Slide 1
D.R.G.E. TRATAMENTO CIRRGICOAspectos Fundamentais Prof. Dr.
Ozimo GamaCirurgia do Aparelho Digestivo
PrevalnciaSintomas associados a DRGEPrevalncia: 20% 1/3: 1x Ms /
7%: 1x Dia 15% achados EDACoelho JC et al., 2005.
DRGE: Tratamento Cirrgico
Quadro ClnicoSINTOMAS TPICOSPirose (80%)Regurgitao (60%)Disfagia
(25%)
DRGE: Tratamento Cirrgico
Quadro ClnicoSINTOMAS ATPICOSTosse (30%)Asma (14%)Rouquido (7%)
Dor torcica (4%)
DRGE: Tratamento Cirrgico
FisiopatologiaELEMENTOS DE CONTENOPresso IntrnsecaExtenso
TotalSegmento AbdominalCoelho J, 2005.
DRGE: Tratamento Cirrgico
FisiopatologiaINSUFICINCIA ESFINCTERIANA TRANSITRIAPresso mdia
< 6 mmHg Extenso 2 cmDeMeester T, 2001.DRGE: Tratamento
Cirrgico
Helicobacter pyloriEfeito protetor ? ( Labenz et al.,
1997)Erradicao X Esofagite de refluxoCepas cag A + ( Vicari et al.,
1998)Gravidade da DRGEH. pylori X DRGE (Oberg et al., 1999)No h
relao fisiopatolgicaDRGE: Tratamento Cirrgico
GERD
Adapted from Quigley 2001Patients with NERD60%Patients with
esophagitis40%Patients without complications 35%Patients with
complications 5%Patients with GERD100%
DRGE: Tratamento Cirrgico
163.GERD: two main categoriesThe definition of GERD provided by
participants at the Genval workshop encompasses two main categories
of disease: GERD without esophagitis and GERD with esophagitis.1
The first category, known as endoscopy-negative reflux disease
(ENRD), is the most common manifestation of GERD, and has been
estimated to account for about 60% of all patients with this
disease.24 ENRD is less commonly known as symptomatic GERD. The
second category of GERD, known as erosive esophagitis, includes
those patients who also satisfy the Genval definition but who have
definite mucosal breaks or metaplasia of the esophagus that are
visible using endoscopy.5 A proportion of these patients will also
have complications indicativeof more extensive mucosal injury;
these include esophageal ulcerations or strictures of the
mucosa.2
1.Dent J, Brun J, Fendrick AM, Fennerty MB, Janssens J, Kahrilas
PJ et al. An evidence-based appraisal of reflux disease management
the Genval Workshop Report. Gut 1999;44 Suppl 2:S116.2.Quigley EM.
Non-erosive reflux disease: part of the spectrum of
gastro-oesophageal reflux disease, a component of functional
dyspepsia, or both? Eur J Gastroenterol Hepatol 2001;13 Suppl
1:S1318.3.Jones R, Hungin A, Phillips J, Mills J.
Gastro-oesophageal reflux disease in primary carein Europe:
clinical presentation and endoscopic findings. Eur J Gen Pract
1995;1:14954.4.Carlsson R, Dent J, Bolling-Sternevald E, Johnsson
F, Junghard O, Lauritsen K et al. The usefulness of a structured
questionnaire in the assessment of symptomatic gastroesophageal
reflux disease. Scand J Gastroenterol 1998a;33:10239.5.Lundell LR,
Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP et al.
Endoscopic assessment of oesophagitis: clinical and functional
correlates and further validation of the Los Angeles
classification. Gut 1999;45:17280.
D.R.G.E.ComplicaesEsofagite erosivaEsfago de Barret
(15%)Estenose (10%)Ulcerao (5%)Sangramento (2%)Malafaia et al.,
2013.DRGE: Tratamento Cirrgico
Intolerncia ao controle clnico prolongadoManifestaes
respiratrias da DRGEFormas complicadas da doenaDRGE com hrnia
hiatalDRGE progressiva
Tratamento CirrgicoIndicaesDRGE: Tratamento Cirrgico
Tratamento CirrgicoPr-OperatrioEndoscopia
DigestivaPhmetria/ManometriaSEED
DRGE: Tratamento Cirrgico
Restabelecer os mecanismos de contenoManter a normalidade na
deglutioPermitir eructar ou mesmo vomitar quando necessrioRestaurar
a presso do esfncter inferiorObter de uma extenso de esfago
abdominal no inferior a 3 centmetrosDE MEESTER, TR et al. Nissen
fundoplication for GERD.Ann. Surg, 1986. Tratamento
CirrgicoObjetivosDRGE: Tratamento Cirrgico
HIATOPLASTIAVALVULOPLASTIA
Tratamento CirrgicoPassos TcnicosDRGE: Tratamento Cirrgico
NISSENTOUPETTratamento CirrgicoTipos de Vlvulas
Multivariate analysis of factors predicting outcome after
laparoscopic Nissen fundoplication (DeMeester TR et al, 1998).
Abnormal 24-hour pH score (OR = 5.4)Typical primary symptom (OR =
5.1)Clinical response to acid suppression therapy (OR = 3.3)
Tratamento Cirrgico PrognsticoDRGE: Tratamento Cirrgico
Tratamento Cirrgico Complicaes
DRGE: Tratamento Cirrgico
Norman Barret, 1950Ulcera esofgica associada aepitlio colunar em
esfago. Acredito tratar-se de uma condio de esfago curto
congnito.
DRGE: Tratamento Cirrgico
condio na qual qualquer extenso de epitlio colunar metaplsico
substitui o epitlio escamoso estratificado que recobre o esfago
distal, reconhecida pela endoscopia e confirmada
histologicamente.Esfago de BarretDefinioDRGE: Tratamento
Cirrgico
BrancosHomens acima de 50 anosLonga histria de DRGEHrnia hiatal
/ Obesidade10% dos pacientes com RGE1 caso de AdenoCA 100
pacientes/ano 39Esfago de BarretEpidemiologiaDRGE: Tratamento
Cirrgico
Esfago de BarretAvaliao EndoscpicaA cada 2 anosDisplasia (+)
Baixo: 6 mesesAlto: 3 mesesBx: 4 quadrantes/2 cm DRGE: Tratamento
Cirrgico
Examples of key clinical findings include:Complete clearance of
non-dysplastic Barrett's esophagus in 98.4% of patients at two and
a half year follow-up. Outstanding safety profile with a less than
or equal to 6% stricture rate, less than 0.02% perforation rate,
and no associated deaths.Overall, complete eradication of
non-dysplastic and dysplastic Barrett's esophagus at rates
exceeding 90% has been shown in numerous studies.Elimination of
abnormal genetic markers associated with Barrett's esophagus after
RFA therapy.No change in the function of the esophagus after RFA
therapy.43
Esfago de BarretSem Displasia ou de Baixo GrauVALVULOPLASTIA
ANTI-REFLUXOTerapia Ablativa
DRGE: Tratamento Cirrgico
Esfago de BarretTERAPIAS ENDOSCPICASTerapia
fotodinmicaCrioablaoRadiofrequnciaMucosectomia DRGE: Tratamento
Cirrgico
48
Esfago de BarretDisplasia de Alto GrauESOFAGECTOMIATerapia
Ablativa
DRGE: Tratamento Cirrgico
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D.R.G.E. TRATAMENTO CIRRGICOAspectos Fundamentais Prof. Dr.
Ozimo GamaCirurgia do Aparelho Digestivo
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