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Valinoti AC, Angeramo CA, Dreifuss N, Herbella FAM, Schlottmann F. MAGNETIC SPHINCTER AUGMENTATION DEVICE FOR GASTROESOPHAGEAL REFLUX DISEASE: EFFECTIVE, BUT POSTOPERATIVE DYSPHAGIA AND RISK OF EROSION SHOULD NOT BE UNDERESTIMATED. A SYSTEMATIC REVIEW AND META-ANALYSIS. Arq Bras Cir Dig 2024; 36:e1781. [PMID: 38451590 PMCID: PMC10911679 DOI: 10.1590/0102-672020230063e1781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 09/10/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Magnetic ring (MSA) implantation in the esophagus is an alternative surgical procedure to fundoplication for the treatment of gastroesophageal reflux disease. AIMS The aim of this study was to analyse the effectiveness and safety of magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD). METHODS A systematic literature review of articles on MSA was performed using the Medical Literature Analysis and Retrieval System Online (Medline) database between 2008 and 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies. RESULTS A total of 22 studies comprising 4,663 patients with MSA were analysed. Mean follow-up was 27.3 (7-108) months. The weighted pooled proportion of symptom improvement and patient satisfaction were 93% (95%CI 83-98%) and 85% (95%CI 78-90%), respectively. The mean DeMeester score (pre-MSA: 34.6 vs. post-MSA: 8.9, p=0.03) and GERD-HRQL score (pre-MSA: 25.8 vs. post-MSA: 4.4, p<0.0001) improved significantly after MSA. The proportion of patients taking proton pump inhibitor (PPIs) decreased from 92.8 to 12.4% (p<0.0001). The weighted pooled proportions of dysphagia, endoscopic dilatation and gas-related symptoms were 18, 13, and 3%, respectively. Esophageal erosion occurred in 1% of patients, but its risk significantly increased for every year of MSA use (odds ratio - OR 1.40, 95%CI 1.11-1.77, p=0.004). Device removal was needed in 4% of patients. CONCLUSIONS Although MSA is a very effective treatment modality for GERD, postoperative dysphagia is common and the risk of esophageal erosion increases over time. Further studies are needed to determine the long-term safety of MSA placement in patients with GERD.
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Affiliation(s)
- Agustin Cesar Valinoti
- Hospital Aleman de Buenos Aires, Esophagus and Stomach Surgical Unit – Buenos Aires, Argentina
| | | | - Nicolas Dreifuss
- Hospital Aleman de Buenos Aires, Esophagus and Stomach Surgical Unit – Buenos Aires, Argentina
| | | | - Francisco Schlottmann
- Hospital Aleman de Buenos Aires, Esophagus and Stomach Surgical Unit – Buenos Aires, Argentina
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Brandalise A, Herbella FAM, Luna RA, Szachnowicz S, Sallum RAA, Domene CE, Volpe P, Cavazzolla LT, Furtado ML, Claus CMP, Farah JFDM, Crema E. BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT. Arq Bras Cir Dig 2024; 36:e1787. [PMID: 38324849 PMCID: PMC10841492 DOI: 10.1590/0102-672020230069e1787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/21/2023] [Indexed: 02/09/2024]
Abstract
Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.
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Affiliation(s)
- André Brandalise
- Centro Médico de Campinas, Robotic Surgery Program - Campinas (SP), Brazil
| | | | - Renato Abrantes Luna
- Universidade Federal do Estado do Rio de Janeiro, Faculty of Medicine and Surgery, Hospital Federal dos Servidores do Estado - Rio de Janeiro (RJ), Brazil
| | - Sergio Szachnowicz
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | | | | | - Paula Volpe
- Centro Integrado de Medicina Avançada - São Paulo (SP), Brazil
| | - Leandro Totti Cavazzolla
- Universidade Federal do Rio Grande do Sul, University Hospital, General Surgery Unit - Porto Alegre (RS), Brazil
| | - Marcelo Lopes Furtado
- Sociedade Brasileira de Hérna e Parede Abdominal, Hospital Pintagueiras, Videolaparoscopic Surgery Service - Jundiaí, São Paulo (SP), Brazil
| | - Christiano Marlo Paggi Claus
- Universidade Positivo, Postgraduate Program in Minimally Invasive Surgery, Department of Surgical Clinic - Curitiba (PR), Brazil
| | | | - Eduardo Crema
- Universidade Federal do Triângulo Mineiro, Digestive Surgical Unit - Uberaba (MG), Brazil
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Herbella FAM, Neto RML, Azevedo R, Patti MG. Normal swallowing physiology. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Allaix ME, Andrade VLA, Azevedo R, Barbieri L, Costantini A, Costantini M, Desai N, El Moheb M, Herbella FAM, Hermann L, Huffman J, Hunold T, Kaperak C, Martin LW, Mervak BM, Neto RML, Olinger K, Patti MG, Puccetti F, Rebecchi F, Robert K, Rosati R, Salvador R, Schlottmann F, Ugliono E, Veloso JCDS, Viktorsson SA, Wang W, Watson TJ, Young AM, Young C. Contributors. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.50006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Patti MG, Schlottmann F, Herbella FAM. Once an achalasia patient always an achalasia patient: evaluation and treatment of recurrent symptoms. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Schlottmann F, Herbella FAM, Patti MG. Achalasia. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00006-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Tustumi F, de Moura DTH, Waisberg J, Herbella FAM. Editorial: Premalignant conditions in the esophagus and stomach. Front Oncol 2022; 12:1091911. [PMID: 36518325 PMCID: PMC9743007 DOI: 10.3389/fonc.2022.1091911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/16/2022] [Indexed: 08/30/2023] Open
Affiliation(s)
- Francisco Tustumi
- Universidade de São Paulo, Department of Gastroenterology, Sao Paulo, Brazil
- Hospital Israelita Albert Einstein, Department of Surgery, Sao Paulo, Brazil
| | | | - Jaques Waisberg
- Centro Universitário Faculdade de Medicina do ABC, Department of Surgery, Santo Andre, Brazil
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Mardiros Herbella FA, Sarr MG, Patti MG. Fourteen Crutches for Mediocrity. The logismoi that jeopardize good research and publication. Cir Esp 2022; 100:262-265. [PMID: 35598955 DOI: 10.1016/j.cireng.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/18/2021] [Indexed: 06/15/2023]
Abstract
Publications are used widely as a measure of academic quality. Many investigators have difficulty publishing in this competitive field. After coming across a religious lecture on the "Fourteen Crutches for Mediocrity", our team adapted this approach to life to the science of publishing: (1) what is the problem of doing it?; (2) there are worse!; (3) everybody does it!; (4) why exaggerate?; (5) I will do it tomorrow!; (6) maybe if …; (7) it is not used anymore!; (8) be a cousin not a brother!; (9) I need to be thanked!; (10) don't eat your own head, let it be!; (11) I can't possibly accomplish it!; (12) I don't feel like doing it!; (13) I am fed up!; (14) I am not worthwhile! These crutches jeopardize good research and thoughtful learned publications.
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Mardiros Herbella FA, Sarr MG, Patti MG. Fourteen Crutches for Mediocrity. The logismoi that jeopardize good research and publication. Cir Esp 2021; 100:S0009-739X(21)00208-6. [PMID: 34366103 DOI: 10.1016/j.ciresp.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/18/2021] [Indexed: 11/26/2022]
Abstract
Publications are used widely as a measure of academic quality. Many investigators have difficulty publishing in this competitive field. After coming across a religious lecture on the "Fourteen Crutches for Mediocrity", our team adapted this approach to life to the science of publishing: (1) what is the problem of doing it?; (2) there are worse!; (3) everybody does it!; (4) why exaggerate?; (5) I will do it tomorrow!; (6) maybe if …; (7) it is not used anymore!; (8) be a cousin not a brother!; (9) I need to be thanked!; (10) don't eat your own head, let it be!; (11) I can't possibly accomplish it!; (12) I don't feel like doing it!; (13) I am fed up!; (14) I am not worthwhile! These crutches jeopardize good research and thoughtful learned publications.
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Herbella FAM, Patti MG. Chicago classification version 4.0© from surgeons' point of view. Neurogastroenterol Motil 2021; 33:e14090. [PMID: 33506552 DOI: 10.1111/nmo.14090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 12/06/2022]
Affiliation(s)
| | - Marco G Patti
- Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
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de Mello Del Grande L, Herbella FAM, Katayama RC, Lima WG, Patti MG. Transdiaphragmatic Pressure Gradient (TPG) Has a Central Role in the Pathophysiology of Gastroesophageal Reflux Disease (GERD) in the Obese and it Correlates with Abdominal Circumference but Not with Body Mass Index (BMI). Obes Surg 2021; 30:1424-1428. [PMID: 31858395 DOI: 10.1007/s11695-019-04345-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Pathophysiology of gastroesophageal reflux disease (GERD) is multifactorial. An increased transdiaphragmatic pressure gradient (TPG) may be a main element for GERD in the obese patient. This study aims to evaluate the role of TPG in the physiopathology of GERD in obese individuals. METHODS We studied 47 unselected consecutive candidates for bariatric operations (body mass index (BMI) > 35). All patients underwent high-resolution manometry and esophageal pH monitoring. Individuals were grouped as GERD + or GERD - based on DeMeester score. Abdominal pressure (AP) and thoracic pressure (TP), transdiaphragmatic pressure gradient (AP-TP), and lower esophageal sphincter (LES) retention pressure (LES basal pressure-TPG) were determined. Manometric variables were compared with a group of 20 lean healthy individuals (BMI < 25). RESULTS There were 27 (57%) GERD + patients and 20 (43%) GERD - patients. TPG, waist circumference, LES retention pressure, and AP were higher in GERD + group as compared with GERD - individuals. GERD - group had manometric parameters similar to controls except for AP. GERD + patients had higher AP and TPG and lower LES retention pressure compared with controls. TPG and LES retention pressure correlated with waist circumference and DeMeester score. BMI correlated with AP but not with waist circumference or DeMeester score. CONCLUSION In the obese, GERD presence and severity were associated to a high TPG due to increase AP that correlates with waist circumference.
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Affiliation(s)
- Leonardo de Mello Del Grande
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Fernando Augusto Mardiros Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Rafael Caue Katayama
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - William Guidini Lima
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Marco G Patti
- Department of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
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Del Grande LDM, Herbella FAM, Patti MG. The Role of the Transdiaphragmatic Pressure Gradient (TGP) in the Pathophysiology of Proximal Reflux. J Gastrointest Surg 2021; 25:351-356. [PMID: 33443690 DOI: 10.1007/s11605-020-04849-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/27/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION An increased transdiaphragmatic pressure gradient (TGP) is a main element for distal gastroesophageal reflux disease (GERD). The role of TGP for proximal reflux is still unclear. This study aims to evaluate the presence, severity, and importance of proximal reflux in relationship to the TGP, comparing healthy volunteers, obese individuals, and patients with chronic obstructive pulmonary disease (COPD). METHODS We studied 114 individuals comprising 19 healthy lean volunteers, 47 obese individuals (mean body mass index 45 ± 7 kg/m2), and 48 patients with COPD. All patients underwent high-resolution manometry and dual-channel esophageal pH monitoring. Esophageal motility, thoracic pressure (TP), abdominal pressure (AP), TGP, DeMeester score, and % of proximal acid exposure time (pAET) were recorded. RESULTS Pathologic distal GERD was found in 0, 44, and 57% of the volunteers, obese, and COPD groups, respectively. pAET was similar among groups, only higher for obese individuals GERD + as compared to obese individuals GERD - and COPD GERD -. pAET did not correlate with any parameter in healthy individuals, but it correlated with AP in the obese, TP in the COPD individuals, and TGP and DeMeester score in both groups. When all individuals were analyzed as a total, pAET correlated with AP, TGP, and DeMeester score. DeMeester score was the only independent variable that correlated with pAET. CONCLUSIONS Our results show that (a) TGP is an important mechanism associated with distal esophageal acid exposure and this fact is linked with proximal acid exposure and (b) obesity and COPD both seem to be primary causes for GERD but not directly for proximal reflux.
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Affiliation(s)
- Leonardo de Mello Del Grande
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Pedro de Toledo 980 conj. 66, Sao Paulo, SP, 04039002, Brazil.
| | - F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Pedro de Toledo 980 conj. 66, Sao Paulo, SP, 04039002, Brazil
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
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Santos TL, Herbella FAM, Azevedo RR. The applicability of high resolution manometry in total laryngectomy. Codas 2020; 32:e20190006. [PMID: 33237186 DOI: 10.1590/2317-1782/20202019006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 12/06/2019] [Indexed: 11/21/2022] Open
Abstract
PURPOSE This study aims to measure the pressure of the pharynx and the pharyngoesophageal segment (PES) at rest and during phonation in total laryngectomized patients, with different levels of voice production. METHODS four total laryngectomized individuals participated in the study, All patients underwent High Resolution Manometry (MAR) at rest and during phonation. After this process, a descriptive analysis of the results was performed. RESULTS we observed that during rest the patients had PES pressure below normal and this data may be related to changes in the muscular connections at the level of the upper esophageal sphincter (UES) especially the interruption of the cricopharyngeal plexus. During phonation, two patients presented higher UES pressure values during phonation, when compared to the values found at rest, suggesting that introduction of air into the esophagus is followed by pharyngoesophageal contraction and that during phonation the patients with good esophageal speech may develop more pressure in this region. CONCLUSION Studies with a greater number of participants may help define, for example, subjects who may benefit from procedures such as cricopharyngeal myotomy or other medical conduct in order to facilitate the acquisition of esophageal voice in these patients.
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Affiliation(s)
- Taís Lima Santos
- Escola Paulista de Medicina - Universidade Federal de São Paulo, São Paulo (SP), Brasil
| | | | - Renata Rangel Azevedo
- Escola Paulista de Medicina - Universidade Federal de São Paulo, São Paulo (SP), Brasil
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Del Grande LDM, Herbella FAM, Katayama RC, Landini Filho LS, Mocerino J, Ferreira AEP. Achalasia and cancer prevention and surveillance. ACTA ACUST UNITED AC 2020. [DOI: 10.21037/aoe.2020.02.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Neto RML, Herbella FAM, Schlottmann F, Patti MG. Does DeMeester score still define GERD? Dis Esophagus 2019; 32:5250774. [PMID: 30561585 DOI: 10.1093/dote/doy118] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/15/2018] [Accepted: 11/06/2018] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux disease (GERD) clinical presentation may encompass a myriad of symptoms that may mimic other esophageal and extra-esophageal diseases. Thus, GERD diagnosis by symptoms only may be inaccurate. Upper digestive endoscopy and barium esophagram may also be misleading. pH monitoring must be added often for a definitive diagnosis. The DeMeester score (DMS) is a composite score of the acid exposure during a prolonged ambulatory pH monitoring that has been used since 1970s to categorize patients as GERD+ or GERD-. We showed in this review that DMS has some limitations and strengths. Although there is not a single instrument to precisely diagnose GERD in all of its variances, pH monitoring analyzed at the light of DMS is still a reliable method for scientific purposes as well as for clinical decision making. There are no data that show that acid exposure time is superior-or for that matter inferior-as compared to DMS.
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Affiliation(s)
- R M L Neto
- Department of Surgery, Escola Paulista de Medicina, São Paulo, Brazil
| | - F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, São Paulo, Brazil
| | - F Schlottmann
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - M G Patti
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Schlottmann F, Strassle PD, Cairns AL, Herbella FAM, Fichera A, Patti MG. Disparities in Emergent Colectomy for Colorectal Cancer Contribute to Inequalities in Postoperative Morbidity and Mortality in The US Health Care System. Scand J Surg 2019; 109:102-107. [PMID: 30696360 DOI: 10.1177/1457496919826720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Colorectal cancer is the third most common cancer among both men and women in the United States. We aimed to determine racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer in the US Health Care system. MATERIAL AND METHODS We performed a retrospective analysis of the National Inpatient Sample including adult patients (⩾18 years) diagnosed with colorectal cancer, and who underwent colorectal resection while admitted between 2008 and 2015. Multivariable logistic and linear regression were used to assess the association between emergent admissions, compared to elective admissions, and postoperative outcomes. RESULTS A total of 141,641 hospitalizations were included: 93,775 (66%) were elective admissions and 47,866 (34%) were emergent admissions. Black patients were more likely to undergo emergent colectomy, compared to white patients (42% vs 32%, p < 0.0001). Medicaid and Medicare patients were also more likely to have an emergent colectomy, compared to private insurance (47% and 36% vs 25%, respectively, p < 0.0001), as were patients with low household income, compared to highest (38% vs 31%, p < 0.0001). Emergent procedures were less likely to be laparoscopic (19% vs 38%, p < 0.0001). Patients undergoing emergent colectomy were significantly more likely to have postoperative venous thromboembolism, wound complications, infection, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality. CONCLUSION There are significant racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer. Efforts to reduce this disparity in colorectal cancer surgery patients should be prioritized to improve outcomes.
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Affiliation(s)
- F Schlottmann
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - P D Strassle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - A L Cairns
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - F A M Herbella
- Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
| | - A Fichera
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M G Patti
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Zaninotto G, Bennett C, Boeckxstaens G, Costantini M, Ferguson MK, Pandolfino JE, Patti MG, Ribeiro U, Richter J, Swanstrom L, Tack J, Triadafilopoulos G, Markar SR, Salvador R, Faccio L, Andreollo NA, Cecconello I, Costamagna G, da Rocha JRM, Hungness ES, Fisichella PM, Fuchs KH, Gockel I, Gurski R, Gyawali CP, Herbella FAM, Holloway RH, Hongo M, Jobe BA, Kahrilas PJ, Katzka DA, Dua KS, Liu D, Moonen A, Nasi A, Pasricha PJ, Penagini R, Perretta S, Sallum RAA, Sarnelli G, Savarino E, Schlottmann F, Sifrim D, Soper N, Tatum RP, Vaezi MF, van Herwaarden-Lindeboom M, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Gittens S, Pontillo C, Vermigli S, Inama D, Low DE. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018; 31:5087687. [PMID: 30169645 DOI: 10.1093/dote/doy071] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.
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Affiliation(s)
- G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - C Bennett
- Office of Research and Innovation, Royal College of Surgeons in Ireland, Ireland
| | - G Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M Costantini
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - M K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - J E Pandolfino
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - M G Patti
- Department of Medicine and Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - U Ribeiro
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - J Richter
- Department of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - L Swanstrom
- Institute of Image-Guided Surgery, Strasbourg, France; Interventional Endoscopy and Foregut Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - J Tack
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - G Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Stanford University, Stanford, California, USA
| | - S R Markar
- Department of Surgery and Cancer, Imperial College, London, UK
| | - R Salvador
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - L Faccio
- Division of Surgery, Padova University Hospital, Padova, Italy
| | - N A Andreollo
- Faculty of Medical Science, State University of Campinas, Campinas, São Paulo, Brazil
| | - I Cecconello
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - G Costamagna
- Digestive Endoscopy Unit, A. Gemelli Hospital, Catholic University, Rome, Italy
| | - J R M da Rocha
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - E S Hungness
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - P M Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
| | - K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Frankfurt, Germany
| | - I Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - R Gurski
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - F A M Herbella
- Department of Surgery, School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - R H Holloway
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, The University of Adelaide, Adelaide, Australia
| | - M Hongo
- Department of Medicine, Kurokawa Hospital, Taiwa, Kurokawa, Miyagi, Japan
| | - B A Jobe
- Esophageal and Lung Institute, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania, USA
| | - P J Kahrilas
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - D A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - K S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - D Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - A Moonen
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - A Nasi
- Digestive Surgery Division, University of São Paulo School of Medicine, São Paulo, Brazil
| | - P J Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - R Penagini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Department of Pathophysiology and Transplantation; Università degli Studi, Milan, Italy
| | - S Perretta
- Institute for Image Guided Surgery IHU-Strasbourg, Strasbourg, France
| | - R A A Sallum
- Department of Gastroenterology, Division of Surgery, University of Sao Paulo, Sao Paulo, Brazil
| | - G Sarnelli
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | - E Savarino
- Department of Surgical, Oncological and Gastroenterologica Sciences, University of Padua, Padua, Italy
| | - F Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - D Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - N Soper
- Department of Surgery, Northwestern University, Chicago, Illinois, USA
| | - R P Tatum
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - M F Vaezi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - M van Herwaarden-Lindeboom
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing (Chrometa), Translational Research Center for Gastrointestinal Disorders (TARGID), University of Leuven, Leuven, Belgium
| | - M F Vela
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - D I Watson
- Department of Surgery, Flinders University, Adelaide, Australia
| | - F Zerbib
- Department of Gastroenterology, University of Bordeaux, Bordeaux, France
| | - S Gittens
- ECD Solutions, Atlanta, Georgia, USA
| | - C Pontillo
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - S Vermigli
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D Inama
- ALMA (Association of patients with achalasia, ONLUS), Naples, Italy
| | - D E Low
- Department of Thoracic Surgery Virginia Mason Medical Center, Seattle, Washington, USA
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Teixeira ACP, Herbella FAM, Bonadiman A, Farah JFDM, Del Grande JC. Predictive factors for short gastric vessels division during laparoscopic total fundoplication. Rev Col Bras Cir 2017; 42:154-8. [PMID: 26291255 DOI: 10.1590/0100-69912015003005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/20/2014] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to determine clinical variables that can predict the need for division of the short gastric vessels (SGV), based on the gastric fundus tension, assessing postoperative outcomes in patients submitted or not to section of these vessels. METHODS we analyzed data from 399 consecutive patients undergoing laparoscopic fundoplication for gastroesophageal reflux disease (GERD). The section of the SGV was performed according to the surgeon evaluation, based on the fundus tension. Patients were divided into two groups: not requiring SGV section (group A) or requiring SGV section (group B). RESULTS the section was not necessary in 364 (91%) patients (Group A) and required in 35 (9%) patients (Group B). Group B had proportionally more male patients and higher average height. The endoscopic parameters were worse for Group B, with larger hiatal hernias, greater hernias proportion with more than four centimeters, more intense esophagitis, higher proportion of Barrett's esophagus and long Barrett's esophagus. Male gender and grade IV-V esophagitis were considered independent predictors in the multivariate analysis. Transient dysphagia and GERD symptoms were more common in Group B. CONCLUSION the division of the short gastric vessels is not required routinely, but male gender and grade IV-V esophagitis are independent predictors of the need for section of these vessels.
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Affiliation(s)
| | | | - Adorísio Bonadiman
- Departamento de Cirurgia Geral e Oncológica, Hospital do Servidor Público Estadual de São Paulo, BR
| | | | - José Carlos Del Grande
- Departamento de Cirurgia, Escola Paulista de Medicina, Universidade Federal de São Paulo, SP, BR
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19
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Abstract
Achalasia may present in a non-advanced or an advanced (end stage) stage based on the degree of esophageal dilatation. Manometric parameters and esophageal caliber may be prognostic for the outcome of treatment. The correlation between manometry and disease stage has not been yet fully studied. This study aims to describe high-resolution manometry findings in patients with achalasia and massive dilated megaesophagus. Eighteen patients (mean age 61 years, 55% females) with achalasia and massive dilated megaesophagus, as defined by a maximum esophageal dilatation >10 cm at the barium esophagram, were studied. Achalasia was considered secondary to Chagas' disease in 14 (78%) of the patients and idiopathic in the remaining. All patients underwent high-resolution manometry. Upper esophageal sphincter was hypotonic and had impaired relaxation in the majority of patients. Aperistalsis was seen in all patients with an equal distribution of Chicago type I and type II. No type III was noticed. Lower esophageal sphincter did not have a characteristic manometric pattern. In 50% of the cases, the manometry catheter was not able to reach the stomach. Our results did not show a manometric pattern in patients with achalasia and massive dilated esophagus.
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Affiliation(s)
- M A Menezes
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Sao Paulo, Brazil
| | - C Andolfi
- Department of Surgery, University of Chicago, Illinois, USA
| | - F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Sao Paulo, Brazil
| | - M G Patti
- Department of Surgery, University of Chicago, Illinois, USA
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20
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Nadaleto BF, Herbella FAM, Pinna BR, Patti MG. Upper esophageal sphincter motility in gastroesophageal reflux disease in the light of the high-resolution manometry. Dis Esophagus 2017; 30:1-5. [PMID: 28375485 DOI: 10.1093/dote/dox001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Indexed: 12/11/2022]
Abstract
This study aims to evaluate the upper esophageal sphincter (UES) motility in patients with gastroesophageal reflux disease (GERD) as compared to healthy volunteers. We retrospectively studied the HRM tests of 44 patients (median age: 61 years, 54% females) under evaluation for GERD. The manometric UES parameters of these patients were compared to 40 healthy volunteers (median age: 27 years, 50% females). Almost half of the patients had a short and hypotonic UES. Patients with extraesophageal symptoms had a higher proportion of hypotonic UES as compared to patients with esophageal symptoms. Reflux pattern did not influence manometric parameters. Proximal reflux (any number of episodes) was present in 37(84%) patients (median number of proximal episodes = 6). Manometric parameters are similar in the presence or absence of proximal reflux. There is not a correlation between the UES length and UES basal pressure. In conclusion, our results show that: (1) the manometric profile of the UES in patients with GERD is characterized by a short and hypotonic UES in half of the patients; (2) this profile is more pronounced in patients with extraesophageal symptoms; and (3) neither the presence of proximal reflux nor reflux pattern bring a different manometric profile.
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Affiliation(s)
- B F Nadaleto
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - B R Pinna
- Department of Ear, Nose and Throat, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - M G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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22
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Adão D, Carlotto JRM, Oyama PRL, Herbella FAM. Spontaneous viral tracheoesophageal fistula. Dis Esophagus 2016; 29:886. [PMID: 25229808 DOI: 10.1111/dote.12286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- D Adão
- Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
| | - J R M Carlotto
- Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
| | - P R L Oyama
- Department of Surgery, Federal University of São Paulo, São Paulo, Brazil
| | - F A M Herbella
- Department of Surgery, Federal University of São Paulo, São Paulo, Brazil.
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23
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Abstract
Intrathoracic stomach is a rare finding. The real value of the high-resolution manometry (HRM) in the preoperative evaluation of these patients has not yet being fully tested. This study aims to evaluate: 1) the HRM pattern of patients with an intrathoracic stomach; and 2) HRM findings as predictors for prosthetic reinforcement of the hiatus. We reviewed 33 patients (27 women, mean age 66 years) with an intrathoracic stomach who underwent HRM. Fifteen patients did the HRM as part of preoperative workup and were operated on in our institution. All patients were submitted to a laparoscopic Nissen fundoplication. HRM results show that the lower esophageal sphincter (LES) was transposed in all patients. Hiatal hernia was diagnosed in 21 (63%) patients. The length of the hernia was 4 ± 2 cm (range, 1 to 9 cm). LES oscillation was observed in 23 (69%) patients with a mean of 1 ± 0.4 cm (range, 0.4 to 2 cm). Hiatal mesh reinforcement was necessary in five (33%) of the operated patients. HRM findings did not predict hiatal mesh reinforcement. Our results show that: 1) HRM has a poor sensibility for hiatal hernia diagnosis; 2) half of the patients with an intrathoracic stomach have a normal HRM; and 3) HRM does not predict mesh hiatal hernia repair.
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Affiliation(s)
- Vanderlei Martinelo
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil; and the
| | | | - Marco G. Patti
- Department of Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
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Martinelo V, Mardiros Herbella FA, Patti MG. High-resolution manometry findings in patients with an intrathoracic stomach. Am Surg 2015; 81:354-357. [PMID: 25831180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Intrathoracic stomach is a rare finding. The real value of the high-resolution manometry (HRM) in the preoperative evaluation of these patients has not yet being fully tested. This study aims to evaluate: 1) the HRM pattern of patients with an intrathoracic stomach; and 2) HRM findings as predictors for prosthetic reinforcement of the hiatus. We reviewed 33 patients (27 women, mean age 66 years) with an intrathoracic stomach who underwent HRM. Fifteen patients did the HRM as part of preoperative workup and were operated on in our institution. All patients were submitted to a laparoscopic Nissen fundoplication. HRM results show that the lower esophageal sphincter (LES) was transposed in all patients. Hiatal hernia was diagnosed in 21 (63%) patients. The length of the hernia was 4 ± 2 cm (range, 1 to 9 cm). LES oscillation was observed in 23 (69%) patients with a mean of 1 ± 0.4 cm (range, 0.4 to 2 cm). Hiatal mesh reinforcement was necessary in five (33%) of the operated patients. HRM findings did not predict hiatal mesh reinforcement. Our results show that: 1) HRM has a poor sensibility for hiatal hernia diagnosis; 2) half of the patients with an intrathoracic stomach have a normal HRM; and 3) HRM does not predict mesh hiatal hernia repair.
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Affiliation(s)
- Vanderlei Martinelo
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
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25
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Lourenço LG, Carlotto JRM, Herbella FAM, Silva DAF, Setti HB. Muscular metastasis from gastric cancer. J Gastrointest Oncol 2014; 5:E100-2. [PMID: 25436130 DOI: 10.3978/j.issn.2078-6891.2014.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 06/23/2014] [Indexed: 11/14/2022] Open
Abstract
The association between gastric cancer and muscle metastasis is extremely rare. Few cases have been reported in the literature. We report a case of a 68-year-old man, with a diagnosis of gastric adenocarcinoma by endoscopy and biopsy. A painful nodule on the right thigh became noticeable during chemotherapy sessions, where positron emission tomography and percutaneous biopsy diagnosed a muscle metastasis of gastric adenocarcinoma. This report demonstrates the importance of further investigation of muscle lesion in patients with gastrointestinal cancer and how we can diagnose and treat these lesions.
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Affiliation(s)
- Laércio Gomes Lourenço
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Diego Adão Fanti Silva
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
| | - Henrique Barroso Setti
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
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26
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Abstract
This review focus on the utility of HRM for the evaluation of gastric motility. The evaluation of gastric motility has clinical implications for the study of a myriad of diseases. Disordered motility represents a spectrum of dysfunction ranging from delayed gastric emptying to abnormally rapid gastric transit. Gastric motility may be measured by a variety of methods with different efficacy and different variables that may be obtained. High-resolution manometry was created and added to the diagnostic armamentarium. The methods and outcomes for the study of proximal motility that may be useful to assess the thoracoabdominal pressure gradient, gastric filling and accommodation are described. Also, studies on antroduodenal manometry are reviewed. High-resolution manometry allows gastric manometry without technical limitations found on conventional manometry; however, studies are still on the phase of understanding the normal findings.
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Affiliation(s)
- Fernando Augusto Mardiros Herbella
- Department of Surgery, Escola Paulista de Medicina, Division of Esophagus and Stomach, Surgical Gastroenterology, Federal University of Sao Paulo, Hospital Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil,
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27
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Abstract
The progression of certain primary esophageal motor disorders to achalasia has been documented; however, the true incidence of this decay is still elusive. This study aims to evaluate: (i) the incidence of the progression of diffuse esophageal spasm to achalasia, and (ii) predictive factors to this progression. Thirty-five patients (mean age 53 years, 80% females) with a manometric picture of diffuse esophageal spasm were followed for at least 1 year. Patients with gastroesophageal reflux disease confirmed by pH monitoring or systemic diseases that may affect esophageal motility were excluded. Esophageal manometry was repeated in all patients. Five (14%) of the patients progressed to achalasia at a mean follow-up of 2.1 (range 1-4) years. Demographic characteristics were not predictive of transition to achalasia, while dysphagia (P= 0.005) as the main symptom and the wave amplitude of simultaneous waves less than 50 mmHg (P= 0.003) were statistically significant. In conclusion, the transition of diffuse esophageal spasm to achalasia is not frequent at a 2-year follow-up. Dysphagia and simultaneous waves with low amplitude are predictive factors for this degeneration.
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Affiliation(s)
- L H S Fontes
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Brazil.
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28
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Vicentine FPP, Herbella FAM, Allaix ME, Silva LC, Patti MG. Comparison of idiopathic achalasia and Chagas' disease esophagopathy at the light of high-resolution manometry. Dis Esophagus 2013; 27:128-33. [PMID: 23795824 DOI: 10.1111/dote.12098] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The comparison between idiopathic achalasia (IA) and Chagas' disease esophagopathy (CDE) may evaluate if treatment options and their outcomes can be accepted universally. This study aims to compare IA and CDE at the light of high-resolution manometry. We studied 86 patients with achalasia: 45 patients with CDE (54% females, mean age 55 years) and 41 patients with IA (58% females, mean age 49 years). All patients underwent high-resolution manometry. Upper esophageal sphincter parameters were similar (basal pressure CDE = 72 ± 45 mmHg, IA = 82 ± 57 mmHg; residual pressure CDE = 9.9 ± 9.9 mmHg, IA = 9.8 ± 7.5 mmHg). In the body of the esophagus, the amplitude was higher in the IA group than the CDE group at 3 cm (CDE = 15 ± 14 mm Hg, IA = 42 ± 52 mmHg, P = 0.003) and 7 cm (CDE = 16 ± 15 mmHg, IA = 36 ± 57 mmHg, P = 0.04) above the lower esophageal sphincter (LES). The LES basal pressure (CDE = 17 ± 16 mmHg, IA = 40 ± 22 mmHg, P < 0.001) and residual pressure (CDE = 12 ± 11 mmHg, IA = 27 ± 13 mmHg, P < 0.001) were also higher in the IA group. Our results show that: (i) there is no difference in regards to the upper esophageal sphincter; (ii) higher pressures of the esophageal body are noticed in patients with IA; and (iii) basal and residual pressures of the LES are lower in patients with CDE. Our results did not show expressive manometric differences between IA and CDE. Some differences may be attributed to a more pronounced esophageal dilatation in patients with CDE.
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Affiliation(s)
- F P P Vicentine
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
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29
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Cassão BD, Herbella FAM, Silva LC, Vicentine FPP. Motilidade esofágica após derivação gástrica em Y-de-Roux para obesidade mórbida: achados à manometria de alta resolução. ABCD, arq bras cir dig 2013; 26 Suppl 1:22-5. [DOI: 10.1590/s0102-67202013000600006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 03/11/2013] [Indexed: 11/22/2022]
Abstract
RACIONAL:A cirurgia bariátrica pode provocar alterações na motilidade esofágica. Entretanto, existe paucidade de estudos com a manometria de alta resolução. OBJETIVO: Avaliar a motilidade esofágica em pacientes submetidos à derivação gástrica em Y-de-Roux para obesidade mórbida. MÉTODOS: Foram estudados 18 pacientes assintomáticos submetidos à derivação gástrica em Y-de-Roux por laparotomia. Todos foram submetidos à manometria de alta resolução em média três anos após a operação. RESULTADOS: O esfíncter esofagiano inferior teve pressão basal média de 18±13 (variação 0-51) mmHg; sete pacientes (39%) apresentaram hipotonia e um (5%) hipertonia. O relaxamento foi anormal em um paciente. O comprimento total e abdominal do esfíncter foi de 4±1 (1-7) cm e 2±1 (0-3) cm, respectivamente. A amplitude distal do corpo esofágico (média de 3 e 7 cm acima do esfíncter) foi de 77±22 (40-120) mmHg e um paciente (5%) teve hipocontratilidade. Ondas peristálticas foram vistas em 95±0% (60-100). O esfíncter esofagiano superior tinha pressão basal média de 118±82 (33 - 334) mmHg; um (5%) paciente apresetnou hipotonia e oito (44%) hipertonia. CONCLUSÃO: Após a derivação gástrica, ocorreu significante hipotonia do esfíncter esofágico inferior e hipertonia do esfíncter esofágico superior.
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30
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Nunes TF, von Atzingen AC, Herbella FAM, D'Ippólito G, Colleoni R. Abdominal pain after the repair of an aortoiliac aneurysm. Acta Gastroenterol Latinoam 2012; 42:84-162. [PMID: 22876706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Thiago F Nunes
- Division of Abdominal Imaging, Department of Radiology, Universidade Federal de São Paulo, Brazil
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31
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Valezi AC, Herbella FAM, Junior JM, de Almeida Menezes M. Esophageal Motility after Laparoscopic Roux-en-Y Gastric Bypass: the Manometry Should Be Preoperative Examination Routine? Obes Surg 2012; 22:1050-4. [DOI: 10.1007/s11695-012-0613-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Santos RS, Lourenço JEV, Herbella FAM, Del Grande JC, Patti MG. Helicobacter pylori has no influence on distal gastric cancer survival. Arq Gastroenterol 2012; 48:109-11. [PMID: 21709951 DOI: 10.1590/s0004-28032011000200005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 12/15/2010] [Indexed: 11/22/2022]
Abstract
CONTEXT There is some evidence that Helicobacter pylori correlates with distal gastric cancer genesis. However, few studies analyzed the survival related to H. pylori infection. OBJECTIVE To correlate gastric cancer survival and H. pylori infection. METHODS Sixty-eight patients with distal gastric cancer that underwent subtotal gastrectomy were studied. Minimal follow-up was 1 month. H. pylori infection was confirmed by biopsy. RESULTS Thirty-four patients (19 males (55.9%), mean age 60.9 ± 14.03, range 33-82 years) were H. pylori positive. Thirty-four patients (16 males (47.1%), mean age 57.9 ± 13.97, range 27-85 years) were H. pylori negative. Groups were comparable in regards to age (P = 0.4), gender (P = 0.5), stage [T (P = 0.2), N (P = 0.6) and M (P = 0.9)]. Survival was not different when groups were compared [P = 0.1616 (hazard ratio 0.6834, 95% CI 0.4009 to 1.1647)]. CONCLUSIONS H. pylori infection does not affect distal gastric cancer survival.
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Affiliation(s)
- Renata S Santos
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil
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Abstract
Esophageal diverticula are rare. The association of cancer and diverticula has been described. Some authors adopt a conservative non-surgical approach in selected patients with diverticula whereas others treat the symptoms by diverticulopexy or myotomy only, leaving the diverticulum in situ. However, the risk of malignant degeneration should be may be taken in account if the diverticulum is not resected. The correct evaluation of the possible risk factors for malignancy may help in the decision making process. We performed a literature review of esophageal diverticula and cancer. The incidence of cancer in a diverticulum is 0.3-7, 1.8, and 0.6% for pharyngoesophageal, midesophageal, and epiphrenic diverticula, respectively. Symptoms may mimic those of the diverticulum or underlying motor disorder. Progressive dysphagia, unintentional weight loss, the presence of blood in the regurgitated material, regurgitation of peaces of the tumor, odynophagia, melena, hemathemesis, and hemoptysis are key symptoms. Risk factors for malignancy are old age, male gender, long-standing history, and larger diverticula. A carcinoma may develop in treated diverticula, even after resection. Outcomes are usually quoted as dismal because of a delayed diagnosis but several cases of superficial carcinoma have been described. The treatment follows the same principals as the therapy for esophageal cancer; however, diverticulectomy is enough in cases of superficial carcinomas. Patients must be carefully evaluated before therapy and a long-term follow-up is advisable.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Abstract
An unbuffered layer of acidity that escapes neutralization by food has been demonstrated in volunteers and gastroesophageal reflux disease patients. This postprandial proximal gastric acid pocket (PPGAP) is manometrically defined by the presence of acid reading (pH<4) in a segment of the proximal stomach between nonacid segments distally (food) and proximally (lower esophageal sphincter or distal esophagus). The PPGAP may have important clinical implications; however, it is still poorly understood. Gastric anatomy and physiology seem to be important elements for PPGAP genesis. Gastric operations and acid suppression medications may decrease distal - proximal intragastric acid reflux and help control gastroesophageal reflux.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Abstract
BACKGROUND An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in the majority of normal individuals and patients with gastroesophageal reflux disease. The role of gastric anatomy, specifically the antrum, in the physiology of the PPGAP is not yet fully elucidated. This study aims to analyze the presence of PPGAP in patients submitted to distal gastrectomy. METHODS A total of 15 patients who had a distal gastrectomy plus DII lymphadenectomy and Roux-en-Y reconstruction for gastric adenocarcinoma (mean age 64.3±8.4 years, 12 females) were studied. All patients were free of foregut symptoms after the operation. Patients underwent a high-resolution manometry. A station pull-through pH monitoring was performed from 5cm below the lower border of the lower esophageal sphincter (LBLES) to the LBLES in increments of 1cm in a fasting state and 10min after a standardized fatty meal. Postprandial proximal gastric acid pocket was defined by the presence of acid reading (pH<4) in a segment of the proximal stomach between non-acid segments distally (food) and proximally (LBLES). The PPGAP extent was recorded. The protocol was approved by local ethics committee. Key Results Acidity was not detected in the stomach of nine patients before meal. After meal, PPGAP was not found in three patients. In three patients (20%), a PPGAP was noted with an extension of 1, 1 and 3cm. CONCLUSIONS & INFERENCES In conclusion, PPGAP is present in a minority of patients after distal gastrectomy; this finding may suggest that the gastric antrum may play a role in the genesis of the PPGAP.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Herbella FAM, Fuziy RA, Takassi GF, Dubecz A, Del Grande JC. Avaliação do treinamento e expectativas profissionais em residentes de cirurgia. Rev Col Bras Cir 2011; 38:280-4. [DOI: 10.1590/s0100-69912011000400013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Accepted: 11/30/2010] [Indexed: 11/22/2022] Open
Abstract
Os programas de residência médica, em especial na cirurgia, vêm passando por modificações constantes, não só em nosso meio, como internacionalmente. Em virtude da deterioração da valorização e remuneração médica, as expectativas e perfil do médico residente na área cirúrgica vêm mudando. A avaliação das atitudes, experiência durante o treinamento e expectativas profissionais nos residentes é tópico importante. Recentes trabalhos internacionais publicados na área demonstram tal fato. É digno de nota a ausência de trabalhos semelhantes em nosso meio e a raridade em outros países. O presente estudo tem por objetivo avaliar em médicos residentes da área de cirurgia, através de questionário, atitudes, experiências durante o treinamento e expectativas profissionais. Foram aplicados e analisados questionários adaptados e traduzidos para o Português em 50 residentes de ambos os sexos e diferentes anos de residência. Os resultados deste trabalho mostram alta satisfação com a especialidade, porém grande preocupação financeira e opiniões conflitantes quanto ao futuro da especiliadade;
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Herbella FAM, Vicentine FPP, Del Grande JC, Patti MG. Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery. Neurogastroenterol Motil 2011; 23:52-5, e4. [PMID: 20946544 DOI: 10.1111/j.1365-2982.2010.01618.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been demonstrated in normal individuals (NI) and patients with gastro-esophageal reflux disease (GERD). The role of gastric anatomy and gastric motility in the physiology of the PPGAP remains elusive. This study aims to analyze the correlation of PPGAP with proximal gastric pressure after gastric surgery. METHODS A total of 26 individuals were studied: eight patients after open Roux-en-Y gastric bypass (RYGB) for morbid obesity, six patients after laparoscopic Nissen fundoplication for GERD, seven patients after open subtotal gastrectomy for gastric cancer and five NI. Patients underwent high resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES) and measure gastric pressure 1, 2, 3, 4 and 5 cm below the LBLES, immediately before swallow and after the end of the LES relaxation. A station pull-through pH monitoring was performed in all but NI, from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal. KEY RESULTS Our results show that: (i) proximal gastric pressures are lower after swallow compared with before swallow in NI; (ii) patients after gastric surgery tend to have higher gastric pressure before and lower after swallow compared with NI and (iii) patients after RYGB with PPGAP have an increased gastric pressure after swallows in the segment where the PPGAP is noticed. CONCLUSIONS & INFERENCES Gastric motility may play a role in the genesis of PPGAP in patients after RYGB. The contribution of gastric motility for the genesis of PPGAP is still elusive in other patients.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Abstract
Even though the history of this condition extends for almost 100 years, the short esophagus (SE) is still one of the most controversial topics in esophageal surgery with its existence still denied by some distinguished surgeons. We reviewed the evolution behind the diagnosis and treatment of the SE and the persons who wrote its history, from the first descriptions by radiologists, endoscopists, and surgeons to modern treatment.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Esophagus Division, Escola Paulista de Medicina, UNIFESP, Rua Napoleão de Barros, São Paulo, Brazil.
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Szor DJ, Herbella FAM, Bonini AL, Moreno DG, Del Grande JC. Gastric fundus tension before and after division of the short gastric vessels in a cadaveric model of fundoplication. Dis Esophagus 2009; 22:539-42. [PMID: 19222530 DOI: 10.1111/j.1442-2050.2009.00945.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Short gastric vessels (SGV) division is a controversial topic in antireflux surgery. Some surgeons do not divide the SGV routinely to perform a fundoplication; however, excessive tension of the gastric fundus (GF) forces this procedure necessary in some cases. This study aims to evaluate in a cadaveric model of Nissen fundoplication: (i) the correlation of GF tension with anatomic parameters; and (ii) the effect of SGV division on GF tension. In total, 23 fresh cadavers (18 men, mean age 62 years) were studied. The abdominal esophagus was dissected, and the GF transposed to a limit of 3 cm to the right border of the esophagus. A dynamometer was attached to the GF and the tension recorded. Cadavers were grouped according to the presence or absence of tension. SGV were divided and GF tension measured again. The presence or absence of initial GF tension was correlated to: (i) number of SGV; (ii) length of the GF; (iii) distance between His angle and the first SGV; and (iv) size of the spleen. The mean GF pressure was 0.5 N +/- 1.0 (0-2.5) before SGV division and 0.1 N +/- 0.3 (0-1.5) after SGV division (P= 0.002). Initial tension was absent in 12 (52.2%) cases. GF tension did not correlate with any of the anatomic parameters. Our results show that: (i) GF tension does not correlate with anatomic parameters; and (ii) SGV division affects GF tension significantly.
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Affiliation(s)
- D J Szor
- Department of Surgery, Sao Paulo Medical School, Federal University of Sao Paulo, Brazil
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40
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Herbella FAM, Aquino JLB, Stefani-Nakano S, Artifon ELA, Sakai P, Crema E, Andreollo NA, Lopes LR, de Castro Pochini C, Corsi PR, Gagliardi D, Del Grande JC. Treatment of achalasia: lessons learned with Chagas' disease. Dis Esophagus 2008; 21:461-7. [PMID: 18430188 DOI: 10.1111/j.1442-2050.2008.00811.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Division of Esophagus and Stomach, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Raz DJ, Tedesco P, Herbella FAM, Nipomnick I, Way LW, Patti MG. Side-to-side stapled intra-thoracic esophagogastric anastomosis reduces the incidence of leaks and stenosis. Dis Esophagus 2008; 21:69-72. [PMID: 18197942 DOI: 10.1111/j.1442-2050.2007.00736.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Trans-hiatal esophagectomy with a hand-sewn anastomosis was for 2 decades the preferred approach in our institution for patients with esophageal cancer. In our experience, this anastomotic technique was associated with a 12% leak rate and a 48% rate of stricture requiring dilatation. We sought to determine if a side-to-side intra-thoracic anastomosis was associated with a lower rate of anastomotic stricture and leak. Thirty-three consecutive patients with distal esophageal cancer or Barrett's esophagus with high grade dysplasia underwent a trans-thoracic esophagectomy with a side-to-side stapled intra-thoracic anastomosis. The overall morbidity was 27%, with no anastomotic stricture or leaks. One patient died (3%). The median time to the resumption of an oral diet was 7 days (range 5-28), and the median length of stay in hospital was 9 days (range 6-45). Trans-thoracic esophagectomy with a side-to-side stapled anastomosis is safe and it is associated with a very low rate of anastomotic complications. We consider this to be the procedure of choice for patients with distal esophageal cancers.
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Affiliation(s)
- D J Raz
- Department of Surgery, University of California, San Francisco, CA 94143-0788, USA
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Herbella FAM, Tedesco P, Nipomnick I, Fisichella PM, Patti MG. Effect of partial and total laparoscopic fundoplication on esophageal body motility. Surg Endosc 2006; 21:285-8. [PMID: 17122978 DOI: 10.1007/s00464-006-0108-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 06/07/2006] [Indexed: 01/12/2023]
Abstract
BACKGROUND Abnormal esophageal body motility often accompanies gastroesophageal reflux disease (GERD). Although the effect of surgery on the pressure and behavior of the lower esophageal sphincter (LES) has been extensively studied, it still is unclear whether a successful fundoplication improves esophageal peristalsis. METHODS The pre- and postoperative esophageal manometries of 71 patients who underwent a successful laparoscopic fundoplication (postoperative DeMeester score < 14.7) were reviewed. The patients were grouped according to the type of fundoplication (partial vs total) and preoperative esophageal peristalsis (normal vs abnormal): group A (partial fundoplication and abnormal esophageal peristalsis; n = 16), group B (total fundoplication and normal peristalsis; n = 41), and group C (total fundoplication and abnormal peristalsis; n = 14). RESULTS The LES pressure was increased in all the groups. A significant increase in amplitude of peristalsis was noted in groups A and C. Normalization of peristalsis was achieved in 31% of the group A patients and 86% of the group C patients. No changes occurred in group B. CONCLUSIONS Laparoscopic fundoplication increased LES pressure and the strength of esophageal peristalsis in patients with abnormal preoperative esophageal motility. A total fundoplication resulted in normalization of peristalsis in the majority of patients.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Abstract
Esophagectomy is associated with a significant number of complications, some of them related to the concomitant vagotomy. The vagal-sparing esophagectomy is an attractive alternative to the conventional procedure; however, few clinical series have attested the integrity of the vagi nerves after esophagectomy. The surgical anatomy of the vagus in the mediastinum has received little interest as well. The anatomy of the vagus was studied in 30 fresh cadavers. Twenty cadavers were submitted to a vagal-sparing esophagectomy, and after the procedure, anatomical vagal integrity was evaluated. Concerning the anatomy of the vagus, one or more vagal trunks were present in all cases. Four patterns were identified: Type I, two distinct trunks without communicating branches, present in eight (26.7%) cases; Type II, two distinct trunks with communicating branches, present in 17 (56.7%) cases; Type III, one or more bifurcated trunks, present in four (13.3%) cases; and Type IV, crossing trunks, present in one (3.3%) case. Regarding the esophagectomy, operative accidents were not noticed; in five cases, there was incomplete removal of the muscular layer of the esophagus. In all cases vagi nerves were preserved. The vagus is preserved in a cadaveric model of the vagal sparing esophagectomy, irrespective of the anatomy of the vagus in the mediastinum.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Esophagus Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP Brazil.
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Pastore R, Crema E, Silveira MDC, Presoto AF, Herbella FAM, Del Grande JC. Eletromanometria esofágica e pHmetria de 24 horas na avaliação pós-operatória da hiatoplastia e válvula anti-refluxo total laparoscópica. Arq Gastroenterol 2006; 43:112-6. [PMID: 17119665 DOI: 10.1590/s0004-28032006000200010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Accepted: 02/02/2006] [Indexed: 11/22/2022]
Abstract
RACIONAL: A operação de "short floppy Nissen" tem como objetivo tratar o refluxo gastroesofágico. Avaliações clínicas e endoscópicas de sua eficiência têm sido demonstradas por diferentes autores, porém estudos comparando pHmetria ácida de 24 horas com exames realizados no pré e pós-operatório têm sido pouco freqüentes. OBJETIVOS: Avaliar os resultados da hiatoplastia e válvula anti-refluxo total laparoscópica no tratamento da doença do refluxo gastroesofágico não complicada através de estudo comparativo pré e pós-operatório de aspectos manométricos e pHmétricos. MÉTODOS: Cinqüenta e nove indivíduos com sintomas típicos de refluxo gastroesofágico submetidos a cirurgia de "short floppy Nissen" por laparoscopia foram estudados prospectiva e consecutivamente no período de março de 2002 a agosto de 2003. Realizou-se no período pré e pós-operatório, em um tempo mínimo de 3 meses, endoscopia digestiva alta, manometria esofágica e pHmetria ácida de 24 horas. RESULTADOS: Dezoito (30,5%) doentes eram do sexo masculino e 41 (69,5%) do feminino, com idade média de 43,8 anos. Houve diferença nos seguintes achados manométricos, quando comparados no período pré e pós-operatório: localização do esfíncter inferior do esôfago em relação à borda nasal; extensão do esfíncter inferior do esôfago; pressão de repouso do esfíncter inferior do esôfago; pressão do corpo esofágico. Houve diferença nos seguintes achados pHmétricos quando comparados no período pré e pós-operatório: redução do número de refluxo ácidos totais; número de refluxos ácidos prolongados; número de refluxos ácidos prolongados em decúbito dorsal; número de refluxos ácidos prolongados em posição ereta; fração de tempo de acidificação em minutos; índice de DeMeester. CONCLUSÕES: A eletromanometria e a pHmetria esofágicas mostraram melhora em cada um dos seus parâmetros com significância estatística entre os pacientes no período pré e pós-operatório de hiatoplastia e válvula anti-refluxo, demonstrando a eficiência do procedimento operatório quando avaliado por esses exames.
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Abstract
Esophageal duplication is a rare congenital esophageal disorder. Surgical excision is the standard treatment for symptomatic esophageal duplication cysts. Traditionally, the resection is accomplished via thoracotomy; however, a minimally invasive approach is possible, avoiding the long hospital stay, the discomfort and the long recovery time due to a thoracotomy. The authors describe two cases of esophageal duplication resected via a left thoracoscopic approach.
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Affiliation(s)
- F A M Herbella
- Departments of Surgery and Medicine, University of California, San Francisco, CA 94143-0790, USA
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Herbella FAM, Del Grande JC. [Autopsies and surgery]. Ann Chir 2005; 130:596. [PMID: 15992763 DOI: 10.1016/j.anchir.2005.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Accepted: 05/22/2005] [Indexed: 05/03/2023]
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Goldenberg A, Matone J, Marcondes W, Herbella FAM, Farah JFDM. Comparative study of inflammatory response and adhesions formation after fixation of different meshes for inguinal hernia repair in rabbits. Acta Cir Bras 2005; 20:347-52. [PMID: 16186957 DOI: 10.1590/s0102-86502005000500002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Compare, in a rabbit model, the inflammatory response and adhesions formation following surgical fixation of polypropilene and Vypro mesh in the inguinal preperitoneal space. METHODS Fourteen male New Zealand rabbits, weighing between 2.000 to 2.500 g were used. A midline incision was made and the peritoneal cavity was exposed. The 2.0 x 1.0 cm polypropylene mesh was fixed in the left flank and secured to the margins with 3-0 prolene in a separate pattern. In the right flank, a 2.0 x 1.0 cm Vypro II mesh was sewn in the same way. After the post surgical period, the animals were again anesthetized and underwent laparoscopic approach, in order to identify and evaluate adhesions degree. Both fixed prosthesis were excised bilaterally with the abdominal wall segment, including peritoneum, aponeurosis and muscle and sent to a pathologist. RESULTS Operative time ranged from 15 to 25 minutes and no difficulties in applying the mesh were found. From the 14 polypropylene meshes fixed to the intact peritoneum, 11 had adhesions to the abdominal cavity (78.6%). Concerning Vypro mesh, 12 animals developed adhesions from the 14 with mesh fixation (85.7%). Histological examination of tissues harvested revealed fibroblasts, collagen, macrophages and lymphocytes between the threads of the mesh. CONCLUSION Polypropylene and Vypro mesh, when implanted in the peritoneal cavity of rabbits provoke similar amount of adhesions. Vypro mesh tissues had higher fibrosis resulting in better mesh incorporation to the abdominal wall.
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Affiliation(s)
- Alberto Goldenberg
- Gastrointestinal Division, Federal University of São Paulo, Escola Paulista de Medicina, São Paulo, Brazil.
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48
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Abstract
Weight loss is a frequent finding in achalasia because of the difficulty in swallowing. Although manometric findings compatible with achalasia have been found in morbidly obese patients, all of them were asymptomatic. The authors report a case of symptomatic achalasia and morbid obesity in a 38-year-old woman. A mental disorder become manifested after the patient was submitted to an esophageal myotomy and fundoplication. With weight gain, postoperative gastroesophageal reflux developed. Drawbacks of further operative procedures in such a patient are discussed.
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Abstract
Eponyms in medicine are frequently criticized because they may not represent the person who first described a syndrome or disease. Although eponyms are very commonly used, most readers are probably unaware of who it was that named the diseases and whether the original description of the disease still corresponds to the modern definition. The 10 most common eponyms in esophageal diseases were revisited. The men and the disease behind Barrett's esophagus, Boerhaave's syndrome, Mallory-Weiss syndrome, Cameron ulcer, Schatzki ring, Paterson-Kelly syndrome, Plummer-Vinson, Chagas's disease, Zenker diverticulum and Killian diverticulum are reviewed here.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Esophagus Division, Escola Paulista de Medicina, Unifesp, Rua Napoleão de Barros, 715 2 andar, São Paulo, SP, Brazil.
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50
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Abstract
Eponyms are frequently used in the surgery in homage to remarkable surgeons, specially creators of new surgical techniques and instruments. Sometimes, however, the right person is not revered or the name persists, but the author's technique has been changed over time and the original procedure is lost. Eponyms of the 10 most famous procedures in esophageal surgery are revisited. Names like Lortat-Jacob, Toupet, Dor, Heller, Nissen, Ivor Lewis, Collis, Merendino, Hill, and Belsey, are reviewed, analyzing the man behind the name, the original technique and its modifications.
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Affiliation(s)
- F A M Herbella
- Department of Surgery, Esophagus Division, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil.
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