Esophagocardioplasty, vagotomy-antrectomy and Roux-en-Y gastrojejunostomy: indication in cases with severe esophageal motor disfunction.

Almost 10% of patients with Crest syndrome associated with severe gastroesophageal reflux and 5-10% of patients with failed cardiomyotomy for achalasia present with cardial or distal esophageal organic stricture. Some of these cases are poor risk patients for surgery and therefore the surgeon must offer a safe procedure with low morbimortality, keeping in mind the pathophysiological motor pattern of these patients.In order to treat the stricture to improve the esophageal transit we treated patients with esophagocardioplasty associated with vagotomy-antrectomy and Roux-en-Y gastrojejunostomy, thereby avoiding the potential acid or biliary reflux in poor risk patients in whom esophagectomy would be a very deleterious procedure. All four patients had a good postoperative evolution and late control demonstrated good esophagogastric transit with no postoperative esophagitis.

Patients Having Bariatric Surgery: Surgical Options in Morbidly Obese Patients with Barrett's Esophagus.

This article summarizes the currently knowledge and results observed in patients with obesity and Barrett's esophagus which were presented and discussed during the IFSO 2014 held in Montreal. In this meeting, the surgical options for the management after bariatric surgery were discussed. For this purpose, a complete revision of the available literature was done including Pubmed, Medline, Scielo database, own experience, and experts opinion. A total of 49 publications were reviewed and included in the present paper. The majority of authors agree that gastric bypass is the procedure of choice. Sleeve gastrectomy is not an absolute contraindication. Up to now, gastric bypass appears to be the best procedure for treatment of obese patients with Barrett's esophagus. Future investigations should give the definitive consensus.

Inversed Y cardioplasty plus a truncal vagotomy-antrectomy and a Roux-en-Y gastrojejunostomy performed in patients with stricture of the esophagogastric junction after a failed cardiomyotomy or endoscopic procedure in patients with achalasia of the esophagus.

Laparoscopic anterior cardiomyotomy in addition to anterior Dor's fundoplication is the procedure of choice for achalasia of the esophagus with approximately 95% success rate. Redo cardiomyotomy is complicated and associated with rerecurrence of dysphagia. Twelve patients with failed redo myotomy were clinically evaluated with radiology, endoscopy, and manometry in whom achalasia type III or IV was confirmed. We propose as treatment for these selected cases an inversed Y cardioplasty + truncal vagotomy, a partial distal gastrectomy and Roux-en-Y gastrojejunostomy in order to facilitate esophageal emptying and avoid the appearance of postoperative gastroesophageal reflux as a side effect of this procedure. One patient was reoperated on in order to enlarge the cardioplasty. Disappearance of dysphagia was confirmed in all patients. Three patients presented reflux symptoms and were treated with 20 mg of Omeprazole 20 twice/day. No food retention, erosive esophagitis, or Barrett's esophagus were observed. The mean resting pressure decreased from 24.9 +/- 8.5 mm Hg to 7.5 +/- 2.5 mm Hg (P = 0.0001). Furthermore, esophageal diameter decreased significantly after a 5-year follow-up. This procedure could be an option for treating patients in which repeated Heller operations have failed.

Open transthoracic or transhiatal esophagectomy versus minimally invasive esophagectomy in terms of morbidity, mortality and survival.

BACKGROUND: Surgical treatment of esophageal cancer is associated with a high rate of morbidity and mortality even in specialized centers. Minimally invasive surgery has been proposed to decrease these complications. METHODS: The authors present their results regarding postoperative complications and the survival rate at 3 years, comparing the classic open procedures (transthoracic or transhiatal esophagectomy) with minimally invasive surgery. Surgical procedures were performed according to procedures published elsewhere. RESULTS: The study enrolled 166 patients who underwent surgery between 1990 and 2003. Open transthoracic surgery was performed for 60 patients. In this group of patients, postoperative mortality was observed in 11% of the cases. Major, minor, and late complications were observed in 61.6% of the patients, and the 3-year survival rate was 30% for this group. Open transhiatal surgery was performed for 59 patients. The morbidity, mortality, and 3-year rate were almost the same as for the transthoracic surgery group. For the 47 patients submitted to minimally invasive procedures (thoracoscopic and laparoscopic), the complications and mortality rates were significantly reduced (38.2% and 6.4%, respectively). For the patients submitted to minimally invasive surgery, the 3-year survival rate was 45.4%. It is important to clarify that the patients submitted to minimally invasive surgery manifested early stages of the diseases, and that this the reason why the morbimortality and survival rates were better. CONCLUSIONS: The transthoracic and transhiatal open approaches have similar early and late results. Minimally invasive surgery is an option for patients with esophageal carcinoma, with reported results similar to those for open surgery. This approach is indicated mainly for selected patients with early stages of the disease.

Nonesophageal side-effects after antireflux surgery plus acid-suppression duodenal diversion surgery in patients with long-segment Barrett's esophagus*.

SUMMARY: During the last years we have employed acid-suppression duodenal diversion procedures (truncal vagotomy-partial gastrectomy plus Roux-en-Y gastrojejunostomy) in addition to antireflux surgery in order to treat all the pathophysiological factors involved in the genesis of Barrett's esophagus. We have observed very good results concerning the clinical and objective control of GERD at the long-term follow up after this procedure. However, it could be associated with other nonesophageal symptoms or side-effects. This study was conducted to evaluate the presence of gastrointestinal symptoms (diarrhea, vomiting, dumping, weight loss and anastomotic ulcers) after this operation. In this prospective study 73 patients were assessed using a careful clinical questionnaire asking regarding these complications at the early (< 6 months) and late (> 6 months) follow-up (average of 32.4 months). In the early postoperative period, diarrhea was present in 64% (19% considered severe 10-90 days after surgery), dumping in 41% and loss of weight in 71% of cases. Diarrhea occurred daily in 47.7% in the early postoperative period, but only in 16% of cases after 1 year. Shortly after surgery, steatorrea was observed in 9% of cases and responded well to medical treatment. Severe diarrhea or dumping was rare (5% of cases). These symptoms improved significantly after 1 year with medical management (45%, 20% and 30%, respectively) and 42% of patients regained their normal body weight. Only two patients presented anastomotic ulcers and were treated satisfactory with proton pump inhibitors. Revisional surgery was indicated in two patients with severe dumping syndrome. Most side-effects identified by this study were mild and diminished 1 year after operation.

Histological inflammatory changes after surgery at the epithelium of the distal esophagus in patients with Barrett's esophagus: a comparison of two surgical procedures.

There are many reports concerning the surgical treatment of patients with Barrett's esophagus, but very few focus on histological changes of inflammatory cells in squamous and columnar epithelium before and late after classic antireflux or acid suppression-duodenal diversion surgery. We evaluate the impact of these procedures in the presence of intestinal metaplasia, dysplasia and Helicobacter pylori in the columnar epithelium. Two groups of patients were studied, 37 subjected to classic antireflux and 96 to acid suppression-duodenal diversion operations. They were subjected to endoscopic and histological studies before and at 1, 3 and more than 5 years after surgery. Manometric evaluations and 24 h pH monitoring were performed before and at 1 year after surgery. The presence of inflammatory cells at both the squamous and columnar epithelium was significantly higher at the late follow up in patients subjected to classic antireflux surgery compared with patients subjected to acid suppression-duodenal diversion operations (P < 0.02 and P < 0.001, respectively). Intestinal metaplasia, present in 100% of patients before surgery, had decreased significantly at 3 years after surgery in patients subjected to acid suppression-duodenal diversion operations compared with classic antireflux procedures, 75% versus 53%, respectively (P < 0.001). The presence of Helicobacter pylori did not vary before or after surgery in either group. In conclusion, acid suppression-duodenal diversion operations are followed by a decreased presence of inflammatory cells in both squamous and columnar epithelium compared with classic antireflux surgery in patients with Barrett's esophagus. Intestinal metaplasia and dysplasia and inflammation findings were also less common after acid suppression-duodenal diversion operation.

Progresión de metaplasia intestinal a adenocarcinoma en esófago de Barrett: utilidad de la vigilancia endoscópica / Progression from intestinal metaplasia to adenocarcinoma in Barrett s esophagus: usefulness of endoscopic surveillance

BACKGROUND: The potential progression from intestinal metaplasia to low grade dysplasia, to high grade dysplasia and to adenocarcinoma represents a well recognized sequence in patients with Barrett's esophagus (BE). The time required for this transformation is not well known. AIM: To report the results of a 10 years follow up of patients with BE. MATERIAL AND METHODS: Between 1989 and 2000 we followed 402 patients with BE. RESULTS: Sixty six subjects (16.2 per cent) presented low grade dysplasia at the time of diagnosis and 10 patients (2 women/8 men) developed adenocarcinoma during the follow-up period. Four out of these 10 patients were operated because of gastro-esophageal reflux disease, but after 3-5 years, reflux symptoms recurred. The other 6 patients rejected surgery and were on Omeprazole with good symptomatic results. Two patients had a short BE (< 3 cm), seven cases had a classic BE (3-10 cm) and one patient had an extensive > 10 cm BE. The mean time elapsed from intestinal metaplasia to low grade dysplasia was 9 months, to high grade dysplasia 56 months and to adenocarcinoma 82 months. From low grade dysplasia to early cancer it was 18 months, from high grade dysplasia to early cancer 14 months and from high grade dysplasia to advanced transmural cancer 14 months. All patients were subjected to esophagectomy. Five patients detected as State I are alive without any evidence of recurrence after 36 to 130 months after surgery. Five patients with advanced transmural carcinoma subjected to radical esophagectomy died because of progression of the malignancy between 3 and 24 months after surgery. CONCLUSIONS: Progression to adenocarcinoma may occur even in absence of reflux symptoms while on acid suppression therapy. Detection at early stage intestinal metaplasia in the esophagus offers a high chance of cure after surgical resection.

Results of surgical treatment for recurrent postoperative gastroesophageal reflux.

The rate of recurrence of reflux esophagitis after classic antireflux surgery (fundoplication) is 10-15%. This rate is different in patients with esophagitis with and without Barrett's esophagus. We evaluated the clinical and laboratory findings in 104 patients with postoperative recurrent reflux esophagitis, determining the results of repeat antireflux surgery or an acid suppression-bile diversion procedure. Repeat fundoplication was performed in 26 patients, and truncal vagotomy, antrectomy, and Roux-en-Y gastrojejunostomy in 78 patients. Esophagectomy as a third operation was performed in seven patients. After repeat antireflux surgery, endoscopic evaluation demonstrated improvement of esophagitis in a small proportion of patients. Barrett's esophagus remained unchanged, and no regression of ulcer or stricture was observed. These complications improved significantly after acid suppression-bile diversion surgery. Incompetent lower esophageal sphincter (LES) was present in 55.8% after initial surgery and in 23% after reoperation. Acid reflux, initially present in 94.6% of patients, was also observed in 93.6% after fundoplication, 68.8% after redo fundoplication, and 16.6% after treatment with the acid suppression-bile diversion technique. A positive Bilitec test was present in 78% of patients before the operation and 56.6% after the repeat operation, and was negative after bile diversion surgery. Among 13 patients (50%) submitted to repeat surgery alone, esophagectomy as a third operation was necessary as a result of severe non-dilatable stricture in seven patients. Our conclusions are that repeat antireflux surgery alone failed to improve Barrett's esophagus complications and that the best results were obtained in patients submitted to acid suppression-bile diversion surgery.

Esophagectomy and laparoscopic gastric mobilization with minilaparotomy for tubulization and esophageal replacement.

Several alternatives for esophageal resection and replacement with laparoscopic, thoracoscopic, video-assisted, or completely endoscopic techniques have been reported. All of these have advantages and disadvantages according to the indications, instrumental requirements, cost, and feasibility. Here we report a new alternative procedure, performing the gastric mobilization and transhiatal esophageal dissection by laparoscopic approach and preparation of the gastric tube through a midline 5-cm minilaparotomy. In this manner we handled the GIA staplers outside of the abdomen, avoiding prolongation of the operating time and the excessive increase of the cost of the procedure. Further, this procedure may help to prevent the risk of postoperative leak of the stapler suture line by reinforcing this suture with a invaginating continuous manual 3-0 reabsorbable suture (Monocryl, Johnson & Johnson, Cincinnati, OH, U.S.A.). A left anterolateral cervicotomy was done to complete the dissection of the esophagus, and the gastric tube was ascended through a retrosternal tunnel to the neck for esophagogastroanastomosis. We operated on a 73-year-old woman, who had a T1 squamous carcinoma of middle third of the esophagus. The operation was performed with no intraoperative complications as a result of the procedure. After surgery, pneumonia with a pleural effusion developed and was evacuated. The patient was discharged from the hospital with no symptoms. We believe that this is a safe, inexpensive, and easy procedure for the transhiatal laparoscopic esophagectomy and its replacement by a gastric tube.

[Preliminary results of laparoscopic video esophagomyotomy in patients with esophageal achalasia]. / Resultados preliminares de la esofagomiotomía por video laparoscopia en pacientes con acalasia esofágica.

BACKGROUND: Laparoscopic esophagomyotomy is becoming a good alternative to pneumatic dilatation, injection of botulinic toxin or classical surgery in the treatment of achalasia. AIM: To report the results of laparoscopic esophagomyotomy in patients with achalasia. PATIENTS AND METHODS: Nineteen patients with achalasia, nine women, aged 9 to 66 years old, operated between 1996 and 2001 are reported. RESULTS: There was no surgical mortality. One patient had a subphrenic abscess due to an unnoticed tear of the esophageal mucosa. During surgery, esophageal mucosa was perforated in 4 patients, that was sutured in three. One patient with an extensive tear of the mucosa required conversion to classical surgery. Patients were followed for 2 to 48 months. Radiological controls showed a significant increase in the diameter of gastroesophageal junction and a diameter reduction of the mid third esophageal segment. Lower esophageal pressure was significantly reduced. All patients experienced a weight increase and reduction of dysphagia. CONCLUSIONS: Laparoscopic esophagomyotomy is a safe an effective therapeutic alternative for achalasia.

Anatomic dilatation of the cardia and competence of the lower esophageal sphincter: a clinical and experimental study.

Anatomic and clinical data suggest that the gastroesophageal junction or cardia in patients with gastroesophageal reflux disease GERD) may be dilated. We hypothesized that anatomic dilatation of the cardia induces a lower esophageal sphincter dysfunction that may be corrected by narrowing the gastroesophageal junction (i.e., calibration of the cardia). We measured the perimeter of the cardia during surgery in control subjects and patients with GERD and Barrett's esophagus. We then tested our hypothesis in a mechanical model. The model was based on a pig gastroesophageal specimen with perpendicularly placed elastic bands around the cardia simulating the action of the "sling" and "clasp" fibers. "Dilatation" of the cardia was induced by displacing the sling band laterally and decreasing its tension. "Calibration" of the cardia was performed by reapproximation of the sling band toward the esophagus but maintaining the same tension as the dilated model. In the "basal," "dilated," and "calibrated" states, the perimeter of the cardia was noted and rapid mechanized pullback manometry with a water-perfused catheter was performed. The opening pressure was determined, and three-dimensional sphincter pressure images were analyzed. The average cardia perimeter was 6.3 cm in control subjects, 8.9 cm in GERD patients, and 13.8 cm in patients with Barrett's esophagus. The arrangement of the bands in the experimental model generated a manometric high-pressure zone similar to that in the human lower esophageal sphincter. Dilatation of the cardia resulted in a decrease in the resting pressure, length, and vector volume of the high -pressure zone, and reduced the opening pressure. Calibration restored the resting and opening pressure, and normalized the three-dimensional pressure image. In patients with GERD and Barrett's esophagus, the cardia is dilated. Our model supports the hypothesis that lower esophageal sphincter function is compromised by anatomic dilatation of the cardia and can be restored by approximation of the "sling" fibers toward the lesser curvature "clasp" fibers). This provides evidence for a correlation between gastroesophageal sphincter dysfunction in reflux disease and its correction by antireflux surgery.

Antireflux surgery, highly selective vagotomy and duodenal switch procedure: post-operative evaluation in patients with complicated and non-complicated Barrett's esophagus.

Antireflux surgery, highly selective vagotomy (HSV) and Roux-en-Y duodenojejunostomy have been suggested for control of pathophysiological factors involved in patients with Barrett's esophagus (BE). The aim of this study was to evaluate prospectively the results of this technique in patients with complicated (n = 21) and noncomplicated (n=45) BE. Complete evaluation of esophageal function, endoscopic histologic and clinical control was carried out before and 2 years after surgery. Post-operative results show recurrence of ulcer in patients with complicated BE, but no recurrence in patients with non-complicated BE. Preoperative esophageal ulcer and stricture were present in 85.3% and 14.3%, respectively, of patients with complicated BE. In this group, recurrence of these complications was 38.1% and 9.5% respectively. The technique offers excellent results in patients with non-complicated BE. However, in patients with complicated BE, the recurrence rate is higher, mainly because of the persistence of acid reflux into the esophagus.

[Survival of patients with esophageal cancer subjected to total thoracic esophagectomy]. / Sobrevida de pacientes con cáncer de esófago sometidos a esofagectomía total torácica.

BACKGROUND: Esophageal carcinoma has a dismal prognosis. Several authors have reported a very low survival in Chile. AIM: To report the survival of patients with esophageal carcinoma, subjected to esophageal resection. MATERIAL AND METHODS: Analysis of 108 patients subjected to thoracic esophageal resection between 1985 and 1996. Patients were classified according to the location of the tumor and its staging. RESULTS: Eleven patients died in the immediate postoperative period and 90 patients were followed. In 53 the exact cause of death was determined. Global five years survival was 29% and median survival was 18 months. Survival was 100% in stage I tumors. Adjuvant therapy resulted in a better survival of stage III tumors. Survival of stage IV tumors was worst than stage I to III tumors. There was no survival difference between squamous carcinoma or adenocarcinoma. Tumors located in the superior third of the esophagus had a worst prognosis. Causes of death were mediastinic metastases, local recidivism, pleural or pulmonary metastases and less frequently, brain, bronchial or bone metastases. CONCLUSIONS: The survival of these, patients with esophageal carcinoma did not differ from the figures reported abroad.

Late results of a randomized clinical trial comparing total fundoplication versus calibration of the cardia with posterior gastropexy.

BACKGROUND: The aim was to perform a prospective randomized study in patients with chronic gastro-oesophageal reflux treated either by total fundoplication or calibration of the cardia with posterior gastropexy. Late follow-up considered subjective and objective parameters, and related outcome to the presence of Barrett's oesophagus. METHODS: A total of 164 patients were randomized to fundoplication (n = 76) or calibration of the cardia (n = 88). They were evaluated by clinical questionnaire, upper gastrointestinal endoscopy with biopsies, oesophageal manometry and gastro-oesophageal reflux studies, including scintigraphy and 24-h oesophageal pH monitoring. RESULTS: There were no operative deaths. There was 95 per cent follow-up at a mean of 85 months. The mean recurrence rate for both operations was near 40 per cent at 10 years, but patients without Barrett's oesophagus had a recurrence rate after both operations of around 23 per cent compared with 83 per cent after 10 years for those with Barrett's oesophagus (P < 0.0001). Low-grade dysplasia developed in 13 per cent of the patients with Barrett's oesophagus. There were significant differences in all objective parameters in a comparison of patients with Visick I or II and those with Visick III or IV disease at the late assessment. CONCLUSION: Both total fundoplication and calibration of the cardia with posterior gastropexy had similar subjective and objective late results. However, results were significantly worse in patients with Barrett's oesophagus.

Intraperitoneal bile collections after laparoscopic cholecystectomy: causes, clinical presentation, diagnosis, and treatment.

BACKGROUND: Bile leakage is more common after laparoscopic cholecystectomy than after open surgery. In our department, the rate of postoperative bile collections after open surgery is 0.2% vs 0.6% after laparoscopic cholecystectomy. METHODS: We studied 13 cases of intraperitoneal bile collection without common bile duct damage drawn from a total of 5,200 laparoscopic cholecystectomies (0.23%). Clinical presentation, symptoms, method of diagnosis, causes, time of diagnosis, correlation of time of diagnosis with definitive treatment, and postoperative results were analyzed. RESULTS: The symptoms appeared between the 5th and 8th postoperative days. They were observed in patients with either chronic or acute cholecystitis. The main causes were misapplication of clips at the cystic duct and open Luschka's duct. Ultrasound failed for early recognition of bile collections. The definitive diagnosis was made by repeat ultrasonography, CAT scan, and ERCP. CONCLUSION: The ideal treatment in these cases is a minimally invasive procedure, but since the diagnosis is frequently delayed, open surgery is performed in the majority of patients. However, there were no mortalities in this group of patients.

Cardiomyotomy in achalasia: which fibers do we cut?

Until now, it has not been quite clear which muscular fibers are cut when a cardiomyotomy for achalasia is carried out. In the present report, in a human achalasic gastroesophageal specimen, the mucosa of the stenotic segment was stripped off, allowing the fibers of the inner muscular coat to be seen. In addition, three cardiomyotomies at different sites were simulated. In achalasic specimens, the stenotic area is formed by the semicircular ('clasp') and oblique ('sling') muscular fibers. Different myotomies section these two muscular bands in distinct proportions. The stenotic segment in achalasia coincides topographically with the anatomic lower esophageal sphincter area. The site of cardiomyotomy is not irrelevant because this sphincter is not an annular muscle and the two muscular components of the sphincter can be sectioned in different ways. This may be important in post-operative results with regard to the relief of dysphagia and the appearance of gastroesophageal reflux.

Gallbladder carcinoma during laparoscopic cholecystectomy: is it associated with bad prognosis?

Laparoscopic cholecystectomy is the treatment of choice for gallstone disease. The ultrasonogram has failed for the early detection of gallbladder cancer, especially if inflammation (chronic or acute) is present. Incidental gallbladder could be an important cancer finding during laparoscopic cholecystectomy, due to the potential cancer cell dissemination during the procedure. In our Department, 6500 laparoscopic cholecystectomies have been performed in the last 5 years and in 15 cases (0.23%) gallbladder cancer was found during surgery or after histological examination of the resected gallbladder. In none of these 15 patients was pre-operative diagnosis of gallbladder carcinoma postulated. When re-evaluation of the pre-operative ultrasonograms was done, it was possible to observe signs suggesting the presence of neoplastic infiltration in 4 of them (28.6%). During videoscopic exploration, also in 4 patients, the suspicion of gallbladder cancer was noted. Laparoscopic cholecystectomy was completed in 9 patients. In 2 of them, in situ or mucosal invasion was demonstrated with a long survival. One patient presented recurrence at the biliary hilum 2,5 years after surgery. Six patients were re-operated and in 4 of them peritoneal or port site metastasis was found; all died early (4.5 month median survival). The other 2 patients were submitted to liver bed resection and lymph node dissection. These patients are free of cancer recurrence after 15 months of follow-up. Six patients were converted to open surgery, performing palliative procedures and died before the 12 month follow-up. The suspicion of pre-operative gallbladder cancer is generally unlikely to be confirmed based on ultrasonographic signs; but, in some cases with high suspicion, further investigation (TAC, tumor markers, etc.) must be indicated in order to avoid poor results. Laparoscopic cholecystectomy could be associated with bad prognosis, and then, when gallbladder cancer is suspected during the laparoscopic procedure, conversion to open surgery could be the best choice.