Possible technical aspects involved in the development of GERD after sleeve gastrectomy: Surgical technique considerations

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Consideraciones para la técnica quirúrgica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1654 "Ancho" => 3258 "Tamanyo" => 427639 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Inversion of the oesophagogastric gradient in vertical gastrectomy." ] ] ] "textoCompleto" => "IntroductionVertical sleeve gastrectomy is the most common bariatric surgery performed in the world, and has also been widely shown to produce symptoms of gastro-oesophageal reflux (GOR) or worsen existing reflux.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a>There are many bariatric surgical techniques. The selection of patients for each technique will depend on their metabolic characteristics, the degree of obesity, metabolic syndrome or weight gain. Often the patient's preference determines the choice of technique (usually “gastric sleeve”).<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>For this reason, in our centre specialised in anterior digestive tract surgery (foregut) patients are evaluated for symptoms of reflux, regurgitation, heartburn or dysphagia, with a complete endoscopic, radiological and oesophageal motility study that is performed routinely for a more precise selection of patients before surgical treatment and so that the chosen technique has the best success rate and the lowest probability of long-term complications. In this sense, the patient with reflux or with a high probability of developing it is directed towards the Roux-en-Y gastric bypass.This article will present the anatomy of the gastro-oesophageal junction (GOJ), the changes that would explain the appearance of reflux symptoms, the pre- and postoperative comparative studies, together with the visualisation of the changes that occur with respect to the volume and morphology of the sleeve through the volumetry.Anatomy and physiology of the normal gastro-oesophageal junction and in the gastrectomised patientThe GOJ is the part of the digestive tract that is in a transitional space between the thorax and the abdomen subjected to different pressures and that has an important range of motility produced by swallowing. The antireflux mechanism is multifactorial, which makes the investigation of its pathology and the approach to its treatment complex.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>The GOJ is anatomically composed of the abdominal oesophagus, the angle of His, the gastric fundus, the Sling fibres, and the Clasp fibres.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> All these structures must be in their normal anatomical position to constitute a perfect gastro-oesophageal antireflux mechanism. The support elements of this mobile area would be provided by the phrenoesophageal ligament, the diaphragmatic crura, the pars condensate, the lesser omentum, the fundus phrenic ligament and the short vessels. When one of these structures fails, the crura can dilate, producing a sliding hiatus hernia that will produce gastroesophageal reflux. The abdominal portion of the oesophagus (4 cm) is subjected to a series of abdominal pressures, gastric pressures and GOJ pressures that create an area of high pressure that would constitute the so-called lower oesophageal sphincter (LOS), which would be a sum of forces rather than a specific muscle sphincter.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>The anatomical, regular and physiological nature of these structures constitutes an anti-reflux valve mechanism, allowing the passage of food from the oesophagus to the stomach and preventing its return<a class="elsevierStyleCrossRef" href="#bib0040">8</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In this mechanism, the Sling fibbers (purple in the illustration) have a highly unique arrangement in the stomach, they go along the anterior wall, rotate around the oesophagus like a loop and go down the posterior slope, fixing on the incisura angularis. They generate the angle of His and act by moving the wall of the oesophagus downward and to the right (purple arrows); This is complemented by Clasp-type fibres (green), which contract by taking the right edge of the oesophagus in the opposite direction, from the right to the left, closing the cardia (green arrows). This closure is complemented by the action of the pressure of the gastric fundus on the oesophagus (complying with Pascal's law [yellow arrows]), which compresses the oesophagus at the level of the oesophagogastric transition, thus completing the antireflux mechanism.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> We repeat that the diaphragmatic crura also participates, it contracts from top to bottom and from front to back, acting as an important part of the antireflux mechanism (according to Zifan, 85%); We also wish to reiterate that any dilation of the crura produces stomach slippage and hiatus hernia, necessarily and obligatorily generating gastroesophageal reflux.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>When one swallows, the sequence would be that the oesophagus propels the food bolus towards the stomach, producing the relaxation of the sling and clasp fibres, opening the cardia and allowing the food to enter. The antireflux mechanism springs into action as soon as what is ingested increases intragastric pressure (this happens when the volumes reach the limit, more than 750 ml), preventing the food backing up from the stomach into the oesophagus. It is in this situation where the clasp and sling fibres contract, closing the cardia with the help of the increase in intragastric pressure and the elevation of the gastric fundus, compressing the oesophageal wall and generating a gate valve mechanism (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRef" href="#bib0030">6</a>The representation of the gate mechanism seen from inside the stomach is called the flap valve (yellow box in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which is what we try to reproduce in surgery when it has been lost, generating reflux and in this way re-establishing functionality and LOS competence.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> This level is equivalent to the transition zone from the entrance of the oesophagus to the stomach, where the intragastric pressure would act in addition to the other forces mentioned, generating the gate or check valve effect on the portion of the oesophagus that is inside the stomach wall.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> This is what Jobe et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> refer to, and what is mentioned by Tom DeMeester as the high pressure zone.The gastrectomy technique would lead to sectioning of the structures involved in the anti-reflux mechanism. These changes produced by the resection of the stomach and gastric fundus would lead, first of all, to a decrease in the existing pressures on the LOS,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> turning it into an incompetent cardia given that the sling fibres, because they are sectioned, cannot contract efficiently. Likewise, the absence of the gastric fundus causes the angle of His to be lost, also losing the gate mechanism, and the reduction in the volume of the stomach would cause intragastric pressure to increase, producing an opening of the greater cardia, leaving it permanently open or yawning, causing incompetence of the antireflux mechanism and promoting the return of gastric contents towards the oesophagus, including bile reflux (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Anatomical-functional factors that cause gastro-oesophageal refluxThe anatomical alterations that would cause gastroesophageal reflux are known:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Hiatus hernia.</li><li class="elsevierStyleListItem" id="lsti0010">•Disappearance of the abdominal oesophagus.</li><li class="elsevierStyleListItem" id="lsti0015">•Disappearance of the gastric fundus.</li><li class="elsevierStyleListItem" id="lsti0020">•Hypotension of the high-pressure area or LOS.</li><li class="elsevierStyleListItem" id="lsti0025">•Permanent loss or opening of the His angle.</li><li class="elsevierStyleListItem" id="lsti0030">•Increase in intra-abdominal pressure.</li><li class="elsevierStyleListItem" id="lsti0035">•Increase in intra-gastric pressure.</li><li class="elsevierStyleListItem" id="lsti0040">•Inversion of oesophagogastric pressure gradient.</li><li class="elsevierStyleListItem" id="lsti0045">•Hyper acidity.</li><li class="elsevierStyleListItem" id="lsti0050">•Abnormal increase of the frequency of transitory relaxations.</li><li class="elsevierStyleListItem" id="lsti0055">•Lack of resistance of oesophageal mucosa to acid.</li><li class="elsevierStyleListItem" id="lsti0060">•Delayed gastric emptying.</li><li class="elsevierStyleListItem" id="lsti0065">•Alterations produced as a consequence of gastric surgery:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0070">oResection of gastric fundus.</li><li class="elsevierStyleListItem" id="lsti0075">oStenosis of the gastric notch or body.</li><li class="elsevierStyleListItem" id="lsti0080">oStomach outflow obstructions.</li><li class="elsevierStyleListItem" id="lsti0085">oGastroparesis.</li><li class="elsevierStyleListItem" id="lsti0090">oProgressive oesophageal dysmotility.</li><li class="elsevierStyleListItem" id="lsti0095">oOesophageal spasm.</li></ul></li></ul>Preoperative studies of candidate patients for bariatric surgeryFor the analysis of all the factors considered in the previous paragraph, a comprehensive study is required so that the functional state of the GOJ may be understood and the physiological alterations produced by the resection or the modification of the anatomy generated in the various surgical techniques may be interpreted.<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a> Evaluation must be comprehensive, i.e., complete, analysing the oesophagus by fluoroscopy, endoscopy and oesophageal motility (manometry-pHmetry-impedance).The results of these tests would allow us to objectively be familiar with pathologies that could cause reflux, such as dysmotility, achalasia, Jackhammer oesophagus or the pathology recently described as oesophageal gastric juntion outflow obstruction [OGJOO]) in both pre and postoperative bariatric surgery patients.<a class="elsevierStyleCrossRef" href="#bib0070">14</a>By complete study we refer to the ideal, which includes: high-resolution oesophageal manometry, 24-h oesophageal pH and impedance measurement, oesophageal fluoroscopy, gastric emptying using scintigraphy, and upper endoscopy.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> Other techniques to use in the preoperative period of non-mandatory revisional surgery may be: endoFLIP and volumetrics using 3D reconstruction with tomography to determine the volume, morphology and type of surgery to which the patient with reflux was subjected.<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a>Pre and postoperative comparative resultsThese include pre- and postoperative results of patients undergoing vertical gastrectomy who agreed to undergo a complete study. There were 245 patients who had acceptable weight loss, with a decrease in BMI from 39.15 to 26.34. The results of each study conducted are presented below, together with an interpretation of them.High resolution oesophageal manometryHigh-resolution manometry is the most important study of oesophageal motility and gives us the most information about the functional state of the swallowing process and oesophageal peristalsis. It allows us to detect and diagnose pathologies that may be a contraindication to performing a certain surgery, such as achalasia or severe reflux. The comparative value of pre- and postoperative manometry will allow us to evaluate the true action, effect or deterioration that surgery produces on the physiology of the oesophagus and the GOJ.Results of pre and postoperative manometryThe most important findings are the changes that occur after vertical sleeve gastrectomy surgery in oesophageal manometry<a class="elsevierStyleCrossRef" href="#bib0090">18</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The preoperative LOS pressure is normal, with an average result of 12.47 ± 7.1 mmHg, compared to that of the postoperative, with an average result of 10.42 ± 8.6 mmHg (low evident LOS pressure), which can reach values below 6 mmHg, tending to be hypotensive and showing incompetence, especially in the presence of a hiatus hernia<a class="elsevierStyleCrossRef" href="#bib0090">18</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).Distal oesophageal pressure had a preoperative value of 101.51 ± 49.2 mmHg and a postoperative value of 85.48 ± 47.1 mmHg, also showing a deterioration in oesophageal body pressure.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Intragastric pressure was evaluated in two ways: the first was by measuring the basal pressure with an empty stomach in the pre- and postoperative period, finding average values of 9.04 ± 5.58 mmHg in the preoperative period and 18.28 ± 11.2 mmHg in the postoperative period (probably related to the decrease in gastric volume). The second way in which we evaluated this parameter was to measure the intragastric pressure after ingesting a glass of water, finding that this post-ingestion pressure of liquid was 30.13 ± 50.9 mmHg preoperatively and 130.51 ± 146.7 mmHg in the postoperative period, which translates into an increase from 18 to 130, approximately 7 times its baseline value, as a consequence of the reduction in gastric volumen.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>The normal oesophagogastric gradient occurs when the pressure of the oesophagus is greater than that of the stomach, translating into a flow in the direction of the oesophagus to the stomach. The inverted oesophagogastric gradient occurs when the pressure of the oesophagus is lower than that of the stomach, resulting in an inverted flow from the stomach towards the oesophagus (gastro-oesophageal reflux). Our results show this, with the inverted gradient occurring in 7.6% of patients preoperatively and increases to 49.4% of patients postoperatively. This phenomenon of gradient inversion constitutes another major factor for the production of reflux<a class="elsevierStyleCrossRef" href="#bib0090">18</a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Due to the nature of the type of surgery, an increase in baseline and post-ingestion gastric intraluminal pressure is common (due to the decrease in stomach volume).<a class="elsevierStyleCrossRef" href="#bib0090">18</a> This increase in pressure is one of the mechanisms responsible for the pathophysiology of post-sleeve reflux, because it alters the pressure gradient between the stomach, the LOS and the oesophageal body, generating a return or regurgitation of gastric contents towards the oesophagus. The inversion of the gradient, according to Poggi et al.,<a class="elsevierStyleCrossRef" href="#bib0095">19</a> ranges pre- and postoperatively from 6% to 48%, respectively.Dysmotility is present in 15% preoperatively, and in the postoperative period it increases to 35%, demonstrating that there is deterioration in motility that will condition the reflux, because after evaluating all our patients we believe that dysmotility never improves, it always worsens with vertical gastrectomy.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>After analysing all the reflux conditioning factors evaluated by manometry, our reflux results by manometry would be 60.3%, with de novo reflux being 34.6%<a class="elsevierStyleCrossRef" href="#bib0090">18</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).According to our results, possible predictors of worsening reflux and de novo reflux would be LOS hypotension, elevated preoperative baseline gastric pressure, inverted oesophagogastric gradient, and dysmotility. Currently, digestive neuromotility study groups grade oesophageal peristalsis with analysis of distal contractile interval (DCI) and elevated integral relaxation pressure (IRP), which is related to LOS competence in pathologies such as achalasia and OGJOO.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Preoperative findings and possible diagnosesThere are functional states of the oesophagus that we must take into account among candidates for bariatric surgery. These patients could be in a potential transitional state of generating reflux in the postoperative period, and these are precisely the cases detected using the Chicago IV classification.<a class="elsevierStyleCrossRefs" href="#bib0100">20,21</a>Cases that should be detected in order not to perform a gastric sleeve:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0100">•Ineffective oesophageal motility (oesophageal dysmotility). Contraindication of gastric sleeve.</li><li class="elsevierStyleListItem" id="lsti0105">•Gastro-oesophageal junction outflow obstruction (OGJOO).</li><li class="elsevierStyleListItem" id="lsti0110">•Asymptomatic in some cases, which may be related to hiatus hernia, early developing achalasia or a functional problem. Gastric sleeve is not recommended.</li><li class="elsevierStyleListItem" id="lsti0115">•Jackhammer hypercontractile oesophagus (relative contraindication for gastric sleeve). Related to substernal pain. You are at risk of fistula.</li><li class="elsevierStyleListItem" id="lsti0120">•Distal oesophageal spasm. Related to gastro-oesophageal reflux. Relative contraindication of gastric sleeve.</li><li class="elsevierStyleListItem" id="lsti0125">•Achalasia. Absolute contraindication of gastric sleeve.</li><li class="elsevierStyleListItem" id="lsti0130">•Hiatus hernia that must be corrected and, at the same time, is one of the most frequent complications of the gastric sleeve that causes GOR disease due to the sleeve slipping into the thorax.</li></ul>Twenty-four-hour pHmetry and 24-h oesophageal impedanceThe pHmetry study is performed together with the oesophageal impedance study with the same catheter that allows us to measure the exposure of the acid of the distal oesophagus to a pH < 4 using pH sensors that are in the middle and at the tip of the catheter. The distal sensor is in the stomach and the proximal sensor is 5 cm above the upper edge of the LOS previously determined by manometry. pHmetry is measured through the DeMeester score (normal value: 14.72) and the percentage of time of exposure to acid (normal value: <4%) of the distal oesophagus.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>The 24 h oesophageal impedance is measured together with the pHmetry catheter through 6 pairs of sensors installed from 3 cm to 17 cm proximal to the upper border of the LOS. This study allows recording the number of reflux episodes (normal value: <80), the type of reflux, whether it is alkaline or acid, and the level of reflux rise to the cervical region.Pre- and postoperative 24-h pH-impedance results of vertical gastrectomy (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>)The DeMeester score in the patients in the pre- and postoperative period was 16.35 ± 14.73 and 44.14 ± 34.43, respectively, that is, in the postoperative period these values tripled, expressing a pathological condition due to acid reflux. With this method, it is possible to diagnose pathological reflux in 82.81% in the postoperative period, with de novo reflux being 51.56%.The preoperative acid exposure time was normal, with a value of 3%, and in the postoperative period it was pathological in 16% of the patients, showing, once again, an evident gastro-oesophageal reflux.Oesophageal impedance showed that 82.8% of patients had postoperative reflux and 42.2% had de novo reflux.These results demonstrate that, through the complete study with manometry, pHmetry and oesophageal impedance tests, with manometry we have enough evidence to consider that it is the only way to make an accurate and irrefutable diagnosis.Importance of oesophageal endoscopy and fluoroscopy in the bariatric patientOesophageal fluoroscopyOesophageal fluoroscopy is not given its due value or importance in the literature. In our service, based on our results, our opinion differs. We usually have the same surgeon perform oesophageal fluoroscopy, thus obtaining the maximum information on oesophageal motility and function. In preoperative studies, visualising the hiatus hernia and reflux leads us to suspect motility problems. Likewise, in the postoperative period it allows us to evaluate the results of the surgery and rule out problems of strictures, leaks and reflux.Upper endoscopyWe consider it mandatory to perform preoperative endoscopy to detect oesophageal pathology, Barrett's, oesophagitis, achalasia, oesophageal diverticula and gastric pathology such as benign GIST-type tumours or incipient malignant tumours that force us to reconsider surgery. Postoperative endoscopy follow-up is to detect signs of reflux related to moderate or severe erosive oesophagitis, Barrett's, and dysplasias.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> There is a suggestion that preoperative endoscopy may not be necessary in the case of bariatric surgery<a class="elsevierStyleCrossRefs" href="#bib0120">24,25</a>; However, endoscopic follow-up is also recommended to detect slippage, Barrett's or reflux. There are studies of post-sleeve Barrett, as reported by Genco et al.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> and Iannelli et al.,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> with results of 17.4% and 18.8% of post-sleeve Barrett, respectively. Our results were 6.6% per year of patients with Barrett's oesophagus, and for our service Barrett's oesophagus is a formal contraindication. These cases can progress to severe dysplasia and cancer, and in our service we have had 2 patients with GOJ cancer.3D-TC volumetricsIn the follow-up protocol we observed that a useful tool is tomography volumetry with 3D reconstruction. Through this procedure we can obtain results on the volume of the sleeve, its morphology, its technical defects and its sliding to the tórax.<a class="elsevierStyleCrossRefs" href="#bib0080">16,28</a> Below we describe the problems that would cause reflux, detectable by 3D-CT volumetry:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0135">a)Slippage occurred in 72.4% of our operated cases, regardless of whether or not correction of the hiatus hernia was performed (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A, where the line of staples goes above the diaphragm).<a class="elsevierStyleCrossRef" href="#bib0080">16</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0140">b)Dilation of the gastric fundus occurred in 22.4% of our patients generally due to dilation from a stenosis of the body or due to an unresected gastric fundus. Global sleeve dilation occurred in 64.7% of operated cases, which indicates a long-term growth or increase in sleeve volume over time and is related to regaining weight (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B–D).<a class="elsevierStyleCrossRef" href="#bib0080">16</a></li><li class="elsevierStyleListItem" id="lsti0145">c)Oesophageal dilation occurred in 27.6% of those operated on in our group, which is explained by forced feeding and increased gastric pressure. When trying to overcome the elevated gastric pressure the oesophagus became dilated during the attempt to pass the food into the stomach. This leads to gastro-oesophageal reflux with severe oesophageal dysmotility and progressive deterioration of oesophageal peristalsis. Severe oesophageal dysmotility never improves, it always worsens (in <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B–D the oesophagus is seen dilated in 3D).<a class="elsevierStyleCrossRefs" href="#bib0055">11,16</a></li><li class="elsevierStyleListItem" id="lsti0150">d)Spiral or corkscrew torsion occurred in 8.6% of our cases, because the gastric tube rotates on its own axis and adopts a spiral shape like a corkscrew. This is due to irregular and asymmetrical stapling. Clinically it is expressed as digestive intolerance with frequent vomiting and generally massive weight loss (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>C). All patients with this complication will develop severe intractable reflux, and usually undergo sleeve revision to bypass surgery.<a class="elsevierStyleCrossRef" href="#bib0080">16</a></li><li class="elsevierStyleListItem" id="lsti0155">e)Stenosis of the incisura angularis occurred in 44% and stenosis of the body occurred in 7.8% of our research group. This alteration occurs when the stapler sticks too much at the level of the incisura angularis or when there was an asymmetric resection of the stomach (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>B–D).<a class="elsevierStyleCrossRef" href="#bib0080">16</a></li><li class="elsevierStyleListItem" id="lsti0160">f)Kinking's presentation occurred in 75.9%. A severe acute angle is formed between the antrum and the gastric body at the level of the incisura, creating partial obstruction when it breaks on itself and prevents the passage of content from the proximal to the distal stomach, generating vomiting and reflux.<a class="elsevierStyleCrossRef" href="#bib0080">16</a></li></ul>Ideal patient selection for vertical gastrectomy flowchartVertical gastrectomy produces anatomical alterations in the GOJ that generates alterations in the entire antireflux valve mechanism. This technique promotes the appearance of reflux and the deterioration of all the anti-reflux functions of the GOJ.Taking into consideration all the above research, we wished to create a flowchart to help us choose which bariatric surgical technique to use in obese patients, mainly deciding between gastric sleeve and bypass. This entire analysis is based on our results of manometry, pHmetry, impedance, oesophageal fluoroscopy and upper endoscopy, with the main interest of identifying patients who have a low probability of developing reflux versus those who have a very high probability of presenting reflux postoperatively; We believe that it is a good way to prevent the patient from having revision surgery for intractable reflux in the future (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres2044360" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1747789" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2044361" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1747790" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Anatomy and physiology of the normal gastro-oesophageal junction and in the gastrectomised patient" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Anatomical-functional factors that cause gastro-oesophageal reflux" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Preoperative studies of candidate patients for bariatric surgery" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Pre and postoperative comparative results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "High resolution oesophageal manometry" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Results of pre and postoperative manometry" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Preoperative findings and possible diagnoses" ] ] ] 9 => array:3 [ "identificador" => "sec0045" "titulo" => "Twenty-four-hour pHmetry and 24-h oesophageal impedance" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Pre- and postoperative 24-h pH-impedance results of vertical gastrectomy (Table 1)" ] ] ] 10 => array:3 [ "identificador" => "sec0055" "titulo" => "Importance of oesophageal endoscopy and fluoroscopy in the bariatric patient" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Oesophageal fluoroscopy" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Upper endoscopy" ] ] ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "3D-TC volumetrics" ] 12 => array:2 [ "identificador" => "sec0075" "titulo" => "Ideal patient selection for vertical gastrectomy flowchart" ] 13 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interests" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-10-15" "fechaAceptado" => "2023-02-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1747789" "palabras" => array:7 [ 0 => "Motility" 1 => "Vertical gastrectomy" 2 => "Sleeve gastrectomy" 3 => "Gastroesophageal reflux" 4 => "Manometry" 5 => "Esophageal impedance" 6 => "pH metry" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1747790" "palabras" => array:7 [ 0 => "Motilidad" 1 => "Gastrectomía vertical" 2 => "Manga gástrica" 3 => "Reflujo gastroesofágico" 4 => "Manometría" 5 => "Impedancia esofágica" 6 => "pHmetría esofágica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Sleeve gastrectomy (SG) is the most common bariatric surgery worldwide and has shown to cause de novo or worsen symptoms of gastroesophageal reflux disease (GERD). Esophageal motility and physiology studies are mandatory in bariatric and foregut centers. The predisposing factors in post-SG patients are disruption of His angle, resection of gastric fold and gastric fundus, increased gastric pressure, resection of the gastric antrum, cutting of the sling fibers and pyloric spasm. There are symptomatic complications due to sleeve morphology as torsion, incisura angularis stenosis, kinking and dilated fundus. In this article, we present recommendations, surgical technique and patient selection flow diagram for SG and avoid de novo or worsening GERD." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La gastrectomía vertical (GV) es la cirugía bariátrica más común realizada en el mundo y asimismo ha demostrado en el transcurso de estos años tener como consecuencia la aparición o empeoramiento de síntomas de reflujo gastroesofágico (RGE). Es imprescindible que en los centros de alta volumen de cirugía de foregut o intestino anterior se realicen estudios de motilidad y fisiología esofágico. En el paciente post GV, los factores condicionantes para desarrollar RGE son la desaparición del ángulo de His, del pliegue gástrico antirreflujo y del fondo gástrico, aumento de la presión intragástrica, resección forzada del antro, sección de las fibras sling y espasmo pilórico. A continuación, están descritas nuestras recomendaciones, técnica quirúrgica y flujograma de selección del paciente ideal para GV y evitar la aparición o empeoramiento de RGE." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "Please cite this article as: Poggi Machuca L, Romani Pozo D, Guerrero Martinez H, Rojas Reyes R, Dávila Luna A, Cruz Condori D, et al. Posibles aspectos técnicos implicados en la aparición de RGE tras gastrectomía vertical. Consideraciones para la técnica quirúrgica. Cir Esp. 2023. https://doi.org/10.1016/j.ciresp.2023.02.005" ] ] "multimedia" => array:22 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1507 "Ancho" => 3258 "Tamanyo" => 502071 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Swallowing sequence and anti-reflux valve. View from gastrostomy (flap valve)." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1681 "Ancho" => 3000 "Tamanyo" => 782215 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Loss of the valve mechanism as a consequence of the resection of the vertical gastrectomy." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1654 "Ancho" => 3258 "Tamanyo" => 427639 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Inversion of the oesophagogastric gradient in vertical gastrectomy." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1509 "Ancho" => 3175 "Tamanyo" => 436781 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Illustration and 3D reconstruction of complications related to the appearance of gastro-oesophageal reflux disease in sleeve gastrectomy. A) Intrathoracic slip. B) Dilation of the gastric fundus and oesophagus. C) Torsion. D) Stenosis/narrowing of the incisura angularis. In all cases slipping of the sleeve is seen." ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1838 "Ancho" => 3256 "Tamanyo" => 813107 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Flowchart for selecting the ideal patient for vertical gastrectomy." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preop. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postop. \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High resolution oesophageal manometry</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LOS pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489591"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.47 ± 7.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.42 ± 8.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Distal oesophageal pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489592"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">101.51 ± 49.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.48 ± 47.18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Basal gastric pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489593"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.04 ± 5.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.25 ± 11.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Post ingestion gastric pressure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489594"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30.13 ± 50.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">130.51 ± 146.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inverted esophagastric gradient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489595"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.60% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">49.40% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oesophageal dysmotility \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489596"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Twenty-four hour oesophageal pHmetry</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DeMeester score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489597"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.35 ± 14.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.14 ± 34.43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Twenty-four hour oesophageal impedance</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pathological impedance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489598"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.80% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Upper endoscopy</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Esophagitis B-C-D-E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202312080922489599"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.40% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Barrett \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="2023120809224895910"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.90% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.60% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Esophageal fluoroscopy</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reflux \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="2023120809224895911"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hiatus hernia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="2023120809224895912"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.40% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41.60% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="2023120809224895913"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61.20% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3389022.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">Preop. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="4" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postop.</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reflux \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reflux \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">De novo \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Persist \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cure \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reflux by manometry \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="2023120809224895914"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60.30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.60% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.60% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.70% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pathological DeMeester \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="2023120809224895915"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.81% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51.56% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.12% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pathological impedance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="2023120809224895916"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.80% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.60% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.70% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3389023.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Paired pre- and postoperative values of the complete study of fluoroscopy, endoscopy and oesophageal motility in vertical gastrectomy patients." ] ] 6 => array:5 [ "identificador" => "202312080922489591" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => 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Possible technical aspects involved in the development of GERD after sleeve gastrectomy: Surgical technique considerations

Posibles aspectos técnicos implicados en la aparición de RGE tras gastrectomía vertical. Consideraciones para la técnica quirúrgica

Luis Poggi Machucaa,b, Diego Romani Pozoa,b,

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diego.romani.p@upch.pe

Corresponding author.

, Harold Guerrero Martineza,b, Rodrigo Rojas Reyesa,b, Andrea Dávila Lunaa,b, Diana Cruz Condoria,b, Luciano Poggia,b

a Departamento de Cirugía General y Laparoscópica, Clínica Anglo Americana, Lima, Peru

b Laboratorio de Neurogastro Motilidad, Centro de Investigación de Fisiología y Cirugía del Aparato Digestivo, Lima, Peru

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Vertical sleeve gastrectomy is the most common bariatric surgery performed in the world&#44; and has also been widely shown to produce symptoms of gastro-oesophageal reflux &#40;GOR&#41; or worsen existing reflux&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are many bariatric surgical techniques&#46; The selection of patients for each technique will depend on their metabolic characteristics&#44; the degree of obesity&#44; metabolic syndrome or weight gain&#46; Often the patient&#39;s preference determines the choice of technique &#40;usually &#8220;gastric sleeve&#8221;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">For this reason&#44; in our centre specialised in anterior digestive tract surgery &#40;foregut&#41; patients are evaluated for symptoms of reflux&#44; regurgitation&#44; heartburn or dysphagia&#44; with a complete endoscopic&#44; radiological and oesophageal motility study that is performed routinely for a more precise selection of patients before surgical treatment and so that the chosen technique has the best success rate and the lowest probability of long-term complications&#46; In this sense&#44; the patient with reflux or with a high probability of developing it is directed towards the Roux-en-Y gastric bypass&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This article will present the anatomy of the gastro-oesophageal junction &#40;GOJ&#41;&#44; the changes that would explain the appearance of reflux symptoms&#44; the pre- and postoperative comparative studies&#44; together with the visualisation of the changes that occur with respect to the volume and morphology of the sleeve through the volumetry&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Anatomy and physiology of the normal gastro-oesophageal junction and in the gastrectomised patient</span><p id="par0025" class="elsevierStylePara elsevierViewall">The GOJ is the part of the digestive tract that is in a transitional space between the thorax and the abdomen subjected to different pressures and that has an important range of motility produced by swallowing&#46; The antireflux mechanism is multifactorial&#44; which makes the investigation of its pathology and the approach to its treatment complex&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The GOJ is anatomically composed of the abdominal oesophagus&#44; the angle of His&#44; the gastric fundus&#44; the Sling fibres&#44; and the Clasp fibres&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> All these structures must be in their normal anatomical position to constitute a perfect gastro-oesophageal antireflux mechanism&#46; The support elements of this mobile area would be provided by the phrenoesophageal ligament&#44; the diaphragmatic crura&#44; the pars condensate&#44; the lesser omentum&#44; the fundus phrenic ligament and the short vessels&#46; When one of these structures fails&#44; the crura can dilate&#44; producing a sliding hiatus hernia that will produce gastroesophageal reflux&#46; The abdominal portion of the oesophagus &#40;4&#8201;cm&#41; is subjected to a series of abdominal pressures&#44; gastric pressures and GOJ pressures that create an area of high pressure that would constitute the so-called lower oesophageal sphincter &#40;LOS&#41;&#44; which would be a sum of forces rather than a specific muscle sphincter&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The anatomical&#44; regular and physiological nature of these structures constitutes an anti-reflux valve mechanism&#44; allowing the passage of food from the oesophagus to the stomach and preventing its return<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In this mechanism&#44; the Sling fibbers &#40;purple in the illustration&#41; have a highly unique arrangement in the stomach&#44; they go along the anterior wall&#44; rotate around the oesophagus like a loop and go down the posterior slope&#44; fixing on the incisura angularis&#46; They generate the angle of His and act by moving the wall of the oesophagus downward and to the right &#40;purple arrows&#41;&#59; This is complemented by Clasp-type fibres &#40;green&#41;&#44; which contract by taking the right edge of the oesophagus in the opposite direction&#44; from the right to the left&#44; closing the cardia &#40;green arrows&#41;&#46; This closure is complemented by the action of the pressure of the gastric fundus on the oesophagus &#40;complying with Pascal&#39;s law &#91;yellow arrows&#93;&#41;&#44; which compresses the oesophagus at the level of the oesophagogastric transition&#44; thus completing the antireflux mechanism&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> We repeat that the diaphragmatic crura also participates&#44; it contracts from top to bottom and from front to back&#44; acting as an important part of the antireflux mechanism &#40;according to Zifan&#44; 85&#37;&#41;&#59; We also wish to reiterate that any dilation of the crura produces stomach slippage and hiatus hernia&#44; necessarily and obligatorily generating gastroesophageal reflux&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">When one swallows&#44; the sequence would be that the oesophagus propels the food bolus towards the stomach&#44; producing the relaxation of the sling and clasp fibres&#44; opening the cardia and allowing the food to enter&#46; The antireflux mechanism springs into action as soon as what is ingested increases intragastric pressure &#40;this happens when the volumes reach the limit&#44; more than 750&#8201;ml&#41;&#44; preventing the food backing up from the stomach into the oesophagus&#46; It is in this situation where the clasp and sling fibres contract&#44; closing the cardia with the help of the increase in intragastric pressure and the elevation of the gastric fundus&#44; compressing the oesophageal wall and generating a gate valve mechanism &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The representation of the gate mechanism seen from inside the stomach is called the flap valve &#40;yellow box in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; which is what we try to reproduce in surgery when it has been lost&#44; generating reflux and in this way re-establishing functionality and LOS competence&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This level is equivalent to the transition zone from the entrance of the oesophagus to the stomach&#44; where the intragastric pressure would act in addition to the other forces mentioned&#44; generating the gate or check valve effect on the portion of the oesophagus that is inside the stomach wall&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This is what Jobe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> refer to&#44; and what is mentioned by Tom DeMeester as the high pressure zone&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The gastrectomy technique would lead to sectioning of the structures involved in the anti-reflux mechanism&#46; These changes produced by the resection of the stomach and gastric fundus would lead&#44; first of all&#44; to a decrease in the existing pressures on the LOS&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> turning it into an incompetent cardia given that the sling fibres&#44; because they are sectioned&#44; cannot contract efficiently&#46; Likewise&#44; the absence of the gastric fundus causes the angle of His to be lost&#44; also losing the gate mechanism&#44; and the reduction in the volume of the stomach would cause intragastric pressure to increase&#44; producing an opening of the greater cardia&#44; leaving it permanently open or yawning&#44; causing incompetence of the antireflux mechanism and promoting the return of gastric contents towards the oesophagus&#44; including bile reflux &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Anatomical-functional factors that cause gastro-oesophageal reflux</span><p id="par0055" class="elsevierStylePara elsevierViewall">The anatomical alterations that would cause gastroesophageal reflux are known&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hiatus hernia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Disappearance of the abdominal oesophagus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Disappearance of the gastric fundus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Hypotension of the high-pressure area or LOS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Permanent loss or opening of the His angle&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Increase in intra-abdominal pressure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Increase in intra-gastric pressure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Inversion of oesophagogastric pressure gradient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Hyper acidity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Abnormal increase of the frequency of transitory relaxations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Lack of resistance of oesophageal mucosa to acid&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Delayed gastric emptying&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Alterations produced as a consequence of gastric surgery&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">o</span><p id="par0125" class="elsevierStylePara elsevierViewall">Resection of gastric fundus&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">o</span><p id="par0130" class="elsevierStylePara elsevierViewall">Stenosis of the gastric notch or body&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">o</span><p id="par0135" class="elsevierStylePara elsevierViewall">Stomach outflow obstructions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">o</span><p id="par0140" class="elsevierStylePara elsevierViewall">Gastroparesis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">o</span><p id="par0145" class="elsevierStylePara elsevierViewall">Progressive oesophageal dysmotility&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">o</span><p id="par0150" class="elsevierStylePara elsevierViewall">Oesophageal spasm&#46;</p></li></ul></p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Preoperative studies of candidate patients for bariatric surgery</span><p id="par0155" class="elsevierStylePara elsevierViewall">For the analysis of all the factors considered in the previous paragraph&#44; a comprehensive study is required so that the functional state of the GOJ may be understood and the physiological alterations produced by the resection or the modification of the anatomy generated in the various surgical techniques may be interpreted&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Evaluation must be comprehensive&#44; i&#46;e&#46;&#44; complete&#44; analysing the oesophagus by fluoroscopy&#44; endoscopy and oesophageal motility &#40;manometry-pHmetry-impedance&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The results of these tests would allow us to objectively be familiar with pathologies that could cause reflux&#44; such as dysmotility&#44; achalasia&#44; Jackhammer oesophagus or the pathology recently described as oesophageal gastric juntion outflow obstruction &#91;OGJOO&#93;&#41; in both pre and postoperative bariatric surgery patients&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">By complete study we refer to the ideal&#44; which includes&#58; high-resolution oesophageal manometry&#44; 24-h oesophageal pH and impedance measurement&#44; oesophageal fluoroscopy&#44; gastric emptying using scintigraphy&#44; and upper endoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Other techniques to use in the preoperative period of non-mandatory revisional surgery may be&#58; endoFLIP and volumetrics using 3D reconstruction with tomography to determine the volume&#44; morphology and type of surgery to which the patient with reflux was subjected&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pre and postoperative comparative results</span><p id="par0170" class="elsevierStylePara elsevierViewall">These include pre- and postoperative results of patients undergoing vertical gastrectomy who agreed to undergo a complete study&#46; There were 245 patients who had acceptable weight loss&#44; with a decrease in BMI from 39&#46;15 to 26&#46;34&#46; The results of each study conducted are presented below&#44; together with an interpretation of them&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">High resolution oesophageal manometry</span><p id="par0175" class="elsevierStylePara elsevierViewall">High-resolution manometry is the most important study of oesophageal motility and gives us the most information about the functional state of the swallowing process and oesophageal peristalsis&#46; It allows us to detect and diagnose pathologies that may be a contraindication to performing a certain surgery&#44; such as achalasia or severe reflux&#46; The comparative value of pre- and postoperative manometry will allow us to evaluate the true action&#44; effect or deterioration that surgery produces on the physiology of the oesophagus and the GOJ&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results of pre and postoperative manometry</span><p id="par0180" class="elsevierStylePara elsevierViewall">The most important findings are the changes that occur after vertical sleeve gastrectomy surgery in oesophageal manometry<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">The preoperative LOS pressure is normal&#44; with an average result of 12&#46;47&#8201;&#177;&#8201;7&#46;1&#8201;mmHg&#44; compared to that of the postoperative&#44; with an average result of 10&#46;42&#8201;&#177;&#8201;8&#46;6&#8201;mmHg &#40;low evident LOS pressure&#41;&#44; which can reach values below 6&#8201;mmHg&#44; tending to be hypotensive and showing incompetence&#44; especially in the presence of a hiatus hernia<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Distal oesophageal pressure had a preoperative value of 101&#46;51&#8201;&#177;&#8201;49&#46;2&#8201;mmHg and a postoperative value of 85&#46;48&#8201;&#177;&#8201;47&#46;1&#8201;mmHg&#44; also showing a deterioration in oesophageal body pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Intragastric pressure was evaluated in two ways&#58; the first was by measuring the basal pressure with an empty stomach in the pre- and postoperative period&#44; finding average values of 9&#46;04&#8201;&#177;&#8201;5&#46;58&#8201;mmHg in the preoperative period and 18&#46;28&#8201;&#177;&#8201;11&#46;2&#8201;mmHg in the postoperative period &#40;probably related to the decrease in gastric volume&#41;&#46; The second way in which we evaluated this parameter was to measure the intragastric pressure after ingesting a glass of water&#44; finding that this post-ingestion pressure of liquid was 30&#46;13&#8201;&#177;&#8201;50&#46;9&#8201;mmHg preoperatively and 130&#46;51&#8201;&#177;&#8201;146&#46;7&#8201;mmHg in the postoperative period&#44; which translates into an increase from 18 to 130&#44; approximately 7 times its baseline value&#44; as a consequence of the reduction in gastric volumen&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The normal oesophagogastric gradient occurs when the pressure of the oesophagus is greater than that of the stomach&#44; translating into a flow in the direction of the oesophagus to the stomach&#46; The inverted oesophagogastric gradient occurs when the pressure of the oesophagus is lower than that of the stomach&#44; resulting in an inverted flow from the stomach towards the oesophagus &#40;gastro-oesophageal reflux&#41;&#46; Our results show this&#44; with the inverted gradient occurring in 7&#46;6&#37; of patients preoperatively and increases to 49&#46;4&#37; of patients postoperatively&#46; This phenomenon of gradient inversion constitutes another major factor for the production of reflux<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">Due to the nature of the type of surgery&#44; an increase in baseline and post-ingestion gastric intraluminal pressure is common &#40;due to the decrease in stomach volume&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This increase in pressure is one of the mechanisms responsible for the pathophysiology of post-sleeve reflux&#44; because it alters the pressure gradient between the stomach&#44; the LOS and the oesophageal body&#44; generating a return or regurgitation of gastric contents towards the oesophagus&#46; The inversion of the gradient&#44; according to Poggi et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> ranges pre- and postoperatively from 6&#37; to 48&#37;&#44; respectively&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Dysmotility is present in 15&#37; preoperatively&#44; and in the postoperative period it increases to 35&#37;&#44; demonstrating that there is deterioration in motility that will condition the reflux&#44; because after evaluating all our patients we believe that dysmotility never improves&#44; it always worsens with vertical gastrectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">After analysing all the reflux conditioning factors evaluated by manometry&#44; our reflux results by manometry would be 60&#46;3&#37;&#44; with de novo reflux being 34&#46;6&#37;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">According to our results&#44; possible predictors of worsening reflux and de novo reflux would be LOS hypotension&#44; elevated preoperative baseline gastric pressure&#44; inverted oesophagogastric gradient&#44; and dysmotility&#46; Currently&#44; digestive neuromotility study groups grade oesophageal peristalsis with analysis of distal contractile interval &#40;DCI&#41; and elevated integral relaxation pressure &#40;IRP&#41;&#44; which is related to LOS competence in pathologies such as achalasia and OGJOO&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Preoperative findings and possible diagnoses</span><p id="par0225" class="elsevierStylePara elsevierViewall">There are functional states of the oesophagus that we must take into account among candidates for bariatric surgery&#46; These patients could be in a potential transitional state of generating reflux in the postoperative period&#44; and these are precisely the cases detected using the Chicago&#8201;IV classification&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Cases that should be detected in order not to perform a gastric sleeve&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Ineffective oesophageal motility &#40;oesophageal dysmotility&#41;&#46; Contraindication of gastric sleeve&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Gastro-oesophageal junction outflow obstruction &#40;OGJOO&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Asymptomatic in some cases&#44; which may be related to hiatus hernia&#44; early developing achalasia or a functional problem&#46; Gastric sleeve is not recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Jackhammer hypercontractile oesophagus &#40;relative contraindication for gastric sleeve&#41;&#46; Related to substernal pain&#46; You are at risk of fistula&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Distal oesophageal spasm&#46; Related to gastro-oesophageal reflux&#46; Relative contraindication of gastric sleeve&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0260" class="elsevierStylePara elsevierViewall">Achalasia&#46; Absolute contraindication of gastric sleeve&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0265" class="elsevierStylePara elsevierViewall">Hiatus hernia that must be corrected and&#44; at the same time&#44; is one of the most frequent complications of the gastric sleeve that causes GOR disease due to the sleeve slipping into the thorax&#46;</p></li></ul></p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Twenty-four-hour pHmetry and 24-h oesophageal impedance</span><p id="par0270" class="elsevierStylePara elsevierViewall">The pHmetry study is performed together with the oesophageal impedance study with the same catheter that allows us to measure the exposure of the acid of the distal oesophagus to a pH&#8201;&#60;&#8201;4 using pH sensors that are in the middle and at the tip of the catheter&#46; The distal sensor is in the stomach and the proximal sensor is 5&#8201;cm above the upper edge of the LOS previously determined by manometry&#46; pHmetry is measured through the DeMeester score &#40;normal value&#58; 14&#46;72&#41; and the percentage of time of exposure to acid &#40;normal value&#58; &#60;4&#37;&#41; of the distal oesophagus&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">The 24&#8201;h oesophageal impedance is measured together with the pHmetry catheter through 6 pairs of sensors installed from 3&#8201;cm to 17&#8201;cm proximal to the upper border of the LOS&#46; This study allows recording the number of reflux episodes &#40;normal value&#58; &#60;80&#41;&#44; the type of reflux&#44; whether it is alkaline or acid&#44; and the level of reflux rise to the cervical region&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pre- and postoperative 24-h pH-impedance results of vertical gastrectomy &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0280" class="elsevierStylePara elsevierViewall">The DeMeester score in the patients in the pre- and postoperative period was 16&#46;35&#8201;&#177;&#8201;14&#46;73 and 44&#46;14&#8201;&#177;&#8201;34&#46;43&#44; respectively&#44; that is&#44; in the postoperative period these values tripled&#44; expressing a pathological condition due to acid reflux&#46; With this method&#44; it is possible to diagnose pathological reflux in 82&#46;81&#37; in the postoperative period&#44; with de novo reflux being 51&#46;56&#37;&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">The preoperative acid exposure time was normal&#44; with a value of 3&#37;&#44; and in the postoperative period it was pathological in 16&#37; of the patients&#44; showing&#44; once again&#44; an evident gastro-oesophageal reflux&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Oesophageal impedance showed that 82&#46;8&#37; of patients had postoperative reflux and 42&#46;2&#37; had de novo reflux&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">These results demonstrate that&#44; through the complete study with manometry&#44; pHmetry and oesophageal impedance tests&#44; with manometry we have enough evidence to consider that it is the only way to make an accurate and irrefutable diagnosis&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Importance of oesophageal endoscopy and fluoroscopy in the bariatric patient</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Oesophageal fluoroscopy</span><p id="par0300" class="elsevierStylePara elsevierViewall">Oesophageal fluoroscopy is not given its due value or importance in the literature&#46; In our service&#44; based on our results&#44; our opinion differs&#46; We usually have the same surgeon perform oesophageal fluoroscopy&#44; thus obtaining the maximum information on oesophageal motility and function&#46; In preoperative studies&#44; visualising the hiatus hernia and reflux leads us to suspect motility problems&#46; Likewise&#44; in the postoperative period it allows us to evaluate the results of the surgery and rule out problems of strictures&#44; leaks and reflux&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Upper endoscopy</span><p id="par0305" class="elsevierStylePara elsevierViewall">We consider it mandatory to perform preoperative endoscopy to detect oesophageal pathology&#44; Barrett&#39;s&#44; oesophagitis&#44; achalasia&#44; oesophageal diverticula and gastric pathology such as benign GIST-type tumours or incipient malignant tumours that force us to reconsider surgery&#46; Postoperative endoscopy follow-up is to detect signs of reflux related to moderate or severe erosive oesophagitis&#44; Barrett&#39;s&#44; and dysplasias&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> There is a suggestion that preoperative endoscopy may not be necessary in the case of bariatric surgery<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a>&#59; However&#44; endoscopic follow-up is also recommended to detect slippage&#44; Barrett&#39;s or reflux&#46; There are studies of post-sleeve Barrett&#44; as reported by Genco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> and Iannelli et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> with results of 17&#46;4&#37; and 18&#46;8&#37; of post-sleeve Barrett&#44; respectively&#46; Our results were 6&#46;6&#37; per year of patients with Barrett&#39;s oesophagus&#44; and for our service Barrett&#39;s oesophagus is a formal contraindication&#46; These cases can progress to severe dysplasia and cancer&#44; and in our service we have had 2 patients with GOJ cancer&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">3D-TC volumetrics</span><p id="par0310" class="elsevierStylePara elsevierViewall">In the follow-up protocol we observed that a useful tool is tomography volumetry with 3D reconstruction&#46; Through this procedure we can obtain results on the volume of the sleeve&#44; its morphology&#44; its technical defects and its sliding to the t&#243;rax&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;28</span></a> Below we describe the problems that would cause reflux&#44; detectable by 3D-CT volumetry&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">a&#41;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Slippage occurred in 72&#46;4&#37; of our operated cases&#44; regardless of whether or not correction of the hiatus hernia was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>A&#44; where the line of staples goes above the diaphragm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">b&#41;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Dilation of the gastric fundus occurred in 22&#46;4&#37; of our patients generally due to dilation from a stenosis of the body or due to an unresected gastric fundus&#46; Global sleeve dilation occurred in 64&#46;7&#37; of operated cases&#44; which indicates a long-term growth or increase in sleeve volume over time and is related to regaining weight &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#8211;D&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">c&#41;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Oesophageal dilation occurred in 27&#46;6&#37; of those operated on in our group&#44; which is explained by forced feeding and increased gastric pressure&#46; When trying to overcome the elevated gastric pressure the oesophagus became dilated during the attempt to pass the food into the stomach&#46; This leads to gastro-oesophageal reflux with severe oesophageal dysmotility and progressive deterioration of oesophageal peristalsis&#46; Severe oesophageal dysmotility never improves&#44; it always worsens &#40;in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#8211;D the oesophagus is seen dilated in 3D&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">d&#41;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Spiral or corkscrew torsion occurred in 8&#46;6&#37; of our cases&#44; because the gastric tube rotates on its own axis and adopts a spiral shape like a corkscrew&#46; This is due to irregular and asymmetrical stapling&#46; Clinically it is expressed as digestive intolerance with frequent vomiting and generally massive weight loss &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>C&#41;&#46; All patients with this complication will develop severe intractable reflux&#44; and usually undergo sleeve revision to bypass surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">e&#41;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Stenosis of the incisura angularis occurred in 44&#37; and stenosis of the body occurred in 7&#46;8&#37; of our research group&#46; This alteration occurs when the stapler sticks too much at the level of the incisura angularis or when there was an asymmetric resection of the stomach &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>B&#8211;D&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">f&#41;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Kinking&#39;s presentation occurred in 75&#46;9&#37;&#46; A severe acute angle is formed between the antrum and the gastric body at the level of the incisura&#44; creating partial obstruction when it breaks on itself and prevents the passage of content from the proximal to the distal stomach&#44; generating vomiting and reflux&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ideal patient selection for vertical gastrectomy flowchart</span><p id="par0345" class="elsevierStylePara elsevierViewall">Vertical gastrectomy produces anatomical alterations in the GOJ that generates alterations in the entire antireflux valve mechanism&#46; This technique promotes the appearance of reflux and the deterioration of all the anti-reflux functions of the GOJ&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Taking into consideration all the above research&#44; we wished to create a flowchart to help us choose which bariatric surgical technique to use in obese patients&#44; mainly deciding between gastric sleeve and bypass&#46; This entire analysis is based on our results of manometry&#44; pHmetry&#44; impedance&#44; oesophageal fluoroscopy and upper endoscopy&#44; with the main interest of identifying patients who have a low probability of developing reflux versus those who have a very high probability of presenting reflux postoperatively&#59; We believe that it is a good way to prevent the patient from having revision surgery for intractable reflux in the future &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0355" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        4 => array:2 [
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          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Anatomy and physiology of the normal gastro-oesophageal junction and in the gastrectomised patient"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Anatomical-functional factors that cause gastro-oesophageal reflux"
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        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Preoperative studies of candidate patients for bariatric surgery"
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        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Pre and postoperative comparative results"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "High resolution oesophageal manometry"
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            1 => array:2 [
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              "titulo" => "Results of pre and postoperative manometry"
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            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Preoperative findings and possible diagnoses"
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          "titulo" => "Twenty-four-hour pHmetry and 24-h oesophageal impedance"
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            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Pre- and postoperative 24-h pH-impedance results of vertical gastrectomy &#40;Table 1&#41;"
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        10 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Importance of oesophageal endoscopy and fluoroscopy in the bariatric patient"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Oesophageal fluoroscopy"
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            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Upper endoscopy"
            ]
          ]
        ]
        11 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "3D-TC volumetrics"
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        12 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Ideal patient selection for vertical gastrectomy flowchart"
        ]
        13 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conflict of interests"
        ]
        14 => array:1 [
          "titulo" => "References"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2022-10-15"
    "fechaAceptado" => "2023-02-13"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1747789"
          "palabras" => array:7 [
            0 => "Motility"
            1 => "Vertical gastrectomy"
            2 => "Sleeve gastrectomy"
            3 => "Gastroesophageal reflux"
            4 => "Manometry"
            5 => "Esophageal impedance"
            6 => "pH metry"
          ]
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          "titulo" => "Palabras clave"
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            0 => "Motilidad"
            1 => "Gastrectom&#237;a vertical"
            2 => "Manga g&#225;strica"
            3 => "Reflujo gastroesof&#225;gico"
            4 => "Manometr&#237;a"
            5 => "Impedancia esof&#225;gica"
            6 => "pHmetr&#237;a esof&#225;gica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Sleeve gastrectomy &#40;SG&#41; is the most common bariatric surgery worldwide and has shown to cause de novo or worsen symptoms of gastroesophageal reflux disease &#40;GERD&#41;&#46; Esophageal motility and physiology studies are mandatory in bariatric and foregut centers&#46; The predisposing factors in post-SG patients are disruption of His angle&#44; resection of gastric fold and gastric fundus&#44; increased gastric pressure&#44; resection of the gastric antrum&#44; cutting of the sling fibers and pyloric spasm&#46; There are symptomatic complications due to sleeve morphology as torsion&#44; incisura angularis stenosis&#44; kinking and dilated fundus&#46; In this article&#44; we present recommendations&#44; surgical technique and patient selection flow diagram for SG and avoid de novo or worsening GERD&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La gastrectom&#237;a vertical &#40;GV&#41; es la cirug&#237;a bari&#225;trica m&#225;s com&#250;n realizada en el mundo y asimismo ha demostrado en el transcurso de estos a&#241;os tener como consecuencia la aparici&#243;n o empeoramiento de s&#237;ntomas de reflujo gastroesof&#225;gico &#40;RGE&#41;&#46; Es imprescindible que en los centros de alta volumen de cirug&#237;a de foregut o intestino anterior se realicen estudios de motilidad y fisiolog&#237;a esof&#225;gico&#46; En el paciente post GV&#44; los factores condicionantes para desarrollar RGE son la desaparici&#243;n del &#225;ngulo de His&#44; del pliegue g&#225;strico antirreflujo y del fondo g&#225;strico&#44; aumento de la presi&#243;n intrag&#225;strica&#44; resecci&#243;n forzada del antro&#44; secci&#243;n de las fibras sling y espasmo pil&#243;rico&#46; A continuaci&#243;n&#44; est&#225;n descritas nuestras recomendaciones&#44; t&#233;cnica quir&#250;rgica y flujograma de selecci&#243;n del paciente ideal para GV y evitar la aparici&#243;n o empeoramiento de RGE&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#8902;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Poggi Machuca L&#44; Romani Pozo D&#44; Guerrero Martinez H&#44; Rojas Reyes R&#44; D&#225;vila Luna A&#44; Cruz Condori D&#44; et al&#46; Posibles aspectos t&#233;cnicos implicados en la aparici&#243;n de RGE tras gastrectom&#237;a vertical&#46; Consideraciones para la t&#233;cnica quir&#250;rgica&#46; Cir Esp&#46; 2023&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.ciresp.2023.02.005">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;ciresp&#46;2023&#46;02&#46;005</span></p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Loss of the valve mechanism as a consequence of the resection of the vertical gastrectomy&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Inversion of the oesophagogastric gradient in vertical gastrectomy&#46;</p>"
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        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Illustration and 3D reconstruction of complications related to the appearance of gastro-oesophageal reflux disease in sleeve gastrectomy&#46; A&#41; Intrathoracic slip&#46; B&#41; Dilation of the gastric fundus and oesophagus&#46; C&#41; Torsion&#46; D&#41; Stenosis&#47;narrowing of the incisura angularis&#46; In all cases slipping of the sleeve is seen&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preop&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">High resolution oesophageal manometry</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LOS pressure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="202312080922489591"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;47&#8201;&#177;&#8201;7&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&#46;42&#8201;&#177;&#8201;8&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Distal oesophageal pressure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><elsevierMultimedia ident="202312080922489592"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">101&#46;51&#8201;&#177;&#8201;49&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">85&#46;48&#8201;&#177;&#8201;47&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Basal gastric pressure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><elsevierMultimedia ident="202312080922489593"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#46;04&#8201;&#177;&#8201;5&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">18&#46;25&#8201;&#177;&#8201;11&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Post ingestion gastric pressure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="202312080922489594"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30&#46;13&#8201;&#177;&#8201;50&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">130&#46;51&#8201;&#177;&#8201;146&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><elsevierMultimedia ident="202312080922489595"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7&#46;60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">49&#46;40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oesophageal dysmotility&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><elsevierMultimedia ident="202312080922489596"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">15&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">35&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
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                  \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Twenty-four hour oesophageal pHmetry</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>DeMeester score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="202312080922489597"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;35&#8201;&#177;&#8201;14&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">44&#46;14&#8201;&#177;&#8201;34&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Twenty-four hour oesophageal impedance</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pathological impedance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="202312080922489598"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#46;80&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Upper endoscopy</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Esophagitis B-C-D-E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="202312080922489599"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Barrett&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="2023120809224895910"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Esophageal fluoroscopy</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Reflux&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="2023120809224895911"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&#46;70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hiatus hernia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="2023120809224895912"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;40&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#46;60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Symptoms</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="2023120809224895913"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"></td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3389022.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Preop&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postop&#46;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reflux&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reflux&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">De novo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Persist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reflux by manometry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="2023120809224895914"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;70&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pathological DeMeester&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="2023120809224895915"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#46;81&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#46;56&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#46;25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pathological impedance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="2023120809224895916"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&#46;30&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#46;80&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;60&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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