Miotomia laparoscopica secondo Heller per acalasia esofagea. C’è bisogno di una fundoplicatio?

The last decade has witnessed radical changes in the treatment of esophageal achalasia due to the development of minimally invasive techniques. Because of the high success rate of the laparoscopic Heller myotomy, a radical shift in the treatment algorithm of these patients has occurred, and today this is the preferred treatment modality for achalasia. This remarkable change is due to the recognition by gastroenterologists and patients that a laparoscopic Heller myotomy outperforms pneumatic dilatation and intra-sphincteric injection of botulinum toxin injection. While there is agreement about the technique of the myotomy per se, some questions still linger about the need for a fundoplication after the myotomy. The following review describes the data present in the literature in order to identify the best procedure that can achieve relief of dysphagia while avoiding development of gastroesophageal reflux

Riparazione laparoscopica delle ernie paraesofagee: un approccio “evidence-based”

The approach to paraesophageal hernias has drastically changed over the last decade. The goal of this paper is to describe in detail our surgical technique of laparoscopic repair of paraesophageal hernias and to provide an evidence-based approach to the most controversial aspects of this type of repair

Anatomic variations in the surgical anatomy of the thoracic esophagus and its surrounding structures

BACKGROUND: Esophagectomy is a challenging procedure due to: a) it is a complex operation; b) it is linked to very high morbidity and mortality rates; c) surgical anatomy of the esophagus is very peculiar. The anatomic variations that can be unexpectedly found during an operation may cause complications and influence the outcome. AIM: To review the anatomic basis for esophagectomy focusing on anatomic variations found in the mediastinal structures based on literature review and cadaver dissection. METHODS: Literature related to the surgical anatomy of the esophagus and mediastinal structures was reviewed. Also, a total of 20 fresh (non-embalmed, non-preserved, time of death under 12 h) human cadavers were dissected. There were 16 male and mean age was 53 ± 23 years. RESULTS: Anatomic variations for aorta, azygos system, pleura, vagus nerve, lymph nodes and thoracic duct were documented. CONCLUSIONS: The organs and structures of the mediastinum may frequently present anatomic variations. Some of these may be clinically significant during an esophagectomy. Because only a part of them may be identified before the operation with the current imaging tools, surgeons must be aware of these anatomic variations.RACIONAL: A esofagectomia é procedimento difícil, devido a: a) ser operação complexa; b) apresentar alta morbidade e mortalidade; c) a anatomia cirúrgica do esôfago é muito peculiar. As variações anatômicas que podem ser encontradas inesperadamente durante uma operação podem causar complicações e influenciar os resultados. OBJETIVO: Revisar a base anatômica para esofagectomia destacando as variações encontradas nas estruturas mediastinais através de revisão de literatura e dissecção de cadáveres. MÉTODOS: A literatura relacionada com a anatomia cirúrgica das estruturas esôfago e mediastino foi revista. Além disso, um total de 20 cadáveres humanos frescos (não embalsamados, não preservados e com tempo de morte com menos de 12 h) foram dissecados. Dezesseis eram do sexo masculino com idade média de 53±23 anos. RESULTADOS: Variações anatômicas de aorta, sistema ázigos, pleura, nervo vago, linfonodos e ducto torácico foram documentadas. CONCLUSÕES: Os órgãos e estruturas do mediastino podem, frequentemente, apresentar variações anatômicas. Algumas delas podem ser clinicamente significativas durante esofagectomia. Devido a que apenas uma parte dessas variações são identificadas antes da operação com os meios de imagens atuais, os cirurgiões devem estar cientes da possibilidade dessas variações anatômicas.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de CirurgiaUniversity of Chicago Pritzker School of Medicine Department of SurgeryUNIFESP, EPM, Depto. de CirurgiaSciEL

A pressão do esfíncter esofagiano superior varia durante a manometria esofágica

BACKGROUND:The upper esophageal sphincter is composed of striated muscle. The stress of intubation and the need to inhibit dry swallows during an esophageal manometry test may lead to variations in basal pressure of this sphincter. Upper esophageal sphincter is usually only studied at the final part of the test. Was observed during the performance of high resolution manometry that sphincter pressure may vary significantly over the course of the test.AIM:To evaluate the variation of the resting pressure of the upper esophageal sphincter during high resolution manometry.METHODS:Was evaluated the variation of the basal pressure of the upper esophageal sphincter during high resolution manometry. Were reviewed the high resolution manometry tests of 36 healthy volunteers (mean age 31 years, 55% females). The basal pressure of the upper esophageal sphincter was measured at the beginning and at the end of a standard test.RESULTS:The mean time of the test was eight minutes. The basal pressure of the upper esophageal sphincter was 100 mmHg at the beginning of the test and 70 mmHg at the end (p<0.001). At the beginning, one patient had hypotonic upper esophageal sphincter and 14 hypertonic. At the end of the test, one patient had hypotonic upper esophageal sphincter (same patient as the beginning) and seven hypertonic upper esophageal sphincter.CONCLUSION:A significant variation of the basal pressure of the upper esophageal sphincter was observed in the course of high resolution manometry. Probably, the value obtained at the end of the test may be more clinically relevant.RACIONAL:O esfíncter esofagiano superior é constituído de musculatura estriada. O estresse da intubação e a necessidade de coibir as deglutições secas durante a manometria esofágica podem alterar a pressão basal do esfíncter esofagiano superior que geralmente é estudado somente ao final da manometria convencional. Notou-se na manometria de alta resolução significante variação no decorrer do exame.OBJETIVO:Avaliar a variação da pressão basal do esfíncter esofagiano superior durante a manometria de alta resolução.MÉTODO:Foi avaliada a variação de pressão basal do esfíncter esofagiano superior durante manometria de alta resolução. Foram estudados 36 voluntários sadios (idade média de 31 anos, 55% de mulheres). A pressão basal foi aferida no início e ao término do exame.RESULTADOS:O tempo médio dos exames foi de oito minutos. A pressão basal do esfíncter esofagiano superior foi de 100 mmHg no início do exame e de 70 mmHg ao final, em média (p<0.001). No início do teste, um paciente tinha o esfíncter esofagiano superior hipotônico e 14 hipertônicos. No final, um paciente tinha o esfíncter esofagiano superior hipotônico (o mesmo do início) e sete hipertônicos.CONCLUSÃO:Há significante variação na pressão basal do esfíncter esofagiano superior no curso manometria de alta resolução. Provavelmente, o valor obtido ao final do exame possa ser mais clinicamente relevante.Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM) Department of SurgeryUniversity of Chicago Department of SurgeryUNIFESP, EPM, Department of SurgerySciEL

Gastroesophageal reflux disease in surgical versus clinical literature: clinicians do not read surgical journals

BACKGROUND: Several diseases may be treated either medically or surgically; however, clinical and surgical therapies are often not treated as different options for the same patient but rather as different medical philosophies. AIM: To assess whether the main surgical and medical journals make references to their counterparts, with gastroesophageal reflux as a model of clinical/surgical disease. METHOD: It was reviewed the leading medical journals in order to verify if surgeons and clinicians make references to their counterparts on their work using gastroesophageal reflux disease as a model of a clinical/surgical disease. It was reviewed the five top-ranked journals in the field of gastroenterology, general surgery and general medicine and a neutral journal. The issues of the year 2008 of the selected journals were searched for papers dealing with gastroesophageal reflux disease. RESULTS: The search in the selected journals retrieved 49 papers, 36 (74%) in clinical journals, 5 (10%) in surgical journals, 2 (4%) in general medicine journals, and 6 (12%) in the neutral journal. Thirty one (63%) had a clinical origin, 13 (26%) a surgical origin, and 5 (10%) a neutral origin. Surgical journals published only surgical papers and general medicine journals published only clinical papers. Clinical journals and general medicine journals showed a higher proportion of clinical/surgical references compared to surgical journals (p<0.001) and the neutral journal (p<0.001). There was no differences in the proportion of clinical/surgical references when surgical and the neutral journal were compared (p=0.06). Clinical journals and general medicine journals showed a similar proportion of clinical/surgical references (p=0.06). CONCLUSION: Clinicians make significantly less references to surgical journals than surgeons do to clinical journals.RACIONAL: Várias doenças podem ser tratadas médica ou cirurgicamente; no entanto, a terapêutica clínica ou cirúrgica não é muitas vezes usada como diferente opção para o mesmo paciente, mas sim como diferente filosofia médica na abordagem. OBJETIVO: Verificar se os principais periódicos cirúrgicos e clínicos fazem referências aos seus congêneres, tendo a doença do refluxo gastroesofágico como um modelo de doença clínico/cirúrgica. MÉTODO: Foram revistos os cinco primeiros periódicos classificados na área de gastroenterologia, cirurgia geral e medicina geral e um jornal neutro. Os números do ano 2008 dos periódicos selecionados foram pesquisados no como lidar com a doença do refluxo gastroesofágico. RESULTADOS: Foram selecionados 49 trabalhos, 36 (74%) em revistas clínicas, 5 (10%) em revistas de cirurgia, 2 (4%) em revistas de medicina geral e 6 (12%) no jornal neutro. Trinta e um (63%) tiveram origem clínica, 13 (26%) cirúrgica, e 5 (10%) a origem foi neutra. Revistas cirúrgicas publicaram apenas artigos cirúrgicos e revistas de medicina geral, publicaram apenas trabalhos clínicos. Revistas e jornais de medicina clínica geral mostraram maior proporção de referências clínico/cirúrgicas em relação às revistas de cirurgia (p<0,001) e do jornal neutro (p<0,001). Não houve diferenças na proporção de referências clínico/cirúrgicas quando revistas cirúrgicas e a neutra foram comparadas (p= 0,06). Revistas clínicas e de medicina geral mostraram semelhante proporção de referências clínico/cirúrgicas (p=0,06). CONCLUSÃO: Os clínicos fazem referências significativamente menores para revistas cirúrgicas do que os cirurgiões fazem para as revistas clínicas.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departmento de CirurgiaUniversity of Chicago Department of SurgeryUNIFESP, EPM, Departmento de CirurgiaSciEL

The numerical simulation tool for the MAORY multiconjugate adaptive optics system

The Multiconjugate Adaptive Optics RelaY (MAORY) is and Adaptive Optics module to be mounted on the ESO European-Extremely Large Telescope (E-ELT). It is a hybrid Natural and Laser Guide System that will perform the correction of the atmospheric turbulence volume above the telescope feeding the Multi-AO Imaging Camera for Deep Observations Near Infrared spectro-imager (MICADO). We developed an end-to-end Monte- Carlo adaptive optics simulation tool to investigate the performance of a the MAORY and the calibration, acquisition, operation strategies. MAORY will implement Multiconjugate Adaptive Optics combining Laser Guide Stars (LGS) and Natural Guide Stars (NGS) measurements. The simulation tool implements the various aspect of the MAORY in an end to end fashion. The code has been developed using IDL and uses libraries in C++ and CUDA for efficiency improvements. Here we recall the code architecture, we describe the modeled instrument components and the control strategies implemented in the code.Comment: 6 pages, 1 figure, Proceeding 9909 310 of the conference SPIE Astronomical Telescopes + Instrumentation 2016, 26 June 1 July 2016 Edinburgh, Scotland, U

Event-Driven User-Centric Middleware for Energy Efficient Buildings and Public Spaces

In this work, the design of an event-driven user-centric middleware for monitoring and managing energy consumption in public buildings and spaces is presented. The main purpose is to increase the energy efficiency, reducing consumption, in buildings and public spaces. To achieve this, the proposed service-oriented middleware has been designed to be event based, also exploiting the user behaviours patterns of the people who live and work into the building. Furthermore, it allows an easy integration of heterogeneous technologies in order to enable a hardware independent interoperability between them. Moreover, a Heating Ventilation and Air Conditioning (HVAC) control strategy has been developed and the whole infrastructure has been deployed in a real-world case study consisting of a historical building. Finally the results will be presented and discusse

Primary Esophageal Motility Disorders: Beyond Achalasia

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders. The Chicago classification introduced new manometric parameters and better defined esophageal motility disorders. Motility disorders beyond achalasia with the current classification are: esophagogastric junction outflow obstruction, major disorders of peristalsis (distal esophageal spasm, hypercontractile esophagus, absent contractility) and minor disorders of peristalsis (ineffective esophageal motility, fragmented peristalsis). The aim of this study was to review the current diagnosis and management of esophageal motility disorders other than achalasia

Designing a Smart City Internet of Things Platform with Microservice Architecture

The Internet of Things (IoT) is being adopted in different application domains and is recognized as one of the key enablers of the Smart City vision. Despite the standard-ization efforts and wide adoption of Web standards and cloud computing technologies, however, building large-scale Smart City IoT platforms in practice remains challenging. The dynamically changing IoT environment requires these systems to be able to scale and evolve over time adopting new technologies and requirements. In response to the similar challenges in building large-scale distributed applications and platforms on the Web, microservice architecture style has emerged and gained a lot of popularity in the industry in recent years. In this work, we share our early experience of applying the microservice architecture style to design a Smart City IoT platform. Our experience suggests significant benefits provided by this architectural style compared to the more generic Service-Oriented Architecture (SOA) approaches, as well as highlights some of the challenges it introduces