1. Prof. ALBERTO DEL GENIO Hon. OESO, FACS Professore Emerito di Chirurgia Seconda Università degli Studi di Napoli RECENTI ACQUISIZIONI DI FISIOPATOLOGIA ESOFAGEA

3. ENDOSCOPIC PRESSURE OF THE WRAP TOUPET DOR NISSEN

4. Del Genio A Low HPZ 360° HPZ Tight wrap Floppy wrap Total wrap Partial wrap High HPZ portion of HPZ Resting pressure range 20-40mmHg

5. “SINCE 1972 STANDARDIZED TECHNIQUE” LENGHT OF THE WRAP (2-3 CM) ANTERIOR FUNDUS PRESERVATION OF VAGAL BRANCHES AND LESSER OMENTUM WIDE TRANSHIATAL MINIMAL RETROESOPHAGEAL PRESERVATION SGV

6. 6

7. HIGH RESOLUTION COMBINED MANOMETRY AND IMPEDANCE (HR-MII) INTRAOPERATIVE CONTROL ESOFAGEAL MOBILIZATION + IATOPLASTY IATOPLASTY + FIRST STICH NISSEN- ROSSETTI IATOPLASTY + SECOND STICH NISSEN-ROSSETTI DISTANCE BETWEEN CRURA AND WRAP IATOPLASTY CORRECTELY FASHIONED FUNDOPLICATIO IATOPLASTY

8. Number524 Male307 Female217 M/F0.96 : 1 Median age42.3 Age Range17-78 Nissen-Rossetti Fundoplication Personal Experience (Feb 1992 -Nov 2007) Del Genio, Febbraio 2010

9. Hospital stay: 2.3 ± 0.9 days Mortality: 0 Intraoperative mucosal injuries: 1/524 (0.2%) Conversions: 1/524 (0.2%) Early Complications 1 pt (0.2%): esophageal perforation (laparotomy + drainage in II p.o. day) 1 pt (0.2%): splenic injury (splenectomy in I p.o. day) 3 pts (0.4%): hemorrage (reintervention via laparoscopy in 2 pts and via laparotomy in 1 pt) Peri-operative Results Del Genio, Febbraio 2010

10. AutorN ptsFUSuccess (%)Morbidity (%) Mortality (%) Cowgill ‘0782910 aa801.50.2 Salminen ’074911 aa81.813.20 Lundell ’07997 aa92.12.40 Zaninotto ’073996-10 aa745.20 Morgenthal ’0731211 aa93.3-0 Rosenthal ’06186 10 aa82130 Del Genio ‘073807aa92.61.10 GERD – Long-term results outcomes from recent series DEL GENIO WORLD J SURG 2007

11. META-ANALISI di 9 studi randomizzati (4 Nissen vs Toupet e 5 Nissen/Toupet vs Dor) better reflux control after Nissen fundoplication it has been consistently shown that tailoring antireflux surgery according to esophageal motility is not indicated there is significance evidence that anterior fundoplication offers less effective long-term reflux control GERD

12. POSTOPERATIVE MANOMETRY

13. PROGRESSION OF THE BOLUS AT IMPEDANCE PERISTALSIS NORMAL WRAP RELAXATION U.E.S. HIGH RESOLUTION MANOMETRY AND IMPEDANCE (HRiM) LES + CRURA POSTOPERATIVE NISSEN-ROSSETTI NORMAL WRAP RELAXATION

14. RESULTS: HRiM PREPOST

15. HRiM: LIQUID SWALLOW

16. HRiM: VISCOUS SWALLOW

17. Pizza, Del Genio et al. Dis Esoph 2008 INFLUENCE OF ESOPHAGEAL MOTILITY ON LARS SURGERY 6 m FW-UP 330/406 (81%) 12m FW-UP 276/406 (68%) 24m FW-UP 260/406 (65%) 48m FW-UP 206/406 (53%) MANOMETRY LES PRESSURE

18. Pizza, Del Genio et al. Dis Esoph 2008 INFLUENCE OF ESOPHAGEAL MOTILITY ON LARS SURGERY 6 m FW-UP 330/406 (81%) 12m FW-UP 276/406 (68%) 24m FW-UP 260/406 (65%) 48m FW-UP 206/406 (53%) MANOMETRY PERISTALSIS

19. BOLUS TOTAL TRANSIT TIME (sec.) at HRiM Del Genio et al. J CLIN GASTROENT 2012 IMPEDANCE

20. p=N.S. Del Genio et al. Eur Surg Res 2007 PERISTALSI SECONDARIA (CLEARANCE)

21. POSTOPERATIVE PH-MONITORING AND COMBINED PH-IMPEDANCE (MII-PH)

22. Del Genio G et al, World J Surg 2007 standard Ph-MONITORING

24. Del Genio G et al. Surg Endosc 2008 Del Genio G et al. Dis Esophag 2009 Del Genio G. et al. Gastroenterol 2010 PH-IMPEDANCE MONITORING

25. Del Genio G et al. Surg Endosc 2008 Del Genio G et al. Dis Esophag 2009 Del Genio G. et al. Gastroenterol 2010 PH-IMPEDANCE MONITORING

26. POSTOPERATIVE OUTCOMES ON PHARYNGEAL REFLUX

27. PH-IMPEDANCE MONITORING Tolone, Del Genio. U Surg 2012

28. SELEZIONE

29. “IMPEDANCE DRIVEN ANTIREFLUX SURGERY” 2010

30. … ALLORA QUANTO CAMBIA L’INDICAZIONE ALLA CHIRURGIA ? Alberto del Genio

31. MII-pH allows identification of 40% of pz with GERD with a NEGATIVE standard pH- monitoring COMBINED 24 HOUR PH-IMPEDANCE Del Genio G et al, J Gastrintest Surg 2008

32. Ref #164, #170, #235

33. HELLER NISSEN-ROSSETTI

34. CONCLUSION LA CHIRURGIA FUNZIONALE NON PUO’ PRESCINDERE DA UNA ATTENTO STUDIO FISIOPATOLOGICO. QUESTO VALE SIA PER LA SELEZIONE DEI PAZIENTI CHE PER IL CONTROLLO DELLA CORRETTA FUNZIONE DELL’INTERVENTO NEL TEMPO. GLI STUDI DI CHIRURGIA FUNZIONALE HANNO A LORO VOLTA COSTITUITO UN VALIDO MODELLO PER UNA AVANZAMENTO DELLA CONOSCENZA DELLA FISOLOGIA E DELLA FISIOPATOLOGIA.