REFAZER FUNDOPLICATURA LAPAROSCÓPICA, REFAZER FUNDOPLICATURA A NISSEN OU TOUPET COMBINADA COM GASTRECTOMIA DISTAL EM Y-ROUX PARA TRATAMENTO DE RECIDIVA APÓS FUNDOPLICATURA A NISSEN

Braghetto, Italo; Korn, Owen; Figueroa-Giralt, Manuel; Valenzuela, Catalina; Burgos, Ana Maria; Mandiola, Carlos; Sotomayor, Camila; Villa, Eduardo

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ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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Sumário

Original Article • ABCD, arq. bras. cir. dig. 35 • 2022 • https://doi.org/10.1590/0102-672020220002e1678 copiar

REFAZER FUNDOPLICATURA LAPAROSCÓPICA, REFAZER FUNDOPLICATURA A NISSEN OU TOUPET COMBINADA COM GASTRECTOMIA DISTAL EM Y-ROUX PARA TRATAMENTO DE RECIDIVA APÓS FUNDOPLICATURA A NISSEN

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

RACIONAL:

A fundoplicatura de Nissen laparoscópica falha em controlar o refluxo gastroesofágico em quase 15% dos pacientes e a maioria deles deve ser reoperada devido aos sintomas. Diferentes técnicas cirúrgicas têm sido sugeridas.

OBJETIVOS:

Apresentar os resultados pós-operatórios de pacientes submetidos a 3 procedimentos diferentes: Reoperação e fundoplicatura de Nissen laparoscópica apenas (Grupo A), reoperação e fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal (Grupo B) ou reoperação e conversão para Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux (Grupo C).

MÉTODOS:

estudo prospectivo incluindo 77 pacientes submetidos inicialmente a fundoplicatura de Nissen laparoscópica que apresentaram recidiva do refluxo gastroesofágico após a operação. Eles foram avaliados antes e após a reoperação com questionário clínico e estudos funcionais específicos. Reestabelecida a anatomia da junção esôfago-gástrica, procedeu-se às referidas cirurgias. Nenhum paciente perdeu seguimento.

RESULTADOS:

Os sintomas persistentes foram observados com maior frequência nos pacientes dos Grupos A ou B, associados à estenose da fundoplicatura, fundoplicatura intratorácico ou fundoplicatura torcida. No Grupo C, os sintomas recorrentes associados a essa alteração anatômica foram observados com pouca frequência. Esfincter esofágico inferior incompetente foi confirmado em 57,7% dos pacientes pertencentes ao Grupo A em comparação com 17,2% após fundoplicatura de Nissen laparoscópica combinado com gastrectomia distal, e 26% após a Toupet laparoscópico combinado com gastrectomia distal e reconstrução em Y-Roux. Nesse grupo, apesar do alto percentual de pacientes com esfincter esofágico inferior incompetente, 8,7% apresentaram refluxo ácido anormal após a cirurgia.

CONCLUSÕES:

As técnicas de Nissen ou Toupet combinados com a gastrectomia distal em Y de Roux são seguras e eficazes para o manejo da falha da fundoplicatura a Nissen. A técnica de Toupet é preferível para pacientes que sofrem principalmente com disfagia e dor.

DESCRITORES:
Refluxo Gastroesofágico; Recidiva; Fundoplicatura; Laparoscopia; Gastrectomia

		A (n=26)	B (n=29)	C (n=23)
EARLY COMPLICATIONS
	Hemoperitoneum	1 (3.8%) (IIIb)^* * Clavien-Dindo classification	–	–
	Pneumonia	–	2 (7.2%) (IIIa)^* * Clavien-Dindo classification	–
	Esophageal perforation	–	1 (3.5% (IIIb)^* * Clavien-Dindo classification	–
	Bowel obstruction	–	1 (3.5%) (IIIb)^* * Clavien-Dindo classification	–
	Subphrenic abscess	2 (7.6%) (IIIb)^* * Clavien-Dindo classification		–
	Intraluminal bleeding	–	1 (3.5%) (IIIa)^* * Clavien-Dindo classification	1 (4.3%) (IIIa)^* * Clavien-Dindo classification
	Vascular brain stroke	–	1 (3.5%) (V)^* * Clavien-Dindo classification	–
	Gastric retention	–	–	2 (8.6%) (IIIa)^* * Clavien-Dindo classification
	Perigastric collection	–	–	1 (4.3%) (IIIa)^* * Clavien-Dindo classification
	Paralytic ileus	–	–	1 (4.3%) (IIIa)^* * Clavien-Dindo classification
TOTAL MORTALITY		3 (11.5%)	6 (20.7%)	5 (21.7%)
LATE COMPLICATIONS		0	1 (3.5%)	0
LATE COMPLICATIONS
	Diarrhea	–	6 (20.7%) (II)^ Visick score.	4 (17.4%) (II)
	Dumping	–	2 (6.9%) (II)^ Visick score.
	Weight loss	–	3 (10.3%) (II)^ Visick score.	3 (13.1%) (II)^ Visick score.
	Anastomotic ulcer	–	–	1 (4.3%) (II)^ Visick score.
	Anemia	–	1 (3.5%) (II)	1 (4.3%) (II)
	Dysphagia (persistent)	6 (23.1%)	8 (27.5%)	1 (4.3%)

			A (n=26)	B (n=29)	C (n=23)
Symptoms
	Heartburn	Pre-operative	26 (100%)	29 (100%)	23 (100%)
	Heartburn	Postoperative	5 (19.2%)	2 (6.8%)	2 (8.6%)
(A vs. B and C=p<0.001)
	Regurgitation	Pre-operative	26 (100%)	28 (100%)	23 (100%)
	Regurgitation	Postoperative	3 (11.5%)	2 (6.8%	0
(A vs. other groups=p<0.001)
	Dysphagia	Pre-operative	2 (7.6%)	4 (13.7%)	18 (78.3%)
	Dysphagia	Postoperative	6^* * Seven patients submitted to second reoperation: five to conversion to redo Nissen with distal gastrectomy and two to Toupet with distal gastrectomy (23.1%)	8 (27.5%)^ Submitted to endoscopic dilatation with Savary bougie.	1 (4.3%)^ Submitted to endoscopic dilatation with Savary bougie.
(A vs. B and C=p<0.001)
	Chest pain	Pre-operative	8 (30.7%)	0	15 (65.2%)
	Chest pain	Postoperative	1 (3.8%)^* * Seven patients submitted to second reoperation: five to conversion to redo Nissen with distal gastrectomy and two to Toupet with distal gastrectomy	0	1 (4.3%)
	Respiratory	Pre-operative	1 (3.8%)	0	0
	Respiratory	Postoperative	1 (3.8%)	0	0

			A (n=26)	B (n=29)	C (n=23)
Radiological findings
	Wrap disruption	Pre-operative	21 (80.7%)	24 (82.7%)	0
	Wrap disruption	Postoperative	0	0	0
	Wrap stricture	Pre-operative	0 (100%)	0	7
	Wrap stricture	Postoperative	5 (19.2%)^* * Endoscopic dilatation not reoperated	6 (20.7%)^* * Endoscopic dilatation not reoperated	1 (8.7%)
(A, B vs. C= p<0.001)
Paraesophageal sliding
	Hernia	Pre-operative	0	0	4
	Hernia	Postoperative	0	0	0
	Slipped Nissen	Pre-operative	2 (7.7%)	1 (3.5%)	2 (8.6%)
	Slipped Nissen	Postoperative	0	0	0
	Intrathoracic wrap	Pre-operative	3 (11.5%)	0	8 (34.7%)
	Intrathoracic wrap	Postoperative	3 (11.5%)	0	0
	Twist or bilobed	Pre-operative	0	0	2 (8.6%)
	Twist or bilobed	Postoperative	4 (15.4%)^ Seven patients submitted to second reoperation: five to conversion to redo Nissen with distal gastrectomy and two to Toupet with distal gastrectomy.	0	0
Reoperated due to refailure			7 (26%)^ Seven patients submitted to second reoperation: five to conversion to redo Nissen with distal gastrectomy and two to Toupet with distal gastrectomy.	0	0

			A (n=26)	B (n=29)	C (n=23)
Endoscopic evaluation
	Esophagitis	Pre-operative	17 (65.4%)	13 (44.8%)	5 (21.7%)
	Esophagitis	Postoperative	6 (23.1%)^* * Medical treatment with esomeprazole;	2 (6.9%)^* * Medical treatment with esomeprazole;	0
	BE with esophagitis	Pre-operative	9 (34.6%)	16 (55.2%)	10 (43.5%)
	BE with esophagitis	Postoperative	4 (19.2%)^* ***** Second reoperation: five to conversion to redo Nissen with distal gastrectomy and two to Toupet with distal gastrectomy; BE: Barrett esophagus; HH: hiatus hernia.	6 (20.6%)^ Persisted Barrett esophagus without esophagitis submitted to complementary radiofrequency ablation	(17.4%)^ Persisted Barrett esophagus without esophagitis submitted to complementary radiofrequency ablation
	Esophagitis with HH	Pre-operative	0	3	8
	Esophagitis with HH	Postoperative	3^* ***** Second reoperation: five to conversion to redo Nissen with distal gastrectomy and two to Toupet with distal gastrectomy; BE: Barrett esophagus; HH: hiatus hernia.	0	0
Reoperated due to refailure			7 (26%)^* ***** Second reoperation: five to conversion to redo Nissen with distal gastrectomy and two to Toupet with distal gastrectomy; BE: Barrett esophagus; HH: hiatus hernia.	0	0

Manometry			A (n=26)	B (n=29)	C (n=23)
	Laparoscopic Nissen fundoplication pressure (mmHg)	Pre-operative	6.1±2.7	10.1±2.6	7.88±2.7
	Laparoscopic Nissen fundoplication pressure (mmHg)	Postoperative	11.1±3.8	15.5±1.3	10.5±3.36
	Total length (cm)	Pre-operative	2.5±0.5	3.9±0.2	3.07±0.61
	Total length (cm)	Postoperative	2.8±0.8	4.05±1.1	3.57±0.53
	Abdominal length (cm)	Pre-operative	0.0	0.3±0.2	0.1±0.2
	Abdominal length (cm)	Postoperative^* * p<0.006	1.8±0.4	1.8±0.4	1.14±0.69
	Number of patients with incompetent laparoscopic Nissen fundoplication	Pre-operative	21 (82%)	29 (100%)	23 (100%)
		Postoperative	9 (34.6%)	5 (17.2%)	6 (26%)
	Amplitude distal waves (mmHg)	Pre-operative	105±17.1	117±18.9	122.4±28.4
	Amplitude distal waves (mmHg)	Postoperative	125±20.3	129±25.2	138.9±28.8
	Peristaltic waves (mean) (%)	Pre-operative	43	88	94
	Peristaltic waves (mean) (%)	Postoperative	72	94	98
	Number of patients with ineffective motility	Pre-operative	12 (46.1%)	8 (27.5%)	3 (13%)
	Number of patients with ineffective motility	Postoperative	6 (23.1%)	5 (17.2%)	1 (4.3%)
24-h pH monitoring
	Time pH<4 (%)	Pre-operative	25.8±4.9	21.5±4.1	19.0±6.62
	Time pH<4 (%)	Postoperative^# # p<0.01.	7.9±3.4	3.6±2.5	4.3±4.04
	DeMeester’s score	Pre-operative	85.3±23.6	69.8±3.4	44.8±21.8
	DeMeester’s score	Postoperative^# # p<0.01.	23.1±6.9	10.3±4.1^# # p<0.01.	11.9±5.14
	Number of patients with pathologic acid reflux	Pre-operative	26 (100%)	29 (100%)	23 (100%)
	Number of patients with pathologic acid reflux	Postoperative	14 (53.8%)	3 (10.1%)	2 (8.6%)

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[1] Correspondence: Italo Braghetto. E-mail: ibraghet@hcuch.cl