Biomedical subjects

Patricio Burdiles

Publications and source records attributed to Patricio Burdiles.

At least 19 recordsLinked to original sources

PubMed2006

Increased production of IL-1alpha and TNF-alpha in lipopolysaccharide-stimulated blood from obese patients with non-alcoholic fatty liver disease.

Enhanced pro-inflammatory cytokine production is considered a pathogenic factor in non-alcoholic fatty liver disease (NAFLD). Peripheral blood production of interleukin-1alpha (IL-1alpha) and tumor necrosis factor-alpha (TNF-alpha) was studied in relation to the severity of histological changes of the liver in obese NAFLD patients. Basal levels in serum and production of IL-1alpha and TNF-alpha in peripheral blood cell cultures after stimulation with lipopolysaccharide (enzyme-linked immunoabsorbent assays) were measured in 11 patients with steatosis and 15 with steatohepatitis, who underwent gastrectomy with a gastro-jejunal anastomosis in roux and Y, and in 9 controls who underwent anti-reflux surgery. Production of IL-1alpha and TNF-alpha was 122 and 67% higher in patients with steatosis than control values, respectively. In patients with steatohepatitis, IL-1alpha production was 300 and 80% higher and that of TNF-alpha 110 and 26% higher, as compared with controls and steatosis patients, respectively. Production of IL-1alpha was positively correlated with that of TNF-alpha (r=0.78, p<0.0001). IL-1alpha and TNF-alpha production were both positively correlated with the degree of steatosis (r=0.68, p<0.001 and r=0.74, p<0.0001) and steatohepatitis (r=0.77 and r=0.75, p<0.0001) at liver biopsy, and with the homeostasis model assessment index (r=0.73, p<0.0001 and r=0.63, p<0.01), respectively. Basal serum IL-1alpha and TNF-alpha levels were comparable in the three groups studied. It is concluded that elevated production of IL-1alpha and TNF-alpha by in vitro stimulated whole blood cell cultures occurs in NAFLD obese patients, which might play a pathophysiological role upon inflammatory leukocyte infiltration of the liver.

Adult↗

PubMed2006

Effect of gastric bypass on Barrett's esophagus and intestinal metaplasia of the cardia in patients with morbid obesity.

Gastric bypass in patients with morbid obesity should be an excellent antireflux procedure, because no acid is produced at the small gastric pouch and no duodenal reflux is present, due to the long Roux-en-Y limb. Five hundred fifty-seven patients with morbid obesity submitted to resectional gastric bypass, and routine preoperative upper endoscopy with biopsy samples demonstrated 12 patients with Barrett's esophagus (2.1%) and three patients with intestinal metaplasia of the cardia (CIM). An endoscopic procedure was repeated twice after surgery, producing seven patients with short-segment Barrett's esophagus (BE) and five patients with long-segment BE. Body mass index (BMI) decreased significantly, from 43.2 kg/m(2) to 29.4 kg/m(2) 2 years after surgery. Symptoms of reflux esophagitis, which were present in 14 of the 15 patients, disappeared in all patients 1 year after surgery. Preoperative erosive esophagitis and peptic ulcer of the esophagus healed in all patients. There was regression from intestinal metaplasia to cardiac mucosa in four patients (57%) with short-segment BE, and in one patient (20%) with long-segment BE. Two (67%) of three cases with CIM had regression to cardiac mucosa. There was no progression to low- or high-grade dysplasia. Gastric bypass in patients with Barrett's esophagus and morbid obesity is an excellent antireflux operation, proved by the disappearance of symptoms and the healing of endoscopic esophagitis or peptic ulcer in all patients, which is followed by an important regression to cardiac mucosa that is length-dependent and time-dependent.

Adult↗

PubMed2006

Regression of intestinal metaplasia to cardiac or fundic mucosa in patients with Barrett's esophagus submitted to vagotomy, partial gastrectomy and duodenal diversion. A prospective study of 78 patients with more than 5 years of follow up.

BACKGROUND: Regression of intestinal metaplasia to cardiac mucosa in patients with Barrett's (BE) esophagus could alter the natural history of BE. OBJECTIVE: To determine the regression of intestinal metaplasia to cardiac mucosa in patients followed more than 5 years after operation, by repeated endoscopy with biopsy. MATERIAL AND METHODS: This prospective study included 78 patients with BE submitted to combined vagotomy, antrectomy (an antireflux procedure), and Roux-en-Y gastrointestinal reconstruction with more than 60 months follow up. Patients were divided in 3 groups: (1) 31 with short-segment BE (< or =30 mm length); (2) 42 with long-segment BE (31 to 99 mm length); and (3) 5 with extra-long-segment BE (> or =100 mm). Each patient had at least three endoscopic procedures with multiple biopsies during a mean follow up of 95 months (range, 60-220 months). Acid and duodenal reflux were also evaluated. RESULTS: Sixty-four percent of patients with short segment BE had regression to cardiac mucosa at a mean of 40 months after operation. Sixty-two percent of patients with long segment BE had regression to cardiac mucosa at a mean of 47 months postoperatively. No regression occurred in the 5 patients with extra-long segment BE. In 20% of patients, regression to fundic mucosa occurred between 78 to 94 months after surgery. One patient progressed to low grade dysplasia, but no patient progressed to high-grade dysplasia or adenocarcinoma. Acid and duodenal reflux studies demonstrated that in asymptomatic patients, reflux was abolished; 90% of the patients had a Visick grade of 1 or 2. CONCLUSIONS: Vagotomy and antrectomy combined with duodenal bile diversion abolish acid and duodenal reflux into the distal esophagus in patients with BE, which is accompanied by a regression of BE from intestinal to cardiac or fundic mucosa in about 60% of patients. This regression is time dependent and varies directly with the length of BE. The potential for an antineoplastic effect, especially in young patients with long segment BE, suggests that this operation may become an attractive option as a definitive surgical treatment. Patients with short segment BE submitted to this procedure behave similar to patients submitted to Nissen fundoplication, and therefore in these patients, we do not advocate this complex operation.

Adolescent↗

PubMed2006

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.

Adult↗

PubMed2005

[Strategies for the surgical treatment of gallbladder cancer].

There is controversy in some aspects of the surgical treatment of non-mucosal gallbladder carcinoma. An accurate staging based on T (wall) involvement is crucial, otherwise understanding may yield falsely pessimistic results. The decision about the type of resection to be performed should be based on patient status (age, performance, comorbidities, etc) and tumor characteristics (histological type, vascular, neural or lymphatic spread, cell differentiation, tumor involvement of surgical margins in cystic duct, etc). For muscular (T1b) involvement, there is a great controversy about performing a simple cholecystectomy or en-block radical resection. For T2 there is consensus that an en-block radical surgery including liver resection (IVb - V) and lymphonodal clearance should be performed, since this approach has a great impact in survival. The role of surgical excision for tumors with serosal or liver involvement is controversial, due to the poor survival of these patients. However we have observed a 13% actuarial survival at 5 years, in this subset of patients.

Carcinoma↗

PubMed2005

[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.

Adolescent↗

PubMed2005

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.

Barrett Esophagus↗

PubMed2005

Results of gastric bypass plus resection of the distal excluded gastric segment in patients with morbid obesity.

Surgical treatment is the procedure of choice for morbidly obese patients. Gastric bypass with a long limb Roux-en-Y anastomosis is the "gold standard" technique for these patients. We sought to determine the early and late results of open gastric bypass with resection of the distal excluded stomach in patients with morbid obesity. We included in this prospective study 400 patients who were seen from September 1999 through August 2003 (311 women and 89 men; mean age, 38.5 years). The mean body mass index of the patients was 46 kg/m2. All underwent 95% distal gastrectomy, with resection of the bypassed stomach, leaving a small gastric pouch of 15 to 20 ml. An end-to-side gastrojejunostomy was performed with circular stapler No. 25. The length of the Roux-en-Y loop was 125 to 150 cm. In all patients, a biopsy was taken from the liver and routine cholecystectomy was performed. Follow-up was as long as 36 months. A barium study was performed in all patients at 5 days after surgery. Mortality and postoperative morbidity rates were 0.5% and 4.75%, respectively, mainly due to anastomotic leak in 10 patients (2.5%). Hospital length of stay was 7 days for 95% of the patients. Follow-up data for longer than 12 months were available in 184 patients. There was excess body weight loss of 70% at 24 and 36 months, and there was an inverse correlation among preoperative body mass index and the loss of weight. Anemia was present in 10%, and incisional hernia was present in 10.2%. At 1 year after surgery, the BAROS index demonstrated very good or excellent index in 96.6% of the patients. Gastric bypass with resection of the distal excluded segment has results very similar to those of gastric bypass alone but eliminates the potential risks of gastric bypass such as anastomotic ulcer, gastrogastric fistula, postoperative bleeding due to peptic ulcer and gastritis, and the eventual future development of gastric cancer. It is also possible to perform via laparoscopy, as we started to do recently.

Adolescent↗

PubMed2005

Serum folate and homocysteine levels in obese females with non-alcoholic fatty liver.

OBJECTIVE: Folate depletion and hyperhomocysteinemia increase the risk for hepatic alcoholic damage and promote oxidative stress in animals. In addition, some investigators have reported an inverse association between serum folate and body mass index and a positive correlation between total homocysteine and fat mass. We investigated whether there is an association between serum folate and total homocysteine concentrations with the presence of non-alcoholic fatty liver disease (NAFLD) in obese subjects. METHODS: Forty-three obese (body mass index > or =35 kg/m2) patients who underwent bariatric surgery and hepatic biopsy were included. Serum total homocyteine, folate and vitamin B12 concentrations and hepatic enzymes were measured. Liver biopsies were graded for the presence of fat, inflammation, and fibrosis on a scale from 0 to 3. A total histologic score was calculated based on the sum of partial scores. Severe NAFLD was defined as a total score of at least 4 or severe steatosis (partial score for fat = 3). RESULTS: Severe NAFLD was present in 17 patients. Serum folate concentration was significantly lower in obese patients with NAFLD than in those with normal liver or minimal alterations (9.3 +/- 3.5 versus 12.2 +/- 3.1 ng/mL, P = 0.005). Serum total homocysteine and vitamin B12 concentrations were similar in both groups. An inverse correlation between serum folate concentration and body mass index was observed (r = -0.31, P = 0.046). CONCLUSIONS: In this study, severe NAFLD in obese subjects was associated with lower serum folate concentrations and serum homocysteine and vitamin B12 concentrations were not associated with liver damage in obese subjects.

Adult↗

PubMed2005

Conservative management of anastomotic leaks after 557 open gastric bypasses.

BACKGROUND: One of the most serious complications after gastric bypass is an anastomotic leak. In a prospective surgical protocol for the management of this complication, the authors determined the incidence of anastomotic leaks. METHODS: From August 1999 to January 2005, 557 patients with morbid obesity were submitted to laparotomic resectional gastric bypass. In all patients a left drain was placed during surgery. All patients had a radiological study with liquid barium sulphate on the 5th postoperative day. After the occurrence of an anastomotic leak, the daily output of the leak was carefully measured. RESULTS: 12 patients developed an anastomotic leak at the gastrojejunostomy. All were managed medically, with antibiotics if necessary, enteral or parenteral feeding and frequent control by imaging procedures. In 8 patients, the left drain was maintained in situ up to 43 days after surgery. In 4 patients, the drain had been removed between the 5th and 8th days after surgery after a normal radiologic study, but had to be inserted under radiological control 2-3 weeks after the gastric bypass. Daily output increased significantly the second week after surgery, and the leak closed at a mean of 30 days after surgery. One patient of the 12 (8%) died 32 days after surgery from septic shock, without any abdominal collection secondary to the leak. CONCLUSION: The occurrence of an anastomotic leak is nearly 2% after gastric bypass. The majority of them can be managed medically, without the need for a reoperation, due to the fact that there is no acid production in the small gastric pouch and there is no intestinal reflux due to the long Roux loop.

Adolescent↗

PubMed2004

Oxidative stress-related parameters in the liver of non-alcoholic fatty liver disease patients.

Oxidative stress is implicated in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). In the present study, hepatic and plasma oxidative stress-related parameters were measured and correlated with clinical and histological findings in 31 NAFLD patients showing increased body mass index. Liver protein carbonyl content was enhanced by 403% in patients with steatosis (n=15) compared with control values (n=12), whereas glutathione content, superoxide dismutase (SOD) activity and the ferric reducing ability of plasma (FRAP) were decreased by 57%, 48% and 21% (P<0.05) respectively. No changes in microsomal p-nitrophenol hydroxylation and the total content of cytochrome P450 (CYP) or CYP2E1 were observed. Patients with steatohepatitis (n=16) exhibited protein carbonyl content comparable with that of controls, whereas glutathione content, SOD and catalase activities were decreased by 27%, 64% and 48% (P<0.05). In addition, FRAP values in patients with steatohepatitis were reduced by 33% and 15% (P<0.05) when compared with controls and patients with steatosis respectively, whereas p-nitrophenol hydroxylation (52%) and CYP2E1 content (142%) were significantly increased (P<0.05) compared with controls. It is concluded that oxidative stress is developed in the liver of NAFLD patients with steatosis and is exacerbated further in patients with steatohepatitis, which is associated with CYP2E1 induction. Substantial protein oxidation is followed by proteolysis of the modified proteins, which may explain the co-existence of a diminished antioxidant capacity and protein oxidation in the liver of patients with steatohepatitis.

Adolescent↗

PubMed2004

[Laparoscopic splenectomy in hematological diseases].

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.

Adolescent↗

PubMed2003

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.

Adult↗

PubMed2003

[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.

Adenocarcinoma↗

PubMed2002

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.

Adolescent↗

PubMed2002

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.

Adolescent↗

PubMed2002

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.

Anastomosis, Roux-en-Y↗

PubMed2002

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.

Adult↗