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The treatment of ingestion of caustic agents is controversial in the literature. Surgical therapy has been shown to be the best way to proceed, but the surgical methodology has been varied according to the patient's involvement. This study aims to expose the experience of a single institution in relation to the methodology used for the surgical treatment of esophageal stenosis by ingestion of a caustic substance. A retrospective study was carried out in which data were collected from 27 patients who underwent a surgical procedure for the treatment of esophageal stenosis due to alkali ingestion at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo between 2010 and 2019 and their subsequent comparison between the conduits used in the surgical intervention. Fisher's test was performed to compare the groups regarding cervical leakage and post-surgical symptoms with a significance level of 5%. Of the 27 surgical procedures for esophageal stenosis due to alkali ingestion, 12 performed gastric conduits and 15 colon conduits. When comparing the groups regarding cervical leaks, no statistically significant difference was noted (p = 0.7060). There were also no statistically significant differences regarding the presence of symptoms in the postoperative period (p > 0.99...) Surgical intervention by both gastric and colon conduits showed no differences in cervical leakage and symptom control. Surgical intervention by both gastric and colon conduits showed no differences in cervical leakage and symptom control.

Gastro-esophageal reflux disease (GERD) patients have a higher prevalence of airway symptoms, such as chronic cough, wheezing, and hoarseness. The therapeutic management of patients with these symptoms is controversial. Therefore, this study aims to perform a systematic review and meta-analysis evaluating the efficacy of anti-reflux surgery for controlling respiratory symptoms related to GERD. A systematic review and meta-analysis was performed. Extraction of the data concerning proportions of participants who were not free of respiratory symptoms related to GERD (cough, wheezing, hoarseness) or not substantially improved at follow-ups (failure to cure) was performed. Of the 3,424 initially screened articles, 68 studies were included for systematic review and 61 were included for meta-analysis, with a cumulative sample size of 3,869 patients. Of all the included patients, after anti-reflux surgery, the general symptoms improvement was 80% (95% CI 75.2–84%). The numbers needed to harm (NNH) and the numbers needed to treat (NNT) were 15.21 and 1.23, respectively. Of the included patients, 83.4% (95% CI 78.3–87.5%) patients reported improvement in cough symptoms after surgery. For the wheezing symptom, 71.5% (95% CI 62.9–78.8%) reported improvement after surgery. Moreover, surgery presented better results in improving respiratory symptoms than medical therapy (risk difference: −0.46; 95% CI -0.77, −0.16). Physicians should strongly consider surgical anti-reflux procedures for controlling respiratory symptoms in GERD patients after proper patient selection. Anti-reflux surgery has shown high efficacy in improving respiratory symptoms related to GERD, even when compared to medical therapy.

Lung diseases have a strong relationship with gastroesophageal reflux disease (GERD). It has been previously demonstrated that conditions such as tracheal stenosis, asthma and even lung transplantation may worsen with reflux and these patients have few symptoms of GERD. With the COVID-19 pandemic, the number of people who needed mechanical ventilation and tracheostomy increased. Our objective was to demonstrate the prevalence of gastro-oesophageal reflux in patients with tracheostomy and describe its characteristics. Methods Esophageal manometry and 24 h pH-metry was performed in 137 consecutive patients with a tracheostomy already in a chronic phase, independent of symptoms. Inquire on respiratory and digestive symptoms was also carried out at the time of the examination. Prevalence of gastroesophageal reflux was identified in this population and description of the groups with reflux and without it, as well as comparison between them. Results Of the 137 patients, 49 were male, the average age was 40.94 ± 17.3 and the body mass index was 26.3 ± 4.85. The prevalence of gastroesophageal reflux was 45.2%. Baseline characteristics were similar between the groups with and without reflux. In the reflux group, the mean DeMeester score was 36.5 ± 20.8 and the presence of lower sphincter hypotonia was found in only 31% of the patients and was not correlated with reflux between the groups (p = 0.285). Regarding the symptoms, 48% had heartburn symptoms and only 30% had a combination of typical symptoms (heartburn + regurgitation). Conclusion The presence of tracheostomy is related to an increased prevalence of reflux, even without typical symptoms most of the time. The mechanism for this is still unknown, perhaps the altered respiratory dynamics has a role. These patients should be investigated with functional exams if they develop any condition that may be affected by reflux.

Highlights • Heterotopic pancreas is a rare congenital anomaly. • Patients may present with complications such as inflammation and abscess. • The management depends on size, ability to exclude other etiologies and symptoms., Introduction Heterotopic pancreas is a rare congenital anomaly. We report a case of esophageal heterotopic pancreas complicated by recurrent mediastinal abscess and treated by minimally invasive resection. Presentation of case A 31-year-old woman was admitted with a history of recurrent chest pain, dysphagia, and heartburn. CT scan revealed focal confined collection in the lower mediastinum surrounding esophagus. Endoscopic ultrasound revealed a subepithelial lesion. The patient was treated by minimally invasive esophagectomy and made an uneventful postoperative recovery. Discussion The management of subepithelial lesions would depend on their size, ability to exclude other etiologies and their associated symptoms. The patient, in this case, was obviously symptomatic and accurate differentiation from malignant etiologies could not be accurately made. Conclusion Although pancreatic heterotopia is rare, it should be remembered in the differential diagnosis of various gastrointestinal lesions.

Barrett’ s esophagus (BE) is a complication of severe gastroesophageal reflux disease (GERD). The major concern aspect is its association to dysplasia and esophageal adenocarcinoma. The endoscopic treatment of the epithelium, as well as the follow-up (FU) period, should be guided according to the diagnosis and the worst degree of dysplasia found in the last endoscopies. However, we are aware of the great difficulty and variation among pathologists in diagnosing and grading dysplasia in BE. Methods Aim: Review new diagnoses of low- and high-grade dysplasia (LGD and HGD) in BE with specialized pathologists during long-term FU in clinical or surgical treatment for GERD From January 1980 to July 2019, 738 patients with BE were FU (average of 98 months), with routine endoscopic examination each 2 years with multiple biopsies, in patients with BE without dysplasia. 48 patients were diagnosed with any grade of dysplasia on FU endoscopic biopsies. The biopsies were reviewed by specialized pathologists and evaluated epidemiologic data, clinical or surgical treatment for the GERD and about the confirmation, downgrade or upgrade of dysplasia degree. Results 48 patients were reviewed, 32 males. The medium age was 61,9 YO (29 -93). Only 18 patients were in follow-up after surgical treatment for GERD. 9 patients had first diagnosis of in situ Adenocarcinoma, after review 8 were confirmed and treated and 1 were downgrade to HGD. 8 patients had first HGD and after review, 2 were upgrade to Adenocarcinoma, 4 were confirmed as HGD (endoscopic treatment) and 2 downgraded to no dysplasia BE. 31 patients had first LGD. 2 had upgrade to HGD/Adeno, 8 are in FU annually and 21 were downgrade to non dysplastic BE. Conclusion The diagnosis of dysplasia in BE remains a challenge. 23 of 48 (47%) of our patients once marked with any grade of dysplasia, were downgrade after pathological review and FU to non dysplasic BE. These difficulty of appropriate dysplasia degree diagnosis could make some mistakes in BE treatment and surveilance.

Systemic sclerosis (scleroderma) is frequently associated with both gastroesophageal reflux disease (GERD) and simultaneous esophageal dysmotility (ED). Antireflux surgery have to considerate the individual esophageal dysmotility degree of each patient. They need GERD treatment as a priority to help control worsening lung function, in patients developing pulmonary fibrosis or in lung transplantation patients. Another issue is the possibility that fundoplications in this patients can cause esophageal stasis, an event that can also disrupt lung function. Methods 113 patients were referred for surgical treatment of GERD, related with pulmonary impairment. SS patients are the most critical, once the ED may be an obstacle to fundoplication. We divided this patients in three groups regarding the esophageal function. A- Partial fundoplication—without important affection of ED, checked by manometry, confirmed with a complete emptying of esophagus in barium swallow test. B- Laparoscopic gastric bypass for treatment of GERD (RYGBP)—aperistalsis or atonic esophageal body, with normal esophageal empty at barium test. C- Esophagectomy—Atonic esophageal body with important delayed emptying of esophagus in barium swallow test. Results We could follow up 4 patients in group A, 3 patients in group B and 2 patients in group C. Median follow-up was 75, 30 and 18 months for Groups A,B and C respectively. All 3 patients in the RYGB group resolved all the symptoms including heartburn and regurgitation, with a sensitive improve in lung function. Only 1 patients in the fundoplication group reported symptom improvement or resolution. The Patients at Group C have no complain of Dysphagia but referred regurgitation and difficulty feedingtill first year. Conclusion Laparoscopic RYGB as an anti-reflux procedure is safe and may provide an alternative to fundoplication in the treatment of GERD for systemic sclerosis patients with esophageal dysmotility. Both reflux control and dysphagia rates were improved in the RYGBP group compared with fundoplication and esophagectomy.. This finding suggests that RYGBP may be an option for the primary manage- ment of scleroderma-associated gastroesophageal reflux in patients without importnat impairing of esophageal emptying.

Gastro-esophageal reflux disease (GERD) patients have a higher prevalence of airway symptoms, such as chronic cough, wheezing, and hoarseness. The therapeutic management of patients with these symptoms is controversial. Therefore, this study aims to perform a systematic review and meta-analysis evaluating the efficacy of anti-reflux surgery for controlling respiratory symptoms related to GERD. Methods A systematic review and meta-analysis was performed. Extraction of the data concerning proportions of participants who were not free of respiratory symptoms related to GERD (cough, wheezing, hoarseness) or not substantially improved at follow-ups (failure to cure) was performed. Results Of the screened articles, 61 were included for meta-analysis, with a cumulative sample size of 3,869 patients. Of all the included patients, after anti-reflux surgery, the general symptoms improvement was 80% (95% CI 75.2–84%). The numbers needed to harm (NNH) and the numbers needed to treat (NNT) were 15.21 and 1.23, respectively. Of the included patients, 83.4% (95% CI 78.3–87.5%) patients reported improvement in cough symptoms after surgery. For the wheezing symptom, 71.5% (95% CI 62.9–78.8%) reported improvement after surgery. Moreover, surgery presented better results in improving respiratory symptoms than medical therapy (risk difference: -0.46; 95% CI -0.77, −0.16). Conclusion Physicians should strongly consider surgical anti-reflux procedures for controlling respiratory symptoms in GERD patients after proper patient selection. Anti-reflux surgery has shown high efficacy in improving respiratory symptoms related to GERD, even when compared to medical therapy.

Corrosive ingestion is a significant challenge for healthcare support. Limited data is available regarding the best treatment, and there is still a lack of consensus about the optimal surgical approach and its outcomes. This study aims to show a single-institution experience of surgical treatment of esophageal stenosis due to corrosive substance ingestion and review the current literature. Methods A retrospective review, including demographics, psychiatric profile, surgical procedures, and outcomes, is described. A systematic review of the literature was performed in PubMed. Results In total, 27 surgical procedures for esophageal stenosis due to corrosive substances ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. The incidence rate of cancer in patients with corrosive esophageal stenosis is 701.7–874.1 per 1,000,000 person-years, and the cancer latency between corrosion ingestion to carcinoma is 10–58 years. Esophagectomy and esophageal bypass were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded. Conclusion The surgical intervention either by esophagectomy or esophageal bypass seems to show a high success rate. However, the outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

Gastric tube fistula is a rare event, but very feared, as it invariably progresses with associated mediastinitis and can be fatal. We present a case in which this fistula occurred together with all diagnostic investigation of etiology and treatment, in addition to a brief review of this complication. Methods A 45-year-old patient underwent minimaly invasive esophagectomy due to end-stage achalasia. After 6 days, she presented acute multivisceral migration to the chest and needed to reintervation by open surgery and hiatoplasty. The patient evolved with outflow of bile through the chest drain. Conservative treatment was attempted. However, after 4 days, she underwent thoracotomy and suture of the orifice, and a nasal tube was maintained to drain the gastric tube. There was no suture dehiscence and in control a seriogram evidenced pyloric stenosis. After 2 months, she was submitted to GPOEM with improvement of gastric emptying and normal return to feeding. Results The risk factors for gastric tube fistula are the same as those for cervical or intrathoracic anastomosis fistula after esophagectomy. Some authors attribute the vascularization of the stomach and malnutrition. However, as shown in this case, impairment of gastric emptying is an important factor to increased pressure and consequent fistula. The patient experienced acute migration through the hiatus, which obstructed the tube for a few hours. And after the defect was corrected, he maintained an increased pressure due to pyloric achalasia, which was initially treated by depressurizing the tube by nasogastric tube and then GPOEM. Conclusion Gastric tube fistula can be avoided when we can establish a good gastric tube emptying condition.

Background Corrosive ingestion is a significant challenge for healthcare systems. Limited data are available regarding the best treatments, and there remains a lack of consensus about the optimal surgical approach and its outcomes. This study aims to review the current literature and show a single institution's experience regarding the surgical treatment of esophageal stenosis due to corrosive substance ingestion. Methods A retrospective review that accounted for demographics, psychiatric profiles, surgical procedures, and outcomes was performed. A systematic review of the literature was performed using PubMed. Results In total, 27 surgical procedures for esophageal stenosis due to corrosive substance ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. Esophagectomies and esophageal bypasses were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded. Conclusion Surgical intervention either by esophagectomy or esophageal bypass results in durable relief from dysphagia. However, successful clinical outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

Objective: to evaluate esophageal dysmotility (ED) and the extent of Barrett’s esophagus (BE) before and after laparoscopic Nissen fundoplication (LNF) in patients previously diagnosed with BE and ED. Methods: twenty-two patients with BE diagnosed by upper gastrointestinal (GI) endoscopy with biopsies and ED diagnosed by conventional esophageal manometry (CEM) were submitted to a LNF, and followed up with clinical evaluations, upper GI endoscopy with biopsies and CEM, for a minimum of 12 months after the surgical procedure. Results : sixteen patients were male (72.7%) and six were females (27.3%). The mean age was 55.14 (± 15.52) years old. and the mean postoperative follow-up was 26.2 months. The upper GI endoscopy showed that the mean length of BE was 4.09 cm preoperatively and 3.91cm postoperatively (p=0.042). The evaluation of esophageal dysmotility through conventional manometry showed that: the preoperative median of the lower esophageal sphincter resting pressure (LESRP) was 9.15 mmHg and 13.2 mmHg postoperatively (p=0.006). The preoperative median of the esophageal contraction amplitude was 47.85 mmHg, and 57.50 mmHg postoperatively (p=0.408). Preoperative evaluation of esophageal peristalsis showed that 13.6% of the sample presented diffuse esophageal spasm and 9.1% ineffective esophageal motility. In the postoperative, 4.5% of patients had diffuse esophageal spasm, 13.6% of aperistalsis and 22.7% of ineffective motor activity (p=0.133). Conclusion: LNF decreased the BE extension, increased the LES resting pressure, and increased the amplitude of the distal esophageal contraction; however, it was unable to improve ED.

Achalasia of the cardia is associated with an increased risk of esophageal carcinoma. The real burden of achalasia at the malignancy genesis is still a controversial issue. Therefore, there are no generally accepted recommendations on follow-up evaluation for achalasia patients. This study aims to estimate the risk of esophageal adenocarcinoma and squamous cell carcinoma in achalasia patients. We searched for association between carcinoma and esophageal achalasia in databases up to January 2017 to perform a systematic review and meta-analysis. A total of 1,046 studies were identified from search strategy, of which 40 were selected for meta-analysis. A cumulative number of 11,978 esophageal achalasia patients were evaluated. The incidence of squamous cell carcinoma was 312.4 (StDev 429.16) cases per 100,000 patient-years at risk. The incidence of adenocarcinoma was 21.23 (StDev 31.6) cases per 100,000 patient-years at risk. The prevalence for esophageal carcinoma was 28 carcinoma cases in 1,000 esophageal achalasia patients (CI 95% 2, 39). The prevalence for squamous cell carcinoma was 26 cases in 1,000 achalasia patients (CI 95% 18, 39) and for adenocarcinoma was 4 cases in 1,000 achalasia patients (CI 95% 3, 6).The absolute risk increase for squamous cell carcinoma was 308.1 and for adenocarcinoma was 18.03 cases per 100,000 patients per year. To the best of our knowledge, this is the first meta-analysis estimating the burden of achalasia as an esophageal cancer risk factor. The high increased risk rate for cancer in achalasia patients points to a strict endoscopic surveillance for these patients. Also, the increased risk for developing adenocarcinoma in achalasia patients suggests fundoplication after myotomy, to avoid esophageal reflux and Barret esophagus, a known risk factor for adenocarcinoma.

Dysplasia and esophageal adenocarcinoma may arise in patients with Barrett's esophagus after fundoplication esophageal pH monitoring showing no acid in esophagus. This suggests the need to develop methodology to evaluate the occurrence of ultra-distal reflux (1cm above the LES). The objective of the study was to compare acid exposition in three different levels: 5cm above the upper border of the LES, 1cm above the LES and in the intrasphincteric region. Eleven patients with Barrett's esophagus after Nissen fundoplication with no clinical, endoscopic and radiologic evidence of reflux were selected. Four-channel pH monitoring took place: channel A, 5cm above the upper border of the LES; channel B, 1cm above the LES; channel C, intrasphincteric; channel D, intragastric. The results of channels A, B and C were compared. There was significant increase in number of reflux episodes and a higher fraction of time with pH

BACKGROUND: Association between esophageal achalasia/ gastroesophageal reflux disease (GERD) and cholelithiasis is not clear. Epidemiological data are controversial due to different methodologies applied, the regional differences and the number of patients involved. Results of concomitant cholecistectomy associated to surgical treatment of both diseases regarding safety is poorly understood. AIM: To analyze the prevalence of cholelithiasis in patients with esophageal achalasia and gastroesophageal reflux submitted to cardiomyotomy or fundoplication. Also, to evaluate the safety of concomitant cholecistectomy. METHODS: Retrospective analysis of 1410 patients operated from 2000 to 2013. They were divided into two groups: patients with GERD submitted to laparocopic hiatoplasty plus Nissen fundoplication and patients with esophageal achalasia to laparoscopic cardiomyotomy plus partial fundoplication. It was collected epidemiological data, specific diagnosis and subgroups, the presence or absence of gallstones, surgical procedure, operative and clinical complications and mortality. All groups/subgroups were compared. RESULTS: From 1,229 patients with GERD or esophageal achalasia, submitted to laparoscopic cardiomyotomy or fundoplication, 138 (11.43%) had cholelitiasis, occurring more in females (2.38:1) with mean age of 50,27 years old. In 604 patients with GERD, 79 (13,08%) had cholelitiasis. Lower prevalence occurred in Barrett's esophagus patients 7/105 (6.67%) (p=0.037). In 625 with esophageal achalasia, 59 (9.44%) had cholelitiasis, with no difference between chagasic and idiopathic forms (p=0.677). Complications of patients with or without cholecystectomy were similar in fundoplication and cardiomyotomy (p=0.78 and p=1.00).There was no mortality or complications related to cholecystectomy in this series. CONCLUSIONS: Prevalence of cholelithiasis was higher in patients submitted to fundoplication (GERD). Patients with chagasic or idiopatic forms of achalasia had the same prevalence of cholelithiasis. Gallstones occurred more in GERD patients without Barrett's esophagus. Simultaneous laparoscopic cholecystectomy was proved safe. RACIONAL: São controversas as relações entre megaesôfago e doença do refluxo gastroesofágico (DRGE) com colelitíase, especialmente a forma mais adequada de conduzir pacientes com ambas. Dados epidemiológicos são díspares devido às diversas metodologias aplicadas, às diferenças regionais e à quantidade de pacientes envolvidos. OBJETIVO: Estudar a prevalência de colelitíase em pacientes submetidos às operações de refluxo gastroesofágico e megaesôfago (chagásicos ou não) e a segurança da colecistectomia estar associada. MÉTODO: Análise retrospectiva de 1410 pacientes operados entre 2000 e 2013. Eles foram divididos em dois grupos: os com DRGE e operados por hiatoplastia/fundoplicatura a Nissen laparoscópicas e os com acalásia por cardiomiotomia e fundoplicatura parcial laparoscópicas. Foram coletados dados epidemiológicos, diagnóstico, a presença ou não de litiase biliar, tratamento cirúrgico efetuado, complicações clínicas ou cirúrgicas e mortalidade. Todos os grupos e subgrupos foram comparados. RESULTADOS: Foram estudados 1229 pacientes portadores de megaesôfago e/ou DRGE, operados por fundoplicatura com hiatoplastia, nos casos de DRGE, e cardiomiectomia com fundoplicatura, nos casos de megaesôfago, no período de 2000 a 2013, verificando-se presença de colelítiase ou colecistectomia prévia. A colelítiase ocorreu mais no sexo feminino (2,38:1) e na faixa etária entre os 50 e 70 anos. A prevalência global foi de 11,43%; 13,08% na DRGE, menor nos portadores de esôfago de Barrett (6,67%) sendo a diferença significativa (p=0,037); e 9,44% no megaesôfago, não havendo diferença significativa entre os chagásicos e os idiopáticos (p=0,677). Não houve mortalidade ou complicações relacionadas à colecistectomia nesta série. CONCLUSÕES: A prevalência de colelitíase é maior nos pacientes com DRGE do que nos com megaesôfago. Não há diferenças na prevalência de colelitíase nos pacientes com megaesôfago chagásico e não chagásico. É mais frequente litíase biliar nos pacientes sem esôfago de Barrett em relação portadores. A colecistectomia videolaparoscópica simultânea se mostrou-se segura.

Woman with 53-years-old diagnosed with congenital esophageal atresia, underwent to several surgical procedures in childhood, the latest was a cervical retrosternal esophagocoloplasty at 11 years old. After 42 years she was evolved with cervical dysphagia, and an initial diagnosis of stenosis of the esophagocolic anastomosis was performed, treated with endoscopic dilation without improvement. Later, biopsies were performed in the area of stenosis in proximal colonic segment (Figure 1) and polypectomy of sessile polyp of 10 mm, 5 cm distal to the stenosis (Figure 2). The pathological assessment showed tubular-villous intramucosal adenocarcinoma at the resected polyp and the area of stenosis was a invasive adenocarcinoma in colonic mucosa. Colonoscopy of remained colon was normal. Staging performed with CT scan showed an eccentric wall thickening of proximal colon transposed with luminal reduction target of left innominate vein; densification of mediastinal fat plane adjacent and regional lymph nodes up to 1.9 cm.

RACIONAL: Displasia e adenocarcinoma esofágico surge em pacientes com esôfago de Barrett submetidos a tratamento cirúrgico (fundoplicatura) com pHmetria esofágica sem evidência de acidez, o que sugere existir refluxo distal ao cateter de pHmetria convencional. OBJETIVO: Desenvolver metodologia para avaliar refluxo ultra-distal (1 cm acima da borda superior de esfíncter inferior do esôfago). MÉTODO: Foram selecionados 11 pacientes com esôfago de Barrett previamente submetidos à fundoplicatura à Nissen, sem sintomas de refluxo, com endoscopia e estudo contrastado de esôfago sem sinais de recidiva. Foi realizada manometria esofágica para avaliar a localização e a extensão do esfíncter esofágico inferior (EIE). Realizou-se então pHmetria esofágica com quatro canais: canal A a 5 cm acima da borda superior do EIE; canal B a 1 cm acima; canal C intraesfincteriano; canal D intragástrico. Avaliou-se o escore de DeMeester no canal A. Comparou-se o número de episódios de refluxo ácido, o número de episódios de refluxo prolongado e a fração de tempo com pH

INTRODUÇÃO: Há relatos de ocorrência de displasia e adenocarcinoma esofágico em pacientes com esôfago de Barrett submetidos a tratamento cirúrgico com fundoplicatura bem sucedido, comprovado pela realização de pHmetria esofágica prolongada sem evidência de acidez em esôfago, o que sugere que pode ocorrer refluxo distal ao cateter de pHmetria, não detectado por esse método. Essa hipótese motivou o desenvolvimento de metodologia para avaliar a presença de refluxo 1cm acima da borda superior do esfíncter inferior do esôfago (EIE). OBJETIVO: Comparar a exposição ácida em 3 diferentes níveis: 5cm acima da borda superior EIE, 1cm acima da borda superior do EIE e em região intra-esfincteriana. CASUÍSTICA E MÉTODO: 11 pacientes com esôfago de Barrett, submetidos à fundoplicatura à Nissen para tratamento do refluxo gastroesofágico, sem sintomas de refluxo e com endoscopia e estudo radiográfico contrastado de esôfago sem sinais de recidiva, foram selecionados. Foram submetidos à manometria esofágica para avaliar a localização e a extensão do EIE. Realizou-se então pHmetria esofágica com 4 canais: canal A: 5cm acima da borda superior do EIE; canal B: 1cm acima; canal C: intraesfincteriano, na porção média entre a borda superior e inferior do EIE; canal D: em posição intragástrica. Avaliou-se o escore de DeMeester no canal A, para detectar refluxo patológico. Comparou-se o número de episódios de refluxo ácido, o número de episódios de refluxo prolongado e a fração de tempo com pH < 4,0 nos canais A e B. Comparou-se a fração de tempo de pH < 4,0 nos canais B e C. A fração de tempo com pH < 4,0 no canal D foi usada como parâmetro para não migração proximal do cateter. RESULTADOS: Houve maior número de episódios de refluxo e maior fração de tempo com pH < 4,0 no canal B do que no canal A, com significância estatística, sendo a mediana do tempo de exposição ácida menor que 1,5%. Por outro lado, houve menor fração de tempo com pH < 4,0 no canal B do que no canal C, sugerindo competência do esfíncter em conter o refluxo gastroesofágico. Um paciente apresentou refluxo patológico no canal A, apesar de não ter evidência até então de refluxo. Dois casos de adenocarcinoma esofágico foram diagnosticados nos pacientes do grupo estudado. CONCLUSÕES: A região 1cm acima da borda superior do EIE está mais exposta a acidez do que a região 5cm acima da borda superior do EIE, embora a exposição ácida seja em níveis bem reduzidos. A região 1cm acima da borda superior do EIE está menos exposta a acidez do que a região intraesfincteriana, demonstrando eficácia da fundoplicatura em conter o refluxo nesse nível INTRODUCTION: There are reports of dysplasia and esophageal adenocarcinoma occurring in patients with Barrett´s esophagus after successful surgical treatment with fundoplication, confirmed with prolonged esophageal pH monitoring showing no acid in esophagus, suggesting that there might be reflux distal to the catheter, not detected by this method. This hypothesis led to the development of methodology to evaluate the occurrence of reflux 1cm above the upper border of the lower esophageal sphincter (LES). OBJECTIVE: Compare the acid exposition in three different levels: 5cm above the upper border of the LES, 1cm above the upper border of the LES and in the intrasphincteric region. CASUISTIC AND METHODS: 11 patients with Barrett´s esophagus, submitted to Nissen fundoplication as treatment for gastroesophageal reflux, with no symptoms of reflux and with endoscopy and contrasted esophageal radiograph, were selected. The patients underwent esophageal manometry to evaluate the location and extension of the LES. After that, they underwent a 4-channel pH monitoring: channel A: 5cm above the upper border of the LES; channel B: 1cm above the upper border of the LES; channel C: intrasphincteric, in the mid-portion between the upper and lower border of the LES; channel D: intragastric. The DeMeester score was assessed in channel A, to detect pathologic reflux. The number of reflux episodes, the number of prolonged episodes and the fraction of time with pH < 4,0 were compared in channels A and B. The fraction of time with pH < 4,0 was compared in channels B and C. The fraction of time with pH < 4,0 in channel D was used as a parameter to ensure no proximal migration of the catheter. RESULTS: There were more episodes of reflux and a higher fraction of time with pH < 4,0 in channel B than in channel A, with statistical significance. On the other hand, there was lesser fraction of time with pH < 4,0 in channel B than in channel C, suggesting competence of the sphincter in preventing gastroesophageal reflux. One patient presented pathologic reflux in channel A, besides no other evidence of that. Two cases of esophageal adenocarcinoma were diagnosed in the studied patients. CONCLUSIONS: the region 1cm above the upper border of the LES is more exposed to acid than the region 5cm above the upper border of the LES, although this exposure occurred in reduced levels. The region 1cm above the upper border of the LES is less exposed to acid than the intrasphincteric region