Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient’s desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.
Despite endoscopic eradication therapy being an effective and durable treatment for Barrett’s esophagus-related neoplasia, even after achieving initial successful eradication, these patients remain at risk of recurrence and require ongoing routine examinations. Failure of radiofrequency ablation and argon plasma coagulation is reported in 10–20% of cases.
The addition of endoscopic ablative therapy plus proton pump inhibitors or fundoplication is postulated for the treatment of patients with long-segment Barrett´s esophagus (LSBE); however, it does not avoid acid and bile reflux in these patients. Fundoplication with distal gastrectomy and Roux-en-Y gastrojejunostomy is proposed as an acid suppression-duodenal diversion procedure demonstrating excellent results at long-term follow-up. There are no reports on therapeutic strategy with this combination.
To determine the early and long-term results observed in LSBE patients with or without low-grade dysplasia who underwent the acid suppression-duodenal diversion procedure combined with endoscopic therapy.
Prospective study including patients with endoscopic LSBE using the Prague classification for circumferential and maximal lengths and confirmed by histological study. Patients were submitted to argon plasma coagulation (21) or radiofrequency ablation (31). After receiving treatment, they were monitored at early and late follow-up (5–12 years) with endoscopic and histologic evaluation.
Few complications (ulcers or strictures) were observed after the procedure. Re-treatment was required in both groups of patients. The reduction in length of metaplastic epithelium was significantly better after radiofrequency ablation compared to argon plasma coagulation (10.95 vs 21.15 mms for circumferential length; and 30.96 vs 44.41 mms for maximal length). Intestinal metaplasia disappeared in a high percentage of patients, and histological long-term results were quite similar in both groups.
Endoscopic procedures combined with fundoplication plus acid suppression with duodenal diversion technique to eliminate metaplastic epithelium of distal esophagus could be considered a good alternative option for LSBE treatment.
The transient dysphagia after fundoplication is common and most often disappears until six weeks postoperatively.
Analyze a group of patients who presented late and persistent dysphagia postoperatively.
Forty-one patients after Nissen fundoplication, 14 male and 27 female, mean age 48 year, were evaluated based on medical history, esophagogastroduodenoscopy, contrast radiographic examination and esophageal manometry. The results were compared with another 19 asymptomatic individuals.
Contrast radiographic examination of the esophagus revealed in six cases delayed emptying, characterizing that four patients had achalasia and two diffuse spasm of the esophagus. Esophageal manometry showed that maximal expiratory pressure of the lower sphincter ranged from 10 to 38 mmHg and mean respiratory pressure from 14 to 47 mmHg, values similar to controls. Residual pressure ranged from 5 to 31 mmHg, and 17 patients had the same values as the control group.
The residual pressure of the lower sphincter was higher and statistically significant in patients with dysphagia compared with those operated without dysphagia. Future studies individualizing and categorizing each motility disorder, employing other techniques of manometry, and the analysis of the residual pressure may contribute to understand of persistent dysphagia in the postoperative fundoplication.
Gastroesophageal reflux disease (GERD) is probably one of the most prevalent diseases in the world that also compromises the quality of life of the affected significantly. Its incidence in Brazil is 12%, corresponding to 20 million individuals.
To update the GERD management and the new trends on diagnosis and treatment, reviewing the international and Brazilian experience on it.
The literature review was based on papers published on Medline/Pubmed, SciELO, Lilacs, Embase and Cochrane crossing the following headings: gastroesophageal reflux disease, diagnosis, clinical treatment, surgery, fundoplication.
Various factors are involved on GERD physiopathology, the most important being the transient lower esophageal sphincter relaxation. Clinical manifestations are heartburn, regurgitation (typical symptoms), cough, chest pain, asthma, hoarseness and throat clearing (atypical symptoms), which may be followed or not by typical symptoms. GERD patients may present complications such as peptic stenosis, hemorrhage, and Barrett's esophagus, which is the most important predisposing factor to adenocarcinoma. The GERD diagnosis must be based on the anamnesis and the symptoms must be evaluated in terms of duration, intensity, frequency, triggering and relief factors, pattern of evolution and impact on the patient's quality of life. The diagnosis requires confirmation with different exams. The goal of the clinical treatment is to relieve the symptoms and surgical treatment is indicated for patients who require continued drug use, with intolerance to prolonged clinical treatment and with GERD complications.
GERD is a major digestive health problem and affect 12% of Brazilian people. The anamnesis is fundamental for the diagnosis of GERD, with special analysis of the typical and atypical symptoms (duration, intensity, frequency, triggering and relief factors, evolution and impact on the life quality). High digestive endoscopy and esophageal pHmetry are the most sensitive diagnosctic methods. The clinical treatment is useful in controlling the symptoms; however, the great problem is keeping the patients asymptomatic over time. Surgical treatment is indicated for patients who required continued drug use, intolerant to the drugs and with complicated forms of GERD.
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.
Barrett’s esophagus (BE) represents the morphological premalignant manifestation of gastroesophageal reflux disease (GERD), which develops as a consequence of the dysfunction and failure of the antireflux mechanism38. BE involves the formation of intestinal metaplasia (IM) from the squamous epithelium of the esophagus, which is a reparative response to reflux-induced damage37. Although the prevalence in Western countries is about 1-2% in the general population and about 10% in population who report acid reflux symptoms, the accurate prevalence of BE in the general population is difficult to determine as the majority of individuals with BE are not diagnosed40,42. Epidemiological and histopathological evidence indicate that many cases of esophageal adenocarcinoma (EAC) arise in individuals with BE by the progression of IM (nondysplastic Barrett’s esophagus [NDBE]) and indefinite for dysplasia (IND) to dysplasia (including low-grade dysplasia [LGD] and high-grade dysplasia [HGD]) and finally to neoplasia46. To date, dysplasia remains the best available marker of cancer risk in patients with BE.
Since BE is considered a complication of chronic GERD, it is perhaps not surprising that risk factors for gastric reflux are also strongly associated with BE30,54. Reflux-induced injury has been linked to cellular and molecular changes in the esophagus12,39. Symptoms of heartburn and regurgitation are strongly associated with the presence of BE, and duration of GERD symptoms may also be a risk factor for BE7. Although GERD is a strong risk factor for both BE and EAC, 40-50% of patients with these disorders do not report chronic reflux symptoms, suggesting that silent reflux or other risk factors such as male sex57, age 50 or older43, white race58, central obesity28, and cigarette smoking9 also likely play a role in the pathogenesis of BE and EAC.
Although BE is well-established precursor for EAC, the assumption that all patients who develop EAC go through the same reflux-induced response leading to adenocarcinoma was challenged by a retrospective analysis that found that only 46% of patients with EAC presented with endoscopic confirmation of BE and histopathological evidence of IM45. Furthermore, comparison of patients with EAC who had confirmed BE at presentation to those without BE suggested the existence of two EAC phenotypes with different tumor behavior and response to therapy45. These findings raise the question of whether EAC always develops through the IM-dysplasia-EAC sequence.
Accepting that a controversy exists, the natural course of progression to dysplasia and cancer in BE in the majority of patients is thought to be stepwise from NDBE to LGD to HGD and cancer. The annual cancer risk depends on the degree of dysplasia, such as 0.33% if there is no dysplasia, 0.54% with LGD, and 7% with HGD47. Thus, the management is based on disease stages.
Proton-pump inhibitor (PPI) therapy is recommended to control reflux symptoms in patients with NDBE. The American College of Gastroenterology (ACG)47, American Gastroenterological Association (AGA)52, and American Society for Gastrointestinal Endoscopy (ASGE)46 all recommend that surveillance endoscopy with four-quadrant biopsies at 2-cm intervals every 3-5 years for NDBE. PPI therapy is associated with a 71% decrease in the risk of developing HGD and EAC in patients with BE50. Long-term therapy (>2-3 years) has a higher protective effect50. Chemoprevention to inhibit the progression to cancer in patients with BE is currently being assessed. Various medications such as aspirin, metformin, and statins have been studied. A randomized controlled trial indicated that the combination of high-dose esomeprazole plus aspirin had the strongest protective effect compared with low-dose esomeprazole without aspirin at a median follow-up of 8.9 years25. However, the ACG guidelines do not currently recommend chemoprevention for all patients with BE, but suggest it should be considered in patients with BE who are appropriate candidates for aspirin use for cardioprotection47.
In BE IND, either the epithelial abnormalities are insufficient for a diagnosis of dysplasia, or the nature of the epithelial abnormalities is uncertain due to inflammation or technical difficulties with specimen processing. The risk of HGD or cancer within 1 year of the diagnosis of IND varies between 1.9% and 15%55. The recommendation from ACG47 for management is to optimize acid suppressive therapy for 3-6 months and then to repeat esophagogastroduodenoscopy (EGD). If indefinite dysplasia is noted again, repeat endoscopy in 12 months is recommended59.
Most patients with an initial diagnosis of LGD (73%) are downstaged to NDBE or to IND after review by expert gastrointestinal pathologists10. Patients with confirmed and persistent LGD are at higher risk of progression11. Once LGD is confirmed by a second gastrointestinal pathologist, the patient should be considered for endoscopic ablation. A landmark study demonstrated the benefit of radiofrequency ablation in achieving complete eradication of dysplasia (90.5% vs. 22.7% for a sham procedure) and complete eradication of IM (77.4% vs. 2.3% for a sham procedure)49. Patients with confirmed LGD who do not undergo eradication therapy should have surveillance endoscopy every 6-12 months.
As with LGD, the diagnosis of HGD needs to be confirmed by a second pathologist with gastrointestinal expertise. In the past, the treatment was esophagectomy, but due to demonstrated lower morbidity and equivalent efficacy of radiofrequency ablation, the current treatment of choice is endoscopic mucosal resection (EMR) of raised lesions, followed by radiofrequency ablation of the entire affected segment23. Pathology is best assessed by EMR, especially in areas of nodularity and ulceration. A randomized controlled study of 42 patients with HGD was randomized between radiofrequency ablation and sham procedure. Complete eradication of dysplasia was achieved in 81% of ablation patients versus 19% with the sham procedure49. Eradication of IM was achieved in 77% of ablation patients versus 2% of patients with the sham therapy49. Results of 3-year follow-up from the same cohort showed complete eradication of dysplasia in 98% and of IM in 91%48. Endoscopic eradication therapy is recommended for all patients with BE and HGD without the potential comorbidity and side effects associated with esophageal resection. Short segment Barrett’s (<3 cm) with HGD can also be assessed for complete ablation with EMR alone. Alternatively, surveillance every 3 months is an option if the patient does not wish to undergo eradication therapy48.
Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested.
This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C).
This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up.
Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery.
Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.
Association between esophageal achalasia/ gastroesophageal reflux disease (GERD) and cholelithiasis is not clear. Epidemiological data are controversial due to different methodologies applied, the regional differences and the number of patients involved. Results of concomitant cholecistectomy associated to surgical treatment of both diseases regarding safety is poorly understood.
To analyze the prevalence of cholelithiasis in patients with esophageal achalasia and gastroesophageal reflux submitted to cardiomyotomy or fundoplication. Also, to evaluate the safety of concomitant cholecistectomy.
Retrospective analysis of 1410 patients operated from 2000 to 2013. They were divided into two groups: patients with GERD submitted to laparocopic hiatoplasty plus Nissen fundoplication and patients with esophageal achalasia to laparoscopic cardiomyotomy plus partial fundoplication. It was collected epidemiological data, specific diagnosis and subgroups, the presence or absence of gallstones, surgical procedure, operative and clinical complications and mortality. All groups/subgroups were compared.
From 1,229 patients with GERD or esophageal achalasia, submitted to laparoscopic cardiomyotomy or fundoplication, 138 (11.43%) had cholelitiasis, occurring more in females (2.38:1) with mean age of 50,27 years old. In 604 patients with GERD, 79 (13,08%) had cholelitiasis. Lower prevalence occurred in Barrett's esophagus patients 7/105 (6.67%) (p=0.037). In 625 with esophageal achalasia, 59 (9.44%) had cholelitiasis, with no difference between chagasic and idiopathic forms (p=0.677). Complications of patients with or without cholecystectomy were similar in fundoplication and cardiomyotomy (p=0.78 and p=1.00).There was no mortality or complications related to cholecystectomy in this series.
Prevalence of cholelithiasis was higher in patients submitted to fundoplication (GERD). Patients with chagasic or idiopatic forms of achalasia had the same prevalence of cholelithiasis. Gallstones occurred more in GERD patients without Barrett's esophagus. Simultaneous laparoscopic cholecystectomy was proved safe.
Surgical treatment of GERD by Nissen fundoplication is effective and safe, providing good results in the control of the disease. However, some authors have questioned the efficacy of this procedure and few studies on the long-term outcomes are available in the literature, especially in Brazil.
To evaluate patients operated for gastro-esophageal reflux disease, for at least 10 years, by Nissen fundoplication.
Thirty-two patients were interviewed and underwent upper digestive endoscopy, esophageal manometry, 24 h pH monitoring and barium esophagogram, before and after Nissen fundoplication.
Most patients were asymptomatic, satisfied with the result of surgery (87.5%) 10 years after operation, due to better symptom control compared with preoperative and, would do it again (84.38%). However, 62.5% were in use of some type of anti-reflux drugs. The manometry revealed lower esophageal sphincter with a mean pressure of 11.7 cm H2O and an average length of 2.85 cm. The average DeMeester index in pH monitoring was 11.47. The endoscopy revealed that most patients had a normal result (58.06%) or mild esophagitis (35.48%). Barium swallow revealed mild esophageal dilatation in 25,80% and hiatal hernia in 12.9% of cases.
After at least a decade, most patients were satisfied with the operation, asymptomatic or had milder symptoms of GERD, being better and with easier control, compared to the preoperative period. Nevertheless, a considerable percentage still employed anti-reflux medications.
Desenvolvido por Surya MKT