Patologa de EsfagoPresentado por: Guillermo Castro R3 CGEnfermedad por Reflujo GastroesofgicoE.R.G.ESndrome que incluye una variedad de sntomas y lesin de tejidos, asociado a la exposicin del esfago a contenido gstrico y biliar.E.R.G.ESntomas Tpicos Sntomas AtpicosComplicacionesE.R.G.ESntomas TpicosPirosisRegurgitacinDolor torcicoDisfagiaHeartburn is most often described as a burning sensation in the epigastrium or retrosternal region that often radiates up into the throat. It may occur after meals or with physical activity such as bending or stooping, and in some patients it occurs predominantly at night.Regurgitation is the sensation of acid or bitter fluid into the back of the throat. Regurgitation is particularly likely to occur after meals or when the patient lies down at night.The patient often describes episodes of awakening from sleep with coughing or choking and with gastric contents in his or her mouth.E.R.G.ESntomas AtpicosRonqueraAsmaNuseasTos CrnicaAspiracinAtypical symptoms of reflux disease include chest pain, hoarseness, and respiratory symptoms, such as asthma, chronic cough, and aspiration pneumonia. Rarely, patients may presentwith protracted hiccups, night sweats, and erosion of their dental enamel.E.R.G.EComplicacionesEstenosisUlcerasMetaplasia BarrettAdenocarcinomaOpciones de TratamientoTratamiento MdicoInhibidores Bomba de ProtonesProcinticosAntagonistas de Receptores H2DiagnsticoEndoscopia/BiopsiaRadiografas con contrastepHmetriaManometra esofgicaEstudios vaciamiento gstricoBarrett esophagus usually appears as salmon-colored mucosal extensions up into the distal esophagus and is confirmed by biopsy that shows intestinal metaplasia.Barium-meal radiography is not performed routinely, although it is useful to evaluate and document a large hiatal hernia.manometry: With this test, the length, location, and pressure of the LES are assessed along with the ability of the LES to relax during swallowing.manometry identifies the rare individual with a primary motility abnormality (such as achalasia or scleroderma) with symptoms of GER.Indicaciones CirugaComplicaciones de ERGE que no responden a tratamiento mdicoSntomas que interfieren con estilo de vidaERGE con hernia paraesofgicaIntolerancia a medicamentosFactores que podran complicar Ciruga (laparoscpica)Ciruga Abdominal previaObesidad MrbidaEstenosis severaEsfago cortoHernia hiatal paraesofgicaFundoplicaturasCompletaNissenParcialesBelsey Mark IV 270 grados anteriorDor 180 - 200 grados anteriorThal 90 grados anteriorToupet 270 grados posteriorWatson 120 grados anterolateralThe Dor fundoplication is a 180- to 200-degree anterior fundoplication that has been used primarily in association with laparoscopic Heller esophagomyotomy for achalasia. The Watson fundoplication involves fixation of the esophagus in an intra-abdominal location with plication of the fundus along the left anterolateral border of the esophagus and has been championed as a more physiologic antirefluxFundoplicatura Nissen

The costal margin and xiphoid process are marked prior to pneumoperitoneum. The laparoscope is placed to the left of the midline in a supraumbilical location approximately 12 cm caudal to the xiphoid process. With the camera port to the left of midline, the surgeon's right-hand 10-mm port is generally 10 cm from the xiphoid and two fingerbreadths below the left costal margin. A 5-mm right lateral port for the liver retractor is placed at least 15 cm from the xiphoid process two fingerbreadths below the right costal margin. The 5-mm assistant's port is located halfway between the camera and liver retractor. The surgeon's left-hand 5-mm port is inserted after the liver retractor is placed and is generally 5 to 10 cm from the xiphoid process in a right paramedian location.Elementos Fundoplicatura NissenDiseccin de los pilares, identificar y preservar los troncos vagales, as como la rama heptica del tronco anteriorDiseccin circumferencial y movilizacin del esfagoCierre de los pilaresMovilizacin del fondo gstrico y diseccin de los gstricos cortosRealizar una fundoplicatura corta alrededor de la porcin inferior del esfago

The gastrohepatic omentum is divided up to the level of the right crus of the diaphragm and the phrenoesophageal membrane is divided in a transverse direction.The gastric fundus is then pulled inferiorly and to the right. The gastrophrenic ligament is divided to mobilize the gastric cardia. hiatal dissection, the assistant retracts the fat pad inferiorly to place tension on the distal esophagus.

Division of the short gastric vessels to the base of the left crus to allow complete fundic mobilisation and facilitates division of the gastropancreatic ligament. The medial border of the left crus of the diaphragm is dissected back to its junction with the right crus, joining the plane previously begun from the right side. A large window is thereby created posterior to the esophagus and proximal stomach and anterior to both crura

The gastric fundus is first pulled posterior and to the right of the esophagus and the shoeshine maneuver is performed to ensure that it slides easily and is not twisted. mobilized to allow at least 3.5 cm of esophagus

deep seromuscular, but non-full-thickness, suture bites in the fundus to the left and right of the esophagus spaced approximately 5 to 8 mm apartchecked for degree of looseness by passing a 5-mm diameter instrument between the left side of the wrap and the esophagus.length of the fundoplication should be less than 2.5 cm and it must be situated around the esophagus rather than inferiorly on the proximal stomachFundoplicaturas ParcialesIndicaciones Fundoplicatura ParcialAnormalidades en motilidad del esfagoPacientes con aerofagiaFondo gstrico insuficienteMiotoma Fundoplicatura Toupet

The fundus is pulled posterior to the esophagus with suture of the leading edge of the wrapped fundus to the right anterior aspect of the esophagus while the left (medial) side of the fundus is sutured to the left anterolateral aspect of the esophagus. Varying numbers of sutures may be placed between the fundus and the crura for further stabilizationFundoplicatura Dor

Complicaciones de la CirugaLesin esplnicaLesin troncos vagalesPerforacin del esfagoNeumomediastinoDisfagiaThe spleen, however, may be injured during transabdominal fundoplication. Capsular avulsion or small tears causing persistent hilar bleeding occur in approximately 5% of patients, and splenectomy rates of 1% to 3%

Late failure following fundoplication presents either as recurrent gastroesophageal reflux or hiatus hernia, or both. There are two reasons for the development of recurrent reflux: loosening of the original fundoplication or wrap slippage.

a.Disrupted wrap. B: Sliding hiatal hernia with wrap in abdomen. C: Slipped fundoplication onto proximal stomach. D: Intrathoracic migration of the fundoplicationCuidados PostoperatoriosSNGLquidos intravenososDieta lquida al primer da PODieta blanda al segundo daEsofagogramaice chips overnight and allowed clear liquids the morning after the operation. If tolerated, a soft diet is ordered for lunchketorolac and ondansetron intravenously through the first 12 to 18 hours after the operation to minimize the need for narcotics and to diminish the chance of postoperative vomitingCuidados PostoperatoriosPaciente puede egresar 3 a 5 das despus de cirugaDieta blanda por 3 a 4 semanasProgresar gradualmente a dieta normal de la 4ta a 8va semanaEvitar bebidas gaseosas por lo menos 3 mesesDurante primeros 3 meses pacientes debern masticar bien la comida3 meses despus de ciruga 20% de los pacientes tendrn restricciones en su dietaDespus de 12 meses 95% podr consumir dieta normalA good outcome following Nissen-Rossetti fundoplication is expected in approximately 90% of patients at 10 years' follow-up. The causes of failure are evenly divided between recurrent reflux and persistent troublesome side effects. Four recent randomized trials of Nissen- Rossetti fundoplication versus Nissen fundoplication with division of the short gastric vessels have shown equivalent outcomes for both reflux control and postfundoplication dysphagia. In two of the trials, the incidence of wind related side effects at late follow-up was less following Nissen-Rossetti fundoplication.5 - 10% Disfagia1 - 2 % requieren dilataciones esofgicasRecurrencia sntomas reflujo hasta 5%Dehiscencia o migracion de fundoplicatura hasta 10%GRACIAS