Cardiomiectomia com fundoplicatura parcial videolaparoscópica no tratamento do megaesôfago não avançado: estudo de 50 casos

Domene, Carlos Eduardo; Santo, Marco Aurélio; Onari, Pedro; Volpe, Paula; Pinotti, Henrique Walter

doi:10.1590/S0100-69911998000400003

Resumos

Foram estudados prospectivamente cinqüenta pacientes com megaesôfago não avançado tratados por cardiomiectomia com fundoplicatura parcial por via laparoscópica, avaliados sob o ponto de vista clínico e funcional. Houve 12% de complicações intra-operatórias, duas complicações pós-operatórias imediatas e um óbito. Não houve conversões ou complicações tardias. Os resultados ótimos e bons somaram 97,9% dos casos. Houve tendência à diminuição radiológica do calibre do esôfago e desaparecimento da esofagite à endoscopia. A eletromanometria mostrou diminuição significativa da pressão média do esfíncter inferior do esôfago após a operação; a pHmetria de 24 horas constatou diminuição da estase esofágica e ausência de refluxo gastro-esofágico no pós-operatório. Não houve diferença entre os resultados do tratamento de pacientes com megaesôfago chagásico e não chagásico. Os pacientes tiveram o benefício da cirurgia laparoscópica de menor dor, rápida realimentação, alta precoce e breve retorno às atividades habituais.

Megaesôfago; Tratamento cirúrgico; Laparoscopia

This is a prospective study of 50 patients with non-advanced achalasia treated by videolaparoscopic cardiomyectomy with partial fundoplication. The technical standardization of the operative procedure was evaluated, and the patients studied by clinical evaluation, endoscopy, eletromanometry, radiology and 24 hour pHmetry. The operation was completed laparoscopically in all patients, with no convertion to laparotomy. There were six (12%) intra-operative complications (mucosal perforation, pleural lesion and subcutaneous emphysema), two (4%) immediate post-operative ocurrencies and one (2%) death. There was no late complication. Clinical evaluation showed significant improvement of dysphagia, no regurgitation and weight gain after operation, and excellent and good results were obtained in 97.9% of the patients. In the post-operative period ocurred radiological improvement of esophageal dilatation and less endoscopic esophagitis. The eletromanometry showed significative decrease of lower esophageal sphincter pressure after operation, as well as 24 hour pHmetry verified less esophageal stasis and no gastro-esophageal refluxo There was no difference in the treatment of chagasic or non-chagasic patients. The benefits of laparoscopic surgery were obtained: less pain, early oral intake, short hospitalization and fast return to norma activities.

Achalasia; Surgical treatment; Laparoscopy

ARTIGOS ORIGINAIS

Cardiomiectomia com fundoplicatura parcial videolaparoscópica no tratamento do megaesôfago não avançado: estudo de 50 casos

Laparoscopic cardiomyectomy with partial fundoplication in the treatment of achalasia: analysis of 50 cases

Carlos Eduardo Domene, TCBC-SP^I; Marco Aurélio Santo^II; Pedro Onari^II; Paula Volpe, ACBC-SP^II; Henrique Walter Pinotti, TCBC-SP^III

^IProfessor Livre-Docente da Disciplina de Cirurgia do Aparelho Digestivo do Hospital das Clínicas - FMUSP

^IIPós-Graduando

^IIIProfessor Titular da Disciplina de Cirurgia do Aparelho Digestivo do Hospital das Clínicas - FMUSP

^{Endereço para correspondência} Endereço para correspondência: Dr. Carlos Eduardo Domene Avenida Arnolfo de Azevedo, 201 01236-030 - São Paulo-SP E-mail: domene@sysnetway.com.br

RESUMO

Foram estudados prospectivamente cinqüenta pacientes com megaesôfago não avançado tratados por cardiomiectomia com fundoplicatura parcial por via laparoscópica, avaliados sob o ponto de vista clínico e funcional. Houve 12% de complicações intra-operatórias, duas complicações pós-operatórias imediatas e um óbito. Não houve conversões ou complicações tardias. Os resultados ótimos e bons somaram 97,9% dos casos. Houve tendência à diminuição radiológica do calibre do esôfago e desaparecimento da esofagite à endoscopia. A eletromanometria mostrou diminuição significativa da pressão média do esfíncter inferior do esôfago após a operação; a pHmetria de 24 horas constatou diminuição da estase esofágica e ausência de refluxo gastro-esofágico no pós-operatório. Não houve diferença entre os resultados do tratamento de pacientes com megaesôfago chagásico e não chagásico. Os pacientes tiveram o benefício da cirurgia laparoscópica de menor dor, rápida realimentação, alta precoce e breve retorno às atividades habituais.

Unitermos: Megaesôfago; Tratamento cirúrgico; Laparoscopia.

ABSTRACT

This is a prospective study of 50 patients with non-advanced achalasia treated by videolaparoscopic cardiomyectomy with partial fundoplication. The technical standardization of the operative procedure was evaluated, and the patients studied by clinical evaluation, endoscopy, eletromanometry, radiology and 24 hour pHmetry. The operation was completed laparoscopically in all patients, with no convertion to laparotomy. There were six (12%) intra-operative complications (mucosal perforation, pleural lesion and subcutaneous emphysema), two (4%) immediate post-operative ocurrencies and one (2%) death. There was no late complication. Clinical evaluation showed significant improvement of dysphagia, no regurgitation and weight gain after operation, and excellent and good results were obtained in 97.9% of the patients. In the post-operative period ocurred radiological improvement of esophageal dilatation and less endoscopic esophagitis. The eletromanometry showed significative decrease of lower esophageal sphincter pressure after operation, as well as 24 hour pHmetry verified less esophageal stasis and no gastro-esophageal refluxo There was no difference in the treatment of chagasic or non-chagasic patients. The benefits of laparoscopic surgery were obtained: less pain, early oral intake, short hospitalization and fast return to norma activities.

Key words: Achalasia; Surgical treatment; Laparoscopy.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Recebido em 7/11/97

Aceito para publicação em 16/4/98

Trabalho realizado na Disciplina de Cirurgia do Aparelho Digestivo do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. -

1. Zeitune JMR. Resposta do esfíncter inferior do esôfago e da gastrinemia ŕ acidificaçăo do antro gástrico em indivíduos normais e em pacientes com megaesôfago chagásico. Tese. FMUSP, 1987.
2. Pinotti HW, Domene CE, Nasi A, et al. Surgical treatment of achalasia - cardiomyotomy and fundoplication by videolaparoscopy. In: Proceedings of the V ISDE World Congress, Kyoto, Japan, 1992, pag.225.
3. Moreno-Gonzalez A, Alvarez AG, Garcia IL. Results of surgical treatment of esophageal achalasia. Multicenter retrospective study of 1.856 cases. IntSurg 1988; 73:69.
4. Jamieson GG. Gastro-esophageal reflux following myotomy for achalasia. Hepato-Gastroenterol 1991; 38:506.
5. Wong RKH, Maydonovitch CL. Achalasia. In: The Esophagus. Castell DO Ed. Little, Brown and Co. Philadelphia, 1995, pag.219.
6. Csendes A, Velasco N, Braghetto I. A prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia of the esophagus. Gastroenterology 1981; 80:789.
7. O'Sullivan G. Oesophageal motility disorders. In: Surgery of the Oesophagus. HennessyTPJ & Cuschieri A Ed. Bailliere Tindall England, 1986, pag.102
8. Graeber GM, Wong RKH. Reflux control in operations for achalasia. In: Benign Esophageal Disease. DeMeesterTR & MatthewsJR Ed. CVMosby Co. St.Louis, 1987, pag.283
9. Lea RE. Reflux control in operations for achalasia. In: Benign Esophageal Disease. DeMeester TR & Matthews JR Ed. CV Mosby Co. St.Louis, 1987, pag.291.
10. Fekété F. Management of failes Heller's operation. In: Benign Esophageal Disease. DeMeester TR & Matthews IR Ed. CVMosby Co. St.Louis, 1987, pag.293.
11. Condon RE. Management of failed Heller's operation. In: Benign Esophageal Disease. DeMeester TR & Matthews JR Ed. CVMosby Co. St.Louis, 1987, pg.304.
12. Isolauri I, Feussner H, Holscher A, et al. Pneumatic dilatation and cardiomyotomy with modified Thal-fundoplasty in the treatment of achalasia of the esophagus. In: Diseases of the Esophagus. Little AG, Ferguson MK, Skinner DB. Futura, 1990.
13. Gayet B, Fékété F. Surgical management of failed esophagomyotomy (Heller's operation). Hepato-Gastroenterol 1991; 38:488.
14. Martins P, Morais BB, Cunha-Melo JR. Postoperative complications in the treatment of chagasic megaesophagus. Int Surg 1993; 78:99.
¹⁵
Pinotti HW, Gama-RodriguesJJ, Ellenbogen G, et al. Nova técnica no tratamento cirúrgico do megaesôfago. Esofagocardiomiotomia associada com esofagofundogastropexia. Rev Goiana Med 1974; 20:1
16. Gutierrez A. Tratamento laparoscópico do megaesôfago. ABCD 1996; 11(1):73
17. Delgado F, Bolufer JM, Martinez-Abad M, et al. Laparoscopic treatment of esophageal achalasia. Surg Laparosc Endosc 1996, 6:83
18. Pinotti HW, Domene CE, Nasi A, et al. Resultados do tratamento cirúrgico via laparoscópica do megaesôfago. Experięncia do HCFMUSP. ABCD 1994; 9(2):9.
19. Morino M, Rebecchi F, Festa V, et al. Laparoscopic Heller myotomy with intraoperative manometry in the management of oesophageal achalasia. lnt Surg 1995; 80:332.
20. Patty MG, Pellegrini CA, Arcerito M, et al. Comparison os medical and minimally invasive surgical therapy for primary esophageal motility disorders. Arch Surg 1995; 130:609.
21. Rosati R, Fumagalli U, Bonavina L, et al. Laparoscopic approach to esophageal achalasia. Am J Surg 1995; 169:424.
22. Paula AL, Hashiba K, Bafutto M, et al. Tratamento laparoscópico do megaesôfago. Relato preliminar de 100 casos. In: Cirurgia Videolaparoscópica, Hospital Samaritano, Goiânia, 1994.
23. Pinotti HW, Felix VN, Zilberstein B, et al. Surgical complications of Chagas' disease: megaesophagus, achalasia of the pylorus and cholelithiasis. World J Surg 1991, 15:198.
24. Felix VN. Tratamento do megaesôfago chagásico incipiente. Tese. FMUSP, S.Paulo, 1994.
25. Couturier D, Samana J. Clinical aspects and manometric criteria in achalasia. Hepato-Gastroenterol 1991; 38:481.
26. Ellenbogen G. Megaesôfago năo avançado. Tratamento pela cardiomiectomia associada a esofagofundogastropexia. Avaliaçăo clínica. morfológica e funcional dos seus resultados. Tese. FMUSP, 1979.
27. Katz P. Esophageal carcinoma and achalasia: another call for screening? World Literat Review 1993, 88:783.
28. Vantrappen G, Janssens J. Place de la manométrie dans le diagnostic des troubles moteurs de l'óesophage. Presse Med 1989; 18:611.
29; DeMeester TR, Wang CI, Wernly JA. Technique, indications and clinical use of 24 hour esophageal pH monitoring. J Thorac Cardiovasc Surg 1980,79:656.
30. DeCaestecker JS, Blackwell JN, Pryde A, et al. Daytime gastro-esophageal reflux is important in esophagitis. Gut 1987,28:519.
31. Smart HL, Foster PN, Evans DF, et al. Twenty four hour oesophageal acidity in achalasia before and after pneumatic dilatation. Gut 1987; 28:883.

Endereço para correspondência:

Dr. Carlos Eduardo Domene

Avenida Arnolfo de Azevedo, 201

01236-030 - São Paulo-SP

E-mail:

domene@sysnetway.com.br

Datas de Publicação

Publicação nesta coleção
23 Jul 2010
Data do Fascículo
Ago 1998

Histórico

Recebido
07 Nov 1997
Aceito
16 Abr 1998

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Zeitune JMR. Resposta do esfíncter inferior do esôfago e da gastrinemia ŕ acidificaçăo do antro gástrico em indivíduos normais e em pacientes com megaesôfago chagásico. Tese. FMUSP, 1987.

[2] 2. Pinotti HW, Domene CE, Nasi A, et al. Surgical treatment of achalasia - cardiomyotomy and fundoplication by videolaparoscopy. In: Proceedings of the V ISDE World Congress, Kyoto, Japan, 1992, pag.225.

[3] 3. Moreno-Gonzalez A, Alvarez AG, Garcia IL. Results of surgical treatment of esophageal achalasia. Multicenter retrospective study of 1.856 cases. IntSurg 1988; 73:69.

[4] 4. Jamieson GG. Gastro-esophageal reflux following myotomy for achalasia. Hepato-Gastroenterol 1991; 38:506.

[5] 5. Wong RKH, Maydonovitch CL. Achalasia. In: The Esophagus. Castell DO Ed. Little, Brown and Co. Philadelphia, 1995, pag.219.

[6] 6. Csendes A, Velasco N, Braghetto I. A prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia of the esophagus. Gastroenterology 1981; 80:789.

[7] 7. O'Sullivan G. Oesophageal motility disorders. In: Surgery of the Oesophagus. HennessyTPJ & Cuschieri A Ed. Bailliere Tindall England, 1986, pag.102

[8] 8. Graeber GM, Wong RKH. Reflux control in operations for achalasia. In: Benign Esophageal Disease. DeMeesterTR & MatthewsJR Ed. CVMosby Co. St.Louis, 1987, pag.283

[9] 9. Lea RE. Reflux control in operations for achalasia. In: Benign Esophageal Disease. DeMeester TR & Matthews JR Ed. CV Mosby Co. St.Louis, 1987, pag.291.

[10] 10. Fekété F. Management of failes Heller's operation. In: Benign Esophageal Disease. DeMeester TR & Matthews IR Ed. CVMosby Co. St.Louis, 1987, pag.293.

[11] 11. Condon RE. Management of failed Heller's operation. In: Benign Esophageal Disease. DeMeester TR & Matthews JR Ed. CVMosby Co. St.Louis, 1987, pg.304.

[12] 12. Isolauri I, Feussner H, Holscher A, et al. Pneumatic dilatation and cardiomyotomy with modified Thal-fundoplasty in the treatment of achalasia of the esophagus. In: Diseases of the Esophagus. Little AG, Ferguson MK, Skinner DB. Futura, 1990.

[13] 13. Gayet B, Fékété F. Surgical management of failed esophagomyotomy (Heller's operation). Hepato-Gastroenterol 1991; 38:488.

[14] 14. Martins P, Morais BB, Cunha-Melo JR. Postoperative complications in the treatment of chagasic megaesophagus. Int Surg 1993; 78:99.

[15] ¹⁵
Pinotti HW, Gama-RodriguesJJ, Ellenbogen G, et al. Nova técnica no tratamento cirúrgico do megaesôfago. Esofagocardiomiotomia associada com esofagofundogastropexia. Rev Goiana Med 1974; 20:1

[16] 16. Gutierrez A. Tratamento laparoscópico do megaesôfago. ABCD 1996; 11(1):73

[17] 17. Delgado F, Bolufer JM, Martinez-Abad M, et al. Laparoscopic treatment of esophageal achalasia. Surg Laparosc Endosc 1996, 6:83

[18] 18. Pinotti HW, Domene CE, Nasi A, et al. Resultados do tratamento cirúrgico via laparoscópica do megaesôfago. Experięncia do HCFMUSP. ABCD 1994; 9(2):9.

[19] 19. Morino M, Rebecchi F, Festa V, et al. Laparoscopic Heller myotomy with intraoperative manometry in the management of oesophageal achalasia. lnt Surg 1995; 80:332.

[20] 20. Patty MG, Pellegrini CA, Arcerito M, et al. Comparison os medical and minimally invasive surgical therapy for primary esophageal motility disorders. Arch Surg 1995; 130:609.

[21] 21. Rosati R, Fumagalli U, Bonavina L, et al. Laparoscopic approach to esophageal achalasia. Am J Surg 1995; 169:424.

[22] 22. Paula AL, Hashiba K, Bafutto M, et al. Tratamento laparoscópico do megaesôfago. Relato preliminar de 100 casos. In: Cirurgia Videolaparoscópica, Hospital Samaritano, Goiânia, 1994.

[23] 23. Pinotti HW, Felix VN, Zilberstein B, et al. Surgical complications of Chagas' disease: megaesophagus, achalasia of the pylorus and cholelithiasis. World J Surg 1991, 15:198.

[24] 24. Felix VN. Tratamento do megaesôfago chagásico incipiente. Tese. FMUSP, S.Paulo, 1994.

[25] 25. Couturier D, Samana J. Clinical aspects and manometric criteria in achalasia. Hepato-Gastroenterol 1991; 38:481.

[26] 26. Ellenbogen G. Megaesôfago năo avançado. Tratamento pela cardiomiectomia associada a esofagofundogastropexia. Avaliaçăo clínica. morfológica e funcional dos seus resultados. Tese. FMUSP, 1979.

[27] 27. Katz P. Esophageal carcinoma and achalasia: another call for screening? World Literat Review 1993, 88:783.

[28] 28. Vantrappen G, Janssens J. Place de la manométrie dans le diagnostic des troubles moteurs de l'óesophage. Presse Med 1989; 18:611.

[29] 29; DeMeester TR, Wang CI, Wernly JA. Technique, indications and clinical use of 24 hour esophageal pH monitoring. J Thorac Cardiovasc Surg 1980,79:656.

[30] 30. DeCaestecker JS, Blackwell JN, Pryde A, et al. Daytime gastro-esophageal reflux is important in esophagitis. Gut 1987,28:519.

[31] 31. Smart HL, Foster PN, Evans DF, et al. Twenty four hour oesophageal acidity in achalasia before and after pneumatic dilatation. Gut 1987; 28:883.

Brasil

Brasil

Cardiomiectomia com fundoplicatura parcial videolaparoscópica no tratamento do megaesôfago não avançado: estudo de 50 casos

Laparoscopic cardiomyectomy with partial fundoplication in the treatment of achalasia: analysis of 50 cases

Resumos

Datas de Publicação

Histórico