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.
Gastroesophageal reflux disease is an increasingly common condition worldwide causing a considerable economic impact. More than half the patients with clinical symptoms of reflux disease display no mucosal erosions on esophagogastroduodenoscopy, making it impossible to confirm the diagnosis without further investigations.
To evaluate the correlation between minimal endoscopic changes on white-light esophagogastroduodenoscopy (carditis, mucosal thickening and invisibility of vessels) and histologic changes observed in distal esophageal biopsies in a sample of patients with symptoms suggestive of reflux disease, and to verify the specificity of these symptoms for non-erosive reflux disease.
Retrospective, cross-sectional study based on information retrieved from a digital database at a Brazilian hospital for the period March-October, 2012. The sample consisted of previously untreated, non-smoking subjects aged >18 years with symptoms suggestive of reflux disease but no esophageal erosions, submitted to esophagogastroduodenoscopy and distal esophageal biopsy.
The final sample included 23 subjects. The most frequently observed change was invisibility of vessels (n=21; 91.3%), followed by mucosal thickening (n=15; 65.2%) and carditis (n=5; 21.7%). The correlation coefficient between each variable and the anatomopathological diagnosis was 0.386 for body mass index, 0.479 for mucosal thickening, -0.116 for invisibility of vessels, 0.306 for carditis and 0.462 for hiatal hernia.
All patients displayed minimal endoscopic changes on esophagogastroduodenoscopy, but only mucosal thickening revealed a moderately significant correlation with severity of esophagitis, although increased body mass index values and the presence of hiatal hernia were also associated.
Obesity is related with higher incidence of gastroesophageal reflux disease. Antireflux surgery has inadequate results when associated with obesity, due to migration and/or subsequent disruption of antireflux wrap. Gastric bypass, meanwhile, provides good control of gastroesophageal reflux.
To evaluate the technical difficulty in performing gastric bypass in patients previously submitted to antireflux surgery, and its effectiveness in controlling gastroesophageal reflux.
Literature review was conducted between July to October 2016 in Medline database, using the following search strategy: (“Gastric bypass” OR “Roux-en-Y”) AND (“Fundoplication” OR “Nissen ‘) AND (“Reoperation” OR “Reoperative” OR “Revisional” OR “Revision” OR “Complications”).
Were initially classified 102 articles; from them at the end only six were selected by exclusion criteria. A total of 121 patients were included, 68 women. The mean preoperative body mass index was 37.17 kg/m² and age of 52.60 years. Laparoscopic Nissen fundoplication was the main prior antireflux surgery (70.58%). The most common findings on esophagogastroduodenoscopy were esophagitis (n=7) and Barrett’s esophagus (n=6); the most common early complication was gastric perforation (n=7), and most common late complication was stricture of gastrojejunostomy (n=9). Laparoscopic gastric bypass was performed in 99 patients, with an average time of 331 min. Most patients had complete remission of symptoms and efficient excess weight loss.
Although technically more difficult, with higher incidence of complications, gastric bypass is a safe and effective option for controlling gastroesophageal reflux in obese patients previously submitted to antireflux surgery, with the added benefit of excess weight loss.
Obese patients with gastroesophageal reflux disease with pathological pH monitoring result may benefit from surgical treatment which is based on the fundoplication technique in association with laparoscopic gastric plication. The Nissen surgery is the gold standard for surgical treatment of gastroesophageal reflux disease, whereas laparoscopic gastric plication is a restrictive surgery that consists of the invagination of the greater curvature, resulting in weight loss.
To compare pre and postoperative pHmetry results and to evaluate weight loss in patients submitted to gastroplasty with fundoplication.
Sixteen patients with class I body mass index with symptoms of gastroesophageal reflux with changes of stomach pH and/or erosive esophagitis seen in endoscopy were selected The evaluation of the weight and 24-h pH monitoring was performed preoperatively and postoperatively. The weight, body mass index, percentage of excess weight loss and DeMeester score of patients that underwent the surgery were evaluated pre and postoperatively.
Regarding pH monitoring, the average preoperative DeMeester index was 28.7, which was followed by a significant postoperative average reduction to 2.8 (p<0,001). Regarding the weight reduction, the average of weight loss was 13.6 kg and body mass index of 5.3 kg/m2 (p<0.001). Furthermore, the average percentage of excess weight loss was 53.9% (standard deviation=26.2).
The combination of Nissen surgery and gastric plication is a viable procedure and appears to be an acceptable option for the treatment of gastroesophageal reflux disease in obese patients, especially patients with obesity class I.
Bariatric surgery in Chile has seen an exponential increase in recent years, especially in sleeve gastrectomy. Its use is currently discussed in patients suffering from gastroesophageal reflux disease. Different options have been considered for the management of these patients but up to now laparoscopic Roux-en-Y gastric bypass seems to be the best option. Sleeve gastrectomy plus concomitant fundoplication or hiatal hernia repair also has been suggested in patients having reflux or small hiatal hernia.
To present a cohort of obese patients with gatroesophageal reflux undergoing this procedure, which seeks to provide the benefits of both laparoscopic gastric sleeve (LSG) and antireflux surgery focused on the evaluation of presence of reflux and BMI after surgery, and to compare the result observed in this cohort with a previous group of obese patients without reflux submitted to sleeve gastrectomy alone.
Retrospective case series in 15 patients who underwent this surgery between the years 2003 and 2012. Clinical records were analyzed and values of 24 hr pH monitoring, esophageal manometry and clinical outcome were recorded. Results were compared to a previous series of patients who underwent LSG. No statistical analyses were made.
Group A consisted of 15 patients submitted to LSG plus fundoplication. 93% (n=14) were female. Mean age was 46.2 years. Mean preoperative body mass index (BMI) was 33.9. All patients had altered pH monitoring and manometry preoperatively. There was one minor complication corresponding to a seroma. There was no perioperative mortality. Group B consisted of 23 obese patients who underwent LSG. These patients developed de novo reflux, hypotensive LES and esophagitis after the surgery. Group A patients showed improvement in esophageal pH monitoring and manometry at three months. During long-term follow-up, six underwent revision surgery, four for weight regain, one regained weight associated with symptomatic reflux, and one underwent re-intervention for reflux.
Good results are observed in the short-term follow up in both reflux resolution and weight loss. Nevertheless, results at long term are discouraging, with 53.3% of the patients requiring revision surgery during follow-up.
Several oral problems may be perceived in individuals who were submitted to bariatric surgery, due to metabolic and behavioral changes relative to diet and oral hygiene. Tooth wear appears to suffer impact after bariatric surgery, because there may be an increase in gastroesophageal reflux.
To systematically review the literature regarding the impact of bariatric surgery on gastroesophageal reflux and tooth wear.
The following databases were accessed by two independent, calibrated examiners: PubMed, Medline, Lilacs, Scielo and Cochrane using the following descriptors: “bariatric surgery” AND “dental erosion” OR “bariatric surgery” AND “dental erosion” AND “gastroesophageal reflux disease”. After excluding duplicate studies, 12 studies were initially evaluated by the title and abstract. The excluded studies were those without relevance to the present research, literature review studies and case reports. Thus, four articles were included in this study. All the articles evaluated indicated high association between gastroesophageal reflux and tooth wear in patients submitted to bariatric surgery. Association of these outcomes was more evident six months after the surgical procedure.
Patients submitted to bariatric surgery showed higher prevalence of gastroesophageal reflux and tooth wear.
Re-fundoplication is the most often procedure performed after failed fundoplication, but re-failure is even higher.
The objectives are: a) to discuss the results of fundoplication and re-fundoplication in these cases, and b) to analyze in which clinical situation there is a room for gastrectomy after failed fundoplication.
This experience includes 104 patients submitted to re-fundoplication after failure of the initial operation, 50 cases of long segment Barrett´s esophagus and 60 patients with morbid obesity, comparing the postoperative outcome in terms of clinical, endoscopic, manometric and 24h pH monitoring results.
In patients with failure after initial fundoplication, redo-fundoplication shows the worst clinical results (symptoms, endoscopic esophagitis, manometry and 24 h pH monitoring). In patients with long segment Barrett´s esophagus, better results were observed after fundoplication plus Roux-en-Y distal gastrectomy and in obese patients similar results regarding symptoms, endoscopic esophagitis and 24h pH monitoring were observed after both fundoplication plus distal gastrectomy or laparoscopic resectional gastric bypass, while regarding manometry, normal LES pressure was observed only after fundoplication plus distal gastrectomy.
Distal gastrectomy is recommended for patients with failure after initial fundoplication, patients with long segment Barrett´s esophagus and obese patients with gastroesophageal reflux disease and Barrett´s esophagus. Despite its higher morbidity, this procedure represents an important addition to the surgical armamentarium.
Gastroesophageal reflux (GER) is one of the most common indications for conversion of sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Objective evaluations are necessary in order to choose the best definitive treatment for these patients.
To present and describe the findings of the objective studies for gastroesophageal reflux disease performed before LSG conversion to LRYGBP in order to support the indication for surgery.
Thirty-nine non-responder patients to proton pump inhibitors treatment after LSG were included in this prospective study. They did not present GER symptoms, esophagitis or hiatal hernia before LSG. Endoscopy, radiology, manometry, 24 h pH monitoring were performed.
The mean time of appearance of reflux symptoms was 26.8+24.08 months (8-71). Erosive esophagitis was found in 33/39 symptomatic patients (84.6%) and Barrett´s esophagus in five. (12.8%). Manometry and acid reflux test were performed in 38/39 patients. Defective lower esophageal sphincter function was observed independent the grade of esophagitis or Barrett´s esophagus. Pathologic acid reflux with elevated DeMeester´s scores and % of time pH<4 was detected in all these patients. more significant in those with severe esophagitis and Barrett´s esophagus. Radiologic sleeve abnormalities were observed in 35 patients, mainly cardia dilatation (n=18) and hiatal hernia (n=11). Middle gastric stricture was observed in only six patients.
Patients with reflux symptoms and esophagitis or Barrett´s esophagus after SG present defective lower esophageal sphincter function and increased acid reflux. These conditions support the indication of conversion to LRYGBP.
Extended vertical gastrectomy is a variation of the vertical gastrectomy technique requiring studies to elucidate safety in relation to gastroesophageal reflux.
To analyze comparatively vertical gastrectomy (VG) and extended vertical gastrectomy (EVG) in rats with obesity induced by cafeteria diet in relation to the presence of reflux esophagitis, weight loss and macroscopic changes related to the procedures.
Thirty Wistar rats were randomized into three groups, and after the obesity induction period by means of a 28-day cafeteria diet, underwent a simulated surgery (CG), VG and VGA. The animals were followed up for 28 days in the post-operative period, and after euthanasia, the reflux esophagitis evaluation was histopathologically performed. Weight and macroscopy were the other variables; weight was measured weekly and the macroscopic evaluation was performed during euthanasia.
All animals presented some degree of inflammation and the presence of at least one inflammation criterion; however, there was no statistically significant difference in the analysis among the groups. In relation to weight loss, the animals in CG showed a gradual increase during the whole experiment, evolving to super-obesity at the end of the study, while the ones with VG and EVG had weight regain after the first post-operative period; however, a less marked regain compared to CG, both for VG and EVG.
There is no difference in relation to reflux esophagitis VG and EVG, as well as macroscopic alterations, and both techniques have the ability to control the evolution of weight during postoperative period in relation to CG.
Gastroesophageal reflux disease is defined by the abnormal presence of gastric content in the esophagus, with 10% incidence in the Western population, being fundoplication one treatment option.
To evaluate the early (six months) and late (15 years) effectiveness of laparoscopic fundoplication, the long term postoperative weight changes, as well as the impact of weight gain in symptoms control.
Prospective study of 40 subjects who underwent laparoscopic Nissen’s fundoplication. Preoperatively and early postoperatively, clinical, endoscopic, radiologic, manometric and pHmetric evaluations were carried out. After 15 years, clinical and endoscopic assessments were carried out and the results compared with the early ones. The presence or absence of obesity was stratified in both early and late phases, and its influence in the long-term results of fundoplication was studied, measuring quality of life according to the Visick criteria.
The mean preoperative ages, weight, and body mass index were respectively, 51 years, 69.67 kg and 25.68 kg/m2. The intraoperative and postoperative complications rates were 12.5% and 15%, without mortality. In the early postoperative period the symptoms were well controlled, hernias and esophagitis disappeared, the lower esophageal sphincter had functional improvement, and pHmetry parameters normalized. In the late follow-up 29 subjects were assessed. During this period there was adequate clinical control of reflux regardless of weight gain. In both time periods Visick criteria improved.
Fundoplication was safe and effective in early and late periods. There was late weight gain, which did not influence effective symptoms control.
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