Estudo manométrico e endoscópico do esôfago e transição esofagogástrica após gastrectomia subtotal distal radical com linfadenectomia à D2 e reconstrução em Y-de-Roux em pacientes portadores de adenocarcinoma gástrico
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Arquivos
Data
2005
Autores
Fonseca, Carlos Alberto Marcovechio [UNIFESP]
Orientadores
Herani Filho, Benedito [UNIFESP]
Tipo
Tese de doutorado
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ISSN da Revista
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Introdução: a função da junção esofagogástrica tem sido motivo de estudos há
quase meio século, quando se começou a quantificar a pressão do esfíncter inferior
do esôfago pela manometria. Desde então tem se procurado relacionar o aumento
da doença do refluxo gastroesofágico após cirurgias gástricas, com a alteração
pressórica desse esfíncter, considerado a principal barreira anti-refluxo, sendo os
resultados controversos, assim como as explicações para os dados observados.
Esta discórdia associada ao fato de que na literatura não encontramos estudos
funcionais dessa região quando do uso da reconstrução em “Y-de-Roux” na
gastrectomia subtotal distal, portanto com preservação do esfíncter inferior do
esôfago, motivou-nos realizar o presente trabalho. Objetivo: analisar
prospectivamente as alterações manométricas e endoscópicas do esôfago e da
transição esofagogástrica, quando do uso da reconstrução em Y-de-Roux na
gastrectomia subtotal distal radical. Método: Foram analisados 26 pacientes
portadores de adenocarcinoma gástrico de corpo distal e/ou antro submetidos à
gastrectomia subtotal distal radical com linfadenectomia à dissecção linfonodal das
cadeias N1 e N2 (D2) e reconstrução em Y-de-Roux, sendo 15 (57,69%) do sexo
feminino, 11 (42,31%) do sexo masculino, 21 da raça branca (80,8%) e cinco da raça
negra (19,2), com acompanhamento médio de 16,1 meses e média de idade de 57,2
anos, que puderam ser avaliados antes e três meses após a cirurgia. Esses doentes
foram avaliados quanto aos seguintes parâmetros: pressão do esfíncter inferior do
esôfago pelos métodos da pressão respiratória média, pressão expiratória máxima e
pressão da crura diafragmática; extensões do EIE, total, abdominal e torácica;
eficácia do peristaltismo esofágico, mensurando amplitude e velocidade das ondas
peristálticas do esôfago; pressão do esfíncter superior do esôfago (ESE); além de
presença de erosão no esôfago distal à endoscopia. Resultado: houve redução nas
médias da pressão respiratória média (19,41mmHg X 15,59mmHg; p=0,0254), da
pressão expiratória média (8,13mmHg X 5,54mmHg; p=0,0209), sem alteração
significante da pressão da crura diafragmática (32,92mmHg X 30,64mmHg;
p=0,3731) e nas extensões total (2,79cm X 2,50cm; p=0,270), abdominal (1,42cm X
1,06cm; p=0,103) e torácica do esfíncter inferior do esôfago (1,37cm X 1,44cm;
p=0,706). Houve também aumento significante da amplitude (91,43mmHg X
124,86mmHg; p<0,011) e da velocidade de condução (3,29cm/s X 4,23 cm/s;
p=0,024) das ondas peristálticas do esôfago e a pressão do ESE não se alterou
(66,73mmHg X 68,28mmHg; p=0,7970). A análise das variáveis hipotonia do
esfíncter inferior do esôfago e esofagite erosiva mostrou variação significante, com
diminuição de ambas (p=0,001 e p=0,002, respectivamente). Conclusão: houve
diminuição da pressão do esfíncter inferior do esôfago, no entanto sem alteração da
pressão da crura diafragmática ou de seu tamanho. Houve ainda melhora do
peristaltismo esofágico, o mesmo ocorrendo com a esofagite erosiva que estava
ausente no pós-operatório.
Introduction: the function of the esophagogastric transition has been the aim of several studies for over half century when it was started to quantify pressure of the lower esophageal sphincter by means of manometry. Since then researchers have been trying to correlate the increase in the gastroesophagic reflux disease after gastric surgeries with pressure alteration of this sphincter, considered as the major antireflux barrier, being the results as well as the elucidation given for the observed data controversial. This controversy associated with the fact that in the literature we could not find functional studies related to this site, when using Rouxem-Y reconstruction in the subtotal distal gastrectomy and in those preserving the lower esophageal sphincter, encouraged us to carry out this study. Purpose: to prospectively analyze manometric and endoscopic esophageal alterations and the esophagogastric transition using Roux-em-Y reconstruction in subtotal radical distal gastrectomy. Method: 26 patients with gastric adenocarcinoma of the distal body and/or antrum were analyzed and submitted to radical subtotal distal gastrectomy with limphadenectomy with N1 and N2 lymphonodal dissection (D2) and Roux-en-Y reconstruction. The study consisted of 15 (57.69%) females, 11 (42.31%) males, 21 Caucasian (80.8%) and five Negroes (19.2%) with a mean follow-up of 16.1 months and mean age of 57.2 years who could be evaluated before and three months after surgery. These patients were evaluated regarding pressure of the lower esophageal sphincter by means of the median pressure respiration methods, maximal expiratory pressure and diaphragmatic crural pressure; total, abdominal and thoracic extension of the lower esophageal sphincter (LES); efficacy of esophageal peristaltism, evaluating amplitude and speed of peristaltic esophageal waves; pressure of the upper esophageal sphincter (UES); besides the presence of erosion in the distal esophagus to endoscopy. Results: reduction of the means median respiration pressure (19.41 mmHg X 15.59mmHg;p=0.0254), maximal respiration pressure (8.13mmHg X 5.54mmHg; p=0.0209) without significant alteration of diaphragmatic crural pressure (32.92mmHg X 30.64mmHg;p=0.3731) and total (2.79cm X 2.50cm; p=0.270), abdominal (1.42cm X 1.06cm; p=0.103) and thoracic extension of the lower esophageal sphincter (1.37cm X 1.44cm; p=0.706) A significant increase in amplitude was observed (91.43mmHg X 124.86mmHg; p<0.011) and speed of conduction (3.29cm/s X 4.23 cm/s; p=0.024) of the peristaltic esophageal waves and the upper esophageal sphincter pressure (UES) did not alter (66.73mmHg X 68.28mmHg; p=0.7970). Analysis of the presence of hypotonic variables of the lower esophageal sphincter and erosive esophagitis showed a significant variation with decrease of both (p=0.001 and p=0.002, respectively) Conclusion: decrease in pressure of the lower esophageal sphincter occurred but without alteration in the pressure of the diaphragmatic crura or in the size of the same. Likewise improvement of the esophagic peristaltism was reported, the same occurring with erosive esophagitis which was absent in the postoperative period.
Introduction: the function of the esophagogastric transition has been the aim of several studies for over half century when it was started to quantify pressure of the lower esophageal sphincter by means of manometry. Since then researchers have been trying to correlate the increase in the gastroesophagic reflux disease after gastric surgeries with pressure alteration of this sphincter, considered as the major antireflux barrier, being the results as well as the elucidation given for the observed data controversial. This controversy associated with the fact that in the literature we could not find functional studies related to this site, when using Rouxem-Y reconstruction in the subtotal distal gastrectomy and in those preserving the lower esophageal sphincter, encouraged us to carry out this study. Purpose: to prospectively analyze manometric and endoscopic esophageal alterations and the esophagogastric transition using Roux-em-Y reconstruction in subtotal radical distal gastrectomy. Method: 26 patients with gastric adenocarcinoma of the distal body and/or antrum were analyzed and submitted to radical subtotal distal gastrectomy with limphadenectomy with N1 and N2 lymphonodal dissection (D2) and Roux-en-Y reconstruction. The study consisted of 15 (57.69%) females, 11 (42.31%) males, 21 Caucasian (80.8%) and five Negroes (19.2%) with a mean follow-up of 16.1 months and mean age of 57.2 years who could be evaluated before and three months after surgery. These patients were evaluated regarding pressure of the lower esophageal sphincter by means of the median pressure respiration methods, maximal expiratory pressure and diaphragmatic crural pressure; total, abdominal and thoracic extension of the lower esophageal sphincter (LES); efficacy of esophageal peristaltism, evaluating amplitude and speed of peristaltic esophageal waves; pressure of the upper esophageal sphincter (UES); besides the presence of erosion in the distal esophagus to endoscopy. Results: reduction of the means median respiration pressure (19.41 mmHg X 15.59mmHg;p=0.0254), maximal respiration pressure (8.13mmHg X 5.54mmHg; p=0.0209) without significant alteration of diaphragmatic crural pressure (32.92mmHg X 30.64mmHg;p=0.3731) and total (2.79cm X 2.50cm; p=0.270), abdominal (1.42cm X 1.06cm; p=0.103) and thoracic extension of the lower esophageal sphincter (1.37cm X 1.44cm; p=0.706) A significant increase in amplitude was observed (91.43mmHg X 124.86mmHg; p<0.011) and speed of conduction (3.29cm/s X 4.23 cm/s; p=0.024) of the peristaltic esophageal waves and the upper esophageal sphincter pressure (UES) did not alter (66.73mmHg X 68.28mmHg; p=0.7970). Analysis of the presence of hypotonic variables of the lower esophageal sphincter and erosive esophagitis showed a significant variation with decrease of both (p=0.001 and p=0.002, respectively) Conclusion: decrease in pressure of the lower esophageal sphincter occurred but without alteration in the pressure of the diaphragmatic crura or in the size of the same. Likewise improvement of the esophagic peristaltism was reported, the same occurring with erosive esophagitis which was absent in the postoperative period.
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Citação
FONSECA, Carlos Alberto Marcovechio. Estudo manométrico e endoscópico do esôfago e transição esofagogástrica após gastrectomia subtotal radical com linfadenectomia à D2 e reconstrução em "Y-de-Roux" em pacientes portadores de adenocarcinoma gástrico. 2005. 108 f.Tese (Doutorado em Ciências) Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2005.