SAN DIEGO — Laparoscopic Roux-en-Y gastric bypass is an attractive surgical strategy for the management of esophageal scleroderma, Dr. Michael S. Kent reported at the annual meeting of the Society of Thoracic Surgeons.

Roux-en-Y gastric bypass (RYGBP) provides better control of medically refractory gastroesophageal reflux and dysphagia with far less abdominal bloating than does fundoplication, the most widely used operation in the treatment of esophageal scleroderma. And RYGBP does so with much less perioperative morbidity than does esophagectomy, another operation used in the disorder, said Dr. Kent of the University of Pittsburgh.

Scleroderma is marked by smooth-muscle atrophy and collagen deposition in the skin, lungs, and gastrointestinal tract. Esophageal involvement is both extremely common and severe; in fact, roughly 80% of scleroderma patients develop heartburn and/or dysphagia within 2 years of diagnosis. Barrett's esophagus and stricture can develop quickly.

The two chief causes of severe reflux in scleroderma patients are an immotile esophagus and an ineffective lower-esophageal sphincter. "Often, no lower esophageal sphincter pressure can be identified on manometry," said Dr. Kent.

Gastric dysmotility is likely to be present, encouraging both acid and alkaline reflux into the esophagus. In addition, these patients often have impaired production of saliva, which normally plays a key role in neutralizing gastric acid.

Dr. Kent presented a retrospective series of 23 esophageal scleroderma patients who underwent surgery at the hands of seven thoracic surgeons at the university. Of these patients, 10 got fundoplication, 8 received RYGBP, and 5 had esophagectomy.

For the scleroderma patients, surgeons modified the standard RYGBP operation used in morbid obesity in three ways: They created a large, nonrestrictive anastomosis between the stomach and small bowel; they fashioned a shorter-than-typical Roux limb from the small upper-stomach pouch to the small bowel in order to minimize malabsorption; and they inserted a feeding tube in the gastric remnant for postoperative nutrition.

No significant complications occurred in the fundoplication or RYGBP patients. Esophagectomy was another matter: One patient with pulmonary hypertension died soon after the operation; one developed pneumonia, one had an anastomotic leak, and one required tracheostomy.

At a median 25 months of follow-up, mean scores on a 5-point dysphagia scale were 1.86 in the fundoplication group and 1.75 in the esophagectomy group, compared with just 0.43 in the RYGBP group. On a 45-point, nine-question reflux scale on which a score of 15 or more is considered clinically significant, mean scores were 15.6 in the fundoplication arm, 10.0 with esophagectomy, and 4.0 in the RYGBP group. Abdominal bloating was fivefold more common after fundoplication than after RYGBP.

Excess weight loss has been viewed as a potential concern with RYGBP in patients with a chronic disease such as scleroderma; however, it was not a problem with the modified procedure as no patient's body mass index dropped below 18 kg/m

Dr. Malcolm M. DeCamp, chief of cardiothoracic surgery at Beth Israel Deaconess Medical Center, Boston, noted after the presentation that pulmonary disease is common in scleroderma patients. The past 5 years have brought growing evidence that fundoplication improves the outcome of lung transplantation in this population, he said, with a reduction in the rate of obliterative bronchiolitis. Dr. DeCamp asked what the results were in such cases when using RYGBP.

Dr. Kent replied that four of the patients reviewed underwent lung transplant after RYGBP. In each case, excellent reflux control was documented by the use of 24-hour esophageal pH monitoring as a precondition for transplant, he said.

03/01/07  

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