REFLUX GASTRO OESOPHAGIEN et BRACHY OESOPHAGE Dr BAHI Sadok Ancien professeur agrégé Résidence les jasmins d’El Manar Mail: bahi.sadok@yahoo.fr

Cas clinique H de 60 ans traité en avril 2005 pour pleuro pneumopathie droite (drain thoracique et antibiotherapie) secondaire à un RGO. FOGD: Oesophagite sévère avec ulcère oesophagien. Le cardia est à 32cm et grosse hernie hiatale.

Radiographie du thorax avril 2005

TOGD avril 2005

Revu en juillet 2005 Comment opérer? Coelio ou classique ? Quel geste faire?

 Quel faire? INTERVENTION 27/7/2005 Incision bi-sous costale Orifice hiatal très large Mise d’un lac sur le cône gastrique Le cardia est inabaissable  Quel faire?

RGO avec cardia inabaissable COLLIS – Nissen Ou bien Diversion duodénale totale ?

Collis - Nissen Iiberation des vx courts de l’estomac Introduction buccale d’un tube de Fauchey pour calibrer la plastie gastrique Section à la pince GIA 70 pour allonger l’œsophage Confection d’un valve complète à la Nissen autour du néo œsophage Fermeture des piliers du diaphragme

Suites immédiates Suites opératoires simples Disparition du pyrosis Absence de dysphagie Sort a J7 post opératoire

TOGD contrôle post opératoire

Suivi à distance: 9ans Septembre 2014 réadmis pour cholécystite aigue Sur le plan digestif pas de pyrosis mais il signale des épisodes de dysphagie Fibroscopie disparition de l’oesophagite et valve visible Scanner et TOGD

Scanner aout 2014

TOGD SEPT 2014

TOGD juillet 2005 TOGD SEPT 2014

QUE FAIRE ?

2ème INTERVENTION SEPT 2014 Laparotomie médiane Cholécystectomie L’orifice hiatal est élargi avec migration de la valve en intra thoracique échec de la tentative de repositionner la valve en intra abdominal Suites favorables Revu 11/11/2014 va bien parfois dysphagie poids 78 kg stable

The Short Esophagus: Pathophysiology, Incidence, Presentation, and Treatment in the Era of Laparoscopic Antireflux Surgery ANNALS OF SURGERY 2000 Vol. 232, No. 5, 630–640 The actual incidence of the short esophagusis estimated to be approximately 10% of patients Because a short esophagus is uncommon, there is a natural concern that many surgeons will not perform enough antireflux procedures to become familiar with its diagnosis and management. A complete understanding of the short esophagus and methods for surgical correction are critical to avoid “slipped” wraps and mediastinal herniation and to achieve the best patient outcome

PREOPERATIVE INDICATORS FOR THE PRESENCE OF A SHORT ESOPHAGUS Patient history Long history of gastroesophageal reflux disease (many years) Previously failed antireflux operation Esophagogastroduodenoscopy Identification of the gastroesophageal junction 5 cm or more above the diaphragmatic hiatus Moderate to severe esophagitis (Savory-Miller grades III–V) History/presence of peptic stricture Barrett’s changes Barium esophagram Large (5 cm or more) type I hiatal hernia that fails to reduce in the upright position Giant type III hiatal hernia Stricture

Identification per operatoire

Steichen’s method for an open gastroplasty Steichen’s method for an open gastroplasty. (A) An EEA stapler is used to create a sealed gastric window. (B) A GIA stapler is used to create the gastroplasty. (C) Collis gastroplasty before Nissen fundoplication.

The combined thoracoscopic/laparoscopic Collis gastroplasty The combined thoracoscopic/laparoscopic Collis gastroplasty. (C, D) After the neoesophagus has been created, a standard fundoplication is performed around it.

The double-stapled laparoscopic gastroplasty The double-stapled laparoscopic gastroplasty. (A–C) The sealed gastric window is created with an EEA stapler. (D, E) A linear laparoscopic GIA stapler is fired next to the bougie to create a 3-cm neoesophagus.

Collis nissen procedure has an excellent CONCLUSION Karen D. Horvath, MD,* Lee L. Swanstrom, MD,† and Blair A. Jobe, MD† From the *Department of Surgery, University of Washington, Seattle, Washington, and the †Department of Minimally Invasive Surgery and Surgical Research, Oregon Health Sciences University and Legacy Health System, Portland, Oregon Collis nissen procedure has an excellent long-term success rate for this complex problem. ignoring the short esophagus, predisposes the patient to wrap herniation, wrap disruption, or a “slipped” wrap. With the development of endoscopic Collis techniques, conversion to an open laparotomy or thoracotomy when a short esophagus is encountered is no longer necessary. The choice of the laparoscopic/thoracoscopic single-stapler technique or the laparoscopic double-stapler technique should be left to the surgeon.