in cholecystectomized patients, in comparison with no treated group. We enrolled 203 patients (101 TUDCA--group A--and 102 control-group B). The two groups were comparable for age (47.1 years in group A and 50.7 years in group B), sex (m/f: 28/73 and 37/65 in the two groups) and for other characteristics connected to surgical procedures. After operation all patients suffered from dyspepsia symptoms. In patients treated with TUDCA we registered a prompt regression in severity of symptoms when compared with no treated group: in fact we noted a significant difference only at the first control planned after one month from operation. No difference were registered at the other controls (two and three months after operation). Two patients in A and 3 in group B manifested adverse events. In conclusion, the treatment with TUDCA, a new hydrophilic bile acid, seems to contribute to the improvement of clinical course in cholecystectomized patients.

On account of dissatisfaction with the two-staged approach to stones in the common bile duct, and the risks associated with endoscopic papillotomy, one-stage laparoscopic duct exploration was commenced. The initial experienced with 20 cases is presented. In 13 cases the transcystic approach to the main duct was not successful, so a choledochotomy was performed, and closed without biliary drainage. The postoperative course was similar to laparoscopic cholecystectomy and was uncomplicated in all patients. The follow-up examination of 12 patients demonstrated a mild stenosis of the main duct in our first case; however, this resolved spontaneously within six months. When indicated, the laparoscopic "ideal" choledochotomy with fibroscopic exploration gives very good early and long term results.

Authors describe laparoscopic treatment of gastroesophageal reflux disease in 12 patients. Particular aspects related to intra-operative complications are referred. Moreover the reasons that make laparoscopic procedure advantageous are discussed.

In a 18 month period 19 patients (4.7%) out of 400 affected by acute cholecystitis underwent laparoscopic cholecystectomy. In 18 cases the diagnosis was preoperative on clinical signs or ultrasound scan basis. Intraoperative and histologic confirm was obtained in all cases. Mean age was 44.9, 11 were males and 8 females. The procedure resulted longer and more difficult compared to the global series of the same period: 90 min. versus 56 min. respectively, with a difficulty score higher than 4 in 89% of cases versus 40% of the global series. Furthermore, in 56% of cases versus 23.3% of the global series an intraoperative contamination from gallbladder content was recorded. Nevertheless, only 1 (5%) minor complication was observed, in the form of omphalitis, which recovered in 2 days. Therefore, discharge was possible in average within 4 days, excluding the first two cases operated, respectively discharged in 5th and 7th p.o. day as a precautionary measure. Early coelioscopic cholecystectomy is safe and effective, if carried out by well trained surgeons, even in acute cholecystitis.