Héctor Valladares

Open transthoracic or transhiatal esophagectomy versus minimally invasive esophagectomy in terms of morbidity, mortality and survival.

BackgroundSurgical treatment of esophageal cancer is associated with a high rate of morbidity and mortality even in specialized centers. Minimally invasive surgery has been proposed to decrease these complications.MethodsThe authors present their results regarding postoperative complications and the survival rate at 3 years, comparing the classic open procedures (transthoracic or transhiatal esophagectomy) with minimally invasive surgery. Surgical procedures were performed according to procedures published elsewhere.ResultsThe study enrolled 166 patients who underwent surgery between 1990 and 2003. Open transthoracic surgery was performed for 60 patients. In this group of patients, postoperative mortality was observed in 11% of the cases. Major, minor, and late complications were observed in 61.6% of the patients, and the 3-year survival rate was 30% for this group. Open transhiatal surgery was performed for 59 patients. The morbidity, mortality, and 3-year rate were almost the same as for the transthoracic surgery group. For the 47 patients submitted to minimally invasive procedures (thoracoscopic and laparoscopic), the complications and mortality rates were significantly reduced (38.2% and 6.4%, respectively). For the patients submitted to minimally invasive surgery, the 3-year survival rate was 45.4%. It is important to clarify that the patients submitted to minimally invasive surgery manifested early stages of the diseases, and that this the reason why the morbimortality and survival rates were better.ConclusionsThe transthoracic and transhiatal open approaches have similar early and late results. Minimally invasive surgery is an option for patients with esophageal carcinoma, with reported results similar to those for open surgery. This approach is indicated mainly for selected patients with early stages of the disease.

Gastroesophageal reflux disease after sleeve gastrectomy.

Gastroesophageal reflux disease is commonly present in obese patients. 1–3 In patients undergoing gastric bypass, the incidence of GERD is as high as 50% to 100%. Therefore, it is very important to evaluate preoperatively the presence of reflux symptoms and endoscopic esophagitis to choose the best treatment of both pathologic conditions: GERD and obesity. There are publications reporting the strategy for treating concomitant hiatal hernia or GERD disease and bariatric procedures for obese patients. Laparoscopic sleeve gastrectomy (LSG) is a frequently used alternative procedure for surgical treatment of obesity. This technique modifies the anatomy of the esophagogastric junction (EGJ) converting it in a straight tubular segment and partially sectioning the sling fibers that may affect the lower esophageal sphincter (LES) mechanism. Consequently, some patients present reflux symptoms associated with endoscopic esophagitis and therefore PPÍs treatment must be indicated. After SG LES incompetence is present in 85% of patients and thus could promote pathologic reflux. However, others have suggested that reflux esophagitis improves after SG; therefore it is a very controversial point. There are very few data regarding GERD or hiatal hernia after SG including endoscopic objective evaluation of reflux. In this paper, we present our experience regarding the frequency of gastroesophageal reflux disease after SG and review the available literature concerning this point.

Laparoscopic anterior cardiomyotomy plus anterior Dor fundoplication without division of lateral and posterior periesophageal anatomic structures for treatment of achalasia of the esophagus.

Laparoscopic cardiomyotomy is the treatment of choice for patients with achalasia of the esophagus. Several different techniques and modifications have been reported concerning the approach (thoracoscopic or laparoscopic), type and length of the myotomy, with or without fundoplication, type of fundoplication, etc. In this prospective study, we report our simplified technique for anterior cardiomyotomy with Dor fundoplication and the results obtained using this procedure. Only the anterior wall of the esophagus was exposed without dissection of the lateral or posterior periesophageal anatomic structures for the technique. Twenty-five patients were operated by a single surgeon. The diagnosis was based on the clinical, radiologic, endoscopic, and functional esophageal tests. Achalasia was classified into 3 types: achalasia type I was diagnosed in 5 patients, type II in 6 patients, and type III in 14 patients. Manometry demonstrated a mean resting pressure of 33.5 mm Hg (range, 18 to 55), associated with incomplete relaxation. The hospital stay was 3 days; the median operative time was 115 minutes (range, 90 to 150), 2 small mucosal perforations occurred which were immediately sutured during surgery without conversion into open technique and no postoperative complications occurred. After operation, lower esophageal sphincter pressure returned to normal values and complete relaxation in all patients. In type II and III achalasia, the esophageal body diameter decreased more than 50% (P=0.001) compared with the preoperative diameter, and the internal diameter of the esophagogastric junction increased significantly (P=0.001). Only 2 patients presented occasional heartburn and 2 patients received 1 session of hydrostatic dilatation due to mild residual dysphagia. No late recurrence of dysphagia has been observed to the present time (1 to 5 y of follow-up). In conclusion, the goals of the surgery for achalasia are obtained with this simplified technique.

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

Inversed Y cardioplasty plus a truncal vagotomy-antrectomy and a Roux-en-Y gastrojejunostomy performed in patients with stricture of the esophagogastric junction after a failed cardiomyotomy or endoscopic procedure in patients with achalasia of the esophagus.

Laparoscopic anterior cardiomyotomy in addition to anterior Dors fundoplication is the procedure of choice for achalasia of the esophagus with approximately 95% success rate. Redo cardiomyotomy is complicated and associated with rerecurrence of dysphagia. Twelve patients with failed redo myotomy were clinically evaluated with radiology, endoscopy, and manometry in whom achalasia type III or IV was confirmed. We propose as treatment for these selected cases an inversed Y cardioplasty + truncal vagotomy, a partial distal gastrectomy and Roux-en-Y gastrojejunostomy in order to facilitate esophageal emptying and avoid the appearance of postoperative gastroesophageal reflux as a side effect of this procedure. One patient was reoperated on in order to enlarge the cardioplasty. Disappearance of dysphagia was confirmed in all patients. Three patients presented reflux symptoms and were treated with 20 mg of Omeprazole 20 twice/day. No food retention, erosive esophagitis, or Barretts esophagus were observed. The mean resting pressure decreased from 24.9 +/- 8.5 mm Hg to 7.5 +/- 2.5 mm Hg (P = 0.0001). Furthermore, esophageal diameter decreased significantly after a 5-year follow-up. This procedure could be an option for treating patients in which repeated Heller operations have failed.

Videothoracoscopic management of middle esophageal diverticulum with secondary bronchoesophageal fistula: Report of a case

Middle esophageal diverticulum is rare, but can result in bronchoesophageal fistula. Previous reports have described open surgical techniques to treat esophageal diverticula, but few have evaluated the effectiveness of a videothoracoscopy approach. We report a case of middle esophageal diverticulum associated with bronchoesophageal fistula, managed successfully with videothoracoscopy. We also review the relevant literature.

Hernias hiatales: ¿cuándo y por qué deben ser operadas?

INTRODUCTION There is controversy in the literature about the choice of expectant medical treatment versus surgical treatment of hiatal hernias, depending on the presence or absence of symptoms. This study presents the results obtained by our group, considering disease duration and postoperative results. PATIENTS AND METHOD A total of 121 patients were included and divided by age, disease duration, type of hiatal hernia and postoperative outcome. RESULTS In 32% of the patients younger than 70 years, symptom duration was longer than 11 years and 68% of those aged more than 71 years had long-term symptoms (p<.05). Type iv hernias (complex) and those with diameters measuring more than 16 cm were observed in the group with longer symptom duration. Complications were more frequent in the older age group, in those with longer symptom duration and in those with type iv complex hernias. There was no postoperative mortality and only one patient (0.8%) with a type iii hernia and severe oesophagitis required reoperation. CONCLUSION We recommend that patients with hiatal hernia undergo surgery at diagnosis to avoid complications and risks. Older patients should not be excluded from surgical indication but should undergo a complete multidisciplinary evaluation to avoid complications and postoperative mortality.

Prevalence of clarithromycin resistance in Helicobacter pylori in Santiago, Chile, estimated by real-time PCR directly from gastric mucosa

BackgroundCurrent available treatments for Helicobacter pylori eradication are chosen according to local clarithromycin and metronidazole resistance prevalence. The aim of this study was to estimate, by means of molecular methods, both clarithromycin and metronidazole resistance in gastric mucosa from patients infected with H.pylori.MethodsA total of 191 DNA samples were analyzed. DNA was purified from gastric mucosa obtained from patients who underwent an upper gastrointestinal endoscopy at an university hospital from Santiago, Chile, between 2011 and 2014. H.pylori was detected by real-time PCR. A 5’exonuclease assay was developed to detect A2142G and A2143G mutations among H.pylori-positive samples. rdxA gene was sequenced in samples harboring A2142G and A2143G mutations in order to detect mutations that potentially confer dual clarithromycin and metronidazole resistance.ResultsNinety-three (93) out of 191 DNA samples obtained from gastric mucosa were H.pylori-positive (48.7%). Clarithromycin-resistance was detected in 29 samples (31.2% [95%CI 22.0–41.6%]). The sequencing of rdxA gene revealed that two samples harbored truncating mutations in rdxA, one sample had an in-frame deletion, and 11 had amino acid changes that likely cause metronidazole resistance.ConclusionsWe estimated a prevalence of clarithomycin-resistance of 31.8% in Santiago, Chile. Three of them harbor inactivating mutations in rdxA and 11 had missense mutations likely conferring metronidazole resistance. Our results require further confirmation. Nevertheless, they are significant as an initial approximation in re-evaluating the guidelines for H.pylori eradication currently used in Chile.

Prevalence of dual clarithromycin and metronidazole resistance in Helicobacter pylori estimated by molecular methods in Santiago, Chile

Background Current available treatments for Helicobacter pylori eradication are chosen according to local clarithromycin and metronidazole resistance prevalence. The aim of this study was to estimate, by means of molecular methods, both clarithromycin and metronidazole resistance in gastric mucosa from patients infected with H.pylori. Methods A total of 191 DNA samples were analyzed. DNA was purified from gastric mucosa obtained from patients who underwent an upper gastrointestinal endoscopy at an university hospital from Santiago, Chile, between 2011 and 2014. H.pylori was detected by real-time PCR. A 5’exonuclease assay was developed to detect A2142G and A2143G mutations among Hpylori-positive samples. rdxA gene was sequenced in samples harboring A2142G and A2143G mutations in order to detect mutations that potentially confer dual clarithromycin and metronidazole resistance. Results Ninety-three (93) out of 191 DNA samples obtained from gastric mucosa were H. pylori-positive (48.7%). Clarithromycin-resistance was detected in 29 samples (31.2% [95%CI 22.0%-41.6%]). The sequencing of rdxA gene revealed that two samples harbored truncating mutations in rdxA, one sample had an in-frame deletion, and 11 had amino acid changes that likely cause metronidazole resistance. Conclusions We estimated a prevalence of clarithomycin-resistance of 31.8% in Santiago, Chile. The proportion of dual clarithromycin and metronidazole resistance could be, at least, 15.0%. Our results require further confirmation. Nevertheless, they are significant as an initial approximation in re-evaluating the guidelines for H.pylori eradication currently used in Chile.