LAPAROSCOPIC ANTIREFLUX SURGERY: WERE OLD QUESTIONS ANSWERED? PARTIAL OR TOTAL FUNDOPLICATION?

Laparoscopic total fundoplication is currently considered the gold standard for the surgical treatment of gastroesophageal reflux disease. Short-term outcomes after laparoscopic total fundoplication are excellent, with fast recovery and minimal perioperative morbidity. The symptom relief and reflux control are achieved in about 80 to 90% of patients 10 years after surgery. However, a small but clinically relevant incidence of postoperative dysphagia and gas-related symptoms is reported. Debate still exists about the best antireflux operation; during the last three decades, the surgical outcome of laparoscopic partial fundoplication (anterior or posterior) were compared to those achieved after a laparoscopic total fundoplication. The laparoscopic partial fundoplication, either anterior (180°) or posterior, should be performed only in patients with gastroesophageal reflux disease secondary to scleroderma and impaired esophageal motility, since the laparoscopic total fundoplication would impair esophageal emptying and cause dysphagia.

Laparoscopic antireflux surgery: were old questions answered? partial or total fundoplication? / Cirurgia laparoscópica antirrefluxo: perguntas antigas foram respondidas? fundoplicatura parcial ou total?

ABSTRACT Laparoscopic total fundoplication is currently considered the gold standard for the surgical treatment of gastroesophageal reflux disease. Short-term outcomes after laparoscopic total fundoplication are excellent, with fast recovery and minimal perioperative morbidity. The symptom relief and reflux control are achieved in about 80 to 90% of patients 10 years after surgery. However, a small but clinically relevant incidence of postoperative dysphagia and gas-related symptoms is reported. Debate still exists about the best antireflux operation; during the last three decades, the surgical outcome of laparoscopic partial fundoplication (anterior or posterior) were compared to those achieved after a laparoscopic total fundoplication. The laparoscopic partial fundoplication, either anterior (180°) or posterior, should be performed only in patients with gastroesophageal reflux disease secondary to scleroderma and impaired esophageal motility, since the laparoscopic total fundoplication would impair esophageal emptying and cause dysphagia.

RESUMO A fundoplicatura total laparoscópica é considerada, atualmente, o padrão ouro para o tratamento cirúrgico da doença do refluxo gastroesofágico. Os resultados de curto prazo após a fundoplicatura total laparoscópica são excelentes, com recuperação rápida e morbidade perioperatória mínima. O alívio dos sintomas e o controle do refluxo são alcançados em cerca de 80 a 90% dos pacientes, 10 anos após a cirurgia. No entanto, é relatada uma incidência pequena, mas clinicamente relevante, de disfagia pós-operatória e sintomas relacionados a gases. Ainda existe debate sobre a melhor operação antirrefluxo e, nas últimas três décadas, os resultados cirúrgicos da fundoplicatura parcial laparoscópica (anterior ou posterior) foram comparados aos obtidos após uma fundoplicatura total laparoscópica. A fundoplicatura parcial laparoscópica, seja anterior (180°) ou posterior, deve ser realizada apenas em pacientes com doença do refluxo gastroesofágico secundária a esclerodermia e motilidade esofágica ineficiente, pois uma fundoplicatura total laparoscópica prejudicaria o esvaziamento esofágico e causaria disfagia.

Fourteen Crutches for Mediocrity. The logismoi that jeopardize good research and publication.

Publications are used widely as a measure of academic quality. Many investigators have difficulty publishing in this competitive field. After coming across a religious lecture on the "Fourteen Crutches for Mediocrity", our team adapted this approach to life to the science of publishing: (1) what is the problem of doing it?; (2) there are worse!; (3) everybody does it!; (4) why exaggerate?; (5) I will do it tomorrow!; (6) maybe if …; (7) it is not used anymore!; (8) be a cousin not a brother!; (9) I need to be thanked!; (10) don't eat your own head, let it be!; (11) I can't possibly accomplish it!; (12) I don't feel like doing it!; (13) I am fed up!; (14) I am not worthwhile! These crutches jeopardize good research and thoughtful learned publications.

Fourteen Crutches for Mediocrity. The logismoi that jeopardize good research and publication

Publications are used widely as a measure of academic quality. Many investigators have difficulty publishing in this competitive field. After coming across a religious lecture on the “Fourteen Crutches for Mediocrity”, our team adapted this approach to life to the science of publishing: (1) what is the problem of doing it?; (2) there are worse!; (3) everybody does it!; (4) why exaggerate?; (5) I will do it tomorrow!; (6) maybe if …; (7) it is not used anymore!; (8) be a cousin not a brother!; (9) I need to be thanked!; (10) don’t eat your own head, let it be!; (11) I can’t possibly accomplish it!; (12) I don’t feel like doing it!; (13) I am fed up!; (14) I am not worthwhile! These crutches jeopardize good research and thoughtful learned publications (AU)

Las publicaciones se utilizan ampliamente como una medida para cualidad académica. Investigadores menos experimentados tiene dificultades para publicar en este campo competitivo. Nuestro equipo adaptó una conferencia religiosa sobre «Catorce muletillas para la mediocridad» al tema de la escritura científica: 1) ¿Qué hay de malo? 2) ¡Los hay peores! 3) ¡Lo hacen todos! 4) ¡Sin exagerar! 5) ¡Mañana! 6) ¡Ojalá! 7) ¡Es que ya no se lleva! 8) ¡Hay que ser hermanos, pero no primos! 9) Para lo que te lo van a agradecer… 10) ¡No te comas la cabeza, déjate llevar! 11) ¡No puedo lograrlo! 12) ¡No me apetece! 13) ¡Estoy harto! 14) ¡Yo no valgo! Logismoi es un término griego que describe pensamientos agresivos o tentadores. Las muletillas presentadas pueden poner en peligro una buena investigación y publicación

Fourteen Crutches for Mediocrity. The logismoi that jeopardize good research and publication.

Publications are used widely as a measure of academic quality. Many investigators have difficulty publishing in this competitive field. After coming across a religious lecture on the "Fourteen Crutches for Mediocrity", our team adapted this approach to life to the science of publishing: (1) what is the problem of doing it?; (2) there are worse!; (3) everybody does it!; (4) why exaggerate?; (5) I will do it tomorrow!; (6) maybe if …; (7) it is not used anymore!; (8) be a cousin not a brother!; (9) I need to be thanked!; (10) don't eat your own head, let it be!; (11) I can't possibly accomplish it!; (12) I don't feel like doing it!; (13) I am fed up!; (14) I am not worthwhile! These crutches jeopardize good research and thoughtful learned publications.

A pictorial presentation of 3. 0 Chicago Classification for esophageal motility disorders / Apresentação em imagens da Classificação de Chicago versão 3. 0 das doenças da motilidade esofagiana

ABSTRACT High resolution manometry changed several esophageal motility paradigms. The 3.0 Chicago Classification defined manometric criteria for named esophageal motility disorders. We present a pictorial atlas of motility disorders. Achalasia types, esophagogastric junction obstruction, absent contractility, distal esophageal spasm, hypercontractile esophagus (jackhammer), ineffective esophageal motility, and fragmented peristalsis are depicted with high-resolution manometry plots.

RESUMO A manometria de alta resolução mudou vários paradigmas da motilidade digestiva. A Classificação de Chicago, na versão 3.0, definiu critérios manométricos para as doenças da motilidade esofagiana. O presente artigo é um atlas das dismotilidades descritas. Tipos de acalásia, obstrução ao nível da junção esofagogástrica, contrações ausentes, espasmo esofagiano distal, esôfago hipercontrátil, motilidade esofagiana ineficaz e peristalse fragmentada são mostradas em traçados de manometria de alta resolução.

A pictorial presentation of 3.0 Chicago Classification for esophageal motility disorders.

High resolution manometry changed several esophageal motility paradigms. The 3.0 Chicago Classification defined manometric criteria for named esophageal motility disorders. We present a pictorial atlas of motility disorders. Achalasia types, esophagogastric junction obstruction, absent contractility, distal esophageal spasm, hypercontractile esophagus (jackhammer), ineffective esophageal motility, and fragmented peristalsis are depicted with high-resolution manometry plots. RESUMO A manometria de alta resolução mudou vários paradigmas da motilidade digestiva. A Classificação de Chicago, na versão 3.0, definiu critérios manométricos para as doenças da motilidade esofagiana. O presente artigo é um atlas das dismotilidades descritas. Tipos de acalásia, obstrução ao nível da junção esofagogástrica, contrações ausentes, espasmo esofagiano distal, esôfago hipercontrátil, motilidade esofagiana ineficaz e peristalse fragmentada são mostradas em traçados de manometria de alta resolução.

Toward a Tailored Treatment of Achalasia: An Evidence-Based Approach.

BACKGROUND: The treatment options in achalasia patients aim to improve symptoms by reducing the functional obstruction at the level of the gastroesophageal junction. Available treatment modalities are endoscopic botulinum toxin injection (EBTI), pneumatic dilatation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM). We provide an evidence-based review of current indications, limitations, and future perspectives of these options for the treatment of achalasia. METHODS: The PubMed/Medline electronic databases and the Cochrane Library were searched. Quality of evidence was assessed according to the GRADE system. RESULTS: Functional outcomes after EBTI are significantly worse than those after PD or LHM. LHM with partial fundoplication is associated with low complication rates and provides excellent long-term results with lower need for additional treatment of recurrent dysphagia than PD. POEM is a new promising treatment option with good short-term outcomes and low morbidity in experienced hands. CONCLUSIONS: LHM should be considered the procedure of choice for the treatment of achalasia in patients who are fit for surgery. Large randomized controlled trials with long follow-up are needed to validate the role of POEM.