Da-vinci robot-assisted surgery vs laparoscopic repair for the treatment of hiatal hernia repair / 中华普通外科杂志

Objective:To compare Da-vinci robotic surgical system with laparoscopic surgery for the repair of hiatal hernia.Methods:The clinical data of 115 patients undergoing minimally invasive Nissen fundoplication at the Department of Hernia and Abdominal Wall Surgery, the Affiliated Hospital,Xuzhou Medical University from Dec 2019 to May 2022 were retrospectively studied. After propensity score matching (PSM), 46 cases in each group were included:Robot-assisted surgery (RS group) and laparoscopic surgery (LS group). Postoperative complications were collected and GERD Questionnaire (GERDQ) were used as the standard in evaluation of the results.Results:Patients in RS group had less intraoperative bleeding ( P<0.001), shorter postoperative gastrointestinal recovery time ( P<0.001), and shorter postoperative hospital stay ( P=0.002). The LS group had a shorter operative time ( P<0.001) and lower total hospital cost ( P<0.001). GERD-Q scores decreased significantly in both groups at 3 and 6 months postoperatively compared with preoperative scores ( P<0.001). There was no statistically significant difference between the two groups in the incidence of postoperative complications ( P>0.05). No recurrence was seen in both groups during postoperative follow-up. Conclusion:Da-vinci robot-assisted repair of hiatal hernia is as safe and feasible as laparoscopic procedures, with less intraoperative trauma and quicker, earlier recovery.

Application of posterior gastric mesentery in laparoscopic gastric surgery / 中华胃肠外科杂志

The posterior gastric mesentery is one of the six mesenteries of the stomach in the membrane anatomy theory. It locates in the upper area of the pancreas, surrounds the posterior gastric vessels, and is adjacent to the short gastric mesentery by the left side, and is adjacent to the left gastric mesentery by the right side, which fixes the fundus body to the posterior abdominal wall of the upper area of pancreas. Due to its anatomical structure, in complete mesentery excision (CME)+D2 surgery, it is a surgical approach to deal with gastric mesentery in the upper area of pancreas; the second step of the "Huang's three-step method" corresponds to the posterior gastric mesentery in the theory of membrane anatomy. In the surgery of benign diseases of the stomach, laparoscopic sleeve gastrectomy (LSG) and laparoscopic Nissen fundoplication, if the short gastric vessels are difficult to be exposed and safely divided, we can dissect the posterior gastric mesentery firstly, and then hoist the fundus of the stomach in order to help dissection of the short gastric vessels. The membrane anatomy theory, as a frontier theory, provides us the new surgical perspectives and paths in gastric surgery.

Laparoscopic floppy Nissen fundoplication: evaluation of outcome in 34 patients operated without prior oesophageal pH and manometry

Background: Aim of the study was to evaluate prospectively the outcomes of laparoscopic floppy Nissen fundoplication in cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD) and hiatus hernia without pre-operative 24 hours oesophageal pH and manometry study. Methods: Thirty-four patients with typical symptoms of GERD, from March 2009 to November 2019, were studied. The study was limited to patients with positive findings on upper GI endoscopy done by operating surgeon with typical symptoms (heartburn, regurgitation, and dysphagia) of GERD and hiatal hernia. Laparoscopic Nissen’s fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only 1 patient, who had negative endoscopic findings, underwent a 24-hour pH-monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient's evaluation of outcome and quality of life after surgery.Result: Laparoscopic Nissen’s fundoplication is an effective long-term treatment for GERD and may be performed in patients with typical symptoms of GERD and hiatus hernia and endoscopic findings suggestive of reflux esophagitis and patient who wants to get rid of life long proton-pump inhibitors (PPI) and antacids medication.Conclusions: Preoperative oesophageal manometry and 24-hour pH monitoring are not mandatory for laparoscopic fundoplication if the patient selection is appropriate but may be required in selected patients with atypical symptoms.

Does the nissen fundoplication procedure improve esophageal dysmotility in patients with barrett's esophagus? / A fundoplicatura a nissen melhora a dismotilidade esofágica em pacientes com esôfago de barrett?

ABSTRACT Objective: to evaluate esophageal dysmotility (ED) and the extent of Barrett's esophagus (BE) before and after laparoscopic Nissen fundoplication (LNF) in patients previously diagnosed with BE and ED. Methods: twenty-two patients with BE diagnosed by upper gastrointestinal (GI) endoscopy with biopsies and ED diagnosed by conventional esophageal manometry (CEM) were submitted to a LNF, and followed up with clinical evaluations, upper GI endoscopy with biopsies and CEM, for a minimum of 12 months after the surgical procedure. Results : sixteen patients were male (72.7%) and six were females (27.3%). The mean age was 55.14 (± 15.52) years old. and the mean postoperative follow-up was 26.2 months. The upper GI endoscopy showed that the mean length of BE was 4.09 cm preoperatively and 3.91cm postoperatively (p=0.042). The evaluation of esophageal dysmotility through conventional manometry showed that: the preoperative median of the lower esophageal sphincter resting pressure (LESRP) was 9.15 mmHg and 13.2 mmHg postoperatively (p=0.006). The preoperative median of the esophageal contraction amplitude was 47.85 mmHg, and 57.50 mmHg postoperatively (p=0.408). Preoperative evaluation of esophageal peristalsis showed that 13.6% of the sample presented diffuse esophageal spasm and 9.1% ineffective esophageal motility. In the postoperative, 4.5% of patients had diffuse esophageal spasm, 13.6% of aperistalsis and 22.7% of ineffective motor activity (p=0.133). Conclusion: LNF decreased the BE extension, increased the LES resting pressure, and increased the amplitude of the distal esophageal contraction; however, it was unable to improve ED.

RESUMO Objetivo: avaliar a dismotilidade esofágica (DE) e a extensão do esôfago de Barrett (EB) antes e depois da fundoplicatura laparoscópica a Nissen (FLN) em pacientes previamente diagnosticados com EB e DE. Método: vinte e dois pacientes com EB diagnosticada por endoscopia digestiva alta (EDA) com biópsias e DE diagnosticada por manometria esofágica convencional (MEC) foram submetidos a FLN, e acompanhados por avaliações clínicas, endoscopia digestiva alta com biópsias e MEC, por no mínimo 12 meses após o procedimento cirúrgico. Resultados: dezesseis pacientes eram do sexo masculino (72,7%) e seis do feminino (27,3%). A média de idade foi de 55,14 (± 15,52) anos e o seguimento pós-operatório médio foi de 26,2 meses. A endoscopia digestiva alta mostrou que o comprimento médio do EB foi de 4,09 cm no pré-operatório e 3,91 cm no pós-operatório (p = 0,042). A avaliação da dismotilidade esofágica por meio da manometria convencional mostrou que a mediana pré-operatória da pressão de repouso do esfíncter esofágico inferior (PREEI) foi de 9,15 mmHg, e de 13,2 mmHg no pós-operatório (p = 0,006). A mediana pré-operatória da amplitude de contração esofágica foi de 47,85 mmHg, e de 57,50 mmHg no pós-operatório (p = 0,408). A avaliação pré-operatória do peristaltismo esofágico mostrou que 13,6% da amostra apresentava espasmo esofágico difuso e 9,1%, motilidade esofágica ineficaz. No pós-operatório, 4,5% dos pacientes apresentaram espasmo esofágico difuso, 13,6% de aperistalse e 22,7% de atividade motora ineficaz (p = 0,133). Conclusões: a FLN diminuiu a extensão do EB, aumentou a pressão de repouso do EEI e aumentou a amplitude da contração esofágica distal; no entanto, não foi capaz de melhorar a DE.

Short-term effects of Da Vinci robot Nissen fundoplication in the treatment of refractory gastroesophageal reflux disease / 中国胸心血管外科临床杂志

@#Objective    To investigate the short-term effects of Da Vinci robot-assisted Nissen fundoplication in the treatment of refractory gastroesophageal reflux disease (rGERD), and to evaluate the safety and efficacy of its surgical treatment. Methods    A total of 40 patients with rGERD treated by Da Vinci robot-assisted surgery from October 2016 to November 2019 in our hospital were collected. There were 23 males and 17 females at age of 34-76 (61±23) years. The related clinical data were retrospectively analyzed, and the operation skills of Da Vinci robot-assisted Nissen fundoplication with rGERD were summarized. Results    There was no perioperative death or serious complication such as esophagogastric fistula. Postoperative reflux symptoms were significantly improved. DeMeester scores after surgery (39.79±35.01 points vs. 2.61±2.40 points, P=0.029), lower esophageal sphincter pressure (8.74±7.21 mm Hg vs. 24.56±8.76 mm Hg, P=0.020), integrated relaxation pressure (7.29±7.21 mm Hg vs. 16.49±9.99 mm Hg, P=0.023), distal contractile integral (600.49 ± 665.30 mm Hg·s·m vs. 510.99 ± 580.60 mm Hg·s·m, P=0.042), GERD-Q scale score (12.98±2.39 points vs. 7.59±1.11 points, P=0.033) were significantly improved compared with those before surgery. Postoperative dysphagia was found in 2 patients. And dysphagia was alleviated after diet adjustment and other treatments. Conclusion    Da Vinci robot-assisted Nissen fundoplication is a safe and effective treatment for rGERD.

Bypass en Y-de-Roux sobre una funduplicatura de Nissen / Roux-en-Y gastric bypass following Nissen fundoplication

El bypass gástrico en Y-de-Roux (RYGB) trata eficazmente la obesidad y a la vez la enfermedad por reflujo gastroesofágico (ERGE). Desafortunadamente, algunos pacientes que finalmente se presentan para cirugía bariátrica han sido previamente sometidos a una funduplicatura de Nissen por ERGE. La conversión a RYGB después de esta funduplicatura ha demostrado ser segura y eficaz, pero con una mayor morbilidad, tiempo operatorio más prolongado y mayor estancia hospitalaria. Se presenta una paciente de 50 años, con IMC 40,4 kg/m², evaluada para cirugía bariátrica. Había sido sometida a funduplicatura de Nissen laparoscópica siete años atrás. Informamos un caso de eliminación laparoscópica de funduplicatura de Nissen y conversión a RYGB. La funduplicatura previa no es una contraindicación para LRYGB. Estos procedimientos deben ser llevados a cabo por cirujanos experimentados, y el abordaje laparoscópico debe ser el método de elección.

Roux-en-Y gastric bypass (RYGB) effectively treats both obesity and gastroesophageal reflux disease (GERD). Unfortunately, some patients finally present for bariatric surgery have previously undergone Nissen fundoplication due to GERD. Conversion to EYGB after Nissen fundoplication is safe and effective, but is associated with greater morbidity and longer operative time and hospital stay. A 50-year-old female patient with a body mass index (BMI) of 40.4 kg/m² was evaluated for bariatric surgery. She had a history laparoscopic Nissen fundoplication seven years before. We report a case of laparoscopic take-down of Nissen fundoplication and conversion to RYGB. A previous fundoplication is not a contraindication for laparoscopic RYGB. These procedures should be performed by well-trained surgeons and laparoscopic approach should be the method of choice.

Divertículos gástricos subcardiales: un hallazgo endoscópico poco frecuente / Subcardial Gastric Diverticula: A Rare Endoscopic Finding

Resumen Los divertículos gástricos (DG) son un hallazgo infrecuente. Suelen ser diagnosticados incidentalmente por métodos radiológicos o endoscópicos; se dividen en congénitos y adquiridos; y generalmente son asintomáticos, pero su expresión clínica va desde dolor abdominal inespecífico hasta cuadros clínicos más dramáticos como perforación y sangrado. Se presenta un caso de 3 DG en un paciente con antecedentes de colecistectomía y funduplicatura de Nissen con historia de dispepsia funcional. Su tratamiento fue conservador.

Abstract Gastric diverticula are uncommon and are usually diagnosed incidentally by radiological or endoscopic methods. They are divided into congenital and acquired diverticula and are usually asymptomatic. Clinical expression ranges from nonspecific abdominal pain to more dramatic clinical conditions such as perforations and bleeding. We present a case of three gastric diverticula in a patient with a history of functional dyspepsia, cholecystectomy and Nissen fundoplication. Treatment was conservative.

Detalles técnicos y morbimortalidad de la fundoplicatura de nissen laparoscópica en 503 pacientes con reflujo gastroesofágico / Laparoscopic Nissen fundoplication: experience in 530 patients

background: Laparoscopic nissen fundoplication is the surgical procedure of choice for patients with gastroesophageal reflux. Aim: To describe the most important surgical stages of the technique and report the rates of complications and mortality. material and methods: In a ten years period, 530 patients were subjec-ted to laparoscopic fundoplication. In all patients a clinical history was obtained and an upper endoscopy with biopsy, esophageal manometry and 24 h pH measurement were performed. Patients with Barret esophagus, hiatal hernia of more than 5 cm and those subjected to other surgical techniques were excluded from analysis. Results: No patient died. The conversion rate was 0.4%. No patient required splenectomy. Two patients had complications and required a second intervention. Mean hospital stay was 2.8 days. Conclusions: Laparoscopic nissen fundoplication is safe and has a low rate of complications.

Objetivo: El presente estudio pretende describir las etapas quirúrgicas más importantes de esta técnica y describir la morbimortalidad publicada por autores nacionales. material y método: Entre enero de 1993 y diciembre de 2013 un total de 530 pacientes se sometieron a una fundoplicatura laparoscópica dentro de un protocolo de estudio prospectivo. En todos se realizó una encuesta clínica, endoscopia con toma de biopsia, manometría esofágica y pH de 24 h. Se excluyeron pacientes con esófago de Barrett, pacientes con hernia hiatal > 5 cm y pacientes sometidos a una técnica quirúrgica diferente. Resultados: La mortalidad operatoria fue cero. La tasa de conversión fue de 0,4%. No hubo esplenectomía. Hubo un total de 2 pacientes complicados (0,4%), siendo todos reoperados. La estadía hospitalaria fue de 2,8 días. Conclusión: La fundoplicatura de Nissen por vía laparoscópica es un procedimiento seguro, de muy baja morbilidad y nula mortalidad operatoria.

Comparative study of Laparoscopic Nissen fundoplication Vs Posterior fundoplication in Gastroesophageal reflux disease

Background: Gastroesophageal reflux Disease is a highly prevalent gastrointestinal (GI) disorder and is one of the most common GI illnesses encountered in clinical practice. Gastroesophageal reflux disease (GERD) is one of the most common conditions presenting to primary care physicians and gastroenterologists. It refers to the abnormal exposure of the oesophageal mucosa to refluxed gastric contents, including acid and pepsin, resulting in symptoms and/or tissue damage. Our aim was to compare the result of nissen and toupet procedures and to determine which procedure is better in terms of symptomatic improvement symptom recurrence and post-operative complications. Materials and methods: This was the both prospective and retrospective study included 29 patients with GERD who were operated upon by Laproscopic Nissen Fundoplication and Laproscopic Posterior Fundoplication. Demographic and clinical profiles of all patients were recorded. All patients were subjected to thorough clinical evaluation, upper GI endoscopy done in all patients, esophageal Manometry and 24 ph study done in selected patients. All preoperative data compared with the postoperative data. Results: In our series 68.9% of the patients were below 50 years. 31.03% was above 50 years. The average age of occurrence was being 41.4 years. In our series Sex distribution were 75.8% of Males and 24.1% of Females. Wound (port site) infection 5 (17.2%) was treated with antibiotics and drainage, chest infection (atelectasis) 7 (24%) treated with IV antibiotics, Pleural effusion 2 (6.8%) was treated with physiotherapy settled down 2-3 days, mild surgical emphysema 2 (6.8%) may be due to good hiatal dissection and proper esophagus mobilization, it settled down in 2 days, urinary tract Patel Y, Baria B, Gohil K, Parmar H. Comparative study of Laparoscopic Nissen fundoplication Vs Posterior fundoplication in Gastroesophageal reflux disease. IAIM, 2016; 3(9): 189-193. Page 190 infection 3 (10.3%) was treated with antibiotics, port site hematoma 3 (10.3%) was managed conservatively. Conclusion: Both Laparoscopic Nissen fundoplication and Laparoscopic posterior fundoplication provides excellent results for GERD in terms of postoperative morbidity and complications.

Gasless laparoscopic surgery plus abdominal wall lifting for giant hiatal hernia-our single-center experience / 华中科技大学学报（医学）（英德文版）

Giant hiatal hernia (GHH) comprises 5% of hiatal hernia and is associated with significant complications. The traditional operative procedure, no matter transthoracic or transabdomen repair of giant hiatal hernia, is characteristic of more invasion and more complications. Although laparoscopic repair as a minimally invasive surgery is accepted, a part of patients can not tolerate pneumoperitoneum because of combination with cardiopulmonary diseases or severe posterior mediastinal and neck emphesema during operation. The aim of this article was to analyze our experience in gasless laparoscopic repair with abdominal wall lifting to treat the giant hiatal hernia. We performed a retrospective review of patients undergoing gasless laparoscopic repair of GHH with abdominal wall lifting from 2012 to 2015 at our institution. The GHH was defined as greater than one-third of the stomach in the chest. Gasless laparoscopic repair of GHH with abdominal wall lifting was attempted in 27 patients. Mean age was 67 years. The results showed that there were no conversions to open surgery and no intraoperative deaths. The mean duration of operation was 100 min (range: 90-130 min). One-side pleura was injured in 4 cases (14.8%). The mean postoperative length of stay was 4 days (range: 3-7 days). Median follow- up was 26 months (range: 6-38 months). Transient dysphagia for solid food occurred in three patients (11.1%), and this symptom disappeared within three months. There was one patient with recurrent hiatal hernia who was reoperated on. Two patients still complained of heartburn three months after surgery. Neither reoperation nor endoscopic treatment due to signs of postoperative esophageal stenosis was required in any patient. Totally, satisfactory outcome was reported in 88.9% patients. It was concluded that the gasless laparoscopic approach with abdominal wall lifting to the repair of GHH is feasible, safe, and effective for the patients who cannot tolerate the pneumoperitoneum.

Seguimiento endoscópico e histológico post ablación con argón plasma del esófago de Barrett extenso en pacientes sometidos a tratamiento quirúrgico previo / Argon plasma ablation of extensive Barrett esophagus: experience in 19 patients

Background: Endoscopic argon plasma ablation of Barrett esophagus decreases the risk of future esophageal cancer development. Aim: To assess the endoscopic regression of columnar epithelium and the presence of intestinal metaplasia among patients operated for Barrett esophagus and subjected to argon plasma ablation. Patients and Methods: In 19 patients with extensive Barrett esophagus subjected to a Nissen fundoplication, Barrett esophagus was endoscopically ablated with argon plasma. Patients were assessed 6 and 12 months after surgery to evaluate the regression of columnar epithelium and the presence of intestinal metaplasia. Results: One, two and three ablation sessions were carried out in 10, three and six patients, respectively. Three patients had complications. The initial length of columnar epithelium segment was 52 +/- 15.6 mm and decreased to 22.6 +/- 10.6 mm (p < 0.05). In 12 patients, there was absence of intestinal metaplasia on follow up, in six it persisted (one of them with "buried cells") and in one patient, dysplasia appeared. Conclusions: Endoscopic argon plasma ablation may have a complementary therapeutic role for the regression of columnar epithelium in Barrett esophagus.

Introducción: Pacientes con esófago de Barrett extenso presentan un riesgo de cáncer. De allí surge la posibilidad de someter a estos pacientes a ablación con argón plasma por vía endoscópica para disminuir este riesgo de desarrollar un adenocarcinoma. Objetivo: Evaluar la regresión endoscópica del epitelio columnar y la presencia de metaplasia intestinal en pacientes operados por esófago de Barrett y sometidos a ablación con argón plasma. Material y Método: Se incluyen 19 pacientes en este estudio, todos ellos con esófago de Barrett extenso confirmado por endoscopia e histología, los cuales se someten a ablación con argón plasma por vía endoscópica. Estos pacientes se controlaron con endoscopia e histológicamente a los 6 meses y al año de operados para evaluar la regresión del área con epitelio columnar y precisar la presencia histológica de metaplasia intestinal. Resultados: En 10 pacientes se efectuó 1 sesión de ablación, en 3 pacientes 2 sesiones y en 6 pacientes se efectuó 3 sesiones de ablación. Tres pacientes presentaron complicaciones. El largo de las lengüetas de epitelio columnar inicial fue de 52 +/- 15,6 mm el cual disminuyó a 22,6 +/- 10,6 mm (p < 0,05). El seguimiento histológico reveló ausencia de metaplasia intestinal en 12 pacientes (63,1 por ciento) persistencia de metaplasia en 6 pacientes (1 de ellos con células en submucosa, "buried cells") y un paciente con aparición de displasia. Conclusión: La ablación con argón plasma puede tener un rol en el tratamiento complementario a la cirugía para mejorar la regresión del epitelio columnar y disminuir los riesgos de presentar un adenocarcinoma de Barrett.

Comparison of clinical effects between laparoscopic Nissen fundoplication combined with highly selective vagotomy and traditional laparoscopic Nissen fundoplication in treatment of gastroesophageal reflux disease / 吉林大学学报(医学版)

Objective To compare the clinical effects of laparoscopic Nissen fundoplication (LNF)combined with highly selective vagotomy(HSV)(LNFHSV)in treatment of gastroesophageal reflux disease(GERD),and to provide reference for the clinical application of LNFHSV.Methods 22 patients with a history of GERD unrelieved by medication and underwent LNFHSV were selected.At the same time ,36 patients with GERD underwent LNF were used as control.The mean operation time,hospital stay,incidence of main operative complications,HSS complete remission and Demeester scores of the patients in two groups were retrospectively analyzed.Results The Demeester scores,hospital stay, incidence of main operative complications of the patients in two groups before operation had no significant differences(P>0.05).The mean operation time in LNFHSV group (90 min±35 min) was longer than that in LNF group(65 min± 21 min).The Demeester scores of the patients in two groups after operation had significant difference(P<0.05).The HSS complete remission rate of the patients in LNFHSV group was 91.1%,the part remission rate was 8.9%,and no effectiveness was 0;they were 83.3%,13.8%,and 2.8% in LNF group;there were significant differences between two groups(P<0.05).Conclusion LNFHSV has better effectiveness in controlling GERD than LNF procedure.

Early experiences of minimally invasive surgery to treat gastroesophageal reflux disease / 대한외과학회지

PURPOSE: There are fewer patients with gastroesophageal reflux disease (GERD) in Korea compared with Western countries. The incidence of GERD has increased in recent years however, concerning many physicians. Here, we report our early experiences of using a recently introduced method of laparoscopic antireflux surgery for the treatment of GERD in Korean patients. METHODS: Fifteen patients with GERD were treated using antireflux surgery between May 2009 and February 2012 at the University of Ulsan College of Medicine and Asan Medical Center. Laparoscopic Nissen fundoplication with 360degrees wrapping was performed on all patients. RESULTS: Eleven male and four female patients were evaluated and treated with an average age of 58.1 +/- 14.1 years. The average surgical time was 118.9 +/- 45.1 minutes, and no complications presented during surgery. After surgery, the reflux symptoms of each patient were resolved; only two patients developed transient dysphagia, which resolved within one month. One patient developed a 6-cm hiatal hernia that had to be repaired and reinforced using mesh. CONCLUSION: The use of laparoscopic surgery for the treatment of GERD is safe and feasible. It is also an efficacious method for controlling the symptoms of GERD in Korean patients. However, the use of this surgery still needs to be standardized (e.g., type of surgery, bougienage size, wrap length) and the long-term outcomes need to be evaluated.

Resultados alejados (10 años) de la fundoplicatura de Nissen en pacientes con reflujo gastroesofágico patológico sin esófago de Barrett / Review of long term results of Nissen fundoplication

Background: Laparoscopic Nissen fundoplication is the most commonly used surgical technique for the treatment of gastroesophageal reflux. Method: This is a review of publications about long term results of the technique. Results: Thirteen papers reporting results at 10 years were identified. Heartburn recurrence was documented in 20 to 23 percent of patients. Symptoms such as bloating were reported by 47 percent of patients after the fundoplication. After 10 years, 25 percent of patients started to use proton pump inhibitors and a new surgical intervention was required by 9 percent. In eight reports, there was no objective assessment of surgical results. In one report only few cases had a radiological assessment. Only in three European reports and one report by us, endoscopy and esophageal manometry were performed. Conclusions: It is concluded that Nissen fun-doplication achieves a relief of gastroesophageal reflux at 10 years in 75 percent of patients. There is a paucity of reports carrying out objective assessments of surgical results.

Introducción: La fundoplicatura de Nissen por vía laparoscópica es la técnica más empleada en pacientes con reflujo gastroesofágico. Objetivo: Revisar las publicaciones referentes a los resultados alejados (10 o más años) de esta cirugía. Método: Se realizó una búsqueda bibliográfica en la literatura inglesa de todos los artículos referentes a este tema. Resultados: Se encontraron en total 13 trabajos relacionados con los resultados a más de 10 años. La recurrencia de la pirosis se presentó entre 20 a 23 por ciento, la aparición de síntomas post fundoplicatura, como el meteorismo, en un 47 por ciento. A los 10 años cerca de 25 por ciento comenzó a ingerir nuevamente inhibidores de la bomba de protones y hubo necesidad de una reoperación en un 9 por ciento. En 8 trabajos no hubo ninguna evaluación objetiva de los resultados quirúrgicos. En 1 trabajo sólo evaluaron radiología en algunos casos. Sólo en 3 trabajos europeos y 1 estudio nuestro se realizaron evaluaciones objetivas, con endoscopia y manometría esofágica. Conclusiones: La fundoplicatura de Nissen es una técnica quirúrgica que controla el reflujo gastroesofágico en el 75 por ciento de los pacientes a más de 10 años de la cirugía. Sin embargo, muy pocos trabajos efectúan evaluaciones objetivas, en la mayoría de las publicaciones, las evaluaciones son sólo sintomáticas y subjetivas.

Expressão de CDX2 e mucinas (MUC1, MUC2, MUC5AC e MUC6) em esôfago de Barrett antes e após fundoplicatura de Nissen / Expression of CDX2 and mucins (MUC1, MUC2, MUC5AC and MUC6) in Barrett's esophagus before and after Nissen fundoplication

INTRODUÇÃO: O esôfago de Barrett (EB) corresponde à substituição do epitélio escamoso por um do tipo intestinal, em resposta ao refluxo crônico nos pacientes com doença do refluxo gastroesofágico (DRGE). É um importante precursor do adenocarcinoma esofágico. A fundoplicatura de Nissen (FN) é uma cirurgia antirrefluxo que visa a reduzir a agressão à mucosa esofágica. Alterações no padrão de expressão imuno-histoquímica de mucinas e de CDX2 no EB antes e depois da FN podem ser úteis na identificação de um padrão de expressão desses marcadores e, eventualmente, na identificação de casos com risco de evolução para malignidade. OBJETIVOS: Avaliar e comparar a imunoexpressão de CDX2 e mucinas no EB de pacientes com DRGE submetidos à FN antes e após a cirurgia. MATERIAIS E MÉTODOS: Estudo retrospectivo de 25 pacientes com diagnóstico de DRGE e EB submetidos à FN, acompanhados por, pelo menos, três anos. Foram feitos análise histológica e estudo imuno-histoquímico das biópsias endoscópicas antes e após a cirurgia, comparando-se a inflamação e a imunoexpressão de MUC1, MUC2, MUC5AC, MUC6 e CDX2. Estimou-se a porcentagem de células com expressão para os marcadores estudados na mucosa de Barrett: 0%-25%, 25%-75% e 75%-100% das células positivas. Foram utilizados os testes de McNemar e Stuart-William e adotou-se o nível de 5% de significância estatística. RESULTADOS E CONCLUSÃO: Não houve diferenças significativas quanto a presença ou intensidade de inflamação, nem da imunoexpressão de mucinas e CDX2 no EB antes e após a FN. O tratamento cirúrgico não influenciou a mudança da expressão dessas glicoproteínas no EB.

INTRODUCTION: Barrett´s esophagus (BE) is characterized by the exchange of esophageal squamous epithelium for intestinal type in response to chronic reflux in patients with gastroesophageal reflux disease (GERD).It is an important precursor of esophageal adenocarcinoma. Nissen fundoplication (NF) is an antireflux surgery which aims to reduce esophageal mucosa inflammation. Changes in the immunohistochemical expression patterns of mucins (MUC1, MUC2, MUC5AC and MUC6) and CDX2 in BE before and after NF may be useful to identify the expression patterns of these markers and, possibly, to detect cases with risks of malignancy. OBJECTIVES: To investigate and compare mucin and CDX2 immunoexpression in BE patients with GERD before and after NF. MATERIAL AND METHODS: This retrospective study comprised 25 patients with GERD and BE who had been submitted to NF. The patients had a 3-year minimum follow up. Histological and immunohistochemical analyses of endoscopic biopsies were performed before and after the surgery, comparing inflammation and MUC1, MUC2, MUC5AC, MUC6 and CDX2 immunoexpression. The percentage of Barrett mucosa cells with expression to the studied markers was estimated at 0%-25%, 25%-75% and 75%-100%. McNemar and Stuart-William tests were used and the significance level of <0.05 was applied. RESULTS AND CONCLUSION: Concerning the presence or the intensity of inflammation and mucin and CDX2 expression in BE, there were no significant differences before and after NF. The surgical procedure did not promote any changes in the expression of these glycoproteins in BE.

Tratamiento quirúrgico de pacientes con enfermedad por reflujo gastroesofágico / Surgical treatment of gastroesophageal reflux

Gastroesophageal reflux disease has great results with medical treatment; however, there is a small group of patients with parcial or total refractarity. Laparoscopic Nissen fundoplication is the preferred surgical treatment as an alternative to medical treatment. In order to ensure success it is critical to make a good selection of the patients and rigurous surgical technique, which has to be performed by expert surgeons.

La enfermedad por reflujo gastroesofágico tiene excelente tratamiento médico, no obstante, existe un pequeño grupo de pacientes con refractariedad parcial o total. La FPNL es el tratamiento quirúrgico de elección como alternativa al tratamiento médico. Para asegurar el mayor éxito es de trascendental importancia la buena selección de los pacientes y la rigurosidad en la técnica quirúrgica, la que debe ser efectuada por cirujanos expertos.

Minimally Invasive Surgery for Gastroesophageal Reflux Disease / 대한소화기학회지

Gastroesophageal reflux disease (GERD) is a chronic disease deteriorating patient's quality of life. With the advent of proton pump inhibitors, treatment failures have decreased considerably. However, surgical therapy offers the potential for cure in more than 90% of patients with GERD. Specific indications for antireflux surgery are: incomplete response to medical therapy, frequent recurrences despite the medical treatment, laryngopharyngeal, and/or respiratory symptoms, and complications of GERD, such as esophageal stricture, erosive esophagitis, esophageal ulcer, and/or Barrett's esophagus. The introduction of laparoscopic surgery in early ninties had a profound impact on many surgical fields, including the treatment of GERD. In this review, laparoscopic Nissen fundoplication is described and controversial topics, such as total vs. partial fundoplication, and the natural history of Barrett's esophagus after antireflux surgery are addressed.

Changes of respiratory and hemodynamic functions in children with laparoscopic Nissen's fundoplication / 上海第二医科大学学报

Objective To observe the changes of respiratory and hemodynamic functions in children with different age undergoing laparoscopic Nissen's fundoplication(LNF). Methods Thirty-three children with LNF were divided into three groups according to the age: group Ⅰ,1 to 12 months,n=13;group Ⅱ,1 to 3 years old,n=10;and group Ⅲ,4 to 7 years,n=10.Heart rate(HR),mean arterial pressure,Ppeak,compliance of the respiratory system(CRS) and end-tidal carbon dioxide pressure(PETCO2) were recorded 5 min before pneumoperitoneum(T0),10 min(T1),60 min(T2) after pneumoperitoneum and 10 min after deflation(T3),and parameters of blood gas analysis such as PaCO2 were measured at the same time. Results Compared with those at T0,HR,Ppeak,PETCO2 and the difference between PaCO2 and PETCO2(Pa-ETCO2)were significantly increased at T1 and T2,while CRS was significantly decreased.The most significant changes were found in group Ⅰ. Conclusion The changes of respiratory and hemodynamic functions are observed in children undergoing LNF,and anesthesia management should be enhanced for those within 1 to 12 months old who experience the most significant changes.

Laparoscopic Nissen Fundoplication and Collis Gastroplasty / 대한흉부외과학회지

The prevalence of gastroesophageal reflux disease has been increased recently in Korea. The use of minimally invasive laparoscopic and thoracoscopic surgery has become popular in the operation of esophageal disease such as esophageal cancer or gastroesophageal reflux disorder. We experienced three cases of laparoscopic Nissen fundoplications and one case of laparoscopic Collis gastroplasty, and we will describe the technical aspect of these surgeries.

A Case of Belsey Mark IV Fundoplication after Failed Nissen Antireflux Surgery / 대한소아소화기영양학회지

Antireflux surgery has been indicated in gastroesophageal reflux disease (GERD) that does not respond to medical treatments. Although the most commonly performed operation is Nissen fundoplication, Belsey Mark IV fundoplication is indicated for more complicated cases, such as, in cases of a failed Nissen operation or a long lasting hiatal hernia. Here, we report a case of Belsey Mark IV fundoplication for a failed Nissen fundoplication. The infant developed frequent times of aspiration pneumonia after initial Nissen for a hiatal hernia with GERD during the newborn period. At 15 months of age, a 2nd Nissen operation was attempted, but fundoplication was not available because of excessive mesenteric adherence to the liver and cardia. Therefore, Belsey Mark IV fundoplication was performed via trans-thoracic approach, which can provide full esophageal mobilization and better visualization of the herniated fundus and the surrounding tissues. Subsequently, she has shown an improved general condition without GERD.