41 - no.3 ± jul./set. 2004. Arq Gastroenterol. 155 !21'!. ARTIGO ORIGINAL / ORIGINAL ARTICLE. ).42/$5#4)/. 2ECURRENCE. PERFORMED. WITH. THE. THE.
$57,*225,*,1$/25,*,1$/$57,&/(
!21'!
#!2$)/0,!349!.$ 2/58 %. 90!24)!, '!342%#4/-93%22! $»2)! 02/#%$52% &/22%/0%2!4)/. /&!#(!,!3)!
(ELIO0/.#)!./ )VAN#%##/.%,,/ ,EOSARTE!,6%3 "ERIVALDO$IAS&%22%)2!AND*OAQUIM'!-! 2/$2)'5%3 !"342!#4 "ACKGROUND !FTERCARDIOMYOTOMYFORTHETREATMENTOFMEGAESOPHAGUS RECURRENCEOFSYMPTOMSOCCURINUPTOOFTHE PATIENTS BUTONLYSOMEREQUIREAREOPERATION!IM 4OEVALUATETHERESULTSOFREOPERATION CARDIOPLASTYWITH2OUX EN 9PARTIALGASTRECTOMY ATECHNIQUEPROPOSEDBY3ERRA $ØRIA#ASUISTICAND-ETHODSn4WENTYPATIENTSWITHACHALASIAPREVIOUSLYTREATEDBYCARDIOMYOTOMY WERE RETROSPECTIVELYSTUDIED4HEETIOLOGYOFSYMPTOMSRECURRENCEWASREmUXESOPHAGITISINNINE PATIENTS HEALINGOFTHEMYOTOMYIN lVE ENDSTAGINGMEGAESOPHAGUSINlVE ANDINCOMPLETEMYOTOMYINONE )NTRAANDPOSTOPERATIVECOMPLICATIONS WEREANALYZED4HEPATIENTSWERESTUDIEDBYCLINICALDYSPHAGIA REGURGITATION HEARTBURNANDWEIGHTGAIN RADIOLOGICALANDENDOSCOPIC EVALUATION INTHEPRE ANDPOSTOPERATIVEPERIOD2ESULTSn&IVE PATIENTSHADCOMPLICATIONSINTHEIMMEDIATEPOSTOPERATIVEPERIOD .ODEATHSWEREOBSERVED$YSPHAGIAIMPROVEDINALLTHEPATIENTS2EGURGITATIONANDHEARTBURNALMOSTDISAPPEAREDINTHEWHOLEGROUP 7EIGHTWASMAINTAINEDORINCREASEDINOFTHEPATIENTS2ADIOLOGICALSTUDIESSHOWEDADECREASEINTHECALIBEROFTHEESOPHAGUSIN WHILETHEREMAININGPATIENTSMAINTAINEDTHEPRE OPERATIVEDIAMETER%NDOSCOPY PERFORMEDDURINGTHELATEPOSTOPERATIVEPERIODIN PATIENTS SHOWEDTHATAMONGTHEWITHREmUXESOPHAGITISIMPROVEDAMONGTHEWITHANORMALESOPHAGUSDURINGTHEPREOPERATIVE PERIOD DEVELOPEDESOPHAGITIS#ONCLUSIONSn4HE3ERRA $ØRIAPROCEDUREFORTHETREATMENTOFMEGAESOPHAGUSINPATIENTSWHOHADALREADY UNDERGONECARDIOMYOTOMYANDWHOSESYMPTOMSRECURRED PRESENTEDALOWMORBIDITYANDNOMORTALITY)TOFFEREDASIGNIlCANTRELIEFOF SYMPTOMSWITHADECREASEOFTHECALIBEROFTHEESOPHAGUSINSEVERALPATIENTS4HEPATIENTSALSOIMPROVEDWITHREGARDSTOREmUXESOPHAGITIS )NSOMECASESREmUXWASSTILLPRESENTAFTERSURGERY/THERSWITHNORMALESOPHAGUSINTHEPREOPERATIVEPERIODDEVELOPEDESOPHAGITIS (%!$).'3 %SOPHAGEALACHALASIA SURGERY'ASTRECTOMY%SOPHAGECTOMY!NASTOMOSIS 2OUX EN 9
).42/$5#4)/.
2ECURRENCE OF DYSPHAGIA AFTER CARDIOMYOTOMY THAT IS PERFORMED TO RELIEVE ACHALASIA ARE GASTROESOPHAGEAL REmUX WITHESOPHAGITIS INCOMPLETEMYOTOMY lBROSISATTHESITEOF THEESOPHAGOGASTRICJUNCTION%'* INADEQUATEINDICATIONOF THE TECHNIQUE FOR PATIENTS WITH SEVERE MEGAESOPHAGUS AND INTRA THORACICMIGRATIONOFTHEGASTRICFUNDUS 2EOPERATIONS IN GENERAL HAVE HAD LESS SUCCESS THAN THE ORIGINALPROCEDURE ANDSOMEPATIENTSREQUIREESOPHAGEAL RESECTION WITHTHEINHERENTWELLKNOWNCOMPLICATIONS 4HESURGICALTREATMENTOFRECURRENTACHALASIAVARIESDEPENDING ONTHEMECHANISMCAUSINGTHERECURRENCE4HUS FORPATIENTS WITHINCOMPLETEMYOTOMYORlBROTICSCARRINGOFTHEMYOTOMY ANEWMYOTOMYCOMPLEMENTEDBYPARTIALFUNDOPLICATION ISINDICATED PROVIDEDTHEESOPHAGEALWALLHASNOTBEENINJURED DURINGDISSECTION &OR PATIENTS WITH SIGNIFICANT REFLUX ESOPHAGITIS OR DOLICHOMEGAESOPHAGUS THE THERAPY OF CHOICE HAS BEEN
ESOPHAGECTOMYWITHOUTTHORACOTOMYANDREPLACINGTHEESOPHAGUS WITHTHESTOMACHCERVICALGASTROPLASTY )NTHEPAST THIS OPERATIONINVOLVEDTHORACOTOMYANDREPLACEMENTOFTHEESOPHAGUS BYTHESTOMACH ORTHECOLON 7HENTHEREISESOPHAGITIS WITHOUTDILATATION ANALTERNATIVEMETHODINCLUDESINTERPOSING AJEJUNALLOOPAFTERRESECTIONOFTHEDISTALESOPHAGUSUSINGTHE -%2%.$)./AND$),,!2$ TECHNIQUE (/,4AND,!2'% IN SUGGESTEDTHEUSEOFTHE 2OUX EN 9PARTIALGASTRECTOMYFORTHEREOPERATIONOFACHALASIA WITHSEVEREREmUXESOPHAGITISSECONDARYTOA'2½.$(!,TYPE CARDIOPLASTY 3%22! $»2)!ETAL COMBINEDALONGLATERO LATERALANASTOMOSISEXTENDINGTHROUGHTHEESOPHAGUSONTOTHE GASTRICFUNDUS'2½.$(!,TYPECARDIOPLASTY TOFACILITATE ESOPHAGEALEMPTYING WITHA2OUX EN 9PARTIALGASTRECTOMY INORDERTOPREVENTBILEREmUXFORINITIALTREATMENTOFPATIENTS WITH#HAGASMEGAESOPHAGUS/NEHUNDREDANDTHIRTYPATIENTS WERESUBMITTEDTOTHISPROCEDURE WITHPOSITIVERESULTSINTERMS OFRELIEFOFDYSPHAGIA3INCETHEN THISHASBEENKNOWNIN"RAZIL ASTHE3ERRA $ØRIAPROCEDURE
&EDERAL5NIVERSITYOF'OIÉNIA-EDICAL3CHOOL 'OIÉNIA '/5NIVERSITYOF3ÍO0AULO-EDICAL3CHOOL 3ÍO0AULO 30 "RAZIL !DDRESSFORCORRESPONDENCE$R)VAN#ECCONELLO !V!RNOLFO!ZEVEDO 3ÍO0AULO 30 "RAZIL
Y±QR±MXOVHW
$UT*DVWURHQWHURO
0ONCIANO( #ECCONELLO) !LVES, &ERREIRA"$ 'AMA 2ODRIGUES*#ARDIOPLASTYAND2OUX EN 9PARTIALGASTRECTOMY3ERRA $ØRIAPROCEDURE FORREOPERATIONOFACHALASIA
,
,,
PROLONGEDRETENTIONOFBARIUM WITHDIFlCULTBARIUMENTRANCEINTO THESTOMACH %NDOSCOPICEVALUATIONnALLPATIENTSUNDERWENTENDOSCOPICASSESSMENT OFTHEESOPHAGUS4HEASPECTOFTHEESOPHAGEALMUCOSAWASTHOROUGHLY ASSESSEDASTOTHEABSENCEORPRESENCEOFREmUXESOPHAGITIS $IAGNOSISOFSYMPTOMRECURRENCEAFTERCARDIOMYOTOMYnRECURRENCE WASCLASSIlEDINTOINCOMPLETEMYOTOMY SCARRINGATTHESITEOFTHE MYOTOMY GASTROESOPHAGEAL REmUX WITH ESOPHAGITIS AND SEVERE MEGAESOPHAGUS GROUP )6 ACCORDING TO THE TIME FOR RECURRENCE OF SYMPTOMS AFTER CARDIOMYOTOMY THE RADIOLOGIC CLASSIlCATION OF ACHALASIA AND THE PRESENCE OR ABSENCE OF REmUX ESOPHAGITIS AT ENDOSCOPY4ABLE 4!",%n%TIOLOGYOFRECURRENCEOFSYMPTOMSAFTERCARDIOMYOTOMY
2EmUXESOPHAGITIS )NCOMPLETEMYOTOMY &IBROSISATTHEMYOTOMY 3EVEREMEGAESOPHAGUS GROUP)6
,9
,,,
&)'52% 2ADIOLOGICCLASSIlCATIONOFACHALASIAINFOURGROUPSACCORDINGTOTHEGRADEOF DILATATIONMOTORALTERATIONSOFTHEESOPHAGUS2EZENDEETAL
4HEPURPOSEOFTHISSTUDYWASTOASSESSTHERESULTSOFTHE3ERRA $ØRIA PROCEDUREFORTHETREATMENTOFACHALASIAINPATIENTSWITHRECURRENCEOF SYMPTOMSAFTERCARDIOMYOTOMY -%4(/$3 4WENTYPATIENTSWITHACHALASIADUETO#HAGASDISEASE WHOHAD PREVIOUSLYUNDERGONECARDIOMYOTOMYWITHORWITHOUTFUNDOPLICATION WERESTUDIED!LLOFTHEMUNDERWENTREOPERATIONBYTHE3ERRA $ØRIA PROCEDURE 0ATIENTSWHOHADESOPHAGEALNEOPLASIAASSOCIATEDWITH ACHALASIAWEREEXCLUDED0ATIENTSAGERANGEDFROMTOMEAN YEARS&IFTEEN WEREMALEANDlVE FEMALE #LINICALEVALUATIONnPATIENTSWEREEVALUATEDASTOTHEPRESENCE OFDYSPHAGIA REGURGITATIONANDHEARTBURN $YSPHAGIAWASRANKEDASMILD WHENOCCURRINGWITHORALINTAKEOF SOLIDFOODS MODERATE WITHPASTYFOOD ANDSEVERE WITHLIQUIDFOOD 2EGURGITATIONANDHEARTBURNWERECLASSIlEDASEITHERPRESENTORABSENT 4HEPATIENTSBODYWEIGHTWASALSOCONSIDERED 2ADIOLOGIC ASSESSMENT n PATIENTS UNDERWENT RADIOLOGIC STUDY OF THE ESOPHAGUS STOMACH AND DUODENUM AND WERE CLASSIlED ACCORDINGTOTHElNDINGSINTOFOURGROUPS USINGTHE2%:%.$%ET AL CLASSIlCATION&IGURE AS GROUP)nESOPHAGEALDIAMETERCLOSETONORMAL WITHMILDEMPTYING DIFlCULTYANDSMALLRETAININGOFBARIUMINTHEESOPHAGUS GROUP )) n ESOPHAGUS WITH MODERATE DILATATION SLOW EMPTYING PRESENCEOFTERTIARYWAVESANDMODERATESTASIS GROUP ))) n SIGNIlCANT DILATATION OF THE ESOPHAGUS HYPOTONIC ESOPHAGUS MASSIVE RETAINING OF BARIUM TERMINAL ESOPHAGUS ELONGATEDATTHECARDIABUTSTILLINVERTICALPOSITION GROUP )6 SIGNIlCANT DILATATION OF THE ESOPHAGUS WITH AXIS TURNEDTOTHERIGHTOVERTHEDIAPHRAGMDOLICHOMEGAESOPHAGUS
4IMEUNTIL RECURRENCEOF SYMPTOMS
'ROUPACCORDING TOESOPHAGOGRAM
%NDOSCOPY
MONTHS AMONTHS MONTHS AMONTHS
) )) ))) )6 ) )) ))) ) )) ))) )6
2EmUXESOPHAGITIS .ORMALMUCOSA .ORMALMUCOSA .ORMALMUCOSA
3URGICALTECHNIQUEnALLTHEPATIENTSWEREREOPERATEDBYTHE3ERRA $ØRIATECHNIQUE &IGURE ASDESCRIBEDBELOW s WASHINGOFTHEESOPHAGUSWITHASODIUMCHLORIDESOLUTIONINSTILLED THROUGHANESOPHAGEALTUBE HBEFORETHEOPERATION s UPPERMEDIANLAPAROTOMY s RELEASEOFADHESIONSFROMTHEPREVIOUSOPERATION SECTIONOFTHELEFT TRIANGULARLIGAMENTOFTHELIVERANDISOLATIONOFTHEESOPHAGUS s LATERO LATERAL GASTROESOPHAGEAL ANASTOMOSIS BY THE 'RÚNDHAL TECHNIQUE WITHONEORTWOLAYERS WITHINTERRUPTEDSTITCHESOR MECHANICALSTAPLER&IGURE! s PARTIAL GASTRECTOMY WITH ORALIS TOTALIS 2OUX EN 9 GASTROJEJUNAL ANASTOMOSIS&IGURE"
$
%
&)'52% 'RNDAHLCARDIOPLASTYAND2OUX EN 9PORTALGASTRECTOMY3ERRA $RIAFOR PROCEDUREREOPERATIONOFACHALASIAAFTERCARDIOMYOTOMY
)NTRA ANDPOSTOPERATIVECOMPLICATIONSnINTRAOPERATIVECOMPLICATIONS WEREASSESSEDMAINLYASTOTHEDIFlCULTIESINDISSECTINGADHESIONSFROM THEORIGINALOPERATION0OSTOPERATIVECOMPLICATIONSINCLUDED s IMMEDIATETHOSEOCCURRINGTODAYSAFTERSURGERY s LATETHOSENOTEDTOMONTHSMEANMONTHS AFTERSURGERY 0ATIENTSUNDERWENTCLINICALEVALUATIONPRESENCEANDINTENSITYOF DYSPHAGIA REGURGITATION AND HEARTBURN IN THE IMMEDIATE AND LATE FOLLOW UPPERIODS7EIGHTGAIN RADIOLOGICCALIBEROFTHEESOPHAGUS
$UT*DVWURHQWHURO
Y±QR±MXOVHW
0ONCIANO( #ECCONELLO) !LVES, &ERREIRA"$ 'AMA 2ODRIGUES*#ARDIOPLASTYAND2OUX EN 9PARTIALGASTRECTOMY3ERRA $ØRIAPROCEDURE FORREOPERATIONOFACHALASIA
ACCORDING TO THE 2%:%.$% ET AL CLASSIlCATION AND ENDOSCOPIC PRESENCEORABSENCEOFREmUXESOPHAGITIS EVALUATIONSWEREASSESSED IN THE LATE POSTOPERATIVE FOLLOW UP4HE RESULTS THUS OBTAINED WERE COMPAREDWITHTHOSEFROMTHEPREOPERATIVEPERIOD 3TATISTICAL ANALYSIS n THE7ILCOXONS TEST WAS USED TO COMPARE THEPRE ANDPOSTOPERATIVERESULTSRELATIVETOTHECLINICALDYSPHAGIA REGURGITATION AND HEARTBURN RADIOLOGIC AND ENDOSCOPIC EVALUATION 3IGNIlCANCELEVELWASESTABLISHEDAT0
7ITHOUT
-ILD
-ODERATEDYSPHAGIA
2%35,43 $IAGNOSIS OF SYMPTOM RECURRENCE n NINE PATIENTS WERE DIAGNOSEDWITHREmUXESOPHAGITIS lVE WITHlBROTICSCARRINGOF THEMYOTOMY lVE WITHSEVEREMEGAESOPHAGUSGROUP)6 AND ONE WITHINCOMPLETEMYOTOMY )NTRA ANDPOSTOPERATIVECOMPLICATIONSnADHESIONSJOININGTHE STOMACHANDNEIGHBORINGSTRUCTURES WHICHWERERELEASEDWITHNOFURTHER CONSEQUENCE WEREFOUNDINALLTHEPATIENTS4HEREWASPERFORATIONIN THEANTERIORWALLOFTHEESOPHAGUSINONEPATIENTDURINGISOLATIONOFTHE ORGAN3UCHPERFORATIONWASWIDENED ANDTHEPROCEDUREWASCOMPLETED WITHLATERO LATERALGASTROESOPHAGEALANASTOMOSIS $URATIONOFTHEOPERATIONRANGEDFROMTOMINUTESMEAN ANDTIMEOFHOSPITALIZATIONLASTEDTODAYSMEAN 4WO PATIENTS DEVELOPED lSTULA OF THE GASTROESOPHAGEAL ANASTOMOSIS ANDWEREFEDPARENTERALLYUNTILTOTALOCCLUSIONOFTHElSTULA 4HEYWEREDISCHARGEDFROMHOSPITALONTHENDANDTHENDPOSTOPERATIVE DAYS RESPECTIVELY4WOPATIENTS HADTRANSIENTDYSPHAGIA ANDONE HADPNEUMOTHORAX)NTHELATTERONETHELEFTPLEURAWASPERFORATED DURINGISOLATIONOFTHEESOPHAGUS WHICHWASTHENSUTUREDHOWEVER HE HADPNEUMOTHORAXSOONAFTERTHEOPERATION!THORACICDRAINAGEWAS SUCCESSFULLYPERFORMED4HEREWASNOMORTALITY #LINICALEVALUATIONnTHREEPATIENTS PRESENTEDWITHMODERATE AND WITHSEVEREDYSPHAGIAPREOPERATIVELY)NTHEIMMEDIATEPOSTOPERATIVE PERIODCLINICALEVALUATIONSHOWED PATIENTSWITHNODYSPHAGIA AND WITHMILDDYSPHAGIA4ABLE !LLPATIENTSSIGNIlCANTLYIMPROVED FROMDYSPHAGIAINTHEPOSTOPERATIVEPERIOD0 4!",% 0RE OPERATIVE AND IMMEDIATE POST OPERATIVE EVOLUTION OF DYSPHAGIAINPATIENTSSUBMITTEDTOTHE3ERRA $ØRIAPROCEDURE FORREOPERATIONOFACHALASIA PATIENTS $YSPHAGIA
0RE OPERATIVE
)MMEDIATEPOST OPERATIVE
3EVEREDYSPHAGIA
0RE OP
,ATEPOS OP
&)'52% 0RE OPERATIVEANDLATEPOST OPERATIVEEVALUATIONOFDYSPHAGIAINPATIENTSSUB MITTEDTOTHE3ERRA $RIAPROCEDUREFORREOPERATIONOFACHALASIA PATIENTS
IMMEDIATE AND INTHELATEPOSTOPERATIVEPERIOD4HUS OFPATIENTSWEREASYMPTOMATICINTHEIMMEDIATE ANDINTHE LATEPOSTOPERATIVEPERIOD4HEREWASASIGNIlCANTDIFFERENCEINTERMS OFREGURGITATIONFROMTHEPRE TOTHEIMMEDIATE0 ANDTOTHE LATE0 POSTOPERATIVEPERIODS (EARTBURN WAS PRESENT IN OF PATIENTS IN THE PRE OPERATIVE ASSESSMENT /NLY PATIENTS SUFFERED HEARTBURN IN THE IMMEDIATE AND IN THE LATE POSTOPERATIVE PERIODS! SIGNIlCANTIMPROVEMENTWASSEENBOTHINTHEIMMEDIATE0 ANDLATE0 POSTOPERATIVEPERIODS )NTERESTINGLY TWO PATIENTSPRESENTEDWITHAMILDDUMPING SYNDROME3YMPTOMSDISAPPEAREDINTHELATEPOSTOPERATIVEPERIOD/NE PATIENTHADANEMIAYEARSAFTERSURGERY 3EVENTEEN PATIENTS WERE ASSESSED AS TO WEIGHT GAIN IN THE LATE POSTOPERATIVEPERIOD&IVE GAINEDWEIGHT SIX REMAINED WITHTHESAMEWEIGHT ANDSIX LOSTWEIGHT!VERAGEWEIGHTGAIN WASKG ANDWEIGHTLOSSWASKG 2ADIOLOGICEVALUATIONnWASPERFORMEDPRE ANDPOSTOPERATIVELYIN PATIENTS0REOPERATIVELY THEEXAMSHOWEDSIX PATIENTSWITH GROUP))) ANDSIX WITHGROUP)6MEGAESOPHAGUSONEPATIENTS ESOPHAGOGRAM WASCOMPATIBLEWITHGROUP))MEGAESOPHAGUS 0OSTOPERATIVELY SIX PATIENTSHADGROUP))ROENTGENOGRAM AND FOUR GROUP)))MEGAESOPHAGUSTHREE PATIENTSREMAINED ASGROUP)6MEGAESOPHAGUS&IGURE 4HEREWASASIGNIlCANTNARROWING 0 OFESOPHAGEALCALIBERAFTERTHEOPERATION INCLUDINGTHREE PATIENTSWHOHADSEVEREMEGAESOPHAGUSBEFORE
N
N
7ITHOUT
-ILD
-ODERATE 3EVERE 4OTAL
'ROUP)))
0
)NTHELATEPOSTOPERATIVEPERIOD PATIENTSCAMEBACKFOREVALUATION !LLSHOWEDIMPROVEMENTFROMDYSPHAGIA4EN HADNODIFlCULTY INSWALLOWING SIX PRESENTEDWITHMILD ANDONE WITH MODERATEDYSPHAGIA!SIGNIlCANTDIFFERENCE0 WASSEENINTHE COMPARISONOFTHEPRE WITHTHELATEPOSTOPERATIVEPERIOD&IGURE 2EGURGITATION WAS FOUND IN OF THE PATIENTS IN THE PREOPERATIVEPERIOD/NLYPATIENTS HADREGURGITATIONINTHE
Y±QR±MXOVHW
'ROUP))
'ROUP)6
0RE OP
,ATEPOS OP
&)'52%n0RE OPERATIVEANDLATEPOST OPERATIVERADIOLOGICASSESSMENTOFPATIENTSSUBMIT TEDTOTHE3ERRA $RIAPROCEDUREFORREOPERATIVEOFACHALASIAPATIENTS
%NDOSCOPIC EVALUATION n PRE AND LATE POSTOPERATIVE ENDOSCOPY WASPERFORMEDINPATIENTS&IGURE 4HREEOFTHENINEPATIENTSWHO HADREmUXESOPHAGITISINTHEPREOPERATIVEPERIODSTILLHADITAFTERTHE OPERATION4HUS SIXPATIENTSEXPERIENCEDIMPROVEMENTFROMESOPHAGITIS
$UT*DVWURHQWHURO
0ONCIANO( #ECCONELLO) !LVES, &ERREIRA"$ 'AMA 2ODRIGUES*#ARDIOPLASTYAND2OUX EN 9PARTIALGASTRECTOMY3ERRA $ØRIAPROCEDURE FORREOPERATIONOFACHALASIA
4WONEWCASESWERESEENAFTERSURGERY.OSIGNIlCANTDIFFERENCEFROM THEPRE TOTHEPOSTOPERATIVEEVALUATIONWASSEEN0 REmUXESOPHAGITIS
WITHOUTREmUXESOPHAGITIS
LATEPOST OP 0RE OP &)'52%n0RE OPERATIVEANDLATEPOST OPERATIVEENDOSCOPICASSESSMENTOFPATIENTSSUB MITTEDTOTHE3ERRA$RIASPROCEDUREFORREOPERATIONOFACHALASIAPATIENTS
$)3#533)/. (ISTORICALLY THETREATMENTOFACHALASIABYCARDIOMYOTOMYWASlRST DESIGNEDBY'/4434%). IN(OWEVER (%,,%2 IN ACCLAIMEDTHEPROCEDUREBYPERFORMINGITINTHEANTERIORANDPOSTERIOR ESOPHAGEALWALLS -YOTOMYBECAMETHESURGERYOFCHOICETOTREATACHALASIABECAUSE OFITSSIMPLETECHNIQUEONTHEANTERIORWALLOFTHEESOPHAGUS ACCESSED EITHERBYABDOMINAL ORTHORACICALROUTE (OWEVER BECAUSEITALTERS THENORMALANATOMYOFTHEGASTROESOPHAGEALJUNCTION THEPROCEDURE OFTENISCOMPLICATEDBYTHEOCCURRENCEOFGASTROESOPHAGEALREmUX )NANATTEMPTTOPREVENTSUCHREmUX FUNDOPLICATIONWASADDEDTO THEMYOTOMY THUSPROMOTINGANANTIREmUXMECHANISMANDOBTAINING IMPROVED RESULTS WITH RATES OF ESOPHAGITIS BETWEEN TO !LTHOUGHCARDIOMYOTOMYWITHFUNDOPLICATIONFORTREATMENT OFNON ADVANCEDMEGAESOPHAGUSBRINGSGOODRESULTSINTO OFTHEPATIENTS DYSPHAGIACANSTILLBEMAINTAINED )TS OCCURRENCE HAS NOT DECREASED ALONG THE YEARS DESPITE THE LARGER EXPERIENCEWITHTHETECHNIQUE 7HENONLYCARDIOMYOTOMYISPERFORMED REmUXESOPHAGITISOCCURRED INTOOFTHEPATIENTS -YOTOMYINCREASESEXPOSUREOF THEESOPHAGUSTOACIDORALCALINESECRETION ANDINDOINGSOITOPENS THEDOORTOFUTURECOMPLICATIONS AMONGWHICHAREINmAMMATIONOFTHE ESOPHAGEALMUCOSA HEARTBURNANDRECURRENCEOFDYSPHAGIA /THERCAUSESOFRECURRENCEOFDYSPHAGIAFOLLOWINGCARDIOMYOTOMY ARE INCOMPLETECARDIOMYOTOMYnREPRESENTEDBYTHEINADEQUATE SECTIONING EITHERINDEPTHORINEXTENSION OFTHEBUNDLEOFMUSCLESOF THE%'*ASACONSEQUENCE DYSPHAGIAREMAINSPRACTICALLYUNALTERED SOONAFTEROPERATION ORWILLHAVEONLYMINORIMPROVEMENTlBROTIC HEALINGATTHESITEOFMYOTOMYnREAPPROACHINGTHElBROTICEDGESOF THEMYOTOMYISTHECAUSEFORRELAPSEOFDYSPHAGIAINTHERELATIVELYLATE POSTOPERATIVEPERIOD"LEEDINGINTHEAREAOFTHEMYOTOMYANDMUCOSA INJURIES ALTHOUGHIDENTIlEDANDTREATEDATTHETIMEOFTHEOPERATION WOULDBETHEMAINCAUSESFORTHISTYPEOFRECURRENCEOFSYMPTOMS INAPPROPRIATEINDICATIONOFTHECARDIOMIOTOMYTECHNIQUEFORSEVERE MEGAESOPHAGUSnTHEAPERISTALTICESOPHAGUSFAILSTOPRESENTAPPROPRIATE EMPTYING THEREFORETHEREISAVERYSHORTPERIODOFIMPROVEMENTFROM DYSPHAGIA &ORAPROPERTREATMENT IDENTIlCATIONOFTHECAUSEOFRECURRENCE OF DYSPHAGIA AFTER SURGICAL TREATMENT OF ACHALASIA IS NECESSARY $ATAOFTHEPREVIOUSOPERATION TIMEFORRECURRENCEOFSYMPTOMSAND lNDINGSDURINGREOPERATIONAREIMPORTANTINFORMATIONFORlNDINGTHE RIGHT DIAGNOSIS /THER INVESTIGATORS ADD ENDOSCOPIC AND RADIOLOGIC EVALUATIONS PREOPERATIVE OR INTRAOPERATIVE ESOPHAGEAL PRESSURE OR HOURESOPHAGEALP(MEASUREMENTS ASDIAGNOSTIC
METHODS)NTHEPRESENTSTUDY TIMETORECURRENCEOFSYMPTOMSAFTER THElRSTOPERATION BARIUMSWALLOWTOOBSERVETHEDEGREEOFESOPHAGEAL DILATATION ANDESOPHAGOSCOPYTOSTUDYMUCOSALDAMAGEWEREUSEDTO DIAGNOSE RELAPSE 2EmUX ESOPHAGITIS WAS OBSERVED IN NINE PATIENTS HEALINGOFMYOTOMYINlVE FAILEDMYOTOMYINSEVERE MEGAESOPHAGUSINlVE ANDINCOMPLETEMYOTOMYINONE 0)./44)AND&%,)8 OBSERVEDTHEFOLLOWINGCAUSESFORRECURRENCE OF SYMPTOMS IN PATIENTS INCOMPLETE MYOTOMY IN REmUXESOPHAGITISIN DOLICHOMEGAESOPHAGUSIN MIGRATIONOFFUNDOPLICATIONINTOTHETHORAXIN ANDHEALINGOF MYOTOMYIN "ASEDONOURRESULTSANDTHOSEFROMTHELITERATURE WECONCLUDETHATINADEQUATEINDICATIONOFCARDIOMYOTOMYFORSEVERE MEGAESOPHAGUS ORINADEQUATEMYOTOMY ARETHEMAINFACTORSOFEARLY FAILUREOFTHElRSTPROCEDURE"OTHAREMANIFESTEDBYEARLYRECURRENCE OFDYSPHAGIA/NTHEOTHERHAND BOTHREmUXESOPHAGITISANDAlBROTIC HEALING AT THE SITE OF CARDIOMYOTOMY CHARACTERISTICALLY SHOW LATER RECURRENCEOFSYMPTOMS "ESIDESCARDIOMYOTOMY OTHERTYPESOFOPERATION SUCHASTHEEARLIER (%92/63+9 ANDTHE'2½.$!(, CARDIOPLASTIES ORMORERECENTLY THE4(!,ETAL PROCEDURE AREUSEDTOTREATACHALASIA BUTAREALSO FOLLOWEDBYRECURRENCEOFSYMPTOMS4HEIRSHORT ANDMEDIUM TERM RESULTSSHOWGASTROESOPHAGEALREmUX ANDLATER STENOSISAND"ARRETTS ESOPHAGUS ASCOMPLICATIONS4HE4(!,ETAL OPERATIONISSTILL USEDINSEVERALMEDICALSERVICESIN"RAZIL FORINITIALORSECOND SURGICALTREATMENTOFACHALASIA &ORTREATINGSEVEREREmUXESOPHAGITISINACHALASIAPATIENTSWHOHAD PREVIOUSLYUNDERGONE'RÚNDAHL CARDIOPLASTY (/,4AND,!2'% IN DESIGNED A SECONDARY OPERATION A 2OUX EN 9 PARTIAL GASTRECTOMYWITHVAGOTOMY !NIMMEDIATEIMPROVEMENTOFSYMPTOMS WASOBTAINED WITHNOEVIDENCEOFPOSTOPERATIVEREmUXESOPHAGITIS &OLLOWING THE PROCEDURE DESCRIBED BY (/,4 AND ,!2'% 3%22! $»2)! ET AL STARTED TO USE AN ASSOCIATION OF 'RÚNDAHL CARDIOPLASTYWITHPARTIAL2OUX EN 9GASTRECTOMY ASTHElRSTTREATMENT FORACHALASIA WITHGOODRESULTS)NTHISOPERATION ALARGEEXPOSITIONOF THEINTRAABDOMINALESOPHAGUSMUSTBEUNDERTAKEN WITHTHEDISSECTION EXTENDEDPROXIMALLYASFARASTHEDILATEDPORTIONOFTHEORGAN WHICH IS EASILY IDENTIlED4HE VAGUS NERVE MUST BE ISOLATED ESPECIALLY ITS ANTERIOR BRANCH HOWEVER THIS CAN BE ACCIDENTALLY INJURED IN SOME INSTANCESWHERETHEREARETECHNICALDIFlCULTIES WHENTHEAREAHASA MASSIVElBROSIS )NREOPERATIONSONTHE%'*THEPROBABILITYOFESOPHAGEALINJURYIS HIGHERDUETOTHEADHESIONSOFTHISORGANWITHNEIGHBORINGSTRUCTURES 4HEINTRAMEDIASTINALESOPHAGEALACCESSBYMEDIANPHRENOTOMY IF NECESSARY ALLOWSFORREACHINGTHEESOPHAGUSOUTSIDETHElBROTICAREA THUSENABLINGBETTERVISUALIZATIONANDSAFEDISSECTIONOFTHESTRUCTURES INTHISAREA /NEPATIENTPRESENTEDAINTRAOPERATIVEPLEURALDAMAGESUTUREOFTHE DAMAGEWASPERFORMEDIMMEDIATELY(OWEVER THEPATIENTDEVELOPED PNEUMOTHORAX REQUIRINGPOSTOPERATIVETHORACICDRAINAGE 4HEMAINPOSTOPERATIVECOMPLICATIONWASlSTULAOFTHEGASTROESOPHAGEAL ANASTOMOTIC WHICHOCCURREDINTWOPATIENTS "OTHWERETREATED WITHTOTALPARENTERALNUTRITIONANDPROGRESSEDWELL4HEOCCURRENCEOF THESElSTULAEWASPROBABLYRELATEDTOTHEDIFlCULTYWITH%'*DISSECTION DUETOTHEADHESIONSRESULTINGFROMTHEPREVIOUSOPERATION/NEOFTHE PATIENTSHADUNDERGONETWOOPERATIONSBEFORE4HISWASALSOOBSERVED BY -%.$%,33/(. ET AL WHO REPORTED HIGHER OCCURRENCE OF
$UT*DVWURHQWHURO
Y±QR±MXOVHW
0ONCIANO( #ECCONELLO) !LVES, &ERREIRA"$ 'AMA 2ODRIGUES*#ARDIOPLASTYAND2OUX EN 9PARTIALGASTRECTOMY3ERRA $ØRIAPROCEDURE FORREOPERATIONOFACHALASIA
lSTULAEWHENPERFORMING4(!,ETAL OPERATIONINPATIENTSWHO HADPREVIOUSLYUNDERGONEMORETHANONEOPERATIONFORTHETREATMENT OFACHALASIA 3%22! $/2)!ETAL DIDNOTREPORTANYlSTULAEINPATIENTS OPERATEDONBYTHEIRTECHNIQUE.EITHERDID'/,$%-"%2' INTHE PATIENTSOPERATEDONBYTHESAMETECHNIQUE INWHICHAVAGOTOMY WASALSOASSOCIATEDWITHTHEPROCEDURE -ANY INVESTIGATORS HAVE USED SELECTIVE CRITERIA TO INDICATE THE TECHNIQUEUSEDFORCORRECTIONOFSYMPTOMSRECURRENCE 4HEREISATRENDTOPERFORMANEWMYOTOMYOVERTHEPREVIOUS ONE ORBESIDEIT INTHECASESOFINCOMPLETEORlBROTICMYOTOMIES %SOPHAGEALRESECTIONWOULDBERESERVEDFORPATIENTSWITHSEVERE MEGAESOPHAGUS !FTER CONSERVATIVE SURGICAL TREATMENT OF ACHALASIA SOME DEGREE OFDYSPHAGIAMAYPERSIST ANDTHISCOULDBEEXPLAINEDBYTHEMOTILITY ALTERATIONSALREADYEXISTINGINTHEESOPHAGUS WHICHDONOTIMPROVE AFTER SURGERY )NTENSE DYSPHAGIA APPEARING EARLY AFTER SURGERY IS RELATEDTOADEFECTIVETECHNIQUE)NINCOMPLETEMYOTOMIES DYSPHAGIA OCCURSINTHEMAJORITYOFPATIENTSUPTOMONTHSAFTERSURGERY )N SEVEREMEGAESOPHAGUS EVENWHENATECHNICALLYPERFECTMYOTOMYIS PERFORMED EMPTYINGOFTHEESOPHAGUSISNOTADEQUATELYDONEBECAUSE ITISANATONICORGAN !LLTHEPATIENTSINTHISSTUDYHADPREOPERATIVEMODERATEORSEVERE DYSPHAGIAANDIMPROVEDSIGNIlCANTLYAFTERTHEPROCEDURE!STOTHERELIEF FROMDYSPHAGIA RESULTSOBTAINEDWITHTHE3ERRA $ØRIAOPERATION ARESIMILARTOTHOSEOBTAINEDWITHCARDIOMYOTOMIES ANDWITHTHE 4HALETALOPERATION 4HE 3ERRA $ØRIA OPERATION ALSO SHOWED IMPROVEMENT OF REGURGITATION MORESIGNIlCANTLYINTHELATEFOLLOW UP4HEOPERATION YIELDEDREDUCTIONOFSTASIS ANDREGRESSIONOFTHEESOPHAGEALCALIBER WAS OBSERVED IN SEVERAL PATIENTS 3IX PATIENTS REMAINED WITH THE SAMEDEGREEOFESOPHAGEALDILATION AFACTTHATWASALSOREPORTEDBY %,,%."/'%. WHOCREDITEDTHELACKOFESOPHAGEALCALIBERREDUCTION AFTERCARDIOMYOTOMYTOlBROSISANDATONY !LTHOUGH THERE WAS IMPROVEMENT OF HEARTBURN TWO PATIENTS DEVELOPED REmUX ESOPHAGITIS POSTOPERATIVELY EVEN USING THE 2OUX EN 9PARTIALGASTRECTOMY DUETOTHELARGECOMMUNICATIONRESULTING FROM THE LATERO LATERAL GASTROESOPHAGEAL ANASTOMOSIS THE PATIENTS PRESENTINGWITHESOPHAGITISWERETREATEDWITHPROTONPUMPINHIBITORS ANDAREPRESENTLYASYMPTOMATIC/NTHEOTHERHAND 3%22!ETAL PERFORMEDANEWMYOTOMYINPATIENTSWITHSYMPTOMRECURRENCEDUETO INCOMPLETEMYOTOMYANDOBSERVEDPOSTOPERATIVEREmUXESOPHAGITISIN OFTHEPATIENTS7ITHTHE4HALETALCARDIOPLASTY ARATEOF POSTOPERATIVEREmUXESOPHAGITIS WASOBSERVED 3EVERALTYPESOFTREATMENTFORSEVEREMEGAESOPHAGUSHAVEBEEN SUGGESTED ALMOSTALWAYSWITHHIGHINDICESOFCOMPLICATIONS STRIPPING MUCOSECTOMY WITH MAINTENANCE OF THE ESOPHAGEAL TUNICA MUSCULARISFOLLOWEDBYCERVICALGASTROPLASTY INESOPHAGECTOMY WITHOUTTHORACOTOMY ANDMORETHANINCOLOPLASTY .OMORTALITYWASOBSERVEDBY#%##/.%,,/ETAL INPATIENTS WHO FAILED CARDIOMYOTOMY AND UNDERWENT ESOPHAGECTOMY WITHOUT THORACOTOMY,ATEPOSTOPERATIVERESULTSWEREOBSERVEDINOFTHE
Y±QR±MXOVHW
PATIENTS)NTHEPRESENTSTUDYTHE3ERRA $ØRIAOPERATION PROVEDSIMILARLY EFlCIENTTOTREATSEVEREMEGAESOPHAGUS4HEMETHODISSIMPLEANDANY SURGEONWHOHASTRAININGINABDOMINALSURGERYCANPERFORMIT 4HE MAIN INDICATION FOR CARDIOPLASTY WITH 2OUX EN 9 PARTIAL GASTRECTOMYISFORREOPERATIONOFACHALASIADUETOREmUXESOPHAGITIS.INE OFTHEPATIENTSWITHGASTROESOPHAGEALREmUXEXPERIENCEDPOSTOPERATIVE IMPROVEMENT ANDINSEVENPATIENTSTHEENDOSCOPICASSESSMENTREVEALED NO ESOPHAGITIS /THER INVESTIGATORS HAVE ALSO USED THE 2OUX EN 9 PARTIALGASTRECTOMY TOTREATREmUXESOPHAGITISINREOPERATIONSOFTHE MEGAESOPHAGUS WITHEXCELLENTRESULTS &UNDOPLICATION IN PATIENTS WITH MASSIVE REmUX FROM PREVIOUS CARDIOMYOTOMY HARDLY EVER SHOWS GOOD RESULTS #%##/.%,,/ ET AL OBSERVEDPERSISTENCEOFSYMPTOMSINPATIENTS IN WHOMPARTIALFUNDOPLICATIONWASASSOCIATEDWITHTHEPREVIOUSLYEXISTING CARDIOMYOTOMY(OWEVER THEYOBSERVEDGOODRESULTSINPATIENTS UNDERGOINGESOPHAGECTOMYWITHOUTTHORACOTOMYWITHCERVICAL GASTROPLASTY(IGHESOPHAGOGASTRICANASTOMOSES ONTHEOTHERHAND ARE FOLLOWEDBYREmUXESOPHAGITISAND"ARRETTSESOPHAGUSINTHECERVICAL STUMP 4HEOCCURRENCEOFESOPHAGITISINCREASESWITHTHEYEARS OFPOSTOPERATIVEFOLLOW UP 4HUS REmUXESOPHAGITISREPRESENTSACOMPLICATIONTOBEFOUNDIN REOPERATIONSFORMEGAESOPHAGUS INDEPENDINGOFTHETECHNIQUEUSED NEW MYOTOMY ESOPHAGECTOMY AND GASTROPLASTY ESOPHAGEAL STUMP ESOPHAGITIS CARDIOPLASTY ANDALSOTHE3ERRA $ØRIAOPERATION 5LCERSOFTHEGASTROJEJUNALANASTOMOSISWERENOTOBSERVED SINCE A VAGOTOMY ASSOCIATED WITH GASTRECTOMY WAS NOT PERFORMED )T IS POSSIBLETHATTHISFACTRELATESTOTHEDECREASEINTHEBASELINESECRETION OFACIDBYTHESTOMACHINPATIENTSWITH#HAGASACHALASIA ANDTO PARTIALGASTRECTOMY 4HE NUTRITIONAL STATUS OF PATIENTS HAVE IMPROVED AFTER TREATING ACHALASIABYCARDIOMYOTOMY CARDIOPLASTY ESOPHAGEALRESECTION ORINREOPERATIONFORMEGAESOPHAGUS 4HEMAJORITYOFPATIENTS INTHISSTUDYEITHERMAINTAINEDORGAINEDWEIGHTHOWEVER LOST WEIGHT4HESERESULTSMAYBERELATEDTOPARTIALGASTRECTOMY &ROMTHECLINICALVIEWPOINT NOSYMPTOMSSUGGESTINGSLOWGASTRIC EMPTYING WERE OBSERVED ALTHOUGH THIS WAS EVIDENCED IN PATIENTS WHOUNDERWENT2OUX EN 9PARTIALGASTRECTOMY TOTREATOTHER DISEASES -ILD DUMPING SYNDROME WAS SEEN IN TWO PATIENTS 4HEYBOTHEXPERIENCEDIMPROVEMENTINTHElRSTPOSTOPERATIVEWEEKS WITHDIETARYMEASURES 4HUS ITWASOBSERVEDTHATTHE3ERRA $ØRIAOPERATION CANBE EASILYPERFORMED WITHLOWMORBIDITYANDMORTALITY)TYIELDEDIMPORTANT RELIEFFROMSYMPTOMS SPECIALLYFROMDYSPHAGIA ANDINMOSTINSTANCES AREDUCTIONOFESOPHAGEALCALIBER4HEREWASALSOIMPROVEMENTOFREmUX ESOPHAGITIS9ET ITISPOSSIBLETHEOCCURRENCEOFREmUXINPATIENTSWHO DIDNOTPRESENTITBEFORE "ECAUSEITYIELDSGOODRESULTSINTERMSOFSYMPTOMSRELIEF ITCAN BE ACCREDITED AS VIABLE ALTERNATIVE FOR TREATING PATIENTS WITH FAILED CARDIOMYOTOMYFORTHETREATMENTOFACHALASIA&URTHERSTUDIES WITH LONGERFOLLOW UPTERMS AREREQUIREDINORDERTOREACHMOREDElNITIVE CONCLUSIONS INSPECIALASTOTHEOCCURRENCEOFLATERCOMPLICATIONSNOT IDENTIlEDINTHEPRESENTSTUDY
$UT*DVWURHQWHURO
0ONCIANO( #ECCONELLO) !LVES, &ERREIRA"$ 'AMA 2ODRIGUES*#ARDIOPLASTYAND2OUX EN 9PARTIALGASTRECTOMY3ERRA $ØRIAPROCEDURE FORREOPERATIONOFACHALASIA
0ONCIANO( #ECCONELLO) !LVES, &ERREIRA"$ 'AMA 2ODRIGUES*#ARDIOPLASTIAEGASTRECTOMIAPARCIALEM9 DE 2OUXOPERAÎÍODE3ERRA $ØRIA PARAREOPERAÎÜES NOMEGAESÙFAGO!RQ'ASTROENTEROL 2%35-/ 2ACIONAL .ASOPERAÎÜESDECARDIOMIOTOMIAPARATRATAMENTODOMEGAESÙFAGOOCORRERECIDIVADOSSINTOMASEMATÏDOSPACIENTES SENDOQUEALGUNS NECESSITAMREOPERAÎÍO/BJETIVO !VALIAROSRESULTADOSDEREOPERAÎÜESATRAVÏSDECARDIOPLASTIAEGASTRECTOMIAPARCIALEM9 DE 2OUX CONFORMETÏCNICAPROPOSTA POR3ERRA $ØRIA#ASUÓSTICAE-ÏTODOSn&ORAMESTUDADOSDEFORMARETROSPECTIVA PACIENTESCOMMEGAESÙFAGOPREVIAMENTETRATADOSPORCARDIOMIOTOMIA !CAUSADERECIDIVADOSSINTOMASFOIESOFAGITEDEREmUXOEMNOVE MIOTOMIAINCOMPLETAEMUM CICATRIZAÎÍODAMIOTOMIAEMCINCO EPRESENÎADEMEGAESÙFAGOAVANÎADOEMCINCO !NALISARAM SEASCOMPLICAÎÜESINTRAEPØS OPERATØRIAS/SPACIENTESFORAMAVALIADOSSOBOPONTODE VISTACLÓNICODISFAGIA REGURGITAÎÍO PIROSEEVARIAÎÍODEPESO RADIOLØGICOEENDOSCØPICO NOPRÏENOPØS OPERATØRIOIMEDIATOETARDIO2ESULTADOSn#INCO DOENTESAPRESENTARAMCOMPLICAÎÜESNOPØS OPERATØRIOIMEDIATO.ÍOHOUVEMORTALIDADE4ODOSOSDOENTESMELHORARAMDADISFAGIA COMQUASE TOTALDESAPARECIMENTODAREGURGITAÎÍOEPIROSE(OUVEMANUTENÎÍOOUAUMENTODEPESOEM DOSPACIENTES/ESTUDORADIOLØGICOMOSTROUDIMINUIÎÍO DOCALIBREDOESÙFAGOEM EMANUTENÎÍONOSDEMAIS.ÍOHOUVEAUMENTODOCALIBREEMNENHUMDOSPACIENTES.OEXAMEENDOSCØPICOREALIZADONO PØS OPERATØRIOTARDIOEMPACIENTES OBSERVOU SEQUEENTREQUEAPRESENTAVAMESOFAGITEDEREmUXO MELHORARAMENTRE QUEAPRESENTAVAMESÙFAGO NORMALNOPRÏ OPERATØRIO DESENVOLVERAMESOFAGITE#ONCLUSÜESn!OPERAÎÍODE3ERRA $ØRIAPARATRATAMENTODOMEGAESÙFAGO OPERADOPORCARDIOMIOTOMIA COMRECIDIVADOSSINTOMAS APRESENTOUBAIXAMORBIDADEEAUSÐNCIADEMORTALIDADE0ERMITIUEXPRESSIVOALÓVIODOSSINTOMASEDIMINUIÎÍODOCALIBREDO ESÙFAGOEMVÈRIOSDOENTES0OSSIBILITOU TAMBÏM MELHORADAESOFAGITEDEREmUXO HAVENDO ENTRETANTO APOSSIBILIDADEDESUAMANUTENÎÍO BEMCOMODO SEUAPARECIMENTOEMDOENTESQUENÍOAAPRESENTAVAM $%3#2)4/2%3 !CALÈSIAESOFÈGICA CIRURGIA'ASTRECTOMIA%SOFAGECTOMIA!NASTOMOSEEM 9 DE2OUX
2%&%2%.#%3
!QUINO*," 2EIS .ETO*! -URARO#, #AMARGO*'*%SOPHAGEALMUCOSECTOMYIN THETREATMENTOFTHEADVANCESMEGAESOPHAGUSANALYSISOFCASES2EV#OL"RAS #IR "ARBOSA( "ARRICHELLO!7 6IANNA!, -ENDELSSONH0-EGAESÙFAGOCHAGÈSICO TRATAMENTOPELACARDIOPLASTIAA4HAL2EV#OL"RAS#IR "ARBOSA( "ARRICHELLO!7 6IANNA!, -ENDELSSONH0 7ATANABE,-4RATAMENTO CIRÞRGICODOMEGAESÙFAGODUASDÏCADASDEEXPERIÐNCIANUMAREGIÍOENDÐMICA2EV 'OIANA-ED #ECCONELLO) -ARIANO DA 2OCHA*2 0OLLARA7- :ILBERSTEIN",ONG TERMEVALUATION OFGASTROPLASTYINACHALASIA)N3IEWERT2 !((OLSCHER!( EDITORS $ISEASESOF THEESOPHAGUS"ERLIN3PRINGER 6ERLAGP #ECCONELLO) :ILBERTEIN" $OMENE#% .ASI! 0INOTTI(72ECURRENCEOFSYMPTOMS AFTER MANAGEMENT OF ACHALASIA )N RD )NTERNATIONAL 0OLYDISCIPLINARY #ONGRESS OF /%3/0ARIS #ECCONELLO) -ARIANO DA 2OCHA*2 :ILBERSTEIN" &ELIX6. 0INOTTI(72EmUX ESOPHAGITISANDDEVELOPMENTOFECTOPICCOLUMNAREPITHELIUMINTHEESOPHAGEALSTUMP AFTERGASTRICTRANSPOSITIONAPROSPECTIVESTUDY)N.ABEYA+ (ANAOKA4 .OGAMI( EDITORS$ISEASESOFTHEESOPHAGUS4OKYO3PRINGER 6ERLAGP #ECCONELLO) 3ALLUM2! :ILBERSTEIN" 0INOTTI(77HENFUNDOPLICATIONISADDEDTO THEMIOTOMY ISTHEREARISKOFINTRA THORACICMIGRATIONOFTHEVALVEAFTERREDUCTIONOF THEESOPHAGEALCALIBER )N'IULI2 'ALMICHE*0 *AMIESON'' 3CARPIGNATO# EDITORS 4HEESOPHAGOGASTRICJUNCTION0ARIS*OHN,IBBEY%UROTEXTP #HAIB3! ,OPASSO&0 0ARRA/- 3AAD7! 6ASCONCELOS%4RATAMENTODOMEGAESÙFAGO PELATÏCNICADE(ELLER 6ASCONCELOS%XPERIÐNCIADECASOS2EV(OSP#LIN&AC -ED3ÍO0AULO #SENDES! 6ELASCO . "RAGHETTO ) ! PROSPECTIVE RANDOMIZED STUDY COMPARING FORCEFULDILATATIONANDESOPHAGOMYOTOMYINPATIENTSWITHACHALASIAOFTHEESOPHAGUS 'ASTROENTEROLOGY #SENDES! 2ESULTS OF SURGICAL TREATMENT OF ACHALASIA OF THE ESOPHAGUS (EPATOGASTROENTEROLOGY $EL'ENIO! $I-ARTINO. -AFETTONE6 )ZZO' :AMPIELLO0 -UGIONE0)NSUCCESSIDELLA TERAPIACHIRURGICADELLACALASIADIAGNOSIETRATTAMENTO!NN)TAL#HIR $OR* (UMBERT0 $OR6 &IGARELATT*,INTERETDELATECNIQUEDE.ISSENMODIlÏDANS LAPRÏVENTIONDUREmUXAPRÏSCARDIOMIOTOMIEEXTRAMUQUEUSEDE(ELLER-EM!CAD #HIR %LLENBOGEN'-EGAESÙFAGONÍOAVANÎADOTRATAMENTOPELACARDIOMIOTOMIAASSOCIADA Ë ESOFAGOFUNDOGASTROPEXIA!VALIAÎÍO CLÓNICA MORFOLØGICA E FUNCIONAL DOS SEUS RESULTADOS;TESELIVREDOCÐNCIA=3ÍO0AULO &ACULDADEDE-EDICINA 5NIVERSIDADEDE 3ÍO0AULO %LLIS &( *R 'IBB 30 2EOPERATION AFTER ESOPHAGOMYOTOMY FOR ACHALASIA OF THE ESOPHAGUS!M*3URG %LLIS&(*R #ROZIER2% 'IBB302EOPERATIVEACHALASIASURGERY*4HORAC#ARDIOVASC 3URG
&ÏKÏTÏ& ,ORTAT *ACOB*,²CHECSETPRÏTENDUSÏCHECSDELOPERATIONDE(ELLERPOUR MÏGA OESOPHAGEIDIOPATHIQUE²TUDEDEMALADESRÏOPÏRÏS!NN#HIR &ÏKÏTÏ& "REIL0(,ESRÏINTERVENCIONAPRÏSINTERVENTIONDE(ELLERPOURACHALASIE EYAUTRESDYSFONCTIONNEMENTSMOTEURSDELOESOPHAGE!CTA#HIR"ELG &ÏKÏTÏ& "REIL0( 4OSSEN*#2EOPERATIONAFTER(ELLERSOPERATIONFORACHALASIAAND OTHERMOTILITYDISORDERSOFTHEESOPHAGUSASTUDYOFEIGHT ONEREOPERATION)NT3URG &ÏKÏTÏ& 0ATERON$7HATISTHEPLACEOFANTRECTOMYWITH2OUX EN 9INTHETREATEMENT OF REmUX DISEASE %XPERIENCE WITH TOTAL DUODENAL DIVERSIONS 7ORLD * 3URG &ELIX6. #ECCONELLO) 0INOTTI(7$IAGNØSTICODACAUSADERECIDIVAAPØSTRATAMENTO CIRÞRGICO DO MEGAESÙFAGO NÍO AVANÎADO !"#$!RQ "RAS #IR $IG 3UPL &ELIX6. 4RATAMENTO DO MEGAESÙFAGO CHAGÈSICO INCIPIENTE %STUDO COMPARATIVO ENTRE A DILATAÎÍO HIDROSTÈTICA FORÎADA DA CÈRDIA E ESOFAGOCARDIOMIOTOMIA COM ESOFAGOGASTROFUNDOPEXIA;TESE=3ÍO0AULO&ACULDADEDE-EDICINA 5NIVERSIDADE DE3ÍO0AULO &EROOQ0! +EREN$&"ARRETTSESOPHAGUSCOMPLICATINGACHALASIAAFTERESOPHAGOMYOTOMY *#LIN'ASTROENTEROL &ERRAZ!!" .ØBREGA*R"' -ATHIAS#! "ACELAR43 ,IMA&%! &ERRAZ%-,ATE RESULTSONTHESURGICALTREATMENTOFCHAGASICMEGAESOPHAGUSWITHTHE4HAL (ATAFUKU PROCEDURE*!M#OLL3URG &ERREIRA 3ANTOS24RATAMENTOCIRÞRGICODAAPERISTALSEESOFÈGICAMEGAESÙFAGO ;TESE
PROVIMENTODECÈTEDRA=2IBEIRÍO0RETO&ACULDADEDE-EDICINADE2IBEIRÍO0RETO 5NIVERSIDADEDE3ÍO0AULO 'AYET" &ÏKÏTÏ&3URGICALMANAGEMENTOFFAILEDESOPHAGOMYOTOMY(ELLEROPERATION (EPATOGASTROENTEROLOGY 'OLDENBERG3#IRURGIAMEGAESÙFAGOnOPERAÎÍODE'RONDAHL $ØRIAMODIlCADA2EV 'OIANA-ED 'OTTSTEIN'4ECHNIKUNDKLINIKDEROESOPHAGUSKOPIE-ITT'RENZGEB-ED#HIR 'ROENEVELDT"*R/VERCARDIOSPASMUS.EDERL4'ENEESK 'RÚNDAHL ." #ARDIAPLASTIK6ED #ARDIOSPASMUS .ORD +IRURGISK &ORENINGS (ELLER%%XTRAMUKOSECARDIAPLASTIKBEIMCHONISCHENCARDIOSPASMUSMITDILATATION DESOESOPHAGUS-ITT'RENZGEB-ED#HIR (ERBELLA&!- $EL'RANDE*# ,OURENÎO,' -ANSUR.3 (ADDAD-#2ESULTADOS TARDIOSDAOPERAÎÍODE(ELLERASSOCIADAËFUNDOPLICATURANOTRATAMENTODOMEGAESÙFAGO ANÈLISEDECASOS2EV!SSOC-ED"RAS (EYROVSKY ( #ASUISTIK UND THERAPIE DER IDIOPATISCHEN DILATATION DER SPEISEOHER /ESOPHAGOGASTROANASTOMOSIS,ANGNBEECKS!RCH+LIN#HIR APUD %LLENBOGEM (OLT #* ,ARGE!- 3URGICAL MANAGEMENT OF REmUX ESOPHAGITIS !NN 3URG
$UT*DVWURHQWHURO
Y±QR±MXOVHW
0ONCIANO( #ECCONELLO) !LVES, &ERREIRA"$ 'AMA 2ODRIGUES*#ARDIOPLASTYAND2OUX EN 9PARTIALGASTRECTOMY3ERRA $ØRIAPROCEDURE FORREOPERATIONOFACHALASIA
*AMIESON '' 'ASTRO ESOPHAGEAL REFLUX FOLLOWING MYOTOMY FOR ACHALASIA (EPATOGASTROENTEROLOGY *EKLER* ,HOTKA*-ODIlED(ELLERPROCEDURETOPREVENTPOSTOPERATIVEREmUXESOPHAGITIS INPATIENTSWITHACHALASIA!M*3URG -ATHIAS*2 &ERNANDEZ! 3NINSKY#! #LENCH-( $AVIS2(.AUSEA VOMITING AND ABDOMINAL PAIN AFTER 2OUX EN 9 ANASTOMOSIS MOTILITY OF THE JEJUNAL LIMB 'ASTROENTEROLOGY -ARIANO DA 2OCHA *2 'AMA 2ODRIGUES ** $!LBUQUERQUE ,!# 'ARRIDO *R!" #ECCONELLO) ,AUDANNA!! 3ALLUM2!! 0INOTTI(73ERUMGASTRIN PEPSINOGEN LEVELSANDGASTRICACIDSECRETIONINPATIENTSWITH#HAGASDISEASE!"#$!RQ"RAS#IR $IG -ARIANO DA 2OCHA*2 #ECCONELLO) :ILBERSTEIN" 3ALLUM2!! 3AKAI0 )SHIOKA3 0INOTTI(7%SÙFAGODE"ARRETTNOCOTOESOFAGIANOAPØSESOFAGECTOMIASUBTOTALCOM ESOFAGOGASTROPLASTIACERVICAL2EV(OSP#LÓN&AC-ED30AULO -ENDELSSONH0 6IANNA!, "ARICHELLO!7 7ATANABE,- "ARBOSA(-EGAESÙFAGOCHAGÈSICO RECIDIVADOTRATAMENTOPELACARDIOPLASTIAË4HAL2EV'OIANA-ED -ERCER#$ (ILL,$2EOPERATIONAFTERFAILEDESOPHAGOMYOTOMYFORACHALASIA#AN *3URG -ERENDINO+! $ILLARD$+4HECONCEPTOFSPHINCTERSUBSTITUTIONBYANINTERPOSED JEJUNALSEGMENTFORANATOMICANDPHYSIOLOGICABNORMALITIESATTHEESOPHAGOGASTRIC JUNCTION WITHSPECIALREFERENCETOREmUXESOPHAGITIS CARDIOSPASMANDESOPHAGEAL VARICES!NN3URG 0ATRICK$, 0AYNE73 /LSEN!- %LLIS&(2EOPERATIONFORACHALASIAOFTHEESOPHAGUS !RCH3URG 0ATTI-' 0ELLEGRINI#! !RCERITO- 4ONG* -ULVIHILL3* 7AY,7#OMPARISON OFMEDICALANDMINIMALLYINVASIVESURGICALTHERAPYFORPRIMARYESOPHAGEALMOTILITY DISORDERS!RCH3URG 0ERACCHIA! .OSADINA! 4REMOLADA# "ARDINI22EOPERATIONAFTER(ELLER|SOPERATION FORMEGAESOPHAGUS#HIRURGIE 0INOTTI(7 'AMA 2ODRIGUES** %LLENBOGEN' 2AIA!.OVATÏCNICANOTRATAMENTO CIRÞRGICODOMEGAESÙFAGOESOFAGOCARDIOMIOTOMIAASSOCIADACOMESOFAGOFUNDOGAST ROPEXIA2EV'OIANA-ED 0INOTTI(7!CESSOEXTRAPLEURALAOESÙFAGOPORFRENOLAPAROTOMIA2EV!SSOC-ED "RAS 0INOTTI(7%SOFAGECTOMIASUBTOTALPORTÞNELTRANSMEDIASTINALSEMTORACOTOMIA2EV !SSOC-ED"RAS 0INOTTI(7 &ELIX6. $OMENE#% 0URCELI%,2ECURRENCEOFDYSPHAGIAINPATIENTS OPERATEDONFORMEGAESOPHAGUSANALYSISOFDETERMININGFACTORS#HIR'ASTROENTEROL
Y±QR±MXOVHW
0INOTTI(7 #ECCONELLO) -ARIANO DA 2OCHA*2 :ILBERSTEIN"2ESECTIONFORACHALASIA OFTHEESOPHAGUS(EPATOGASTROENTEROLOGY 0INOTTI(7 &ELIX6. :ILBERSTEIN" #ECCONELLO)3URGICALCOMPLICATIONSOF#HAGAS DISEASESMEGAESOPHAGUS ACHALASIAOFTHEPYLORUS ANDCHOLELITHIASIS7ORLD*3URG 0INOTTI(7 &ELIX6.2EOPERAÎÍONOMEGAESÙFAGORECIDIVADOPORTRANSECÎÍOMEDIANA DODIAFRAGMA)N0INOTTI(7 EDITOR!CESSOAOESÙFAGOTORÈCICOPORTRANSECÎÍO MEDIANADODIAFRAGMA3ÍO0AULO!THENEUP 0INOTTI(7 -ARIANO DA 2OCHA*2!CESSOPORTRANSECÎÍOMEDIANADODIAFRAGMADO ESÙFAGONOTRATAMENTODOMEGAESÙFAGOAVANÎADO RESULTADOSIMEDIATOS)N0INOTTI (7 EDITOR!CESSOAOESÙFAGOTORÈCICOPORTRANSECÎÍOMEDIANADODIAFRAGMA3ÍO 0AULO!THENEUP 2ASSI,%SOFAGOCOLOPLASTIARETROESTERNALNOTRATAMENTOCIRÞRGICODODOLICOMEGAESÙFAGO 2EV'OIANA-ED 2EZENDE*- ,AUAR+- /LIVEIRA!2!SPECTOSCLÓNICOSERADIOLØGICOSDAAPERISTALSE DOESÙFAGO2EV"RAS'ASTROENTEROL 2OUX00%#HIRUGIEGASTROINTESTINALE2EV#HIR 3ERRA(/ &ELIX6. #ECCONELLO) 0INOTTI(7-ANOMETRICASPECTSOFTHEINCOMPLETE MYOTOMY!"#$!RQ"RAS#IR$IG 3ERRA (/ &ELIX6. #ECONNELLO ) 0INOTTI (7 2EAPLICATION OF MYOTOMY AND FUNDOPLICATION IN THE SURGICAL TREATMENT OF RECURRENT DYSPHAGIA AFTER INCOMPLETE MYOTOMY2EV(OSP#LIN&AC-ED3ÍO0AULO 3ERRA $ØRIA/" 3ILVA $ØRIA/- 3ILVA $ØRIA/2.OVACONDUTACIRÞRGICAPARAOTRATAMENTO DOMEGAESÙFAGOTÏCNICADE3ERRA$ØRIA !N0AUL-ED#IR 3ERRA $ØRIA/"4RATAMENTOCIRÞRGICODOMEGAESÙFAGOOPERAÎÍODE3ERRA$ØRIA2EV 'OIANA-ED 3TIPA3 "ELSEY2%SOPHAGOMYOTOMYANDANTIREmUXOPERATIONFORACHALASIA#HIR 'ASTROENTEROL 4HAL0! (ATAFUKU4 +URTZMAN2.EWOPERATIONFORDISTALESOPHAGEALSTRICTURE !RCH3URG 6OGEL"3 6AIR$" 7OODWARD-$!LTERATIONINGASTROINTESTINALEMPTYINGOFM 4ECHNETIUM LABELED SOLIDS FOLLOWING SEQUENTIAL ANTRECTOMY TRUNCAL VAGOTOMY AND 2OUX 9GASTROENTEROSTOMY!NN3URG :AAIJER*(#ARDIOSPASMINTHEAGED!NN3URG
2ECEBIDOEM !PROVADOEM
$UT*DVWURHQWHURO
