Achalasia is a rare motility disorder of the esophagus. According to the Chicago Classification criteria, there are three clinical types of Achalasia and the treatment is patient-tailored. Laparoscopic Heller-Dor is the gold-standard treatment for the most frequent types of Achalasia. However, robotic surgery is able to combine the clinical advantages of minimally invasive surgery with a powerful dexterity on complex anatomic structures. The aim of this study is to report the institutional experience developed in a referral center of esophageal surgery in the treatment of Achalasia by Robotic Heller-Dor. We retrospectively analyzed data of patients that consecutively underwent Robotic Heller-Dor at our institution between January 2012 and January 2020 using the Da Vinci® Surgical System. Sixty-nine patients underwent Robotic Heller-Dor. Among the patients, 35 (51%) were classified as type I, 29 (42%) as type II, and 5 (7%) as type III. The Da Vinci® SI HD Surgical System and the Da Vinci® XI HD Surgical System were used in 56 (81%) and 13 (19%) patients, respectively. No mucosal perforation was observed and post-operative mortality was absent. The mean follow-up was 23.3 months (6–84). Ten patients (14.5%) reported post-operative complaints. In our opinion, Robotic Heller-Dor is an effective tool in the treatment of Achalasia. Robotic Heller-Dor may be a suitable procedure for learning and teaching robotic surgery in the perspective of pursing more complex esophago-gastric surgical procedures.

Figure 1.Three-dimensional surface plot of pressure from high-resolution anorectal manometry test used to calculate the integrated pressurized volume (IPV, mmHg s cm).Note that the X-axis depicts time (sec), the Y-axis depicts the distance from the anus (cm), and the Z-axis depicts the pressure (mmHg).

Crystalluria is a marker of urine supersaturation with substances deriving from metabolic disorders, inherited diseases or drugs. The investigation of crystalluria must be done according to a protocol which includes the delivery to the laboratory of a proper urine sample, the use of a microscope equipped with polarized light, the accurate knowledge of urine pH, and a comprehensive examination of the crystals, which is based on their identification, quantification and size measurement. For unusual crystals, infrared spectroscopy may also be needed.If the formation of stones is always preceded by crystalluria, the reverse is not true. In addition to the crystalline composition, stone morphology provides valuable information on stone activity and, for some crystalline species, major information regarding the underlying pathology. Fourier transform infrared spectroscopy (FTIR) reliably identify specific forms of nephrolithiasis, as common-type stones made of calcium oxalate (CaOx) and/or calcium phosphate that is combined with morphology classification; using this method, stones may be classified into 6 types subdivided in 22 subtypes.The investigation of crystalluria is an inexpensive and valuable tool for the detection and the monitoring of inherited and acquired diseases associated with urinary stone formation or acute or chronic renal function impairment from intrarenal crystal precipitation.Selective FTIR identification of the composition of core (or the umbilication), middle part, and surface of every stone allows identification of the initiating lithogenic process (in the nucleus or in the Randall's plaque) and the factors which subsequently contributed to stone growth. In conclusion, the proposed morpho-constitutional method of urinary stone analysis, which moreover is rapid and low cost, provides clinically relevant orientations for targeted etiologic evaluation.

The purpose of this retrospective study was to analyze our results after laparoscopic repair of giant hiatal hernias with direct closure of the hiatus, since the reports document a radiological recurrence rate as high as 42%. Various studies have shown that laparoscopic hernia repair is safe and effective, and carries a lower morbidity than the open approach, but the high recurrence rates still being reported (ranging from 10 to 42%) have prompted many authors to recommend using a prosthesis. This is a report on the follow-up of 38 patients with type III and IV hiatal hernia who underwent laparoscopic repair with direct hiatal closure without the aid of meshes. From January 2000 to March 2010, 38 patients with III and IV hiatal hernia were treated at the Surgery Division of Cisanello Hospital in Pisa. Data were collected retrospectively and included demographics, preoperative symptoms, radiographic and endoscopic findings, intraoperative and postoperative complications, postoperative symptoms, barium X-ray and follow-up by medical examination and symptoms questionnaire. The sample included 12 males and 26 females, between 36 and 83 years (median age 62) with 26 type III (68.4%) and 12 type IV (31.6%) hernias. There were no conversions to laparotomy and no intraoperative or postoperative mortality. A 360° Nissen fundoplication was performed in 22 patients (57.9%) and a 270° Toupet fundoplication in 16 patients (42.1%). One patient had intraoperative complications (2.6%), and postoperative complications occurred in another three (7.9%). The follow-up was complete in all patients and ranged from 12 to 88 months (median 49 months). Barium swallow was performed in all patients and recurrence was found in five patients (13.1%); three of these patients (7.9%) were asymptomatic, while two (5.2%) were reoperated. All 38 patients' symptoms improved. Judging from our data, the recurrence rate after laparoscopic giant hiatal hernia repair with direct hiatal closure can be lowered by complying with several crucial surgical principles, e.g., complete sac excision and appropriate crural closure, adequate esophageal lengthening, and the addition of an antireflux procedure and a gastropexy. We recorded a radiological recurrence rate of 13.1% (5/38) and patient satisfaction in our series was quite high (92%). Based on these findings, the laparoscopic treatment of giant hernias with direct hiatal closure seems to be a safe and effective procedure.

Inflammatory pseudotumors (IPTs) are rare, tumor-like benign lesions that occur in various organs and tissues including the GI tract. Despite features that mimic a neoplasm, IPTs probably represent an inflammatory response to a variety of as yet unknown agents. This is a description of a case of a pseudotumor that arose in the proximal third of the esophagus as an unusual complication of a traumatic mucosal injury, and which was followed by spontaneous and complete resolution.

We created an in vitro model of the gut-liver axis to study intestinal ischemia and shock.In this model, ischemic enterocytes directly activate hepatic macrophages to produce proinflarnmatory cytokines.N-acetylcysteine (NAC) is known to decrease cytokine release after endotoxic shock.We hypothesized that NAC functions independent of endotoxin in intestinal ischemia.Kupffer cells (KC), which are hepatic macrophages, were isolated from rat livers and grown in culture.Rat intestinal epithelial cells, lEC-6, were treated with or without NAC (ImglmL), and cultured under normoxic and anoxic (90% N 2 , 10% CO 2 ) conditions for 24, 48, and 72 hours.KCs were grown in the conditioned media of the intestinal cells.Intestinal cell conditioned media and KC supernatants were tested for TNF-a and IL-6 production by ELISA.Data from nine samples per treatment group were analyzed by ANOVA.Intestinal cell conditioned media had no significant cytokine production with increasing anoxia time (See figure, "Control", p>0.05).In contrast, KC cytokine production increased significantly with increasing intestinal cell anoxia time ("KC", p<0.02).Intestinal cell treatment with NAC decreased cytokine production by KCs equal to that of the control ("KC+ NAC", p<0.OO2).NAC blocks the intestinal ischemia cytokine cascade in our in vitro model of the gut-liver axis.We showed that NAC functions directly on the end-organ, independent of the effects of endotoxin.