Funduplicatura con disección extensa de la unión esofagogástrica: lecciones aprendidas y resultados tras 178 pacientes consecutivos / Fundoplication with extensive dissection of the esophagogastric junction: Lessons learned and outcomes from 178 consecutives patients

Introducción: La cirugía antirreflujo se asocia con frecuencia a tasas significativas de recurrencia y complicaciones, habiéndose propuesto varias técnicas quirúrgicas para minimizarlas. El objetivo del estudio es evaluar los resultados a tres años de una funduplicatura con disección extensa de la unión esofagogástrica (UEG). Métodos: Estudio observacional retrospectivo que incluyó a 178 pacientes con enfermedad por reflujo gastroesofágico (ERGE) o hernia de hiato (HH) a los que se les realizó una funduplicatura con disección extensa de la UEG entre 2015 y 2020. La recidiva herniaria, los síntomas y la calidad de vida al primer año y a los tres siguientes de la cirugía fueron evaluados mediante tránsito baritado, endoscopia y cuestionarios para síntomas y calidad de vida (Gastro Esophageal Reflux Disease-Health Related Quality of Life [GERD-HRQL]). Resultados: La tasa de pirosis fue de 7,5 y 10,7% al año y a los tres siguientes, respectivamente, regurgitación de 3,8 y 6,9% y disfagia de 3,7 y 7,6%. La presencia de hernia hiatal se evidenció preoperatoriamente en 55,1% y en 7,8 y 9,6% en el seguimiento y la mediana de la escala GERD-HRQL fue de 27, 2 y 0, respectivamente. No aparecieron casos de telescopaje de la funduplicatura ni síntomas que sugieran lesión vagal. No se encontraron diferencias al comparar los distintos tipos de funduplicatura en términos de recidiva del reflujo, complicaciones o recurrencia de la hernia. Conclusiones: La funduplicatura con disección extensa de la UEG contribuye a su correcto posicionamiento y mejor anclaje, lo que asocia bajas tasas de recidiva herniaria y del reflujo, así como disminuye la posibilidad de telescopaje y lesión vagal.(AU)

Introduction: Antireflux surgery is commonly associated with significant recurrence and complication rates, and several surgical techniques have been proposed to minimize them. The aim of this study is to evaluate the results of a fundoplication with extensive dissection of the esophagogastric junction 1 and 3 years after the procedure.Methods: Retrospective observational study including 178 patients with gastroesophageal reflux disease or hiatal hernia who underwent fundoplication with extensive dissection of the esophagogastric junction between 2015 and 2020. Hernia recurrence, symptoms and quality of life at 1 and 3 years after surgery were assessed by barium transit, endoscopy and questionnaires for symptoms and quality of life (GERD-HRQL). Results: Heartburn rate was 7.5% and 10.7% at 1 and 3 years respectively, regurgitation 3.8% and 6.9% and dysphagia was 3.7% and 7.6%. The presence of hiatal hernia was evident preoperatively in 55.1% and in 7.8% and 9.6% at follow-up and the median GERD-HRQL scale was 27, 2 and 0, respectively. There were no cases of slippage of the fundoplication or symptoms suggestive of vagal injury. No differences were found when comparing the different types of fundoplication in terms of reflux and recurrence or complications. Conclusions: Fundoplication with extensive dissection of the esophagogastric junction contributes to correct positioning and better anchorage of the fundoplication, which is associated with low rates of hiatal hernia and reflux recurrence, as well as absence of slippage and lower possibility of vagal injury.(AU)

Fundoplication with extensive dissection of the esophagogastric junction: Lessons learned and outcomes from 178 consecutives patients.

INTRODUCTION: Antireflux surgery is commonly associated with significant recurrence and complication rates, and several surgical techniques have been proposed to minimize them. The aim of this study is to evaluate the results of a fundoplication with extensive dissection of the esophagogastric junction 1 and 3 years after the procedure. METHODS: Retrospective observational study including 178 patients with gastroesophageal reflux disease or hiatal hernia who underwent fundoplication with extensive dissection of the esophagogastric junction between 2015 and 2020. Hernia recurrence, symptoms and quality of life at 1 and 3 years after surgery were assessed by barium transit, endoscopy and questionnaires for symptoms and quality of life (GERD-HRQL). RESULTS: Heartburn rate was 7.5% and 10.7% at 1 and 3 years respectively, regurgitation 3.8% and 6.9% and dysphagia was 3.7% and 7.6%. The presence of hiatal hernia was evident preoperatively in 55.1% and in 7.8% and 9.6% at follow-up and the median GERD-HRQL scale was 27, 2 and 0 respectively. There were no cases of slippage of the fundoplication or symptoms suggestive of vagal injury. No differences were found when comparing the different types of fundoplication in terms of reflux and recurrence or complications. CONCLUSIONS: Fundoplication with extensive dissection of the esophagogastric junction contributes to correct positioning and better anchorage of the fundoplication, which is associated with low rates of hiatal hernia and reflux recurrence, as well as absence of slippage and lower possibility of vagal injury.

Gastroesophageal reflux after Roux-en-Y gastric bypass: Is it just related to technical details?

Although it is uncommon, gastroesophageal reflux disease can present after Roux-en-Y gastric bypass, and it is usually related to technical errors. Hiatal hernia, a narrow calibrated gastrojejunostomy and a long gastric pouch are all factors associated with the development of pathologic gastroesophageal reflux. Techniques are available to treat this condition, such as fundoplications with the gastric remnant, gastropexy to the arcuate ligament, teres ligament repair, or sphincter augmentation with the LINX device. Despite the growing number of reports of gastroesophageal reflux after Roux-en-Y gastric bypass, it should be still considered the best surgical option for patients with obesity and a large hiatal hernia or complications secondary to gastroesophageal reflux disease.

Obesity related pathophysiological aspects favouring Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a complex entity and one of the most frequents in general population. Association of GERD with obesity is clearly defined from an epidemiological point of view, where up to 40% of patients with overweight and obesity present reflux. Most of the risk factors associated to GERD are shared and especially frequent in patients with obesity. The pathophysiology that explain this correlation is complex and multifactorial, and includes both aspects related to physiology of motility, and anatomic changes. The malfunction of the lower esophageal sphincter, the greater transdiaphragmatic pressure gradient, pathological accumulation of fat and the high rate of hiatal hernia that comes with overweight will be the main factors that explain this correlation. Other factor like pathological eating habits or obesity related diseases have also an important role. In summary, it is the sum of the factors more than just one of them what would explain the pathophysiology of GERD in obese population.

Cirugía laparoscópica de la hernia paraesofágica congénita en neonatos y lactantes / Laparoscopic surgery of congenital paraesophageal hernia in newborns and infants

Introducción: Las hernias paraesofágicas congénitas (HPC) sonuna patología poco frecuente en la edad pediátrica. Pueden presentarclínica desde la época neonatal precisando una reparación quirúrgicatemprana. Casos clínicos: Presentamos 3 casos diagnosticados de HPC tipoIV en pacientes menores de 1 año, que presentaron síntomas desdela época neonatal, en los que se ha realizado reparación quirúrgicalaparoscópica. Un paciente presentaba diagnóstico prenatal. La edaden el momento de la cirugía fue 6 días, 36 días y 9 meses. El pesoen el momento de la cirugía fue de 3,60 kg, 3,79 kg y 8,20 kg. Lospacientes fueron intervenidos por laparoscopia realizando excisión delsaco herniario, cierre de pilares diafragmáticos, colocación de mallareabsorbible de refuerzo y una funduplicatura Nissen. El tiempo mediode cirugía fue de 130 minutos. No hubo complicaciones intraoperato-rias. Un paciente presentó una hernia de deslizamiento que se reparóposteriormente sin complicaciones. El tiempo medio de seguimientoes de 24 meses.(AU)

Introduction: Congenital paraesophageal hernia (CPH) is a rarepathology in pediatric patients. Clinical signs may occur as early as innewborns, which means it requires early surgical repair. Clinical cases: This is a series of three patients under 1 year of agediagnosed with type IV CPH – with symptoms occurring since they werenewborns – who underwent laparoscopic surgical repair. One patient hadbeen diagnosed prenatally. Age at surgery was 6 days, 36 days, and 9months, respectively. Weight at surgery was 3.60 kg, 3.79 kg, and 8.20kg, respectively. The patients underwent laparoscopy, with removal ofthe hernia sac, closure of the diaphragmatic pillars, placement of a rein-forcement absorbable mesh, and Nissen fundoplication. Mean operatingtime was 130 minutes. No intraoperative complications were recorded. One patient developed a sliding hernia, which was subsequently repairedwithout complications. Mean follow-up time was 24 months.(AU)

Cuando no todo es lo que parece_: masa extracardíaca en la aurícula izquierda: reporte de un caso en Uruguay / When not everything is what it seems_: extra-cardiac mass in the left atrium: a case report in Uruguay / Quando nem tudo é o que parece_: massa extracardíaca em átrio esquerdo: relato de um caso no Uruguai

La hernia hiatal es una entidad relativamente frecuente y puede ser un hallazgo incidental en un estudio ecocardiográfico. Describimos el caso de una paciente con diagnóstico de masa en la aurícula izquierda (AI) sin clara etiología, a quien se le realiza el diagnóstico de hernia hiatal por resonancia magnética cardíaca (RMC) y luego se demuestra mediante ecocardiografía de contraste el contenido gástrico de la masa tras la ingestión de una bebida carbonatada, lo que permite de forma rápida y sencilla aclarar el diagnóstico.

Hiatal hernia is a relatively common entity, and may be an incidental finding in an echocardiographic study. We describe the case of a patient with a diagnosis of a mass in the left atrium with no clear etiology, in whom the diagnosis of hiatal hernia is made by cardiac magnetic resonance imaging and then demonstrated by contrast echocardiography the gastric content of the mass after the ingestion of a carbonated drink, which allows quickly and easily to clarify the diagnosis.

A hérnia de hiato é uma entidade relativamente comum, e pode ser um achado incidental em um estudo ecocardiográfico. Descrevemos o caso de um paciente com diagnóstico de massa em átrio esquerdo sem etiologia definida, em que o diagnóstico de hérnia de hiato é feito por ressonância magnética cardíaca e posteriormente demonstrado por ecocardiografia contrastada com uma bebida gaseificada, permitindo esclarecer de forma rápida e fácil o diagnóstico.

Tratamento alternativo para hérnia de hiato volumosa: relato de caso / Alternative treatment for big hiatus hernia: case report

Introdução: A hérnia paraesofágica é uma patologia rara, no qual ocorre herniação de estruturas abdominais através do hiato esofágicodo diafragma. Os sintomas mais comuns incluem disfagia, refl uxo, regurgitação e suas complicações são principalmente sangramento,respiratórias, obstrução e volvo gástrico. Quanto ao diagnóstico, a seriografi a e a endoscopia são preconizadas, sendo a cirurgia otratamento defi nitivo. Objetivo: Relatar um caso de Hérnia de Hiato classifi cada como paraesofágica, volumosa, na qual a pessoafoi submetida a um tratamento alternativo terapêutico para este tipo de enfermidade. Material e Método: Estudo de relato de caso,retrospectivo, guiado por análise de prontuário médico e revisão da literatura. Resultados: No tratamento da hérnia de hiato foi feita aadaptação de materiais, tornando uma cirurgia, a priori, de alto custo/benefício, numa relação custo/benefi cio baixa, já que se obteve omesmo objetivo usando o pericárdio bovino (média de R$ 80,00) ao invés da tela Proceed® (média de R$ 3.000). Conclusão: O pericárdiobovino pode ser uma opção de baixo custo, além de boa disponibilidade, fácil manejo e bons resultados no pós-operatório.

Introduction: Paraoesophageal hernia is a rare pathology in which abdominal structures are herniated through the esophageal hiatus ofthe diaphragm. The most common symptoms include dysphagia, refl ux, regurgitation and its complications are mainly bleeding, dyspnea,obstruction and gastric volvulus. Regarding the diagnosis, seriography and endoscopy are recommended, being surgery the defi nitivetreatment. Objective: To report a case of a large paraoesophageal hernia, where the patient was submitted to an alternative therapeutictreatment for this kind of disease. Material and Method: Retrospective case report study based on medical record analysis and onliterature review. Results: For the treatment of hiatal hernia, materials were adapted, making a priori on in a high cost/benefi t surgery,but with a low cost/benefi t ratio, since the same goal was obtained using the bovine pericardium (mean cost of R$ 80.00) instead of theProceed® screen (average cost of R$ 3.000). Conclusion: The bovine pericardium can be a low-cost option, besides the good availability,easy handling and good postoperative results.

Introducción: La hernia paraesofágica es una patología rara, en el cual ocurre herniación de estructuras abdominales a través del hiatoesofágico del diafragma. Los síntomas más comunes incluyen disfagia, refl ujo, regurgitación y sus complicaciones son principalmentesangrado, respiratorio, obstrucción y volvo gástrico. En cuanto al diagnóstico, la seriografía y la endoscopia son preconizadas, siendo lacirugía el tratamiento defi nitivo. Objetivo: Informar un caso de hernia de Hiato clasifi cada como paraesofágica, voluminosa, en la cualla persona fue sometida a un tratamiento alternativo terapéutico para este tipo de enfermedad. Material y método: Estudio de relato decaso, retrospectivo, guiado por análisis de prontuario médico y revisión de la literatura. Resultados: En el tratamiento de la hernia dehiato se hizo la adaptación de materiales, haciendo una cirugía, a priori, de alto costo/benefi cio, en una relación costo/benefi cio baja,ya que se obtuvo el mismo objetivo usando el pericardio bovino (promedio de R$ 80,00) en lugar de la pantalla Proceed® (promedio deR$ 3.000). Conclusión: El pericardio bovino puede ser una opción de bajo costo, además de buena disponibilidad, fácil manejo y buenosresultados en el postoperatorio.

[Management of gastroesophageal reflux in children. Single centre experience in conventional and laparoscopic Nissen fundoplication in the last 15 years]. / Manejo del reflujo gastroesofágico en niños. Funduplicatura de Nissen convencional y por laparoscopia en los últimos 15 años en un centro especializado.

INTRODUCTION: Nissen fundoplication (NF) is the most used and effective technique for the treatment of gastroesophageal reflux in children. The laparoscopic approach (LNF) is safe, with low morbidity and high success rate, although some cases require a conventional approach (CNF). The aim of the study is to compare the results between LNF and CNF in our centre. MATERIAL AND METHODS: A retrospective review was performed on patients <14years after NF between 2000 and 2015. A comparison was made of the complications, hospital stay, and follow-up for both approaches. RESULTS: Of the total 75 NF performed, 49 (65.3%) were LNF, 23 (30.7%) CNF, and 3 (4.0%) reconversions. Concomitant laparoscopic gastrostomy was performed in 10.7%, and open gastrostomy in 5.3% of cases. Prior to NF, 10.7% had a gastrostomy. The mean age was 4 years and 68.7% were male. Of the diagnoses, 36% had encephalopathy, 14.7% hiatal hernia, 5.4% oesophageal atresia, and 5.4% an acute life-threatening event. No differences were found in operation time. More than two-thirds (36%) had complications, which were more frequent in the CNF (OR=3.30, 95%CI: 1.1-9.6). The hospital-stay decreased by 9 days in the LNF (95%CI: 5.5-13.5). Mean follow-up was 26 months (95%CI: 20.9-31.6). Mortality during follow-up was of 5.3% (5 respiratory failure, 1 sudden cardiac death, and 2 due to complications of the encephalopathy), 4.2% required re-fundoplication, 15.8% had symptomatic improvement, and 64.0% had absence of symptoms. CONCLUSIONS: The LNF is an effective technique for the treatment of gastroesophageal reflux, with lower morbidity and shorter hospital stay than CNF. It is recommended as the first surgical option.

ENDOSCOPIC CHANGES RELATED TO GASTROESOPHAGEAL REFLUX DISEASE: COMPARATIVE STUDY AMONG BARIATRIC SURGERY PATIENTS / ALTERAÇÕES ENDOSCÓPICAS RELACIONADAS À DOENÇA DO REFLUXO GASTROESOFÁGICO: ESTUDO COMPARATIVO ENTRE OBESOS SUBMETIDOS À CIRURGIA BARIÁTRICA

Background:Obesity is correlated with several comorbidities, including gastroesophageal reflux disease. Its main complications are detectable by endoscopy: erosive esophagitis and Barrett's esophagus.Aim: To correlate erosive esophagitis and hiatal hernia with the degree of body mass index (BMI).Method: Was performed a retrospective analysis of 717 preoperative endoscopic reports of bariatric patients. Fifty-six (8%) presented hiatal hernia, being 44 small, nine medium and five large. Esophagitis was classified by Los Angeles classification.Results: There was no correlation between the presence and dimension of hiatal hernia with BMI. One hundred thirty-four (18.7%) patients presented erosive esophagitis. Among them, 104 (14.5%) had esophagitis grade A; 25 (3.5%) grade B; and five (0.7%) grade C. When considering only the patients with erosive esophagitis, 77.6% had esophagitis grade A, 18.7% grade B and 3.7% grade C. Were identified only two patients with Barrett's esophagus (0,28%).Conclusion: There was a positive correlation between the degree of esophagitis with increasing BMI.

Racional:A obesidade está correlacionada com diversas comorbidades, dentre elas a doença do refluxo gastroesofágico. Ela tem como um de seus principais desencadeantes a hérnia do hiato, e como suas principais complicações a esofagite erosiva e o esôfago de Barrett.Objetivo: Correlacionar o grau do índice de massa corporal (IMC) com a presença e tamanho da hérnia hiatal, e com a presença e gravidade da esofagite erosiva e esôfago de Barrett.Método: Foi realizada análise retrospectiva de laudos endoscópicos pré-operatórios de 717 pacientes submetidos à cirurgia bariátrica. A hérnia de hiato esteve presente em 56 pacientes (8%), sendo que delas 44 eram pequenas, nove médias e cinco grandes. O grau da esofagite obedeceu o preconizado pela Classificação de Los Angeles.Resultados: Não houve correlação entre a presença ou tamanho da herniação hiatal com o IMC. Dos pacientes avaliados, 134 (18,7%) apresentavam esofagite erosiva. Dentre elas 104 (14,5%) eram grau A; 25 (3,5%) grau B e cinco (0,7%) grau C. Considerando-se apenas os portadores de esofagite erosiva, 77,6% eram grau A; 18,7% grau B; e 3,7% grau C. Foram identificados apenas dois casos de esôfago de Barrett (0,28% da amostra total).Conclusão: Observou-se correlação positiva entre o grau de esofagite com o aumento do IMC.