Abstract
Antrectomy with Roux-en-Y gastrojejunostomy was performed in 83 patients with “complicated” forms of peptic esophagitis. The esophagitis was considered complicated either because of the severity of the lesions (stricture, brachyesophagus, or endobrachyesophagus) or because of postoperative conditions after one or more previous operations (Heller's myotomy, esophagogastric resections, or hiatal hernia repair).
A standard procedure was performed in 56 patients while technical adjustments were required for 27 patients who had previously undergone surgery. Two patients died from pulmonary embolism. Early postoperative complications occurred in 11% of patients. Healing of esophagitis was observed for all the patients treated with the standard procedures. Six partial regressions and 1 complete regression of Barrett's mucosa were observed. Digestive sequellae were minor and decreased with time. Assessment of pH and small bowel manometry showed that the reflux was controlled and no small bowel motility disturbance was observed when the standard technique was used including a small gastric resection. The main digestive sequellae, including lack of healing of esophagitis, dumping syndrome, and gastrojejunal anastomotic ulcer, occurred when a two-thirds gastrectomy was performed in order to avoid vagotomy.
Résumé
On a pratiqué une antrectomie associée à une gastrojéjunostomie chez 83 patients ayant une oesophagite peptique “compliquée”, soit en raison de la sévérité des lésions (sténose, endobrachyoesophage) soit, dans 52 cas, en raison de conditions post-opératoires induites par une ou plusieurs interventions comme la myotomie de Heller, une résection oesogastrique ou certains cas sélectionnés de patients réopérés pour une cure de hernie hiatale.
Une intervention “standard” a été pratiquée chez 56 patients alors que des adaptations techniques ont été nécessaires chez 27 patients déja opérés antérieurement. Deux patients sont décédés d'embolie pulmonaire. Des complications précoces ont été observées chez 11% des patients. La cicatrisation de l'oesophagite a été obtenue chez tous les patients ayant bénéficié d'une intervention standard. On a observé 6 régressions complètes et une régression incomplète chez les patients porteurs d'un endobrachyoesophage (oesophage de Barett). Les séquelles digestives ont été minimes et ont diminué avec le temps. La pHmétrie et la manométrie du grêle ont confirmé que le reflux était contrôlé et qu'il n'y avait pas de trouble moteur de l'intestin grêle après l'intervention standard comprenant une résection gastrique minime. Les principales séquelles digestives, comprenant l'absence de cicatrisation de l'oesophagite, le dumping syndrome et l'ulcère anastomotique ont été observées en cas de gastrectomie des 2/3 sans vagotomie.
Resumen
Se ha realizado antrectomía con gastroyeyunostomía de Roux-en-Y en 83 pacientes con formas “complicadas” de esofagitis péptica debidas a la severidad de la lesión (estrechez, braquiesófago, endobraquiesófago) en 52 casos, o a condiciones postoperatorias desarrolladas después de una o varias operaciones tales como miotomía de Heller, resecciones esofagogástricas o reoperaciones después de corrección de hernia hiatal. Los propósitos del presente estudio fueron: a) informar los resultados de la exclusión duodenal total en 83 pacientes con esofagitis péptica complicada; b) analizar los resultados del seguimiento de estos pacientes; c) valorar la utilidad de este procedimiento en el tratamiento de la enfermedad por reflujo.
Se realizó un procedimiento estándar en 56 casos, en tanto que fué necesario practicar ajustes técnicos en 27 pacientes que habían sido previamente operados. Dos pacientes murieron por embolia pulmonar. Se registraron complicaciones postoperatorias tempranas en 11% de los casos. Se observó cicatrización de la esofagitis en todos los pacientes tratados con el procedimiento estándar; se registró regresión parcial de mucosa de Barrett en 6 casos y regresión completa en uno. Las secuelas digestivas fueron menores y disminuyeron con el paso del tiempo. La determinación del pH y la manometría de intestino delgado demostraron que el reflujo fue controlado, y no se observó anormalidad de la motilidad intestinal cuando se utilizó la técnica operatoria estándar, incluyendo una resección gástrica menor. Las principales secuelas digestivas, incluyendo escape anastromótico, síndrome de dumping y úlcera anastomótica gastroyeyunal ocurrieron cuando se realizó gastrectomía de dos tercios para evitar vagotomía. Al final del seguimiento 80% de los pacientes consideraban tener un resultado excelente, 17% presentaban alguna secuela y 3% estaban peor que antes de procedimiento. La mortalidad fue de 2.4% y la morbilidad de 11%.
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Fekete, F., Pateron, D. What is the place of antrectomy with Roux-en-Y in the treatment of reflux disease? Experience with 83 total duodenal diversions. World J. Surg. 16, 349–354 (1992). https://doi.org/10.1007/BF02071547
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DOI: https://doi.org/10.1007/BF02071547