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      Case report of robotic dor fundoplication for scleroderma esophagus with aperistalsis on manometry

      International Journal of Surgery Case Reports
      Elsevier BV

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          Comparison of surgical approaches to recalcitrant gastroesophageal reflux disease in the patient with scleroderma.

          Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility seen in this disease. We hypothesized that laparoscopic Roux-en-Y gastric bypass (RYGBP) would lead to less dysphagia and better control of GERD symptoms. This report summarizes our initial results of RYGBP compared with other surgical approaches.
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            Antireflux operations in patients with scleroderma.

            Fourteen patients with scleroderma underwent antireflux operations (10 short Nissen, 2 Collis-Nissen, 1 Collis-Belsey, and 1 vagotomy and antrectomy with Roux-en-Y). Esophageal function was assessed preoperatively and postoperatively with a follow-up range of 8 to 181 months (mean, 65 months). Reflux symptoms were relieved in 10 of the 14 patients (p < 0.01), as shown by a decrease in their 24-hour acid exposure of from 15% to 7.5% (p < 0.05). However, the lower esophageal sphincter pressure gradient created by the operations did not increase significantly (3.7 +/- 3.4 mm Hg to 5.5 +/- 3.5 mm Hg). The esophageal acid exposure decreased sufficiently to promote some alleviation of the esophagitis. Radiologic signs of stenosis regressed in 6 of 7 patients. Postoperative endoscopic assessment revealed complete or partial healing of erosions seen preoperatively in 6 of the 7 patients so studied, and healing of all ulcers in 3 patients. Twelve patients continued to have columnar metaplasia. Manometric studies disclosed no significant changes in propulsion and contractility. Distal esophageal resting pressures rose significantly from 6.2 to 9.4 mm Hg (p < 0.05 mm Hg), suggestive of stasis. Radionuclide transit studies, however, showed no significant decrease in the esophageal emptying capacity after operation. It is concluded that conventional antireflux operations in patients with scleroderma can palliate reflux damage without jeopardizing esophageal function.
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              Combined Collis gastroplasty--fundoplication operations for scleroderma reflux esophagitis.

              Thirty-seven patients with scleroderma and reflux esophagitis, including 16 (43%) with peptic esophageal strictures, have been treated with a combination of the Collis gastroplasty and either a Belsey (240 degree) or Nissen (360 degree) fundoplication. Follow-up data have been obtained through personal interviews, esophageal manometry, and acid reflux testing. There have been no postoperative deaths or wound-healing complications. Five (31%) of the 16 patients with strictures still require intermittent dilatations. In the Collis-Belsey group (17 patients), after an average follow-up of 42 months, reflux symptoms have been eliminated in 11, are mild in three, and moderate or severe in three. Distal esophageal high-pressure zone (HPZ) tone and length have increased from an average of 4.6 mm Hg and 1.6 cm preoperatively to 8.6 mm Hg and 2.3 cm postoperatively. Acid reflux testing with the intraesophageal pH electrode, however, has demonstrated moderate-to-severe reflux in seven patients (41%). In the Collis-Nissen group (20 patients), after an average follow-up of 22 months, reflux symptoms have been eliminated in 17, are mild in two, and severe in one. Average HPZ tone and length have increased from 2.5 mm Hg and 1.2 cm preoperatively to 12 mm Hg and 4.2 cm postoperatively. The acid reflux test has revealed moderate or severe reflux in five patients (25%). Gratifying subjective and objective reflux control can be achieved in scleroderma patients with minimal operative morbidity.
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                Author and article information

                Journal
                10.1016/j.ijscr.2017.06.020
                http://creativecommons.org/licenses/by-nc-nd/4.0/

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