[Severe peptic esophagitis. Classification and therapeutic indications]

The place of conservative procedures and resection in the surgical treatment of complicated peptic oesophagitis is still controversial. In order, to propose decisional criteria for the therapeutic choice, we reviewed 102 patients operated on from 1979 to 1987, with strictures (n = 61), Barrett's oesophagus (n = 27) or previous surgical treatment (Heller, resection, repeated fundoplications, n = 33). Patients were classified into 3 grades: a) The first group consisted of low, short, dilatable and reversible strictures without Barrett's, oesophagus, treated by dilatations and fundoplication (n = 36). b) The second group consisted of Barrett's oesophagus, peptic oesophagitis after surgery and acquired short oesophagus with or without dilatable stricture, treated by Roux-en-Y duodenal diversion (n = 60) with dilatation in case of stricture. Collis-Nissen's procedure could be used for such cases, but conservative procedures via a thoracic approach has no indications for us. c) Group 3 was treated by resection (colonic interposition when possible) and consisted of peptic ulcers, extensive sinuous and poorly dilatable strictures or suspected cancer (n = 9). Decisional factors were: stricture (size, height, level, response to preoperative dilatation), ulcer (hemorrhagic or suspicion of carcinoma), acquired short oesophagus, Barrett's oesophagus, previous surgical treatment. Intensity or type of reflux was not decisional. With this policy, only 3 recurrences occurred, all after reposition for stricture, successfully treated by resection or duodenal diversion. The low recurrence rate confirms the decisional value of the chosen criteria.