Antonio Martino

Objective: The standard treatment for Zenker's diverticulum (ZD) is transoral septotomy, which has evolved to include techniques such as septal traction to improve outcomes. This study reports the clinical results from our center using a modified transoral septotomy (MTS). Methods: From 2023 to 2025, 21 patients with ZD were treated with MTS at our center. A dysphagia screening questionnaire was utilized to assess the frequency and severity of dysphagia and regurgitation. All patients underwent a surgical examination, preoperative endoscopy, and preoperative barium swallow. This prospective study aimed to evaluate the outcomes of MTS in treatment‐naïve and recurrent ZD cases, highlighting the technique's appeal due to its minimally invasive nature and enhanced patient outcomes. Results: Among the 21 patients (16 males, 5 females, median age 82.5 years, interquartile range (IQR): 61–80), symptom scores improved from a median of 12 (IQR: 10–16) pre‐surgery to 0 (IQR: 0–2) post‐surgery ( p < 0.00001). Post‐procedure, 87% of patients were completely asymptomatic, with a total failure rate of 5%. The treatment was successful in 95% of patients overall and in 100% of those with recurrent ZD. Conclusion: Despite inherent study limitations, modified transoral septotomy significantly improves treatment outcomes for ZD patients. Level of Evidence: 2 (observational study with significant effect)—Oxford Centre for Evidence‐Based Medicine 2011 Levels of Evidence.

Background: Postoperative pulmonary complications (PPCs) remain a challenge after esophagectomy. Despite improvement in surgical and anesthesiological management, PPCs are reported in as many as 40% of patients. The main aim of this study is to investigate whether early application of high-flow nasal cannula (HFNC) after extubation will provide benefit in terms of reduced PPC frequency compared to standard oxygen therapy. Methods: Patients aged 18–85 years undergoing esophagectomy for cancer treatment with radical intent, excluding those with American Society of Anesthesiologists (ASA) score >3 and severe systemic comorbidity (cardiac, pulmonary, renal or hepatic disease) will be randomized at the end of surgery to receive HFNC or standard oxygen therapy (Venturi mask or nasal goggles) after early extubation (within 12 hours after the end of surgery) for 48 hours. The main postoperative goals are to obtain SpO₂ ≥94% and adequate pain control. Oxygen therapy after 48 hours will be stopped unless the physician deems it necessary. In case of respiratory clinical worsening, patients will be supported with the most appropriate tool (noninvasive ventilation or invasive mechanical ventilation). Pulmonary [pneumonia, pleural effusion, pneumothorax, atelectasis, acute respiratory distress syndrome (ARDS), tracheo-bronchial injury, air leak, reintubation, and/or respiratory failure] complications will be recorded as main outcome. Secondary outcomes, including cardiovascular, surgical, renal and infective complications will also be recorded. The primary analysis will be carried out on 320 patients (160 per group) and performed on an intention-to-treat (ITT) basis, including all participants randomized into the treatment groups, regardless of protocol adherence. The primary outcome, the PPC rate, will be compared between the two treatment groups using a chi-square test for categorical data, or Fisher’s exact test will be used if the assumptions for the chi-square test are not met. Discussion: Recent evidence demonstrated that early application of HFNC improved the respiratory rate oxygenation index (ROX index) after esophagectomy but did not reduce PPCs. This randomized controlled multicenter trial aims to assess the potential effect of the application of HFNC versus standard oxygen over PPCs in patients undergoing esophagectomy. Trial Registration: This study is registered at clinicaltrial.gov NCT05718284, dated 30 January 2023.

Background: Postoperative pulmonary complications after esophagectomy still represent a matter of concern. High flow nasal cannula (HFNC) early after major abdominal and thoracic surgery has demonstrated some advantages over conventional oxygen therapy. Data about respiratory effect of HFNC after esophagectomy is scarce. The primary aim of this study is to investigate if the early use of HFNC after esophagectomy could enhance patients’ postoperative respiratory oxygenation (ROX) index and, ultimately, reduce postoperative pneumonia. Methods: In this single center retrospective study all patients undergoing to esophagectomy for cancer from May 2020 to November 2022 were evaluated. Historical cohort (HC) received postoperative oxygen supplementation with Venturi mask or nasal goggles, and a cohort was put under HFNC (HFNC cohort). ROX index, blood gas analysis, radiological atelectasis score (RAS), post-operative complications’ data and information on hospital stay have been collected and analyzed. Results: Seventy-one patients were included for the final statistical analysis, 31 in the HFNC and 40 in the HC cohort. Mean age was 64±10 years and body mass index (BMI) was 26 [24–29] kg/m². ROX index was higher in the HFNC patients than in the HC, 20.8 [16.7–25.9] vs. 14.9 [10.8–18.2] (Pvs. 7.39 [7.37–7.43] than HC, while PaCO₂ was lower in HFNC cohort compared with HC, 39 [36–41] vs. 42 [39–45] mmHg, respectively (P=0.01). RAS was similar between the two cohorts of patients, 1.5±0.98 vs. 1.4±1.04 in the HFNC and the HC cohort, respectively (P=0.611). Lower acute respiratory failure (ARF) rate was recorded among HFNC than HC cohort, 0% vs. 13% respectively, P=0.06. No difference in pneumonia frequency between two cohorts was shown. Conclusions: HFNC improved the ROX index after esophagectomy through significant respiratory rate reduction. This tool should be considered for early respiratory support after extubation in this category of patients, not only as a rescue therapy for ARF, but also to optimize early postoperative respiratory function. Whether this will improve patients’ outcomes requires further large randomized controlled trials.

In Systemic Sclerosis (SSc), gastroesophageal reflux disease (GERD) occurs in 75% of patients. Chronic doses of proton pump inhibitors may elicit in the general population long-term risk. When medical therapy fails, surgery can be employed but consensus on surgical procedures for refractory GERD is still lacking in SSc. Our aim was to evaluate the surgical approaches employed in the management of refractory GERD with a systematic literature research (SLR). Four research questions, based on the PICO framework, guided the SLR which was conducted up to December 22nd, 2021. The search was performed across different databases including PubMed, MEDLINE (OVID), EMBASE, Cochrane Library, Web of Science, Google Scholar, Emcare and Academic Search Premier. References were independently screened by two reviewers (PMC and AA) who also independently assessed the full text of eligible articles, and extracted data. Due to heterogeneity of retrieved studies, narrative summaries are used to present the data. In 30/916 papers, eligible for review, 348 patients were identified: 257 underwent an anti-reflux surgical procedure and included in the analysis. Refractory GERD was the most frequent indication for surgery, and post-operative dysphagia was a frequent complication. In 18 studies, fundoplication (FP) was effective, whereas 4 studies had equivocal findings and 5 didn’t report efficacy. Surgical procedures have changed in time: overall, the Collis-Nissen FP was the most popular in old studies, followed by Nissen FP, while Dor FP has been used more recently. The data extracted show also an acceptable rate of mortality and morbidity related to surgery. In SSc, FP seems a safe and effective procedure for GERD management. In many studies, transient post-operative dysphagia was related with the posterior FP. Our SLR shows that the surgical management of GERD is still highly challenging and minimal requirements should be provided to perform surgical studies in SSc, designing studies to define clinical criteria for surgical referral. In SSc, the right timing for surgery and the best surgical procedure still remain an unmet need.

Background: Chylothorax is a relatively rare complication after surgery of the mediastinum. The occurrence and the results of surgical treatment of this condition are difficult to foresee due to the wide heterogeneity in thoracic duct anatomy. Case summary: We report two cases of postoperative chylothorax treated with ligation by video-assisted thoracoscopic surgery (VATS). The first patient developed a massive left chylothorax shortly after discharge, following radical excision of a seminoma-involved left para-aortic lymphadenopathy. The second patient developed a high-output right chylothorax following VATS upper bilobectomy. In both cases, a surgical revision by VATS was performed. Inguinal injection of indocyanine green allowed an easy visualization of the lymphatic leakage point. In both cases, oral feeding was rapidly restarted after surgery. No recurrence of chylothorax was observed. Conclusion: The use of indocyanine green may greatly improve the identification of the thoracic duct during surgical ligation by VATS, with a favorable impact on the postoperative course and overall admission costs.