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

BACKGROUND

Surgical treatment of esophageal cancer is associated with a high rate of morbidity and mortality even in specialized centers. Minimally invasive surgery has been proposed to decrease these complications.

METHODS

The authors present their results regarding postoperative complications and the survival rate at 3 years, comparing the classic open procedures (transthoracic or transhiatal esophagectomy) with minimally invasive surgery. Surgical procedures were performed according to procedures published elsewhere.

RESULTS

The study enrolled 166 patients who underwent surgery between 1990 and 2003. Open transthoracic surgery was performed for 60 patients. In this group of patients, postoperative mortality was observed in 11% of the cases. Major, minor, and late complications were observed in 61.6% of the patients, and the 3-year survival rate was 30% for this group. Open transhiatal surgery was performed for 59 patients. The morbidity, mortality, and 3-year rate were almost the same as for the transthoracic surgery group. For the 47 patients submitted to minimally invasive procedures (thoracoscopic and laparoscopic), the complications and mortality rates were significantly reduced (38.2% and 6.4%, respectively). For the patients submitted to minimally invasive surgery, the 3-year survival rate was 45.4%. It is important to clarify that the patients submitted to minimally invasive surgery manifested early stages of the diseases, and that this the reason why the morbimortality and survival rates were better.

CONCLUSIONS

The transthoracic and transhiatal open approaches have similar early and late results. Minimally invasive surgery is an option for patients with esophageal carcinoma, with reported results similar to those for open surgery. This approach is indicated mainly for selected patients with early stages of the disease.

Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months

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.

[An update on esophageal perforation]

Esophageal perforation is a complicated clinical entity that demands a high level of diagnostic and therapeutic skills. The management alternatives vary from conservative treatment to esophagectomy, including primary suture and esophageal exclusion. This paper is a review of the literature and personal experience with this condition, focusing on etiology, clinical presentation, diagnostic workout, treatment, complications and mortality. Finally, we propose a management algorithm.

Laparoscopic cardial calibration and gastropexy for treatment of patients with reflux esophagitis: pathophysiological basis and result

Laparoscopic antireflux surgery is the gold standard procedure for treatment of patients with reflux esophagitis. The current results of the laparoscopic approach are absolutely comparables with the results obtained during the open surgery era. The Nissen, Nissen-Rossetti, or Toupet techniques are the more frequently used. We have performed cardial calibration and posterior gastropexy or Nissen fundoplication by the open approach with similar results. The purpose of this article is to present the anatomo-physiological basis for employing cardial calibration and posterior gastropexy in patients with reflux esophagitis. This study includes 108 symptomatic patients, 12 of them with associated extraesophageal manifestations ( posterior laryngitis). Endoscopic mild or moderate esophagitis was confirmed in 83 patients, Barrett's esophagus in 12 patients, and type I or II hiatal hernia in 13 patients. All patients were also submitted to manometry, 24 hour intraesophageal pH monitoring, and barium swallow before and after surgery. Follow-up ranged from 12 to 36 months. There were no conversion, major intraoperative, or postoperative complications; nor were there any deaths. Postoperative dysphagia was present in 5% of cases. Symptomatic recurrence of reflux was observed in 10.3% and endoscopic presence of esophagitis in 12.3% of cases . Lower esophageal sphincter pressure increased significantly after surgery, even in patients with endoscopic recurrence. 24-hour intraesophageal monitoring improved after surgery, except in patients with objective recurrence of esophagitis. In conclusion, laparoscopic cardial calibration with posterior gastropexy presents comparable results to those reported after Nissen fundoplication and therefore could be another excellent therapeutic option in patients with reflux esophagitis.

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

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

[Effects of gastric bypass on weight, blood glucose, serum lipid levels and arterial blood pressure in obese patients]

BACKGROUND

Type 2 diabetes, hypertension and serum lipid abnormalities are common among obese people and they should improve with weight reduction.

AIM

To study the outcome of these abnormalities after bariatric surgery in morbid obesity patients.

MATERIAL AND METHODS

Two hundred thirty two morbid obese patients subjected to gastric bypass, were evaluated in the preoperative period and every three months after surgery, during a minimum of 12 months. Clinical evolution, blood glucose, serum insulin, insulin resistance measured with the homeostasis model assessment (HOMA) and serum lipid levels were analyzed.

RESULTS

In the preoperative period, 17% had type 2 diabetes, 49% had abnormal serum lipid levels and 25% had high blood pressure. Sixty six percent had at least one of these abnormalities and 20% had more than one. During follow up, body mass index decreased from 44 to 29.3 kg/m2. Total and HDL cholesterol, blood glucose and insulin resistance significantly decreased from the third month after surgery. Diabetes disappeared in 97% of diabetic subjects, blood pressure normalized in 53% of subjects with hypertension and serum lipid levels returned to normal in 88% of subjects with dyslipidemia.

CONCLUSIONS

Gastric bypass in morbid obese patients achieves a significant and important weight reduction that results in significant reductions in the frequency of diabetes, dyslipidemia and hypertension among operated obese subjects.

Anatomical deformities after laparoscopic antireflux surgery

Laparoscopic Nissen, Nissen-Rossetti, cardial calibration with gastropexy, and other modifications are the procedures commonly used for surgical treatment of gastroesophageal reflux disease. Postoperative failures have been reported ranging from 10% to 15% associated with postoperative symptoms or recurrent gastroesophageal reflux. In this paper, we present 38 patients submitted to different procedures in which different "abnormal" deformities were found during the postoperative radiological evaluation with barium swallow. The symptoms associated with these deformities were pain (62%), dysphagia (43%), early satiety (37%), postprandial discomfort (35%), and recurrent postoperative reflux (30%). Dysphagia and pain were frequently observed after the Nissen-Rossetti technique, in which a bilobed stomach and stricture (46%) were confirmed. Hiatal hernia was observed in two patients, and slipped Nissen in one patient associated to pain and early satiety. Patients were submitted to conservative treatment (endoscopic dilatation, proton pump inhibitors, and prokinetics), but 10 patients were submitted to redo surgery. There were no complications, and good results were obtained after redo operations.

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

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

Adenocarcinoma appearing very late after antireflux surgery for Barrett's esophagus: long-term follow-up, review of the literature, and addition of six patients

Antireflux surgery is supposed to prevent the development of adenocarcinoma in patients with Barrett's esophagus. The purpose of this study was to determine the prevalence of adenocarcinoma late after antireflux surgery. A total of 161 patients with long-segment Barrett's esophagus had antireflux surgery and were followed for a mean of 148 months (range 54 to 268 months) Clinical, endoscopic, histologic, and functional studies were performed. Of the original 161 patients, 147(91.3%) completed long-term follow-up. Six patients (4.1%) developed adenocarcinoma 4,5,6,9,17, and 18 years, respectively, after surgery. Five were men. Two of them were asymptomatic for 12 and 17 years. Three of them had extra-long-segment Barrett's esophagus. Five underwent manometric evaluation with only one showing an incompetent lower esophageal sphincter. In two cases, 24-hour pH studies showed massive acid reflux. Two patients had early adenocarcinoma, whereas four had advanced carcinoma. Adenocarcinoma in long-segment Barrett's esophagus seems to develop mainly in patients with recurrence of pathologic reflux, especially among men. A review of the English language literature during the last 23 years found 25 articles dealing with Barrett's esophagus and antireflux surgery. Most of these reports had only a few patients with short-term follow-up (<60 months). To determine the true prevalence of this complication, a long-term objective follow-up is necessary.

Esplenectomía laparoscópica en enfermedades hematológicas

BACKGROUND

Idiopathic thrombocytopenic purpura (ITP) is the most common indication for elective splenectomy. The laparoscopic approach has been used over the past ten years.

AIM

To report our experience with laparoscopic splenectomy.

PATIENTS AND METHODS

Retrospective review of 27 patients subjected to splenectomy due to hematological diseases. Among them, 17 patients (78% female, age range 17-70 years old) were subjected to a laparoscopic splenectomy. Eligibility criteria were the presence of benign disease, an informed consent by the patient, a spleen size of less than 20 cm by ultrasound and absence of previous surgery in the upper left quadrant. The rest of the patients were subjected to an open splenectomy.

RESULTS

Seventy one percent of patients subjected to laparoscopic splenectomy had an ITP. Mean operating time was 184 minutes. The mean spleen size was 11 cm and the mean weight was 186 g (70-450). No patient died or had complications. No patient required a conversion to an open surgery. Transfusions were not required. The median hospital stay was 3 days.

CONCLUSIONS

Elective laparoscopic splenectomy is a safe and low risk surgical procedure.

[Progression from intestinal metaplasia to adenocarcinoma in Barrett s esophagus: usefulness of endoscopic surveillance]

BACKGROUND

The potential progression from intestinal metaplasia to low grade dysplasia, to high grade dysplasia and to adenocarcinoma represents a well recognized sequence in patients with Barrett's esophagus (BE). The time required for this transformation is not well known.

AIM

To report the results of a 10 years follow up of patients with BE.

MATERIAL AND METHODS

Between 1989 and 2000 we followed 402 patients with BE.

RESULTS

Sixty six subjects (16.2%) presented low grade dysplasia at the time of diagnosis and 10 patients (2 women/8 men) developed adenocarcinoma during the follow-up period. Four out of these 10 patients were operated because of gastro-esophageal reflux disease, but after 3-5 years, reflux symptoms recurred. The other 6 patients rejected surgery and were on Omeprazole with good symptomatic results. Two patients had a short BE (< 3 cm), seven cases had a classic BE (3-10 cm) and one patient had an extensive > 10 cm BE. The mean time elapsed from intestinal metaplasia to low grade dysplasia was 9 months, to high grade dysplasia 56 months and to adenocarcinoma 82 months. From low grade dysplasia to early cancer it was 18 months, from high grade dysplasia to early cancer 14 months and from high grade dysplasia to advanced transmural cancer 14 months. All patients were subjected to esophagectomy. Five patients detected as State I are alive without any evidence of recurrence after 36 to 130 months after surgery. Five patients with advanced transmural carcinoma subjected to radical esophagectomy died because of progression of the malignancy between 3 and 24 months after surgery.

CONCLUSIONS

Progression to adenocarcinoma may occur even in absence of reflux symptoms while on acid suppression therapy. Detection at early stage intestinal metaplasia in the esophagus offers a high chance of cure after surgical resection.

Results of surgical treatment for recurrent postoperative gastroesophageal reflux

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

[Prader-Willi Syndrome (PWS) associated to morbid obesity: surgical treatment]

Prader-Willi Syndrome (PWS) is a multisystemic genetic disease characterized by hypothalamic hypogonadism, mental retardation and compulsive hyperphagia associated with early and severe obesity. Complications of overweight, such as type-2 diabetes Mellitus, dyslipidemia and diffuse atheromatosis are common. We report a 15 years old morbid obese male with PWS, with a body mass index of 57.7 kg/m2, refractory to weight-lowering treatments. He underwent preoperative evaluation and treatment by a multidisciplinary team, and subjected to a 95% gastrectomy, leaving a 50 ml remnant pouch and a long limb (120 cm) Y-Roux gastro-jejuno anastomosis. There were no surgical complications, oral feeding was initiated at the 5th day with an hypocaloric diet. During the first postoperative year, the patient lost 70 kg, achieving a body mass index of 30 kg/m2. Surgical treatment can become a therapeutic choice for obesity in PWS patients.

Length of the esophagus in patients with gastroesophageal reflux disease and Barrett's esophagus compared to controls

BACKGROUND

It is a current opinion among surgeons that the esophagus is shorter in patients with reflux disease and particularly in those with complicated Barrett's esophagus. However, objective evidence of this is scarce. Therefore we attempted to determine the occurrence and magnitude of this phenomenon among our patients.

METHODS

One hundred ninety control subjects, 77 patients with severe erosive esophagitis, 74 with Barrett's esophagus, and 29 with complicated Barrett's esophagus (ulcer, stenosis) were grouped according to height. The length of the esophagus was determined by standard manometric study, measuring the distance from the crycopharingeal sphincter to the distal limit of the lower esophageal sphincter. Values were expressed in cm as the mean +/- SD.

RESULTS

The esophageal length according to height was 1 to 2 cm shorter in patients compared to controls, but these differences were not significant.

CONCLUSIONS

No differences were found between patients with progressive severity of the disease. This study confirms that the presence of a so-called "short esophagus" does not exist or is not relevant in our patients with gastroesophageal reflux disease, including those with complicated Barrett's esophagus.

Barrett's esophagus complicated with stricture: correlation between classification and the results of the different therapeutic options

Benign esophageal stricture is a serious complication of persistent gastroesophageal reflux in patients with esophagitis and Barrett's esophagus. A classification of the severity of the stricture is proposed, based on its internal diameter, its length, and the ease or difficulty in dilating it. Among 185 patients with esophageal strictures secondary to reflux esophagitis, 77 (41.6%) corresponded to type I or mild stricture, 73 (39.4%) to type II or moderate, and 35 (19.6%) to type III. Medical treatment was performed in only 15 cases, with 73% recurrence. Three types of surgical procedures were employed, always after dilatation, improvement of nutritional status, and a complete preoperative work-up: (1) conservative antireflux surgery, which had a high incidence of recurrence (41.1%); (2) acid suppression and duodenal diversion, in which 68 patients had a mortality rate of 2.9% and a recurrence rate of 4.4% (p <0.002); and (3) esophageal resection, which in 7 patients resulted in 1 death and no late recurrence. It is concluded that classification of the severity of the stricture is important to indicate the most appropriate treatment. Conservative antireflux surgery is followed by a high recurrence rate at late follow-up, whereas acid suppression and duodenal diversion seem to be an adequate procedure that is followed by a very low recurrence rate. Esophageal resection is indicated only for patients with severe or critical esophageal strictures.

[Early enteral nutrition in cancer patients subjected to a total gastrectomy]

BACKGROUND

Total parenteral nutrition has a high cost and frequency of complications. Enteral feeding is a feasible alternative that can be started early in the postoperative period.

AIM

To assess digestive tolerance to early enteral feeding in cancer patients undergoing total gastrectomy and to compare early enteral feeding (EEF) with total parenteral nutrition plus enteral feeding (TPN + EF), initiated after overcoming postoperative ileus.

PATIENTS AND METHODS

Subjects with a resectable gastric cancer were considered eligible for the study. During surgery a nasoenteral tube was placed and patients were prospectively randomized to EEF or TPN + EF. Digestive tolerance, effectiveness, complications and costs between both modalities of nutritional support were compared.

RESULTS

Twenty eight patients (15 male, aged 63 +/- 14 years old) were studied. Fourteen patients were randomized to EEF and 14 to TPN + EF. Diarrhea occurred in 14 and 29% of EEF and TPN + EF patients respectively, (p: NS). Patients with TPN + EF received an average of 28 Cal/kg/day and 1.1 g/kg/day proteins. Patients with EEF received an average of 29 Cal/kg/day and 0.8 g/kg/day proteins. At the eighth postoperative day, serum albumin was 3.9 +/- 0.7 and 3.2 +/- 0.5 g/dl in EEF and TPN + EF patients respectively (p < 0.05), serum prealbumin was 16.9 +/- 5 and 12.3 +/- 4.3 mg/dl in EEF and TPN + EF patients respectively (p < 0.05) and nitrogen balance was +2.4 +/- 1.5 and -1.6 +/- 0.6 g/24 h in EEF and TPN + EF patients respectively (p < 0.05). Postoperative hyperglycemia was observed with a lower frequency and nutritional support costs and length of hospital stay were significantly lower in the EEF group.

CONCLUSIONS

After total gastrectomy EEF is well tolerated, safe and effective, even during the early postoperative ileus. This therapeutic modality could be the first choice for nutritional support in these patients.

[Current management of achalasia of the esophagus: critical review and clinical experience]

The therapeutic options for treatment of Achalasia of the esophagus include medical treatment, endoscopic and surgical procedures. The latter can be either conservative, such as cardiomyotomy or more aggressive, such as cardioplasty or esophageal resection. In this article, we discuss the early and long term results after the different therapeutic options. We also present the results of our recent surgical experience. The definitive results seem to be better after surgical treatment compared to medical management or endoscopic procedures.

Effect of duodenal diversion on low-grade dysplasia in patients with Barrett's esophagus: analysis of 37 patients

It is well known that in patients with Barrett's esophagus (BE), even after antireflux surgery, intestinal metaplasia can progress to dysplasia or even adenocarcinoma. However, the opposite-that is regression of dysplastic changes to intestinal metaplasia after antireflux surgery-has been documented in only a few reports. The objective of this study was to determine the effect of a duodenal diversion operation on low-grade dysplasia in patients with BE. Thirty-seven patients with either short-segment (n = 12) or long-segment (n = 25) BE underwent antireflux surgery plus either a duodenal switch procedure (13 patients) or a partial distal gastrectomy with Roux-en-Y gastrojejunal anastomosis (24 patients). All of them were subjected to complete clinical, endoscopic, histologic, manometric, and 24-hour pH testing, and 24-hour monitoring of the bile exposure in distal esophagus. There were no deaths in this series, and morbidity occurred in only one patient (2.7%). Manometric assessment after surgery showed a significant increase in sphincter pressure, abdominal length, and total length (P < 0.001). Acid reflux showed a significant decrease after surgery, and duodenal reflux was completely abolished in all except one patient. Follow-up in all patients was longer than 24 months (mean 60 months). Three to four endoscopic procedures were performed after surgery in each patient, and several biopsy specimens were taken distal to the squamo-columnar junction during each endoscopic procedure. Eleven patients (91%) with short-segment BE demonstrated histologic regression to either cardiac mucosa or nondysplastic intestinal metaplasia. Among the 25 patients with long-segment BE, there was a 62.5% rate of histologic regression to nondysplastic epithelium when the length of BE measured between 31 and 99 mm and 33% histologic regression when the length of BE was 101 mm or more. There were no cases of progression to high-grade dysplasia or adenocarcinoma. The endoscopic length of the columnar-lined esophagus did not change late after surgery. In 65% of patients with BE, antireflux surgery, gastric acid reduction, and duodenal diversion produced histologic regression of low-grade dysplasia to nondysplastic mucosa. This effect was even more pronounced when the length of BE was shorter. It seems to be permanent, and no progression to high-grade dysplasia or adenocarcinoma has occurred.

Early and late results of the acid suppression and duodenal diversion operation in patients with barrett's esophagus: analysis of 210 cases

The usual surgical treatment for patients with Barrett's esophagus (BE) is a classic Nissen fundoplication or posterior gastropexy with cardial calibration. However, some surgical reports as well as our experience suggest that the rate of failure of the Nissen fundoplication or Hill's posterior gastropexy in patients with BE is significantly higher than in those with reflux esophagitis without BE, probably due in part to the persistence of duodenal reflux into the esophagus. Our aim was to determine the late subjective and objective results of an operation consisting in "acid suppression" (vagotomy-partial gastrectomy) and "duodenal diversion" (Roux-en-Y anastomosis) as a primary surgical procedure for patients with BE. Altogether, 210 patients were subjected to this technique. It consisted in a primary operation in 142 patients and revision surgery in 68. They underwent complete clinical, radiologic, endoscopic, histologic, and manometric studies. In some cases 24-hour pH studies, Bilitec studies, gastric emptying, and gastric acid secretion evaluations were performed. There were two deaths (0.95%), and postoperative morbidity was low (5.3%). The late mean follow-up (58 months) for 146 patients who completed a follow-up longer than 24 months showed Visick I and II grades in 91.1% of the cases. In 14.9% of the cases 24-hour pH monitoring showed excessive acid reflux 1 year after surgery. No dysplasia or adenocarcinoma has appeared up to now. Functional studies showed significant alleviation of lower esophageal sphincter (LES) incompetence, with abolition of duodenal reflux into the esophagus. Gastric emptying of solids was normal, and basal and peak gastric acid output remained at a low level 8 to 10 years after surgery. In patients with BE, with severe damage of the LES and esophageal peristalsis, the "suppression diversion" operation completely abolishes the reflux of injurious components of the refluxate and improves sphincter competence. This effect is permanent and avoids the appearance of dysplasia or adenocarcinoma.

A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187 patients with gastric carcinoma

BACKGROUND

Classic surgical treatment of upper third gastric carcinoma is based on an extended total gastrectomy, including splenectomy. The purpose of this study was to perform a prospective randomized clinical trial comparing the early and late results of total gastrectomy (TG) versus total gastrectomy plus splenectomy (TGS).

METHODS

One hundred eighty-seven patients with gastric carcinoma were included. In all patients a D2 total gastrectomy was performed. During surgery they were randomized to 1 of 2 operative options. They were monitored to their death or to 5 years later if they were alive.

RESULTS

Operative mortality was similar after both operations (3% after TG and 4% after TGS). Septic complications after surgery were higher after TGS compared with TG (P <.04). Five-year survival rates were not statistically different between groups or in subset analysis according to stage of disease.

CONCLUSIONS

On the basis of the results of the present prospective randomized trial, splenectomy is not necessary in early stages of disease. A low operative mortality rate (less than 3%) must be achieved to obtain good long-term results.

Dysplasia and adenocarcinoma after classic antireflux surgery in patients with Barrett's esophagus: the need for long-term subjective and objective follow-up

OBJECTIVE

To assess the clinical, endoscopic, and functional results in a group of patients with Barrett's esophagus undergoing classic antireflux surgery in whom dysplasia and adenocarcinoma were found at a late objective follow-up.

SUMMARY BACKGROUND DATA

There have been isolated reports of patients with Barrett's esophagus undergoing antireflux surgery who show dysplasia or even adenocarcinoma on follow-up.

METHODS

Of 161 patients undergoing surgery, dysplasia developed in 17 (10.5%) at late follow-up and adenocarcinoma developed in 4 (2.5%). These 21 patients represent the group assessed and were compared with 126 surgical patients with long-segment Barrett's in whom dysplasia did not develop. They were evaluated by clinical questionnaire, multiple endoscopic procedures and biopsy specimens, 24-hour pH studies, and 24-hour bilirubin monitoring.

RESULTS

Of the 17 patients with dysplasia, 3 were asymptomatic at the time that dysplastic changes appeared; all patients with adenocarcinoma had symptoms. Two patients (12%) in the dysplasia group had short-segment Barrett's; all patients with adenocarcinoma had long-segment Barrett's. Manometric studies revealed an incompetent lower esophageal sphincter in 70% of the dysplasia group, similar to nondysplasia patients with recurrence, and in 100% of the adenocarcinoma group. The 24-hour pH study showed pathologic acid reflux in 94% of the patients with dysplasia, similar to patients with recurrence without dysplasia, whereas bilirubin monitoring showed duodenal abnormal reflux in 86% of the patients. Among patients with dysplasia, three different histologic patterns were identified. All patients with adenocarcinoma had initially intestinal metaplasia, with appearance of this tumor 6 to 8 years after surgery.

CONCLUSIONS

Patients with Barrett's esophagus who undergo antireflux surgery need close and long-term endoscopic and histologic surveillance because dysplasia or even adenocarcinoma can appear at late follow-up. Metaplastic changes from fundic to cardiac mucosa and then to intestinal metaplasia and later to dysplasia or adenocarcinoma can clearly be documented. There were no significant differences in terms of clinical, endoscopic, manometric, 24-hour pH, and bilirubin monitoring studies between patients with recurrence of symptoms without dysplastic changes, and patients with dysplasia. Therefore, the high-risk group for the development of dysplasia is mainly the group with failed antireflux surgery.

Roux-en-Y long limb diversion as the first option for patients who have Barrett's esophagus

In summary, vagotomy plus antrectomy and the Roux-en-Y procedure is based on the following points: (a) patients who have BE show several foregut abnormalities, including incompetent lower esophageal sphincter, impairment in the esophageal clearance, severe gastroesophageal acid reflux, and frequent duodenoesophageal reflux; (b) late results of classic antireflux procedure in BE are poor with a high recurrence rate owing to a progressive loosening of the wrap; (c) the esophageal damage is produced by the injurious component of the refluxate; and (d) among patients who underwent classic antireflux surgery, a certain proportion developed dysplasia or even adenocarcinoma in the follow-up. The authors have observed that the simple correction of the valve is not enough in many cases, because it does not abolish the gastroesophageal reflux but only diminishes it. In patients who have BE and therefore have impaired esophageal clearance, few reflux episodes can maintain or even induce more damage. With the reduction diversion antireflux procedure, the quality of the corrected valve is secondary, and the main goal is to avoid the reflux of injurious components of the refluxate instead of the refluxate itself, which is almost always impossible. Late results support this hypothesis, and the authors propose this surgical procedure as an alternative treatment in patients who have complicated BE or in patients who have long-segment BE. Among patients who have gastroesophageal reflux and intestinal metaplasia of the cardia or with a noncomplicated short-segment BE, laparoscopic antireflux surgery is the authors' first choice, and only the late objective evaluation of surgical treatment demonstrates which surgical technique is the more adequate to a particular patient who has BE.

[Preliminary results of laparoscopic video esophagomyotomy in patients with esophageal achalasia]

BACKGROUND

Laparoscopic esophagomyotomy is becoming a good alternative to pneumatic dilatation, injection of botulinic toxin or classical surgery in the treatment of achalasia.

AIM

To report the results of laparoscopic esophagomyotomy in patients with achalasia.

PATIENTS AND METHODS

Nineteen patients with achalasia, nine women, aged 9 to 66 years old, operated between 1996 and 2001 are reported.

RESULTS

There was no surgical mortality. One patient had a subphrenic abscess due to an unnoticed tear of the esophageal mucosa. During surgery, esophageal mucosa was perforated in 4 patients, that was sutured in three. One patient with an extensive tear of the mucosa required conversion to classical surgery. Patients were followed for 2 to 48 months. Radiological controls showed a significant increase in the diameter of gastroesophageal junction and a diameter reduction of the mid third esophageal segment. Lower esophageal pressure was significantly reduced. All patients experienced a weight increase and reduction of dysphagia.

CONCLUSIONS

Laparoscopic esophagomyotomy is a safe an effective therapeutic alternative for achalasia.