Valter Felix, MD PhD
Professor
FMUSP/Nucleus of General and Specialized Surgery
São Paulo, Brazil
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Ioshiaki Yogi
Doctor
Nucleus of General and Specialized Surgery
São Paulo, Brazil
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Karen Terra
Student
Nucleus of General and Specialized Surgery
São Paulo, Brazil
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Nayara Santos
Student
Nucleus of General and Specialized Surgery
São Paulo, Brazil
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Rafael Rodrigues
Student
Nucleus of General and Specialized Surgery
São Paulo, Brazil
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Title: Severe hemorrhagic esophagitis in chronic renal failure
Introduction: Gastroesophageal reflux disease (GERD) tends to be mild when associated to chronic renal failure (CRF), but some cases can assume extreme gravity
Hypothesis: We can expect good results of surgical treatment of severe GERD in hemodialysis (HD) patients.
Methods: This study included three stable CRF male patients (mean age 64y (range 61-71), due to diabetic nephropathy, who underwent HD twice a week, with mean cardiothoracic ratio (CTR) 54.2 (range: 39.5-63.8). mean systolic BP 158.5mmHg (range: 120-230) and mean diastolic BP 79.4mmHg (range: 58-112). They presented mean BUN 110mg/dL (range: 105-240) and mean creatinine 10.4 mg/dL (range: 6.8-14.6) and complained of heartburn. They had a first digestive hemorrhagic episode and were submitted to esophagogastroscopy, showing a severe erosive esophagitis; Helicobacter pylori has not been identified in any patient. At this time, his serum gastrin dosage reached 200 picograms/mL on average (190-210) (normal 0-180). They were admitted to the intensive care unit and recovered from a hypovolemic state with the administration of crystalloids and packed red cells, 1-3 units (Hb reached 6 g/dL on average) (5.6-6.4). Hemorrhagic erosions were controlled with PPI (80 mg once a day). Before six months (range: 2-5) they relapsed bleeding despite being maintained on PPI therapy (40 mg once a day), requiring new admission to intensive care unit and new packed red cells transfusion. Then we decided to submit them to surgical treatment, after being stabilized, performing videolaparoscopic esophagogastric fundoplication, with a preoperative dialysis performed within 24 hours before surgery. Goals of anesthetic management included maintaining normotension, isovolemia and good cardiac output.
Results: There was no mortality and no significant change from their usual clinical conditions. The complaint of heartburn was abolished and an endoscopy about three months later showed a complete regression of esophageal erosions.
Conclusions: GERD can be severe in CRF patients due to diabetic nephropathy and hypergastrinemia. Surgical treatment can be performed to contain intense hemorrhagic conditions in these patients and the prognosis is good with adequate perioperative and anesthetic care.ic vasospasm.