During the COVID-19 pandemic, surgical departments were forced to re-schedule their activity giving priority to urgent procedures and non-deferrable oncological cases. There is a lack of ...evidence-based literature providing clinical and organizational guidelines for the management of a general surgery department. Aim of our study was to review the available recommendations published by general Surgery Societies and Health Institutions and evaluate the underlying Literature.
A review of the English Literature was conducted according to the AMSTAR and to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.
After eligibility assessment, a total of 22 papers and statements were analyzed. Surgical societies have established criteria for triage and prioritization in order to identify procedures that can be postponed after the pandemic and those that should not. Prioritization among oncologic cases represents a difficult task: clinicians have to balance a possible delay in cancer diagnosis or treatment against the risk for a potential COVID-19 exposure. There is broad agreement among guidelines that indication to proceed with surgery should be discussed in virtual Tumor Boards taking into consideration alternative therapeutic approaches. Several guidelines deal with the role of laparoscopic surgery during the pandemic: a tailored approach is currently suggested, with a case-by-case evaluation provided that appropriate personal protective equipment is available in order to minimize the potential risk of transmission. Finally, there is a considerable agreement in the published Literature concerning the management of the personnel during the peri- and intraoperative phase and on the technical advices regarding the induction, operative and recover maneuvers in COVID-19 cases.
During COVID-19 pandemic, it is of paramount importance to face the emergency in the most effective and efficient manner, retrieving resources from non-essential settings and, at the same time, providing care to high priority non-COVID-19 related diseases.
•The COVID-19 pandemic has forced surgical departments to reschedule their activity.•The development of a surgical plan with criteria for elective cases prioritization is necessary.•It is essential to ensure emergency surgery care, preferring non operative management if feasible and safe.•All patients should be considered COVID-19 suspected cases until proven otherwise.
Background
The aim of this study was to assess the long-term outcome of laparoscopic Heller-Dor (LHD) myotomy to treat achalasia at a single high-volume institution in the past 25 years.
Methods
...Patients undergoing LHD from 1992 to 2017 were prospectively registered in a dedicated database. Those who had already undergone surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium swallow, endoscopy, and manometry were performed before and after surgery; and 24-h pH monitoring was done 6 months after LHD.
Results
One thousand one patients underwent LHD (M:F = 536:465), performed by six staff surgeons. The surgical procedure was completed laparoscopically in all but 8 patients (0.8%). At a median of follow-up of 62 months, the outcome was positive in 896 patients (89.5%), and the probability of being cured from symptoms at 20 years exceeded 80%. Among the patients who had previously received other treatments, there were 25/182 failures (13.7%), while the failures in the primary treatment group were 80/819 (9.8%) (
p
= 0.19). All 105 patients whose LHD failed subsequently underwent endoscopic pneumatic dilations with an overall success rate of 98.4%. At univariate analysis, the manometric pattern (
p
< 0.001), the presence of a sigmoid megaesophagus (
p
= 0.03), and chest pain (
p
< 0.001) were the factors that predicted a poor outcome. At multivariate analysis, all three factors were independently associated with a poor outcome. Post-operative 24-h pH monitoring was abnormal in 55/615 patients (9.1%).
Conclusions
LHD can durably relieve achalasia symptoms in more than 80% of patients. The pre-operative manometric pattern, the presence of a sigmoid esophagus, and chest pain represent the strongest predictors of outcome.
Phase unwrapping is the reconstruction of a function on a grid given its values mod 2/spl pi/. Phase unwrapping is a key problem in all quantitative applications of synthetic aperture radar (SAR) ...interferometry, but also in other fields. A new phase unwrapping method, which is a different approach from existing techniques, is described and tested. The method starts from the fact that the phase differences of neighboring pixels can be estimated with a potential error that is an integer multiple of 2/spl pi/. This suggests the formulation of the phase unwrapping problem as a global minimization problem with integer variables. Recognizing the network structure underlying the problem makes for an efficient solution. In fact, it is possible to equate the phase unwrapping problem to the problem of finding the minimum cost flow on a network, for the solution of which there exist very efficient techniques. The tests performed on real and simulated interferometric SAR data confirm the validity of the approach.
Background
POEM has recently had a widespread diffusion, aiming at being the treatment of choice for esophageal achalasia. The results of ongoing RCTs against laparoscopic myotomy are not available, ...yet. We, therefore, designed this propensity score (PS) case-control study with the aim of evaluating how POEM compares to the long-standing laparoscopic Heller myotomy + Dor fundoplication (LHD) and verifying if it may really replace the latter as the first-line treatment for achalasia.
Methods
Two groups of consecutive patients undergoing treatment for primary achalasia from January 2014 to November 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous endoscopic treatment were included, whereas patients with previous LHD or POEM were excluded. A total of 140 patients in both centers were thus matched. LHD and POEM were performed following established techniques. The patients were followed with clinical (Eckardt score), endoscopic, and pH-manometry evaluations.
Results
The procedure was successfully completed in all the patients. POEM required a shorter operation time and postoperative stay compared to LHD (p < 0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (five mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p = 0.33). Two patients in the POEM group and one in the LHD were lost to follow-up. One patient in both groups died during the follow-up for unrelated causes. At a median follow-up of 24 months 15–30 for POEM and 31 months 15–41 for LHD (p < 0.05), 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p < 0.12). Four years after the treatment, the probability to have symptoms adequately controlled was > 90% for both groups (p = 0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; 24-h pH-monitoring showed however an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p < 0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p < 0.05).
Conclusion
POEM provides the same midterm results as LHD. This study confirms, however, a higher incidence of postoperative GERD with the former, even if its real significance needs to be further evaluated.
Background & Aims Patients with achalasia are treated with either pneumatic dilation (PD) or laparoscopic Heller myotomy (LHM), which have comparable rates of success. We evaluated whether manometric ...subtype was associated with response to treatment in a large population of patients treated with either PD or LHM (the European achalasia trial). Methods Esophageal pretreatment manometry data were collected from 176 patients who participated in the European achalasia trial. Symptoms (weight loss, dysphagia, retrosternal pain, and regurgitation) were assessed using the Eckardt score; treatment was considered successful if the Eckardt score was 3 or less. Manometric tracings were classified according to the 3 Chicago subtypes. Results Forty-four patients had achalasia type I (25%), 114 patients had achalasia type II (65%), and 18 patients had achalasia type III (10%). After a minimum follow-up period of 2 years, success rates were significantly higher among patients with type II achalasia (96%) than type I achalasia (81%; P < .01, log-rank test) or type III achalasia (66%; P < .001, log-rank test). The success rate of PD was significantly higher than that of LHM for patients with type II achalasia (100% vs 93%; P < .05), but LHM had a higher success rate than PD for patients with type III achalasia (86% vs 40%; P = .12, difference was not statistically significant because of the small number of patients). For type I achalasia, LHM and PD had similar rates of success (81% vs 85%; P = .84). Conclusions A higher percentage of patients with type II achalasia (based on manometric tracings) are treated successfully with PD or LHM than patients with types I and III achalasia. Success rates in type II are high for both treatment groups but significantly higher in the PD group. Patients with type III can probably best be treated by LHM. Trialregister.nl number NTR37; ISRCTN56304564.
Many experts consider laparoscopic Heller's myotomy (LHM) to be superior to pneumatic dilation for the treatment of achalasia, and LHM is increasingly considered to be the treatment of choice for ...this disorder.
We randomly assigned patients with newly diagnosed achalasia to pneumatic dilation or LHM with Dor's fundoplication. Symptoms, including weight loss, dysphagia, retrosternal pain, and regurgitation, were assessed with the use of the Eckardt score (which ranges from 0 to 12, with higher scores indicating more pronounced symptoms). The primary outcome was therapeutic success (a drop in the Eckardt score to ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for retreatment, pressure at the lower esophageal sphincter, esophageal emptying on a timed barium esophagogram, quality of life, and the rate of complications.
A total of 201 patients were randomly assigned to pneumatic dilation (95 patients) or LHM (106). The mean follow-up time was 43 months (95% confidence interval CI, 40 to 47). In an intention-to-treat analysis, there was no significant difference between the two groups in the primary outcome; the rate of therapeutic success with pneumatic dilation was 90% after 1 year of follow-up and 86% after 2 years, as compared with a rate with LHM of 93% after 1 year and 90% after 2 years (P=0.46). After 2 years of follow-up, there was no significant between-group difference in the pressure at the lower esophageal sphincter (LHM, 10 mm Hg 95% CI, 8.7 to 12; pneumatic dilation, 12 mm Hg 95% CI, 9.7 to 14; P=0.27); esophageal emptying, as assessed by the height of barium-contrast column (LHM, 1.9 cm 95% CI, 0 to 6.8; pneumatic dilation, 3.7 cm 95% CI, 0 to 8.8; P=0.21); or quality of life. Similar results were obtained in the per-protocol analysis. Perforation of the esophagus occurred in 4% of the patients during pneumatic dilation, whereas mucosal tears occurred in 12% during LHM. Abnormal exposure to esophageal acid was observed in 15% and 23% of the patients in the pneumatic-dilation and LHM groups, respectively (P=0.28).
After 2 years of follow-up, LHM, as compared with pneumatic dilation, was not associated with superior rates of therapeutic success. (European Achalasia Trial Netherlands Trial Register number, NTR37, and Current Controlled Trials number, ISRCTN56304564.).
Phase unwrapping and integration of finite differences are key problems in several technical fields, among which is synthetic aperture radar (SAR) interferometry. In this paper, we propose a general ...formulation for robust and efficient integration of finite differences and for phase unwrapping, which includes standard techniques (e.g., minimum cost flow and least squares phase unwrapping) as subcases. The proposed approach allows obtaining more reliable and accurate solutions by exploiting redundant differential estimates (not only between nearest neighboring points) and multidimensional information (e.g., multitemporal). In addition, a model of the signal (e.g., multibaseline or multifrequency) or external data (e.g., GPS or leveling measurements) can be integrated. The method requires the solution of linear or quadratic programming problems, for which computationally efficient algorithms exist. The validation tests performed on real and simulated SAR data confirm the validity of the method, which was integrated in our production chain and successfully used also in massive productions.
Satellite synthetic aperture radar (SAR) interferometry (InSAR) is a powerful technology to monitor slow ground surface movements. However, the extraction and interpretation of information from big ...sets of InSAR measurements is a complex and demanding task. In this paper, a new method is presented for automatically detecting potential instability risks affecting buildings and infrastructures, by searching for anomalies in the persistent scatterer (PS) deformations, either in the spatial or in the temporal dimensions. In the spatial dimension, in order to reduce the dataset size and improve data reliability, we utilize a hierarchical clustering method to obtain convergence points that are more trustworthy. Then, we detect deformations characterized by large values and spatial inhomogeneity. In the temporal dimension, we use a signal processing method to decompose the input into two main components: regular periodic deformations and piecewise linear deformations. After removing the periodic component, the velocity variation in each identified temporal partition is analyzed to detect anomalous velocity trends and accelerations. The method has been tested on different sites in China, based on InSAR measurements from COSMO-SkyMed data. The results, verified with in-field surveys, confirm the potential of the method for the automatic detection of deformation anomalies that could cause building or infrastructure stability problems.
It is currently unclear if the three manometric patterns of esophageal achalasia represent distinct entities or part of a disease continuum. The study’s aims were: a) to test the hypothesis that the ...three patterns represent different stages in the evolution of achalasia; b) to investigate whether manometric patterns change after Laparoscopic-Heller-Dor (LHD).
We assessed the patients diagnosed with achalasia who underwent LHD as their first treatment from 1992 to 2016. Their symptoms were scored using a detailed questionnaire for dysphagia, food-regurgitation, and chest pain. Barium-swallow, endoscopy, and esophageal-manometry were performed before and 6 months after surgery.
The study population consisted of 511 patients (M:F=283:228). Patients’ demographic and clinical data showed that those with pattern III had a shorter history of symptoms, a higher incidence of chest pain, and a less dilated gullet (p<0.001). All patients with a sigmoid-shaped mega-esophagus had pattern I achalasia. One patient with a diagnosis of pattern III achalasia developed pattern II at a follow-up manometry before surgery.
At a median follow-up of 30 months (IQR 12–56), the outcome of surgery was positive in 479 patients (91.7%).
All patients with pattern I preoperatively had the same pattern after LHD, whereas more than 50% of patients with pattern III before treatment showed pattern I or II after surgery.
This study supports the hypothesis/theory that the different manometric patterns represent different stages in the evolution of the disease—where pattern III is the earliest stage, pattern II an intermediate stage, and pattern I the final stage.
Persistent scatterer interferometry is a widely used technique to detect and monitor slow terrain movements, with millimetric accuracy, from satellite synthetic aperture radar (SAR) data. We have ...recently proposed a method, named persistent scatterer pair (PSP), aimed at overcoming some limitations of standard techniques. The PSP method is characterized by the fact of exploiting only the relative properties of neighboring pairs of points for both detection and analysis of persistent scatterers (PSs), intended in the general sense of scatterers that exhibit interferometric coherence for the time period and baseline span of the acquisitions, including both point-like and distributed scatterers. Thanks to the pair-of-point approach, the PSP technique is intrinsically not affected by artifacts slowly variable in space, like those depending on atmosphere or orbits. Moreover, by exploiting a very redundant set of pair-of-point connections, the PSP approach guarantees extremely dense and accurate displacement and elevation measurements, both in correspondence of structures and when the backscattering is weak or distributed as in the case of natural terrains. In all cases, the measurements keep the full resolution of the input SAR images. In this work, the qualifying characteristics of the PSP technique are described, and several application examples and validation tests based on COSMO-SkyMed data are reported, which demonstrate the validity of the proposed approach.
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