RESUMO
AIM: Dysfunction of the lower esophageal sphincter (LES), gastroesophageal reflux disease, and erosive esophagitis in patients undergoing subtotal gastrectomy are commonly recognized occurrences, but until now the causes remain unclear. The hypothesis of this study is that subtotal gastrectomy provokes changes on the LES resting pressure and its competence, due to the anatomical damage of it, given that the oblique "Sling" fibers, one of the muscular components of the LES, are transected during this surgical procedure. METHODS: Seven adult mongrel dogs (18-30 kg) were anesthetized and admitted for transection of the proximal stomach. Later, the proximal gastric remnant was closed by a suture. Intraoperatively, slow pull-through LES manometries were performed on each dog, under basal conditions (with the intact stomach), and in the closed proximal gastric remnant. The mean of these measurements is presented, with each dog serving as its control. RESULTS: The mean LES pressure (LESP) measured in the proximal gastric remnant, compared with the LESP in the intact stomach, was decreased in five dogs, increased in one dog, and remained unchanged in other dogs. CONCLUSION: The upper transverse transection of the stomach and closing the stomach remnant by suture provoke changes in the LESP. We suggested that these changes in the LESP are secondary to transecting the oblique "Sling" fibers of the LES, one of its muscular components. The suture and closing of the proximal gastric remnant reanchor these fibers with more, less, or the same tension, whether or not modifying the LESP.
OBJETIVO: Disfunção do esfíncter esofágico inferior (EEI), doença do refluxo gastroesofágico e esofagite erosiva em pacientes submetidos à gastrectomia subtotal são ocorrências comumente reconhecidas, mas até agora as causas permanecem obscuras. A hipótese deste estudo é que a gastrectomia subtotal provoque alterações na pressão de repouso do EEI e na sua competência, devido ao dano anatômico desta, visto que as fibras oblíquas "Sling", um dos componentes musculares do EEI, são seccionadas durante este procedimento cirúrgico. MÉTODOS: Sete cães adultos sem raça definida (18-30 kg) foram anestesiados e submetidos à transecção do estômago proximal. Em seguida, o remanescente gástrico proximal foi fechado por sutura. No intraoperatório, manometria lenta foi realizada em cada cão, em condições basais (com estômago intacto) e no remanescente gástrico proximal fechado. A média dessas medidas é apresentada, com cada cão servindo como seu próprio controle. RESULTADOS: A pressão média do EEI medida no remanescente gástrico proximal, em comparação com a pressão do EEI no estômago intacto, foi diminuída em cinco cães, aumentada em um cão e sem alterações no outro cão. CONCLUSÃO: A secção transversa superior do estômago e o fechamento do remanescente do estômago por sutura provocam alterações na pressão do EEI. Sugerimos que essas mudanças na pressão do EEI são secundárias à secção das fibras oblíquas "Sling" do esfíncter, um de seus componentes musculares. A sutura e o fechamento do remanescente gástrico proximal, reancora essas fibras com mais, menos ou a mesma tensão, modificando ou não a pressão do EEI.
Assuntos
Esfíncter Esofágico Inferior , Refluxo Gastroesofágico , Animais , Cães , Esfíncter Esofágico Inferior/cirurgia , Junção Esofagogástrica , Gastrectomia/efeitos adversos , Humanos , ManometriaRESUMO
RESUMO - RACIONAL: Disfunção do esfíncter esofágico inferior (EEI), doença do refluxo gastroesofágico e esofagite erosiva em pacientes submetidos à gastrectomia subtotal são ocorrências comumente reconhecidas, mas até agora as causas permanecem obscuras. OBJETIVO: A hipótese deste estudo é que a gastrectomia subtotal provoque alterações na pressão de repouso do EEI e na sua competência, devido ao dano anatômico desta, visto que as fibras oblíquas "Sling", um dos componentes musculares do EEI, são seccionadas durante este procedimento cirúrgico. MÉTODOS: Sete cães adultos sem raça definida (18-30 kg) foram anestesiados e submetidos à transecção do estômago proximal. Em seguida, o remanescente gástrico proximal foi fechado por sutura. No intraoperatório, manometria lenta foi realizada em cada cão, em condições basais (com estômago intacto) e no remanescente gástrico proximal fechado. A média dessas medidas é apresentada, com cada cão servindo como seu próprio controle. RESULTADOS: A pressão média do EEI medida no remanescente gástrico proximal, em comparação com a pressão do EEI no estômago intacto, foi diminuída em cinco cães, aumentada em um cão e sem alterações no outro cão. CONCLUSÃO: A secção transversa superior do estômago e o fechamento do remanescente do estômago por sutura provocam alterações na pressão do EEI. Sugerimos que essas mudanças na pressão do EEI são secundárias à secção das fibras oblíquas "Sling" do esfíncter, um de seus componentes musculares. A sutura e o fechamento do remanescente gástrico proximal, reancora essas fibras com mais, menos ou a mesma tensão, modificando ou não a pressão do EEI.
ABSTRACT - BACKGROUND: Dysfunction of the lower esophageal sphincter (LES), gastroesophageal reflux disease, and erosive esophagitis in patients undergoing subtotal gastrectomy are commonly recognized occurrences, but until now the causes remain unclear. AIM: The hypothesis of this study is that subtotal gastrectomy provokes changes on the LES resting pressure and its competence, due to the anatomical damage of it, given that the oblique "Sling" fibers, one of the muscular components of the LES, are transected during this surgical procedure. METHODS: Seven adult mongrel dogs (18-30 kg) were anesthetized and admitted for transection of the proximal stomach. Later, the proximal gastric remnant was closed by a suture. Intraoperatively, slow pull-through LES manometries were performed on each dog, under basal conditions (with the intact stomach), and in the closed proximal gastric remnant. The mean of these measurements is presented, with each dog serving as its control. RESULTS: The mean LES pressure (LESP) measured in the proximal gastric remnant, compared with the LESP in the intact stomach, was decreased in five dogs, increased in one dog, and remained unchanged in other dogs. CONCLUSION: The upper transverse transection of the stomach and closing the stomach remnant by suture provoke changes in the LESP. We suggested that these changes in the LESP are secondary to transecting the oblique "Sling" fibers of the LES, one of its muscular components. The suture and closing of the proximal gastric remnant reanchor these fibers with more, less, or the same tension, whether or not modifying the LESP.
Assuntos
Humanos , Animais , Cães , Refluxo Gastroesofágico , Esfíncter Esofágico Inferior/cirurgia , Junção Esofagogástrica , Gastrectomia/efeitos adversos , ManometriaAssuntos
Gastrectomia , Refluxo Gastroesofágico/epidemiologia , Gastroplastia , Laparoscopia , Obesidade Mórbida/cirurgia , Adolescente , Adulto , Idoso , Estudos de Coortes , Feminino , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/prevenção & controle , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/complicações , Obesidade Mórbida/patologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Laparoscopic sleeve gastrectomy has been accepted as an option for surgical treatment of obesity. After surgery, some patients present reflux symptoms associated with endoscopic esophagitis, therefore PPI's treatment must be indicated. PURPOSE: This study aims to evaluate the manometric characteristic of the lower esophageal sphincter (LES) before and after sleeve gastrectomy MATERIAL AND METHOD: This prospective study includes 20 patients submitted to esophageal manometry in order to determine the resting pressure, and total and abdominal LES length before and after the sleeve gastrectomy. Statistical variations on the LESP were validated according to Student's "t" test. RESULTS: Seventeen female and three male patients were included, with a mean age of 37.6 +/- 12.6 years. All patients reduced their body weight, from an initial BMI of 38.3 kg/m(2) to 28.2 kg/m(2) 6 months after surgery. No postoperative complications were observed in these patients. Preoperative mean LESP was 14.2 +/- 5.8 mmHg. Postoperative manometry decreased in 17/20 (85%), with a mean value of 11.2 +/- 5.7 mmHg (p = 0.01). Seven of them presented LESP <12 mmHg and ten patients <6 mmHg after the operation. Furthermore, the abdominal length and total length of the high pressure zone at the esophagogastric junction were affected. CONCLUSION: A sleeve gastrectomy produces an important decrease in LES pressure, which can in turn cause the appearance of reflux symptoms and esophagitis after the operation due to a partial resection of the sling fibers during the gastrectomy.
Assuntos
Esfíncter Esofágico Inferior/fisiopatologia , Junção Esofagogástrica/anatomia & histologia , Gastrectomia/efeitos adversos , Refluxo Gastroesofágico/etiologia , Obesidade/cirurgia , Adulto , Índice de Massa Corporal , Esfíncter Esofágico Inferior/fisiologia , Monitoramento do pH Esofágico , Esofagite/tratamento farmacológico , Esofagite/etiologia , Junção Esofagogástrica/fisiologia , Esofagoscopia , Feminino , Refluxo Gastroesofágico/tratamento farmacológico , Humanos , Laparoscopia , Masculino , Manometria , Obesidade/complicações , Estudos Prospectivos , Inibidores da Bomba de Prótons/uso terapêutico , Resultado do TratamentoRESUMO
HYPOTHESIS: The results of surgical treatment of patients with long-segment Barrett esophagus (BE) have been extensively reported. However, few publications refer to the results of surgery 5 years after the fact among patients with short-segment BE. This study aimed to determine the late results of 3 surgical procedures in patients with short-segment BE by subjective and objective measurements. DESIGN: Prospective, nonrandomized study starting on March 1, 1987, and ending on December 31, 2005. SETTING: A prospective, descriptive study of a group of patients. PATIENTS: A total of 125 patients with short-segment BE underwent 3 operations in different periods: duodenal switch plus highly selective vagotomy and antireflux technique in 31 patients, vagotomy plus partial gastrectomy and Roux-en-Y loop with antireflux surgery in 58 patients, and laparoscopic Nissen fundoplication in 36 patients. MAIN OUTCOME MEASURES: Late subjective and objective outcomes of the 3 different surgical procedures. RESULTS: No operative mortality and only 2 postoperative complications (1.6%) occurred. The regression from intestinal metaplasia to cardiac or oxyntocardiac mucosa occurred in 60.8% to 65.4% of the patients, at a mean time of 39 to 56 months after surgery. Visick grading showed Visick grade I or II in 86.3% to 100.0% of the patients. No progression to low- or high-grade dysplasia or adenocarcinoma occurred. CONCLUSIONS: On the basis of these results, laparoscopic Nissen fundoplication seems to be the surgical option for patients with short-segment BE because it is less invasive, has fewer side effects, and produces good results in the long-term follow-up.
Assuntos
Anastomose em-Y de Roux , Esôfago de Barrett/patologia , Esôfago de Barrett/cirurgia , Fundoplicatura , Gastrectomia , Refluxo Gastroesofágico/terapia , Monitoramento do pH Esofágico , Seguimentos , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/patologia , Humanos , Laparoscopia , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Vagotomia Gástrica ProximalRESUMO
BACKGROUND: Non cardiac chest pain can be caused by esophageal problems such as gastroesophageal reflux or smooth muscle motor disorders. AIM: To perform esophageal manometry in patients with non cardiac chest pain. MATERIAL AND METHODS: One hundred patients with chest pain in whom coronary problems were discarded, were studied. A computerized esophageal manometry was performed in all and 24 hours esophageal pH measurement was done in 21 patients. RESULTS: Esophageal manometry was normal in eight patients. Nutcracker esophagus was the most common finding, in 36 patients. Twenty eight had a hypotensive sphincter, 16 had unspecific motor disorders, nine had diffuse esophageal spasm, two had a non achalasic esophageal aperistalsis and one had a hypertensive sphincter. CONCLUSIONS: Only eight of 100 patients referred to esophageal manometry for non cardiac chest pain, had a normal study.
Assuntos
Dor no Peito/etiologia , Transtornos da Motilidade Esofágica/complicações , Manometria/métodos , Dor no Peito/diagnóstico , Transtornos da Motilidade Esofágica/diagnóstico , Humanos , Concentração de Íons de HidrogênioRESUMO
BACKGROUND: The endoscopic view of the gastric cardia could be related with the manometric competence of the lower esophageal sphincter (LES) and with pathological gastroesophageal reflux. AIM: To compare the endoscopic aspect of the cardia with the results from esophageal manometry and 24 h esophageal pH monitoring. MATERIALS AND METHODS: The cardia of a group of 150 patients (aged 19 to 72 years, 89 women) with gastroesophageal reflux symptoms was classified as normal or open, during upper gastrointestinal endoscopy. All subjects were subjected to a manometric study to measure LES pressure and determine LES incompetence and to a 24 h esophageal pH measurement. RESULTS: LES pressure was 14.7+/-6.2 and 8.7+/-4.2 mmHg in patients with normal and open cardia, respectvively (p <0.001). Likewise, 43 and 79% of patients with normal and open cardia had an incompetent LES, respectively (p <0.001). Pathological acid reflux was present in 43 and 71% of patients with normal or open cardia, respectively (p <0.001). CONCLUSIONS: The endoscopic appearance of the cardia can identify patients with pathological gastroesophageal reflux.
Assuntos
Cárdia , Endoscopia do Sistema Digestório , Refluxo Gastroesofágico/fisiopatologia , Adulto , Idoso , Cárdia/patologia , Cárdia/fisiologia , Doença Crônica , Feminino , Refluxo Gastroesofágico/patologia , Humanos , Concentração de Íons de Hidrogênio , Masculino , Manometria , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Background: Non cardiac chest pain can be caused by esophageal problems such as gastroesophageal reflux or smooth muscle motor disorders. Aim: To perform esophageal manometry in patients with non cardiac chest pain. Material and methods: One hundred patients with chest pain in whom coronary problems were discarded, were studied. A computerized esophageal manometry was performed in all and 24 hours esophageal pH measurement was done in 21 patients. Results: Esophageal manometry was normal in eight patients. Nutcracker esophagus was the most common finding, in 36 patients. Twenty eight had a hypotensive sphincter, 16 had unspecific motor disorders, nine had diffuse esophageal spasm, two had a non achalasic esophageal aperistalsis and one had a hypertensive sphincter. Conclusions: Only eight of 100 patients referred to esophageal manometry for non cardiac chest pain, had a normal study.
Assuntos
Humanos , Dor no Peito/etiologia , Transtornos da Motilidade Esofágica/complicações , Manometria/métodos , Dor no Peito/diagnóstico , Transtornos da Motilidade Esofágica/diagnóstico , Concentração de Íons de HidrogênioRESUMO
Gastric bypass in patients with morbid obesity should be an excellent antireflux procedure, because no acid is produced at the small gastric pouch and no duodenal reflux is present, due to the long Roux-en-Y limb. Five hundred fifty-seven patients with morbid obesity submitted to resectional gastric bypass, and routine preoperative upper endoscopy with biopsy samples demonstrated 12 patients with Barrett's esophagus (2.1%) and three patients with intestinal metaplasia of the cardia (CIM). An endoscopic procedure was repeated twice after surgery, producing seven patients with short-segment Barrett's esophagus (BE) and five patients with long-segment BE. Body mass index (BMI) decreased significantly, from 43.2 kg/m(2) to 29.4 kg/m(2) 2 years after surgery. Symptoms of reflux esophagitis, which were present in 14 of the 15 patients, disappeared in all patients 1 year after surgery. Preoperative erosive esophagitis and peptic ulcer of the esophagus healed in all patients. There was regression from intestinal metaplasia to cardiac mucosa in four patients (57%) with short-segment BE, and in one patient (20%) with long-segment BE. Two (67%) of three cases with CIM had regression to cardiac mucosa. There was no progression to low- or high-grade dysplasia. Gastric bypass in patients with Barrett's esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent.
Assuntos
Esôfago de Barrett/terapia , Cárdia/patologia , Derivação Gástrica , Mucosa Intestinal/patologia , Obesidade Mórbida/cirurgia , Adulto , Biópsia , Índice de Massa Corporal , Monitoramento do pH Esofágico , Esofagite Péptica/terapia , Esofagoscopia , Feminino , Seguimentos , Mucosa Gástrica/patologia , Gastroscopia , Humanos , Masculino , Metaplasia , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Cicatrização/fisiologiaRESUMO
INTRODUCTION: Laparoscopic esophagomyotomy is the preferred approach to patients with achalasia of the esophagus, However, there are very few long-term follow-up studies (>10 years) in these patients. OBJECTIVE: To perform a very late subjective and objective follow-up in a group of 67 patients submitted to esophagomyotomy plus a partial antireflux surgery (Dor's technique). MATERIAL AND METHODS: In a prospective study that lasted 30 years, 67 patients submitted to surgery were divided into 3 groups: group I followed for 80 to 119 months (15 patients); group II, with follow-up of 120 to 239 months (35 patients); and group III, with follow-up more than 240 months (17 patients). They were submitted to clinical questionnaire, endoscopic evaluation, histologic analysis, radiologic studies, manometric determinations, and 24-hour pH studies late after surgery. RESULTS: Three patients developed a squamous cell esophageal carcinoma 5, 7, and 15 years after surgery. At the late follow-up, Visick III and IV were seen in 7%, 23%, and 35%, according to the length of follow-up of each group. Endoscopic examination revealed a progressive nonsignificant deterioration of esophageal mucosa, histologic analysis distal to squamous-columnar junction showed a significant decrease of fundic mucosa in patients of group III, with increase of intestinal metaplasia, although not significant time. Lower esophageal sphincter showed a significant decrease of resting pressure 1 year after surgery, which remained similar at the late control. There was no return to peristaltic activity. Acid reflux measured by 24-hour pH studies revealed a progressive increase, and the follow-up was longer. Nine patients developed Barrett esophagus: 6 of them a short-segment and 3 a long-segment Barrett esophagus. Final clinical results in all 67 patients demonstrated excellent or good results in 73% of the cases, development of epidermoid carcinoma in 4.5%, and failures in 22.4% of the patients, mainly due to reflux esophagitis. Incomplete myotomy was seen in only 1 case. CONCLUSION: In patients with achalasia submitted to esophagomyotomy and Dor's antireflux procedure, there is a progressive clinical deterioration of initially good results if a very long follow-up is performed (23 years after surgery), mainly due to an increase in pathologic acid reflux disease and the development of short- or long-segment Barrett esophagus.