Controversias en el tratamiento de la acalasia / Controversies in the treatment of achalasia

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Laparoscopic surgery for duodenal ulcer: first results of a multicenter study applying a personal procedure.

BACKGROUND/AIMS: First results from 14 different centers applying a personal procedure for the treatment of duodenal ulcer by laparoscopic surgery. METHODOLOGY: One hundred and thirty-six patients were operated on in 14 surgical centers between January 1991 and February 1995. All patients underwent posterior truncal vagotomy (PTV) and anterior linear gastrectomy (ALG) for chronic duodenal ulcer. RESULTS: The mean duration of operation was 65 min (range: 25-180) and there were no peroperative complications or deaths. Immediate post-operative morbidity rate was 2-9%, with a mean hospital stay of 3-1 days (range: 2-13). A total of 131 patients were evaluated between 6 and 33 months (mean: 25) after operation. Of these, 126 (96.2%) were graded as Visick I or II. Four (3.0%) were Visick III, and one patient (0.8%) was considered Visick IV. Gastric function studies were performed in 45 patients before and after operation, with a maximum acid output reduction of 83% 3 months after the operation CONCLUSIONS: Laparoscopic PTV with ALG constitutes a simple, efficient, rapid and safe method in the treatment of patients with chronic duodenal ulcer.

Laparoscopy and septic dissemination caused by perioperative perforation of the occluded small bowel: an experimental study.

Based on the observation of septic shock and severe respiratory impairment in two patients subjected to laparoscopic surgery for small bowel occlusion, an experimental study was carried out in rabbits to evaluate the effect of intra-abdominal CO2 hyperpressure on massive bacterial spread. Increased bacterial access to the blood was observed as a result of the mechanical effect of the hyperpressure associated with the highly septic contents of the occluded bowel. The important risk of bacterial dissemination following accidental peroperative perforation requires extreme caution in the laparoscopic management of late occlusions of the small intestine.

Laparoscopic surgery for duodenal ulcer: first results of a multicentre study applying a personal procedure.

Between January 1991 and February 1995 data were gathered on 136 patients operated on in 14 surgical centres. All patients underwent posterior truncal vagotomy (PTV) and anterior linear gastrectomy (ALG) for chronic duodenal ulcer. Recurrence and repeated bleeding were the main indications for surgery. An antireflux technique was simultaneously carried out in 17 patients, while 13 underwent cholecystectomy. There were no peroperative complications or deaths, and the mean duration of operation was 65 (range 25-180) min. Immediate postoperative morbidity rate was 2.9 per cent, with a mean hospital stay of 3.1 (range 2-13) days. A total of 131 patients were evaluated between 6 and 33 (mean 25) months after operation. Of these, 126 (96.2 per cent) were graded as Visick I or II. Four (3.0 per cent) were Visick III, and one patient (0.8 per cent) was considered Visick IV. Gastric function studies were performed in 45 patients before and after operation, with a maximum acid output reduction of 83 per cent 3 months after the operation. Laparoscopic PTV with ALG constitutes a simple, efficient, rapid and safe method in the treatment of patients with chronic duodenal ulcer.

[Nerve regeneration in the anterior gastric wall after gastrotomy and posterior truncal vagotomy in the rat]. / Regeneración nerviosa en la pared anterior del estómago después de gastrotomía y vagotomía troncular posterior en la rata.

A study was made to compare nerve regeneration of the anterior gastric wall following either seromyotomy or gastrotomy with eversion suturing; both approaches extending from the antrum to the fundus. Twenty-eight preadult Wistar rats were divided into three groups: Group I (control: sham operated animals; n = 8); Group II (seromyotomy with posterior truncal vagotomy; n = 10); and Group III (gastrotomy with posterior truncal vagotomy; n = 10). Nerve regeneration was evaluated immunohistochemically two months after the operation. Groups II and III presented gastric dilatation postmortem. Both groups showed complete denervation of the anterior gastric wall, with no vagal fibers crossing the section line. Amputation neuromas and Schwann cells were commonly observed. In conclusion, both seromyotomy and gastrotomy are efficient methods for denervating the anterior gastric wall.

[Reoperations after esophagomyotomy in esophageal motility disorders]. / Reoperaciones tras la esofagomiotomía en los trastornos motores esofágicos.

Out of 96 patients with the diagnosis of primary esophageal motor disorders and treated by esophagomyotomy, a group of 9 patients is reported in whom reoperation was necessary because of persistence or worsening of the previous symptoms (8 patients) or persistent reflux esophagitis (one patient). Clinical and laboratory examinations together with the operative findings allowed classification of these patients: incomplete myotomy proximally (4 patients) or distally (one patient), fibrotic scar at the site of previous myotomy (2 patients), persistence of intact muscle fibers (one patient) and reflux esophagitis for lack of an antireflux intervention during myotomy. Treatment consisted of completing myotomy proximally or distally, resection of the fibrous tissue and an antireflux operation when indicated. Clinical results were excellent in 6 patients (66.6%), fair in 2 patients (22.2%) and bad in one case (11.1%). Fair or bad results were seen in patients with total absence of motor response to deglutition. After operation there was disappearance of vigorous contractions in the esophagus, as shown by manometry and recovery of esophageal peristalsis in another patient. We conclude that in order to improve the results of the surgical treatment of motor esophageal disorders it is essential to correctly classify the type of disorder present by means of manometry and to add a partial funduplication to ensure absence of reflux without dysphagia.