RESUMO
The endoscopic treatment of gastroesophageal reflux disease (GERD) has evolved significantly in the past 20 years. Current practices include devices specifically designed for GERD. Newer techniques aim to use less extra equipment, to be less costly, and to use accessories readily available in endoscopy units, as well as using standard endoscopes to apply such techniques. It is of utmost importance to properly select the patients for endoscopic therapy, and it should be done in a multidisciplinary approach.
El tratamiento endoscópico de la enfermedad por reflujo gastroesofágico (ERGE) ha evolucionado significativamente en los últimos 20 años. Las prácticas actuales incluyen dispositivos diseñados específicamente para la ERGE. Las técnicas más nuevas tienen como objetivo utilizar menos equipos adicionales, ser menos costosos y utilizar accesorios fácilmente disponibles en las unidades de endoscopia, así como utilizar endoscopios estándar para aplicar dichas técnicas. Es de suma importancia seleccionar adecuadamente a los pacientes para la terapia endoscópica, y debe hacerse en un enfoque multidisciplinario.
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Refluxo Gastroesofágico , Refluxo Gastroesofágico/cirurgia , Refluxo Gastroesofágico/terapia , Humanos , Esofagoscopia/métodos , Fundoplicatura/métodos , Seleção de Pacientes , Endoscopia Gastrointestinal/métodosRESUMO
INTRODUCTION: Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment. AIM: The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD. METHODS: The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires. RESULTS: Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient. CONCLUSIONS: An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.
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Refluxo Gastroesofágico , Idoso , Feminino , Humanos , Gravidez , Endoscopia , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/terapiaRESUMO
Low sphincter pressure and inability of the crural diaphragm to elevate it at the esophagogastric junction are important pathophysiological mechanisms of gastroesophageal reflux disease (GERD). The object of this study was to depict how Nissen fundoplication changed the resting and inspiratory pressures of the anti-reflux barrier. We selected 14 patients (eight males; mean age 42.7 years; mean body mass index 27.8) for surgery. They answered symptoms questionnaires and underwent high-resolution manometry (HRM) before and 6 months after Nissen fundoplication. We used a standard manometric protocol (resting and liquid swallows) and assessment of esophagogastric junction (EGJ) pressure metrics during standardized forced inspiratory maneuvers against increasing loads (Threshold Maneuvers). We used the Wilcoxon test for comparison of pre and postoperative data. After fundoplication, heartburn and regurgitation scores diminished remarkably (from 4.5 and 2, respectively, to zero; P = 0.002 and P = 0.0005, respective medians). Also, the median expiratory EGJ pressure had a significant increase from 8.1 to 18.1 mmHg (P = 0.002), while mean respiratory pressure and EGJ contractility integral (EGJ-CI) increased without statistical significance (P = 0.064 and P = 0.06, respectively). Axial EGJ displacement was lower after fundoplication. The EGJ relaxation pressure (P = 0.001), the mean distal esophageal intrabolus pressure (P = 0.01) and the distal latency (P = 0.017) increased after fundoplication. There was a reduction in the contraction front velocity (P = 0.043). During evaluation with standardized inspiratory maneuvers, the inspiratory EGJ pressures (under loads of 12, 24, 36 and 48 cmH2O) were lower after surgery for all loads (median for load 12 cmH2O: 145.6 vs. 102.7 mmHg; P = 0.004). Fundoplication and hiatal closure increased the expiratory EGJ pressure and promoted a great GERD symptom relief. The surgery seemed to overcompensate a reduced EGJ mobility and inspiratory pressure.
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Fundoplicatura , Refluxo Gastroesofágico , Masculino , Humanos , Adulto , Junção Esofagogástrica/cirurgia , Refluxo Gastroesofágico/cirurgia , Manometria/métodosRESUMO
Introduction: Patients with obesity are often affected by gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is considered the ideal operation for patients with severe obesity and GERD. Although the majority of patients improve their reflux with the operation, some might persist symptomatic and others can even develop de novo GERD. The aim of this study was to determine pathophysiologic factors involved in the development of GERD after RYGB surgery and define potential treatments for this condition. Materials and Methods: Studies including patients with GERD before and after RYGB and/or analyzing possible GERD therapies were analyzed by the authors. Searches were conducted in PubMed, Cochrane Library, and Embase databases. Results: GERD can persist, worsen, or develop after RYGB. There are certain technical elements of the operation identified as potential risk factors for GERD. Medical therapy is effective in the majority of patients. Both endoscopic and surgical procedures can also help resolving GERD after RYGB. Conclusions: Although the majority of patients with GERD after RYGB can be effectively managed with medical therapy, some may require endoscopic or surgical treatment. Critical technical elements of RYGB should be considered to reduce the risk of postoperative GERD.
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Derivação Gástrica , Refluxo Gastroesofágico , Humanos , Refluxo Gastroesofágico/etiologia , Refluxo Gastroesofágico/fisiopatologia , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Obesidade Mórbida/cirurgia , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/etiologia , Fatores de RiscoRESUMO
OBJECTIVES: To determine risk factors for arching/irritability in high-risk infants and examine the significance of comorbidity and gastroesophageal reflux (GER) characteristics. STUDY DESIGN: Retrospective analysis of 24-hour pH-impedance studies of symptomatic infants in a neonatal intensive care unit (ICU) (n = 516, 30.1 ± 4.5 weeks of gestation, evaluated at 41.7 ± 3.2 weeks postmenstrual age) was conducted. Comparisons were made between infants with >72 vs ≤72 arching/irritability events per day. We characterized risk factors for arching/irritability along with clinical, pH-impedance, and outcome correlates. RESULTS: Of 39â973 arching/irritability events and 42â155 GER events, the averages per day were 77.6 ± 41.0 and 81.7 ± 48.2, respectively. Acid reflux and impedance bolus characteristics were not significantly different between infants with >72 and ≤72 arching/irritability events (P ≥ .05). The odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for postmenstrual age and weight at evaluation were significant for risk factors of preterm birth (2.3 [1.2-4.4]), moderate or severe neuropathology (2.0 [1.1-3.6]), and presence of oral feeding at testing (1.57 [1.07-2.30]). CONCLUSIONS: Acid GER disease is unlikely the primary cause of arching/irritability and empiric treatment should not be used when arching/irritability is present. Prematurity and neurologic impairment may be more likely the cause of the arching/irritability. Arching/irritability may not be a concern in orally fed infants.
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Refluxo Gastroesofágico , Doenças do Recém-Nascido , Nascimento Prematuro , Lactente , Feminino , Recém-Nascido , Humanos , Estudos Retrospectivos , Unidades de Terapia Intensiva Neonatal , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/epidemiologia , Fatores de Risco , BiomarcadoresRESUMO
Diagnosing GERD is difficult, because reflux is a physiological phenomenon, there are various methods and variables and each of them has limitations such as day-to-day variability. The Lyon 2.0 consensus suggests that the ways to establish a conclusive diagnosis of GERD are the presence of an ASD greater than 6.0% or endoscopic esophagitis grades B-C-D of Los Angeles. The absence of significant esophagitis and a TEA of less than 4.0% allow GERD to be ruled out. ASDs between 4.0 and 6.0% are in an intermediate range, which does not allow GERD to be ruled out or diagnosed. In these contexts, the use of the total number of reflux events in a ph-impedanciometry study, the basal nocturnal mucosal impedance or the presence of a hiatal hernia can modify this intermediate probability and would allow therapeutic decisions to be made. Finally, Lyon 2.0 su - ggests that monitoring of more than 72 hours is recommended over monitoring of shorter duration, due to its greater sensitivity.
El diagnóstico de la ERGE es difícil, debido a que el reflujo es un fenómeno fisiológico, existen diversos métodos y variables y cada uno de ellos tiene limitantes como la variabilidad día a día. El consenso de Lyon 2.0 sugiere que las formas de establecer un diagnóstico concluyente de ERGE son la presencia de un TEA mayor de 6,0% o esofagitis endoscópica grados B-C-D de Los Angeles. La ausencia de esofagitis significativa y un TEA menor de 4,0% permiten descartar la ERGE. TEAs entre 4,0 y 6,0% están en un rango intermedio, que no permite des- cartar ni diagnosticar ERGE. En estos contextos, el uso del número total de eventos de reflujo en un estudio de ph-impedanciometria, la impedancia basal mucosa nocturna o la presencia de hernia hiatal pueden modificar esta probabilidad intermedia y permitirían tomar decisiones terapéuticas. Finalmente, Lyon 2.0 sugiere que monito- rizaciones de más de 72 h son recomendables por sobre monitorizaciones de menor duración, debido a su mayor sensibilidad.
Assuntos
Humanos , Refluxo Gastroesofágico/diagnóstico , Monitoramento do pH Esofágico/tendências , Refluxo Gastroesofágico/etiologia , Monitoramento do pH Esofágico/métodos , Avaliação de SintomasRESUMO
Análisis del libro: Esquizofrenia y Ciclotimia, resultados y problemas, Comp. Gerd Huber, Ed. Morata, Madrid, 1972.
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Esquizofrenia , Humanos , Transtorno Ciclotímico , Metotrexato , Ciclofosfamida , Prednisona , Estudos RetrospectivosRESUMO
The advancement of knowledge in pathophysiology and underlying etiologies of gastroesophageal reflux disease (GERD) has allowed the development of the concept of disease beyond the acidity of reflux. The variability in the symptom presentation and the response to treatment cannot be attributed only to reflux composition, since esophageal factors, such as structural, mechanical, biochemical, and physiological aspects, play an important role. The proposed personalized approach to GERD uses a stepwise approach that optimizes performance and phenotypic outcome while minimizing invasiveness, risk, and cost. Throughout the staggered approach to determine the GERD phenotype, clinicians may choose to stop further testing and continue treatment if available information identifies a different GERD phenotype. Since not all phenotypes GERD are the same and not all treatments are appropriate for all patients, therapeutic strategies must be personalized according to their phenotype.
El avance del conocimiento sobre la fisiopatología y la etiología subyacentes a la enfermedad por reflujo gastroesofágico (ERGE) ha permitido que el desarrollo de esta se extienda más allá de la acidez del reflujo. La variabilidad en la presentación de los síntomas y la respuesta al tratamiento no se puede atribuir solo a la composición del reflujo, ya que factores esofágicos, como aspectos estructurales, mecánicos, bioquímicos y fisiológicos, desempeñan un papel importante. El enfoque personalizado propuesto para la ERGE utiliza un método gradual que optimiza el rendimiento y el resultado fenotípico, y minimiza la invasividad, el riesgo y el costo. A lo largo del método escalonado para determinar el fenotipo de la ERGE, los médicos pueden optar por detener las pruebas adicionales y continuar con el tratamiento si la información disponible identifica un fenotipo de ERGE distinto. Dado que la ERGE no es la misma y no todos los tratamientos disponibles para controlarla son apropiados para todos los pacientes, las estrategias terapéuticas deben personalizarse de acuerdo con su fenotipo.
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Refluxo Gastroesofágico , Humanos , Refluxo Gastroesofágico/etiologia , Refluxo Gastroesofágico/diagnóstico , Estudos RetrospectivosRESUMO
BACKGROUND: The future of minimally invasive surgery in revisional surgery is experiencing changes with new equipment such as the magnetic assistance that can be used with single port devices in order to perform an incisionless surgery (Luengas R, Galindo J, Castro M, et al. Surg Obes Relat Dis. 2021;17(1):147-152). Magnetic assistance through an auxiliary grasper with two internal magnets serves beyond liver retraction in different steps of the surgery improving the surgical field by obtaining a better visualization and triangulation. PURPOSE: Expose the feasibility of using two internal magnetic graspers by single port performing a conversion surgery of sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB). METHODS: A 36-year-old female patient underwent a SG in 2015 and consults in 2021 because of severe GERD with a 33-point GERD-HRQL score. She has preoperative evaluation for a conversion surgery from SG to RYGB. Using a single port device through the umbilicus, an additional 5 mm trocar was placed in the left side of the abdomen. Two internal magnets were introduced through the umbilicus, and they were controlled by two external magnets placed over the abdomen with an articulated arm. The first magnet was used for liver retraction and the second one to perform both anastomoses, close the intermesenteric and Petersen defect, acting as an auxiliary grasper. The ethical committee approval was obtained through an informed consent from the participant included in the study.
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Cirurgia Bariátrica , Derivação Gástrica , Refluxo Gastroesofágico , Laparoscopia , Obesidade Mórbida , Feminino , Humanos , Adulto , Obesidade Mórbida/cirurgia , Laparoscopia/efeitos adversos , Reoperação/efeitos adversos , Estudos Retrospectivos , Derivação Gástrica/efeitos adversos , Gastrectomia/efeitos adversos , Refluxo Gastroesofágico/etiologia , Fenômenos Magnéticos , Cirurgia Bariátrica/efeitos adversosRESUMO
Obesity is a risk factor for gastroesophageal reflux disease. Studies addressing the brain-esophagus axis in obese are lacking. In obese with and without heartburn, we assessed: (i) the brain responses to esophageal acid perfusion during functional brain imaging; (ii) esophageal impedance baseline before and after acid perfusion; and (iii) abdominal fat distribution. In this exploratory study, 26 obese underwent functional magnetic resonance imaging (fMRI) of the brain combined with esophageal acid perfusion. Esophageal impedance baseline was determined before and after fMRI, followed by tomographic quantification of the abdominal fat. Among 26 obese (54% men, 39.7 years old, 33.5 kg/m2), there were 17 with heartburn and 9 without heartburn. Before fMRI, the esophageal impedance baseline was lower in obese with heartburn than without heartburn (median 1187 vs. 1890 Ω; P = 0.025). After acid perfusion, impedance baseline decreased in obese with heartburn (from 1187 to 899 Ω; P = 0.011) and was lower in this group than in obese without heartburn (899 vs. 1614 Ω; P = 0.001). fMRI task-residual analysis showed that obese with heartburn presented higher functional connectivity in several brain regions than obese without heartburn. Abdominal fat area did not differ between obese with and without heartburn either for total (72.8 ± 4.4% vs. 70.3 ± 6.0%; P = 0.280), subcutaneous (42.2 ± 9.0% vs. 37.4 ± 9.0%; P = 0.226), or visceral (30.6 ± 7.9% vs. 33.0 ± 7.8%; P = 0.484). In subjects with obesity, the brain-esophagus axis is disrupted centrally with higher functional brain connectivity and peripherally with decreased esophageal mucosa integrity in the presence of heartburn.
Assuntos
Monitoramento do pH Esofágico , Azia , Humanos , Masculino , Adulto , Feminino , Esôfago/patologia , Impedância Elétrica , Ácidos , Obesidade/complicações , Encéfalo/diagnóstico por imagem , Encéfalo/patologiaRESUMO
Background: The planning of revisional bariatric surgery is a complex process. The availability of accurate anatomical information is especially important for the planning of such challenging surgical procedures, we present our initial experience using three-dimensional-computed tomography (3D-CT) images to preoperatively assess the anatomy of patients before bariatric revisional surgery. Methods: We used 3D reconstructed images of CT scans to assess the anatomy and plan revisional surgery in 144 patients 98 of them had a previous sleeve gastrectomy 41 had a previous gastric by-pass and 4 Vertical banded gastroplasties. An effervescent preparation was used to distend the stomach and the proximal bowel allowing volume estimation. Results: Eleven sleeve patients underwent a re-sleeve gastrectomy and 44 were revised to a "Roux-en-Y" gastric bypass (RYGBP). Forty-two patients with a previous gastric by-pass were revised due to weight regain or other issues and 4 patients with previous vertical banded gastroplasty (VBGP) were revised to RYGBP. 3D-CT scans provided valuable information for the planning of all revisional procedures by offering accurate information about the existing anatomy and measures of the volume of the gastric pouch, the size of the gastro-jejunal anastomosis in gastric by-pass cases, or the volume and shape of the gastric tube in gastric sleeve cases. Conclusion: 3D-CT is a fast, widely available, reliable, and accurate tool to assess the anatomy after bariatric procedures. This noninvasive method can be particularly useful for the evaluation of postbariatric patients with failures, suboptimal results, and complications, and for the planning of revisional surgery.
RESUMO
Background: Modifications of gastric anatomy, function, and of the esophagogastric junction secondary to sleeve gastrectomy (SG) can worsen the symptoms of gastroesophageal reflux disease (GERD). Its late diagnosis and poor treatment can lead to serious complications. In recent years, attempts have been made to optimize preoperative studies and improve surgical techniques to prevent this problem. The aim of this study was to update on the presence of GERD and their symptoms post-SG. Methods: A literature review of articles based on randomized clinical trials on the presence of GERD after SG was carried out, in a period of 10 years. Results: A result of 336 articles was obtained, of which 327 were discarded and 9 were included. The variables of GERD post-SG were analyzed according to their symptoms ("improved," "worsened," and "unchanged"), "remission," or appearance "de novo." Conclusion: GERD is a frequently associated pathology in obese patients. Several authors reported that symptoms worsen after SG, and has been diagnosed de novo. The application of exhaustive preoperative studies and a correct surgical technique could reduce its incidence.
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Refluxo Gastroesofágico , Laparoscopia , Obesidade Mórbida , Gastrectomia/efeitos adversos , Refluxo Gastroesofágico/etiologia , Refluxo Gastroesofágico/cirurgia , Humanos , Obesidade Mórbida/cirurgiaRESUMO
BACKGROUND: Gastroesophageal reflux disease (GERD) is a common disease among patients with obesity, with an associated prevalence of 39 to 61% between the population who attends a bariatric surgery evaluation. Laparoscopic sleeve gastrectomy (LSG) has become a popular and valid option for obesity treatment, even though the literature is ambivalent regarding the increase or decrease in GERD after this surgery. Thus, it is necessary to propose new surgical techniques as a solution to GERD in patients with a concomitant LSG or with a history of it. Therefore, we present a modified technique based on Hill's gastropexy described originally in 1967. OBJECTIVE: Describe and propose a surgical procedure for GERD management based on the Hill technique that can be applied in all patients who undergo an LSG or with a history of it. METHODS: Retrospective observational study with a prospective database in which we described, Hill modified technique in a group of 16 patients with GERD who underwent this procedure concomitantly with an LSG or who presented with GERD after LSG with a 3-year follow-up. The surgical technique is based on an intra-abdominal esophageal length of a minimum of 3 cm and posterior fixation of the gastroesophageal junction to the crus. RESULTS: Postoperative controls have shown satisfactory results in the control and management of GERD symptoms in this group of patients, with very few to no complications associated with the procedure and without reintervention or medication out of the standard protocol. CONCLUSION: Hill modified technique can be used and presented as an option for GERD control in patients with LSG.
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Cirurgia Bariátrica , Refluxo Gastroesofágico , Laparoscopia , Obesidade Mórbida , Gastrectomia , Refluxo Gastroesofágico/etiologia , Refluxo Gastroesofágico/cirurgia , Humanos , Obesidade Mórbida/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Peroral endoscopic myotomy (POEM) demonstrated similar efficacy to surgical myotomy in the management of achalasia. However, gastroesophageal reflux disease (GERD) is common after POEM. The aim of this study is to identify factors associated with GERD after POEM. METHOD: After searching electronic databases, randomized trials and observational studies including patients with achalasia or other spastic esophageal disorders, treated by POEM, and providing GERD data were selected. GERD was evaluated by 3 methods: pH monitoring, endoscopic findings, and symptoms. For each method, an analysis was performed comparing the outcomes related to the following independent variables: full-thickness (FT) vs circular myotomy, anterior vs posterior, long myotomy vs short myotomy, naive vs previous treatment failure, previous Heller myotomy (HM) vs non-previous-HM, Type I vs II, Type I vs III, and Type II vs III. RESULTS: 2869 publications were identified, and 25 studies met criteria for inclusion in the qualitative analysis. Of these, 18 were included in the meta-analysis. According to the endoscopic findings, circular and anterior myotomy demonstrated a lower trend of GERD with borderline significance (p = 0.06; p = 0.07, respectively). In the pH monitoring and symptom analyses, circular myotomy, anterior myotomy, treatment naive, and non-HM patients were associated with a lower occurrence of GERD; however, no statistically significant difference was found. When comparing achalasia subtypes, no statistical difference was found in all analyses. CONCLUSION: This systematic review and meta-analysis suggest that a circular anterior approach may limit post-POEM GERD and should be considered in appropriate patients.
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Acalasia Esofágica/cirurgia , Refluxo Gastroesofágico/etiologia , Miotomia/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Esofagite Péptica/etiologia , Miotomia de Heller/efeitos adversos , Miotomia de Heller/métodos , Humanos , Masculino , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural/métodos , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: Laryngopharyngeal reflux (LPR) poses a diagnostic challenge. Clinical diagnosis, based on suggestive symptoms and laryngoscopic signs of inflammation, should be acceptable, as long as diligent differential diagnosis is sought. In order to minimize subjectivity, a number of diagnostic instruments have been proposed, being the most common the Reflux Symptom Index and the Reflux Finding Score (RFS). The latter has been translated into several languages including Portuguese, but it still has not been properly validated in this language. OBJECTIVE: To validate the Brazilian Portuguese version of the RFS. MATERIAL AND METHOD: For validity and internal consistency, 172 adults were studied (106 with LPR and 66 healthy controls). Flexible transnasal laryngoscopy images were randomly examined twice by each of the two experienced otolaryngologists with a 72-hour interval. Strict exclusion criteria were applied to avoid other possible known causes of chronic laryngitis. For assessment of reproducibility and temporal stability, a random sample of 108 subjects (53 patients and 55 controls) were tested and retested. RESULTS: A statistically significant difference was observed in the mean RFS between patients with LPR (10.26 ± 3.58) and controls (5.52 ± 1.34) (P < 0.001). The interclass correlation coefficient comparing test and retest for both raters was high (R1 = 0.956; R2 = 0.948). CONCLUSION: The Brazilian Portuguese version of the RFS proved to be a reliable and reproducible instrument for the diagnosis of LPR with a sensitivity of 82.08%, a specificity of 93.94%, a positive predictive value of 95.60%, and a negative predictive value was 76.54%.
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Laringite , Refluxo Laringofaríngeo , Adulto , Brasil , Humanos , Idioma , Refluxo Laringofaríngeo/diagnóstico , Laringoscopia , Reprodutibilidade dos TestesRESUMO
PURPOSE: Closure of GG fistulas after RYGB is challenging due to epithelialization of the tract. Common endoscopic therapies are less efficacious than surgical revision, which is unfortunately fraught with high morbidity and mortality. Cardiac septal defect occluders (CSDO) have been successfully used for the management of gastrointestinal fistulas, but use has never been reported in management of GG fistulas. Thus, we describe the first off-label use of CSDO for the treatment of a GG fistula. MATERIALS AND METHODS: Endoscopy and fluoroscopic examination determined the appropriate size of CSDO for closure. A guidewire was placed in the remnant stomach followed by placement of the delivery system. Then, under fluoroscopy, we deployed the first flange of the CSDO in the remnant stomach. Then, under fluoroscopy and endoscopic visualization, the second flange is deployed in the gastric pouch. RESULTS: A 51-year-old woman, status-post RYGB in 2008, presented with a 6-month history of weight regain and reflux. She had regained weight to 84 kg (BMI = 32 kg/m2) when she was found to have a GG fistula. She underwent successful CSDO placement and, 3 months later, had lost 10 kg with significant improvement in her reflux. Repeat evaluation confirmed successful fistula closure. CONCLUSION: The use of CSDO was technically feasible and appeared to be effective and safe. Future studies should continue to investigate the role of CSDO in management of this challenging condition.
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Derivação Gástrica , Fístula Gástrica , Defeitos dos Septos Cardíacos , Obesidade Mórbida , Endoscopia , Feminino , Fístula Gástrica/etiologia , Fístula Gástrica/cirurgia , Humanos , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgiaRESUMO
OBJECTIVE: To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) in patients with obesity. METHODS: Patients with class II or III obesity were treated with LSG or LRYGB. Procedure choice was based on patients and surgeon preferences. GERD symptoms, endoscopy, barium swallow X-ray, esophageal manometry, and 24-h pH monitoring were obtained before and 1 year after surgery. RESULTS: Seventy-five patients underwent surgery (83% female, 39.3 ± 12.1 years, BMI of 41.5 ± 5.1 kg/m2): 35 (46.7%) had LSG and 40 (53.3%) LRYGB. LSG patients had lower BMI (40.3 ± 4.0 kg/m2 vs. 42.7 ± 5.7 kg/m2; p = 0.041) and trend toward lower prevalence of GERD (20% vs. 40%; p = 0.061). One year after surgeries, GERD was more frequent in LSG patients (74% vs. 25%; p < 0.001) and all LSG patients with preoperative GERD continue to have GERD postoperatively. De novo GERD occurred in 19 of 28 (67.9%) of LSG patients and 4 of 24 (16.7%) patients treated with LRYGB (OR 10.6, 95%CI 2.78-40.1). Independent predictors for post-operative GERD were as follows: LSG (OR 12.3, 95%CI 2.9-52.5), preoperative esophagitis (OR 8.5, 95% CI 1.6-44.8), and age (OR 2.0, 95%CI 1.1-3.4). CONCLUSIONS: One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB. LSG was the strongest predictor for GERD in our trial. Preoperative counseling and choice of bariatric surgical options must include a detailed assessment and discussion of GERD-related surgical outcomes.
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Cirurgia Bariátrica , Derivação Gástrica , Refluxo Gastroesofágico , Laparoscopia , Obesidade Mórbida , Feminino , Gastrectomia , Refluxo Gastroesofágico/epidemiologia , Refluxo Gastroesofágico/etiologia , Refluxo Gastroesofágico/cirurgia , Humanos , Masculino , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Background: Roux-en-Y gastric bypass (RYGB) is frequently performed for weight loss purposes in the morbidly obese population. The popularity and acceptance of this procedure have increased the knowledge of the physiological (anatomical and functional) changes that this technique produces in the organism. RYGB improves gastric emptying and gastroesophageal reflux symptoms. Materials and Methods: We analyzed 6 patients in whom an RYGB was performed for non-bariatric purposes. Symptom questionnaire was used to evaluate response. Results: None of the patients qualified for bariatric surgery, as all had a body mass index (BMI) <35 kg/m2. Five patients were operated on for severe gastroesophageal reflux disease symptoms, and one for gastroparesis. All patients had good to excellent results, with marginal modification of their BMI. Conclusion: Non-bariatric RYGB can be considered in patients with functional diseases of the upper gastrointestinal tract, regardless of their BMI.
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Derivação Gástrica , Refluxo Gastroesofágico/cirurgia , Gastroparesia/cirurgia , Adolescente , Adulto , Índice de Massa Corporal , Feminino , Esvaziamento Gástrico , Gastroparesia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Redução de PesoRESUMO
Background: Most of the obese patients undergoing an anti-reflux operation experience recurrence of gastroesophageal reflux disease (GERD). Laparoscopic Roux-en-Y gastric bypass (LRNYGB) has been accepted as the bariatric surgery of choice for a previous GERD-operated obese patients. Methods: We present 85 consecutive patients from a single institution, previously submitted to antireflux surgery and then to LRNYGB. Preoperative endoscopy was carried out in all patients; 49 (57.64%) patients had findings of fundoplication failure or signs of persistent GERD, of those 20 (40.81%) with esophagitis. Results: From the bypass, per or postoperative minor to moderate complications occurred in 12 patients (14.11%): 2 (2.35%) conversions to laparotomy, 1 (1.17%) melena, 8 (9.41%) stenosis of gastrojejunostomy, treated by a simple endoscopic dilatation with a balloon, and 1 (1.17%) gastrogastric fistula. A follow-up endoscopy of 79 of 85 (92.9%) patients was carried out after 6 months of LRNYGB. Eight of 79 (10.12%) patients had persistent esophagitis that represented 40% (8 of 20 patients) of persistent reflux esophagitis even after LRNYGB. All of them were men. Conclusion: LRNYGB after laparoscopic fundoplication is a feasible procedure with an excepted higher rate of complications because of the complexity of the procedure. Nevertheless esophagitis still persisted in many of those patients.
Assuntos
Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Refluxo Gastroesofágico/cirurgia , Obesidade/cirurgia , Adulto , Idoso , Conversão para Cirurgia Aberta , Endoscopia Gastrointestinal , Esofagite Péptica/etiologia , Feminino , Fundoplicatura , Refluxo Gastroesofágico/complicações , Humanos , Complicações Intraoperatórias/etiologia , Laparoscopia , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Período Pré-OperatórioRESUMO
BACKGROUND: Erosive esophagitis (EE) is related to esophageal mucosal damage caused by GERD and is implicated in the development of Barret´s esophagus and adenocarcinoma, which incidence is rising in association with obesity. It is known that the correlation between symptoms and endoscopic findings is relatively poor, with a predictive value of only 40%. The objective of this study is to report the incidence of EE 1 year after sleeve gastrectomy (SG) and gastric bypass (GBP) in consecutive patients in order to obtain an objective parameter of the impact of the two most popular bariatric procedures on esophageal mucosa. METHODS: A retrospective review of a prospective database including every primary GBP and SG consecutive cases performed between January 2014 and December 2016. Esophagitis evolution was compared between patients with adequate weight loss versus those with inadequate weight loss. The comparison of baseline and 1-year EE, BMI, %EWL, and %TWL was made by using the Chi square test for categorical variables and Student "t" test for continuous samples. RESULTS: Two hundred and twenty-seven patients were included. GBP was performed to 35.2% (n = 80) and SG to 64.8% (n = 147). Pre- and postoperatively EE evolution in GBP decreased from 54 to 26.2% (p = 0.002) and in SG increased from 8.2 to 30% (p = 0.04) Barret´s esophagus in GBP decreased from 7.5 to 5% (p = 0.001). No statistical difference was observed when we compared the evolution of EE in patients with adequate or inadequate weight loss in both groups. CONCLUSIONS: The incidence of EE 1 year after SG is greater than GBP. Moreover, not only GBP seems to improve this condition, but also SG tends to worsen EE. These results are to be associated with GERD disease.