This systematic review aims to evaluate the current evidence regarding safety and efficacy of magnetic sphincter augmentation (MSA) for the treatment of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG). Conversion to Roux-en-Y gastric bypass (RYGB) carries the risk of surgical and metabolic complications and may be contraindicated in patients with normalized or near-normalized body mass index. The LINX™ procedure aims to restore LES competency and to repair the crura. We included 109 patients (14 studies) undergoing LINX™ implant after LSG. Median follow-up was 18.9 months (range 0.3–63). Both the GERD-HRQL (38 ± 13 vs. 10 ± 11; p = 0.0078) and daily PPI use (97.4

Obesity is associated with an increased risk of several chronic comorbidities, which may also be determined by dysfunctional autonomic nervous system (ANS). The influence of bariatric surgery (BS) on ANS balance was explored in previous studies, but with high heterogeneity in both the assessment timing and methods employed. In the present observational study, we applied a clinical protocol which considers two subsequent phases. Twenty-nine non-diabetic obese subjects were studied at baseline (T0), after one month of lifestyle modification (prehabilitation) (phase 1-T1), and after eight months following BS (phase 2-T2). ANS regulation was assessed across the three study epochs by means of ANSI, a single composite percent-ranked proxy of autonomic balance, being free of gender and age bias, economical and simple to apply in a clinical setting. The aim of the present study was to investigate the effects of the clinical protocol based on prehabilitation and subsequent BS on the ANS regulation by means of ANSI. Potential intertwined correlations with metabolic parameters were also investigated. Notably, we observed a progressive improvement in ANS control, even by employing ANSI. Moreover, the reduction in the markers of sympathetic overactivity was found to significantly correlate with the amelioration in some metabolic parameters (fasting glucose, insulin levels, and waist circumference), as well as in stress and tiredness perception. In conclusion, this study provides convincing evidence that a unitary proxy of cardiac autonomic regulation (CAR) may reflect the progressive improvement in autonomic regulation following behavioral and surgical interventions in obese patients. Intriguingly, this might contribute to reducing cardiovascular and metabolic risk.

Low-calorie Mediterranean-style or low-carbohydrate dietary regimens are widely used nutritional strategies against obesity and associated metabolic diseases, including type 2 diabetes. The aim of this study was to compare the effectiveness of a balanced Mediterranean diet with a low-carbohydrate diet on weight loss and glucose homeostasis in morbidly obese individuals at high risk to develop diabetes. Insulin secretion, insulin clearance, and different β-cell function components were estimated by modeling plasma glucose, insulin and C-peptide profiles during 75-g oral glucose tolerance tests (OGTTs) performed at baseline and after 4 weeks of each dietary intervention. The average weight loss was 5%, being 58% greater in the low-carbohydrate-group than Mediterranean-group. Fasting plasma glucose and glucose tolerance were not affected by the diets. The two dietary regimens proved similarly effective in improving insulin resistance and fasting hyperinsulinemia, while enhancing endogenous insulin clearance and β-cell glucose sensitivity. In summary, we demonstrated that a low-carbohydrate diet is a successful short-term approach for weight loss in morbidly obese patients and a feasible alternative to the Mediterranean diet for its glucometabolic benefits, including improvements in insulin resistance, insulin clearance and β-cell function. Further studies are needed to compare the long-term efficacy and safety of the two diets.

Purpose Obesity clearly increases cardiovascular risk, often inducing high blood pressure (BP), impaired left ventricular (LV) function, and increased arterial stiffness. Intensive weight loss and bariatric surgery induce improvement in hypertension and diabetes for morbid obesity. Carotid artery haemodynamics is a powerful prognostic indicator for stroke and cognitive decline independent of BP. The aim of this study was to evaluate the impact of a 3-stage bariatric strategy of diet, bariatric surgery, and consequent weight loss on carotid haemodynamics and cardiac diastolic function. Material and Methods This prospective study included 26 patients (45 ± 10 years, 4 men) with severe obesity undergoing bariatric surgery without comorbidities (hypertension, diabetes, etc.). Anthropometry, BP, Doppler echocardiography, and common carotid haemodynamics by ultrasound were measured at three times: (1) baseline, (2) after 1-month diet (post-diet), and (3) 8 months after surgery (post-surgery). The lnDU-loop method was used to estimate local carotid pulse wave velocity ( nc PWV). Results Baseline BMI was 47.9 ± 7.1 kg/m 2 and reduced by 5% and 30% post-diet and post-surgery, respectively. BP decreased only post-diet, without pulse pressure change. However, nc PWV, 6.27 ± 1.35 m/s at baseline, was significantly reduced by 10% and 23% post-diet and post-surgery, respectively, also adjusted for BP changes. The E/A ratio rose from 0.95 ± 0.20 to 1.27 ± 0.31 ( p < 0.005), without change in LV geometry or mass, while heart rate and cardiac output fell substantially. Conclusion Weight loss following diet and bariatric surgery is associated with reduced carotid arterial stiffness and improved LV diastolic function. Diet and bariatric surgery are effective treatments for morbid obesity with its concomitant adverse cardiovascular effects.

AIM:To evaluate the distinct contribution of obesity and diabetes (DM) to the skin modification in metabolic diseases.METHODS:We analysed all patients admitted for bariatric surgery in our hospital with BMI between 38 and 47 kg/m2, with (Group 1) or without (Group 2) DM and compared them with a group of nonobese diabetic patients (Group 3) and healthy volunteers (Group 4). The following features were evaluated: hardness, temperature, hydration and thickness alongside with anthropometric measures of foot and leg.RESULTS:For the general characteristics, patients differed in age and body mass index. As predictable all circumferences (dorsal foot, sovramalleolar and under the knee) were significantly higher in obese with no differences depending on DM (all parameters: p<0.01 in Group 1 and Group 2 vs Group 3 and Group 4). Skin temperature was significantly higher in all obese, irrespectively from the presence of DM (1st metatarsal head: p=0.02 Group 1 and Group 2 vs Group 3 and Group 4; 5th metatarsal head: p<0.01 in Group 1 and Group 2 vs Group 3 and Group 4). Skin hydration score showed increased anhydrosis in both diabetics and severe obesity (p<0.01 in Group 1 and Group 3 vs Group 2 and Group 4). Increase in thickness of skin and subcutaneous tissues was observed (at heel: p<0.01 in Group 1 and Group 2 vs Group 3 and Group 4 and under the scaphoid p=0.03 Group 1 and Group 2 vs Group 3 and Group 4) and plantar fascia (in both regions p=0.02 Group 1 and Group 2 vs Group 3 and Group 4) in all obese patients, with or without DM.CONCLUSION:Severe obesity significantly affects both shape and structure of the foot, possibly exposing these patients to a higher risk of biomechanical stress. On such a background DM, modifying skin hydration and protective mechanisms exerts a synergistic role further increasing the risk of trauma and ulcers.

A 42-y-old man with morbid obesity underwent laparoscopic gastric bypass without acute complications but in the following ten months suffered abdominal pain, vomiting, diarrhea and developed severe protein-energy malnutrition. After non-conclusive laboratory tests and imaging, exploratory laparoscopy showed an internal herniation that was corrected. Persisting post-operative leak required several laparotomic revisions. Roux-en-O misconstruction was recognised and rectified, but retrograde peristalsis resolved only after jejuno-ileal rotation of the antiperistaltic limb. Late detection of the causes of severe protein-energy malnutrition following bariatric surgery may be due to non specific postoperative symptoms and difficult imaging interpretation. Though rare, gastric bypass wrong configurations should always be included in the differential diagnosis. Jejunoileal rotation of the segment showing retrograde peristalsis could be a surgical option, alternative to resection, to spare bowel length. Appropriate follow-up plays a key role in the postbariatric nutritional surveillance and early identification and management of the complications. Eliana De Rosa1*, Carmela De Caprio1, Carlo Moretto2, Rosario Bellini2, Rossana Daniela Berta2, Marco Anselmino2, Franco Contaldo1 and Fabrizio Pasanisi1 1Department of Clinical Medicine and Surgery, Interuniversity Research Center for Obesity and Eating Disorders, Italy 2Bariatric Surgery Unit, Azienda Ospedaliero-Universitaria Pisana, Italy

Gastric bypass surgery (RYGB) leads to improvement or remission of type 2 diabetes (T2D). Long-term studies indicate that the remission rate is higher 2 than 10 years post-surgery; whether the positive effects of surgery on ß-cell function (ß-GS) and glucose metabolism are maintained long term after surgery has not been determined. We studied 21 patients (12 T2D and 9 nondiabetic (ND)) before (B), 1 (1y) and 7 years (7ys) after RYGB with the use of a mixed meal test (MTT) in combination with glucose tracers to measure postmeal glucose fluxes and a euglycemic insulin clamp for insulin sensitivity (M). ß-GS (insulin secretion and dose response curve) was assessed by mathematical modelling. Weight loss 1y after RYGB was 30% and 35% of initial weight for ND and T2D respectively, and 24% and 30% at 7ys. T2D was resolved 1y post surgery in T2D and this outcome was maintained at 7ys (HbA1c 58±4 vs. 35±1 vs. 41±2 mmol/mol; B, 1y and 7ys). M value improved at 1y in proportion to the weight lost (5.0±0.8 to 7.2±0.7 in ND, and 4.3±0.8 to 7.5±0.7 mg. kgffm-1. min-1 in T2D, p<0.01 for both), and was maintained at 7ys (7.0±0.8 in ND and 6.9±0.9 mg.kgffm-1. min-1 in T2D, p=ns vs. 1y). Plasma glucose profiles were similar in ND and T2D at 1y and 7ys. After RYGB, most of the oral glucose appeared in the circulation in the first 90 min after meal ingestion in both groups and the dynamic of the oral glucose Ra was unchanged at 7ys. Suppression of endogenous glucose production (EGP) was improved in both groups during the first 90 min at 7ys compared to 1y; in T2D, mean EGP was significantly decreased. In T2D, the improvement in ß-GS seen at 1y (34±6 to 67±11 pmol.min-1.m-2.mM-1, p=0.001) was maintained at 7ys (80±21) at a similar level as in ND (138±18 vs. 87± 9 vs. 82±11, B, 1- and 7ys). Conclusion: In both ND and T2D, RYGB induces marked improvements in glucose tolerance, insulin sensitivity (both muscle and hepatic) and ß-cell function that are maintained 7 years after surgery. Disclosure S. Camastra: None. B.D. Astiarraga: None. C. Barbieri: None. M. Gaggini: None. M. Palumbo: None. R. Berta: None. D. Ciociaro: None. M. Anselmino: None. A. Mari: None. E. Ferrannini: None. A. Gastaldelli: Advisory Panel; Self; Gilead Sciences, Inc.. Other Relationship; Self; European Foundation for the Study of Diabetes. Consultant; Self; INVENTIVA SA.

Obesity is characterized by insulin-resistance (IR), enhanced lipolysis, and ectopic, inflamed fat. We related the histology of subcutaneous (SAT), visceral fat (VAT), and skeletal muscle to the metabolic abnormalities, and tested their mutual changes after bariatric surgery in type 2 diabetic (T2D) and weight-matched non-diabetic (ND) patients. We measured IR (insulin clamp), lipolysis ( 2 H 5 -glycerol infusion), ß-cell glucose-sensitivity (ß-GS, mathematical modeling), and VAT, SAT, and rectus abdominis histology (light and electron microscopy). Presurgery, SAT and VAT showed signs of fibrosis/necrosis, small mitochondria, free interstitial lipids, thickened capillary basement membrane. Compared to ND, T2D had impaired ß-GS, intracapillary neutrophils and higher intramyocellular fat, adipocyte area in VAT, crown-like structures (CLS) in VAT and SAT with rare structures (cyst-like) ~10-fold larger than CLS. Fat expansion was associated with enhanced lipolysis and IR. VAT histology and intramyocellular fat were related to impaired ß-GS. Postsurgery, IR and lipolysis improved in all, ß-GS improved in T2D. Muscle fat infiltration was reduced, adipocytes were smaller and richer in mitochondria, and CLS density in SAT was reduced. In conclusion, IR improves proportionally to weight loss but remains subnormal, whilst SAT and muscle changes disappear. In T2D postsurgery, some VAT pathology persists and beta-cell dysfunction improves but is not normalized.

Background Remnant dimension is considered one of the crucial elements determining the success of sleeve gastrectomy (SG), and dilation of the gastric fundus is often believed to be the main cause of failure. Objectives The main outcome of this study is to find correlations between remnant morphology in the immediate post-operative stage, its dilation in years, and the long-term results. The second purpose aims to correlate preoperative eating disorders, taste alteration, hunger perception, and early satiety with post-SG results. Materials and Methods Remnant morphology was evaluated, in the immediate post-operative stage and over the years (≥2 years), through X-ray of the oesophagus-stomach-duodenum calculating the surface in anteroposterior (AP) and right anterior oblique projection (RAO). Presurgery diagnosis of eating disorders and their evaluation through “Eating Disorder Inventory-3” (EDI3) during follow-up were performed. Change in taste perception, sense of appetite, and early satiety were evaluated. Patients were divided into two groups: “failed SGs (EWL<50%) and “efficient SGs” (EWL >50%). Results There were a total of 50 patients (37 F, 13 M), with mean age 52 years, preoperative weight 131 ± 21.8 kg, and BMI 47.4 ± 6.8 kg/m 2 . Post-operative remnant mean dimensions overlapped between the two groups. On a long-term basis, an increase of 57.2 and 48.4% was documented in the AP and RAO areas respectively. In “failed” SGs, dilation was significantly superior to “efficient” SGs (AP area 70.2 vs 46.1%; RAO area 59.3 vs 39%; body width 102% vs 41.7%). Preoperative eating disorders were more present in efficient SGs than in failed SGs with the exception of sweet eating. There were no significant changes to taste perception during follow-up. Fifty-two percent of efficient SGs vs 26% of failed SGs reported a persistent lack of sense of hunger; similarly, 92.5 vs 78% declared the persistence of a sense of early satiety. The two groups did not statistically differ as far as all the variables of the EDI3 are concerned. Conclusion On a long-term basis, the remnant mean dilation is around 50% compared to the immediate post-operative stage but failed SGs showed larger remnant dilation than efficient SGs and, in percentage, the more dilated portion is the body of the stomach. As far as all the EDI3 variables obtained are concerned, the two groups did not statistically differ. Of all eating disorders, sweet eating seems to be weakly connected to SG failure.

Background: Laparoscopic sleeve gastrectomy (LSG) is an approved primary procedure for morbid obesity, but it is associated with serious complications, such as staple line leaks and bleeding. The objective of this study was to assess the effectiveness of staple line reinforcement (SLR) in reducing leaks and bleeding after LSG.Methods: A total of 1162 patients underwent LSG (305 males, 857 females). The mean age was 43.7 years and the mean body mass index was 48 kg/m(2). The patients were divided into 6 groups based on the type of SLR, including a no-SLR control group, with evaluation of leaking and bleeding risk and correlation of patients' characteristics with complications.Results: A total of 189 patients underwent LSG without reinforcement. The SLR method was oversewing in 476 patients, bovine pericardium in 312, synthetic polyester in 76, glycolide/trimethylene copolymer in 63, and thrombin matrix in 46. The overall leak frequency was 2.8%; higher with synthetic polyester (7.8%), 4.8% with no reinforcement, and lower with bovine pericardium strips (.3%; P < .01). Postoperative hemorrhage occurred in 35 patients (3%), with a higher frequency being observed without SLR (13.7%; P = .02). Only diabetes was a risk-factor for a leak (P < .01).Conclusion: SLR with bovine pericardium strips significantly reduced the leak risk. Postoperative bleeding was significantly lower with all SLR-methods, although there was no significant difference among the various techniques. Patients with type If diabetes had a higher risk of staple line leak after LSG. Further randomized, controlled studies are needed to improve our understanding of the efficacy of SLR during LSG. (C) 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.

CONTEXT:Bariatric surgery can induce remission in a high proportion of severely obese patients with type 2 diabetes mellitus (T2DM).OBJECTIVE:Our objective was to investigate predictors and mechanisms of surgery-induced diabetes remission.PATIENTS AND SETTING:Forty-three morbidly obese subjects (body mass index = 45.6 ± 5.0 kg/m(2)), 32 with T2DM and 11 nondiabetic [normal glucose tolerance (NGT)], participated at a clinical research center.INTERVENTION:Patients underwent Roux-en-Y gastric bypass.MAIN OUTCOME MEASURES:Diabetes remission and β-cell function were evaluated.RESULTS:Subjects were tested before and 45 d and 1 yr after surgery. Weight decreased similarly in T2DM and NGT (-39 kg at 1 yr, P < 0.0001). Insulin sensitivity improved in both groups in proportion to the changes in body mass index but remained lower in T2DM than NGT (386 ± 91 vs. 479 ± 89 ml/min · m(2), P < 0.01). Based on glycosylated hemoglobin and oral glucose testing, diabetes had remitted in nine patients at 45 d and in an additional 16 at 1 yr. In T2DM, β-cell glucose sensitivity increased early after surgery but was no further improved and still abnormal at 1 yr [median, 48 (coefficient interval, 53) pmol/min · m(2) · mm vs. median, 100 (coefficient interval, 68) of NGT, P < 0.001]. Baseline β-cell glucose sensitivity was progressively worse in early remitters, late remitters, and nonremitters (median, 54[coefficient interval, 50] vs. median, 22[coefficient interval, 26] vs. median, 4[coefficient interval, 10] pmol/min · m(2) · mm) and, by logistic regression, was the only predictor of failure [odds ratio for bottom tertile = 7.9 (95% confidence interval = 1.2-51.9); P = 0.03].CONCLUSIONS:In morbid obesity, Roux-en-Y gastric bypass causes rapid and profound metabolic adaptations; insulin sensitivity improves in proportion to the weight loss, and β-cell glucose sensitivity increases independently of weight loss. Over a period of 1 yr after surgery, diabetes remission depends on the starting degree of β-cell dysfunction.

There is no uniform consensus on the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). In this paper, we present a 10-year retrospective audit of our cases of LC without IOC, performed by a search of readmission cases through our electronic database. Data regarding all patients subjected to LC at our unit in the period January 1996-December 2006 were obtained through our hospital database system. Subsequently, a query was made to ascertain if there were any readmissions to any of our city hospitals, up to December 2006. A total of 1321 patients underwent LC at our unit in the period January 1, 1996-December 31, 2006. The median operating time for LC without IOC was 58 minutes (range, 15-370). The median hospital stay was 2 days (range, 1-30). Postoperative outcome was uneventful in 1250 patients (94.7%). There was no mortality. Grade I and II complications occurred in the remaining 71 patients. Patients were stratified by risk of common bile duct stones (BDSs) according to clinical, ultrasonographic, and serum chemistry data. Patients with suspected BDS underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) and BDS clearance (142 patients). No patient in our series of LC was readmitted to any of the city hospitals for biliary desease up to 10 years after the operation. Our retrospective audit confirms the safety of LC without routine IOC and the rarity of readmissions for retained BDS and supports the policy of selective IOC.

According to the WHO about 300 million people in the world are affected by obesity with an increasing trend. The aim of the present study was to assess our preliminary results with sleeve gastrectomy. Over the period from June 2006 to March 2008, 25 laparoscopic sleeve gastrectomy were performed at our Department of Surgery for morbid obesity by the same surgeon. The operation consists in resection of approximately three quarters of the stomach with the creation of a long slender gastric tube, dividing the stomach vertically in two parts and removing all the left side with the greater curvature and gastric fundus. The mean age of the patients was 38 +/- 9 years, and the mean BMI 48 +/- 3. The mean operative time was 110 minutes, and the mean hospital stay 6 days. Mean intraoperative bleeding was negligible (20 cc). In our study we observed just one case of gastric leakage from the staple line, treated by surgical drainage and by placement of an endoscopic stent. There were no cases of bleeding of the resection margin and no long-term stenosis; there was no mortality. The mean follow-up was 18 months. BMI showed a mean reduction of about 17 points. During postoperative visits all the patients reported marked reduction of hunger sensation, together with a sense of early satiety. On the basis of these preliminary results we can consider laparoscopic sleeve gastrectomy as a safe, functional and definitive procedure that constitutes a valid alternative in bariatric surgery, though it is as yet not completely standardised and requires a longer follow-up.

The aim of the study was to consider all the factors associated with the development of postoperative dysphagia which, in its transitory form, can be present in as many as 40 to 70% of cases. From 1996 to 2007, 302 Nissen fundoplications were performed at our department of surgery. We divided this series into two groups, the first consisting of 149 cases (from March 1996 to March 2004) where short gastric vessels were not dissected (nl-VGB) and the second of 153 cases (from April 2004 to December 2007) where short gastric vessels were dissected (I-VGB).The incidence of postoperative dysphagia was distinctly lower in I-VGB than in nl-VGB (4.5% vs 19.5%). One month after operation, the incidence of postoperative dysphagia in I-VGB and nl-VGB was 12% and 1,5%, respectively, while 3 months after surgery the percentages were 2% and 0.5%. Exclusion of cases performed during the learning curve period yielded similar results. At postoperative examinations we noticed a substantial reduction in gastro-oesophageal reflux disease symptoms in both groups, with no significant difference between the two. L-VGB patients appeared clearly more satisfied after operation than nl-VGB patients (97% vs 88%), even if the results were similar after 3 months. Our experience confirms the good results obtained with Nissen fundoplication with a distinct, rapid reduction in postoperative dysphagia.

The preoperative diagnosis of polycystic liver is easily obtainable by ultrasound, while computed tomography is more sensitive for making the differential diagnosis versus other hepatic lesions. This report describes a case of polycystic liver with mass-related symptoms. A laparoscopic fenestration of the larger and superficial cysts was performed. At a three-years follow-up neither postoperative complications nor recurrent episodes were observed. A number of studies have shown that the rates of cyst and symptom recurrence are 9% and 4.5%, respectively, and that the reduction of liver volume is 12.5%. in our opinion the choice of adequate treatment must be based on an accurate evaluation of the patient's clinical aspects and on tthe characteristics of cystic lesions, such as number, size and location. In conclusion, laparoscopic fenestration of liver cysts is a safe, effective procedure for obtaining excellent outcomes in terms of absence of recurrence, as well as being a more sparing approach.

The demand for shorter admissions and quicker recoveries prompted us to adopt a new approach, favouring day surgery as the preferred organisational modality. Since 2004, 312 Milligan-Morgan haemorrhoidectomies have been performed at our department of surgery. The operations were performed at our proctological outpatient unit by means of LigasureTM with immediate discharge. In our study we observed postoperative bleeding in 3 cases (0.96%), while 4 patients (1.28%) required an ordinary admission. There were no cases of acute urinary retention in our experience. Operating time is about 12-16 minutes; and recovery time around 60-70 minutes. Over the period 1992-2003, 978 Milligan-Morgan haemorrhoidectomies were performed at our department of surgery using diathermy. Historical comparison of the results of the two groups shows a reduction in complications, operating times and recovery times. On the basis of our experience, radiofrequency ablation causes less postoperative pain and makes for shorter recovery times compared with diathermy, because of its lower tissue damage. The aim of the present study was to verify the safety and effectiveness of day surgery haemorroidectomy in selected cases.

BACKGROUND:Among bariatric operations, laparoscopic adjustable gastric banding (LAGB) has been the preferred one in Europe and Australia, and has become recently popular in the USA. Like every surgical procedure, however, it is not devoid of specific complications, like slippage, band erosion, outlet obstruction and port problems. Assuming that the absence of the pouch may avoid postoperative slippage, we introduced the technique of esophago-gastric placement, instead of the original gastric banding technique. A further technical variant, introduced in June 2002, consists of suturing the gastric fundus to the left hemidiaphragm, using two non-resorbable sutures and pledgets.METHODS:Between January 1999 and July 2005, 400 LAGBs have been placed in 90 males and 310 females, with the technical variants above. Mean age was 42 (range 17-69 years), and mean BMI was 44.8 kg/m(2) (range 33-67).RESULTS:Mean hospital stay was 2.5 days (range 1-17). Mortality has been zero. Major complications included: 16 slippages (after a range of 6-45 months), 5 outlet obstructions (immediately after the operation), and one intragastric migration (after 2 years). Minor complications included 18 port problems. Since the introduction of gastric fundus fixation to the diaphragm in 2002, gastric slippage has decreased from 8% to 0.9%. BMI has decreased from 44.8 to 32 kg/m(2) at 60 months.CONCLUSIONS:The technique herein presented is effective and useful to prevent postoperative gastric slippage. It does not induce pseudo-achalasia, if strictly controlled. In fact, it is avoided by the patient due to the immediate appearance of dysphagia, in the case of wrong food ingestion. Long-term clinico-radiological follow-up confirms that the technique is safe and effective in motivated patients with good compliance and willing to undergo periodic studies.