REFLUX GASTRO OESOPHAGIEN et BRACHY OESOPHAGE

Présentation au sujet: "REFLUX GASTRO OESOPHAGIEN et BRACHY OESOPHAGE"— Transcription de la présentation:

1 REFLUX GASTRO OESOPHAGIEN et BRACHY OESOPHAGE
Dr BAHI Sadok Ancien professeur agrégé Résidence les jasmins d’El Manar Mail:

2 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.

3 Radiographie du thorax avril 2005

4 TOGD avril 2005

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

6  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?

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

8 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

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

10 TOGD contrôle post opératoire

11 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

12 Scanner aout 2014

13 TOGD SEPT 2014

14 TOGD juillet 2005 TOGD SEPT 2014

15 QUE FAIRE ?

16 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

17 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

18 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

19 Identification per operatoire

20 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.

21 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.

22 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.

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25 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.