Manejo quirúrgico del reflujo gastroesofágico en la Universidad Nacional de Colombia, sede Bogotá
Palabras clave:
reflujo gastroesofágico, esofagitis, monitorización del pH esofágico, fundoplicación, laparoscopíaResumen
La enfermedad por reflujo gastroesofágico en nuestro medio es un problema que aún sigue siendo manejado médicamente y la ayuda quirúrgica no está siendo fomentada, principalmente por los gastroenterólogos clínicos. Se ofrece únicamente el manejo médico y se torna un problema crónico que podría solucionarse, evitando la administración permanente de medicamentos. Con esta revisión se busca indicar una manera eficaz para detectar al paciente con reflujo gastroesofágico, que puede beneficiarse de la cirugía para controlar su enfermedad
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Referencias bibliográficas
1. Molano J, Piñeros S, López C. Dispepsia y reflujo gastroeso- fágico en adolescentes escolarizados. Revista Colombiana de Gastroenterología. 2008;23:46-56.
2. Karhilas PJ, Hogan W. Gastroesophageal reflux disease. In: Sleisenger M, Fordtran J, editors. Gastrointestinal disease: Pathophysiology, diagnosis and management. Philadelphia: Saunders Company; 1993. p. 378-401.
3. Arango L, Ángel A. Reflujo gastroesofágico: conceptos ac- tuales, evaluación y presentación de 50 enfermos intervenidos laparoscópicamente con seguimiento a 6 meses. Rev Colomb Cir. 1997;12:251-63.
4. Flook N, Jones R, Vakil N. Approach to gastroesophageal reflux disease in primary care. Can Fam Physician. 2008;54:701-5.
5. Flook N, Unge P, Agreus L, Karlson BW, Nilson G. Approach to managing undiagnosed chest pain. Could GERD be the caused? Can Fam Physycian. 2007;53:261-6.
6. Richter JE, Bradley LA, Castell DO. Esophageal chest pain: Current controversies in pathogenesis, diagnosis and therapy. Ann Intern Med. 1989;110:66-8.
https://doi.org/10.7326/0003-4819-110-1-66
7. Harding SM, Richter JE, Guzzo MR, Schan CA, Alexander RW, Bradley LA, et al. Asthma and gastroesophageal reflux: Acid suppression therapy improves asthma outcome. Am J Med. 1996;100:395-405.
https://doi.org/10.1016/S0002-9343(97)89514-9
8. De Caesteker J. ABC of the upper gastrointestinal tract. Oe- sophagus: Heartburn. BMJ. 2001;323:736-9.
https://doi.org/10.1136/bmj.323.7315.736
9. American Society for Gastrointestinal Endoscopy (ASGE). The role of endoscopy in the management of GERD. Guidelines for clinical application. Gastrointest Endosc. 1999;49:834-5.
https://doi.org/10.1016/S0016-5107(99)70313-5
10. Talwar V, De Caesteker J. Hiatus hernia and gastro-oesophageal reflux disease. Medicine. 2007;35:194-8.
https://doi.org/10.1016/j.mpmed.2007.01.011
11. Fass R, Fennerty B, Vakil N. Nonerosive reflux disease -current conceps and dilemas. Am J Gastroenterol. 2001;96:303-14.
https://doi.org/10.1111/j.1572-0241.2001.03511.x
12. Patti MG. Advances in diagnostic testing for gastroesophageal reflux disease. World J Gastroenterol. 2010;16:3750-6.
https://doi.org/10.3748/wjg.v16.i30.3750
13. Fiocca R, Mastracci L, Ridell R, Takubo K, Vieth M, Yerian L, et al. Development of consensus guidelines for the histologic recognition of microscopic esophagitis in patients with gas- troesophageal reflux disesase: The Esohisto Project. . Human Pathology. 2010;41:223-31.
https://doi.org/10.1016/j.humpath.2009.07.016
14. Hirano I, Richter JE, Practice Parameters Committee of the American College of Gastroenterology. ACG practice guidelines: Esophageal reflux disease. Am J Gastroenterol. 2007;102:668-85.
https://doi.org/10.1111/j.1572-0241.2006.00936.x
15. Katz PO. Review article: Intragastric and oesophageal pH moni- toring in patients with gastro-esophageal reflux disease. Aliment Pharmacol Ther. 2006;23(Suppl.1):3-11.
https://doi.org/10.1111/j.1365-2036.2006.02801.x
16. DeVault KR, Caastell DO. Update guidelines for the diagnosis and treatment of gastroesophaegeal reflux disease. Am J Gas- troenterol. 2005;100:190-200.
https://doi.org/10.1111/j.1572-0241.2005.41217.x
17. Tutuian R, Castell DO. Review article: Complete gastro- oesophageal reflux monitoring -combined pH and impedance. Aliment Pharmacol Ther. 2006;24(Suppl.2):27-37.
https://doi.org/10.1111/j.1365-2036.2006.03039.x
18. Sifrim D, Castell D, Dent J, Kharilas PJ. Gastro-oesophageal reflux monitoring: Review and consensus report on detec- tion and definitions of acid, non-acid, and gas reflux. Gut. 2004;53:1024-31.
https://doi.org/10.1136/gut.2003.033290
19. Galli J, Volante M, Parrilla C, Rigante M, Valenza V. Oropharyn- goesophageal scintigraphy in the diagnostic algorithm of laryn- gopharyngeal reflux disease: A useful exam? J Otolaryngol Head Neck Surg. 2005;132:717-21.
https://doi.org/10.1016/j.otohns.2005.01.043
20. Richter JE. Diagnostic test for gastroesophageal reflux disease. Am J Med Sci. 2003;326:300-8.
https://doi.org/10.1097/00000441-200311000-00006
21. Hani A. Pruebas diagnósticas en enfermedad por reflujo gas- troesofágico (ERGE). Revista Colombiana de Gastroenterología. 2009;24210-22.
22. Ozin Y, Dagli U, Kuran S, Sahin B. Manometric findings in patients with isolated distal gastroesophageal reflux. World J Gastroenterol. 2009;15:5461-4.
https://doi.org/10.3748/wjg.15.5461
23. Frazzoni M, De Micheli E, Savarino V. Different patterns of oe- sophageal acid exposure distinguish complicated reflux disease from either erosive reflux oesophagitis or non-erosive reflux disease. Aliment Pharmacol Ther. 2003;18:1091-8.
https://doi.org/10.1046/j.1365-2036.2003.01768.x
24. Lemme EM, Abrahao-Junior LJ, Manhaes Y, Shechter R, Carvalho BB, Alvariz A. Ineffective esophageal motility in gastroesophageal erosive reflux disease and in nonerosive reflux disease: Are they different? J Clin Gastroenterol. 2005;39:224-7.
https://doi.org/10.1097/01.mcg.0000152782.22266.7c
25. Martinek J, Benes M, Hucl T, Drastich P, Stirand P, Spicak J. Non-erosive and erosive gastroesophageal reflux diseases: No difference with regard to reflux pattern and motility abnorma- lities. Scand J Gastroenterol. 2008;43:794-800.
https://doi.org/10.1080/00365520801908928
26. Ho SC, Chang CS, Wu CY, Chen GH. Ineffective esophageal motility is a primary motility disorder in gastroesophageal reflux disease. Dig Dis Sci. 2002;47:652-6.
https://doi.org/10.1023/A:1017992808762
27. Nagpal AP, Soni H, Haribhakti S. Is oesophageal manometry a must before laparoscopic fundoplication? Analysis of 46 consecutive patients treated without preoperative manometry. J Minim Access Surg. 2010;6:66-9.
https://doi.org/10.4103/0972-9941.68581
28. Haack HG, Hansen RD, Malcolm A, Kellow JE. Ineffective oesophageal motility: Manometric subsets exhibit different symptom profiles. World J Gastroenterol. 2008;14:3719-24.
https://doi.org/10.3748/wjg.14.3719
29. Patiño JF. Reflujo gastroesofágico. En: Patiño JF. Lecciones de cirugía, Primera edición, Bogotá; Editorial Médica Panameri- cana; 2000. p. 421-32.
30. Camilleri M, Thompson DG, Malagelada JR. Functional dyspep- sia. Symptoms and underlying mechanism. J Clin Gastroenterol. 1986;8:424-9.
https://doi.org/10.1097/00004836-198608000-00008
31. Greydanus MP, Vassallo M, Camilleri M, Nelson DK, Hanson RB, Thomforde GM. Neurohormonal factors in functional dyspepsia: Insights on pathophysiological mechanisms. Gas- troenterology. 1991;100:1311-8.
https://doi.org/10.1016/0016-5085(91)70018-S
32. Rodríguez A, Zuleta J. De la fisiología del vaciamiento gástrico al entendimiento de la gastroparesia. Rev Col Gastroenterol. 2010;25:219-25.
33. Abell TL, Bernstein RK, Cutts T, Farrugia G, Forster J, Hasler WL, et al. Treatment of gastroparesis: A multidisciplinary clinical review. Neurogastroenterol Motil. 2006;18:263-83.
https://doi.org/10.1111/j.1365-2982.2006.00760.x
34. Koskenpato J, Korppi-Tommola T, Kareima K, Farkkila M. Long term follow up study of gastric emptying and Helicobacter pylori eradication among patients with functional dyspepsia. Dig Dis Sci. 2000;45:1763-8.
https://doi.org/10.1023/A:1005582211673
35. DeVault KR, Castell DO. Guidelines for the diagnosis and treatment of gastroesophagal reflux disease. Arch Intern Med. 1995;155:2165-73.
https://doi.org/10.1001/archinte.1995.00430200044008
36. Kahrilas PJ, Quigley EMM. Clinical esophageal pH recording: A technical review for practice guideline development. Gas- troenterology. 1996;110:1982-96.
https://doi.org/10.1053/gast.1996.1101982
37. Bansal A, Wani S, Rastogi A. Impact of measurement of esopha- geal acid exposure close to the gastroesophageal junction on diagnostic accuracy and event-symptom correlation: A prospecti- ve study using wireless dual pH monitoring. Am J Gastroenterol. 2009;104:2918-25.
https://doi.org/10.1038/ajg.2009.506
38. Shay S, Tutuian R, Sifrim D, Vela M, Wise J, Blaji N, et al. Twenty-four hours ambulatory simultaneous impedance and pH monitoring: A multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol. 2004;99:1037-43.
https://doi.org/10.1111/j.1572-0241.2004.04172.x
39. Sifrim D, Castell D, Dent J, Kahrilas PJ. Gastro-oesophageal reflux monitoring: Review and consensus report on detec- tion and definitions of acid, nonacid, and gas reflux. Gut. 2004;53:1024-31.
https://doi.org/10.1136/gut.2003.033290
40. Pandolfino JE, Richter JE, Ours T, Guardino JM, Chapman J, Kahrilas PJ. Ambulatory esophageal pH monitoring using a wireless system . Am J Gastroenterol. 2003;98:740-9.
https://doi.org/10.1111/j.1572-0241.2003.07398.x
41. Mekapati J, Knight LC , Maurer AH, Fisher RS, Parkman HP. Trans-sphincteric pH profile at the gastroesophageal junction. Clin Gastroenterol Hepatol. 2008;6:630-4.
https://doi.org/10.1016/j.cgh.2008.01.003
42. Pandolfino JE, Zhang Q , Ghosh SK, Post J, Kwiatek M, Kahrilas PJ. Acidity surrounding the squamocolumnar junction in GERD patients: 'Acid pocket' versus 'acid film'. Am J Gastroenterol. 2007;102:2633-41.
https://doi.org/10.1111/j.1572-0241.2007.01488.x
43. Wenner J, Hall M , Hoglund P, Johansson J, Johnsson F, Oberg S. Wireless pH recording immediately above the squamocolumnar junction improves the diagnostic performance of esophageal pH studies. Am J Gastroenterol. 2008;103:2977-85.
https://doi.org/10.1111/j.1572-0241.2008.02174.x
44. Bredenoord AJ, Weusten BL, Timmer R, Conchillo JM, Smout AJ. Addition of esophageal impedance monitoring to pH mo- nitoring increases the yield of symptom association analysis in patients off PPI therapy. Am J Gastroenterol. 2006;101:453-9.
https://doi.org/10.1111/j.1572-0241.2006.00427.x
45. Wenner J, Johnsson F, Johansson J, Oberg S. Acid reflux im- mediately above the squamocolumnar junction and in the distal esophagus: Simultaneous pH monitoring using the wireless capsule pH system. Am J Gastroenterol. 2006;101:1734-41.
https://doi.org/10.1111/j.1572-0241.2006.00653.x
46. Sgromo B, Irvine LA, Cuschieri A. Long-term comparative outcome between laparoscopic total Nissen and Toupet fundo- plication: Symptomatic relief, patient satisfaction and quality of life. Surg Endosc. 2008;22:1048-53.
https://doi.org/10.1007/s00464-007-9671-4
2. Karhilas PJ, Hogan W. Gastroesophageal reflux disease. In: Sleisenger M, Fordtran J, editors. Gastrointestinal disease: Pathophysiology, diagnosis and management. Philadelphia: Saunders Company; 1993. p. 378-401.
3. Arango L, Ángel A. Reflujo gastroesofágico: conceptos ac- tuales, evaluación y presentación de 50 enfermos intervenidos laparoscópicamente con seguimiento a 6 meses. Rev Colomb Cir. 1997;12:251-63.
4. Flook N, Jones R, Vakil N. Approach to gastroesophageal reflux disease in primary care. Can Fam Physician. 2008;54:701-5.
5. Flook N, Unge P, Agreus L, Karlson BW, Nilson G. Approach to managing undiagnosed chest pain. Could GERD be the caused? Can Fam Physycian. 2007;53:261-6.
6. Richter JE, Bradley LA, Castell DO. Esophageal chest pain: Current controversies in pathogenesis, diagnosis and therapy. Ann Intern Med. 1989;110:66-8.
https://doi.org/10.7326/0003-4819-110-1-66
7. Harding SM, Richter JE, Guzzo MR, Schan CA, Alexander RW, Bradley LA, et al. Asthma and gastroesophageal reflux: Acid suppression therapy improves asthma outcome. Am J Med. 1996;100:395-405.
https://doi.org/10.1016/S0002-9343(97)89514-9
8. De Caesteker J. ABC of the upper gastrointestinal tract. Oe- sophagus: Heartburn. BMJ. 2001;323:736-9.
https://doi.org/10.1136/bmj.323.7315.736
9. American Society for Gastrointestinal Endoscopy (ASGE). The role of endoscopy in the management of GERD. Guidelines for clinical application. Gastrointest Endosc. 1999;49:834-5.
https://doi.org/10.1016/S0016-5107(99)70313-5
10. Talwar V, De Caesteker J. Hiatus hernia and gastro-oesophageal reflux disease. Medicine. 2007;35:194-8.
https://doi.org/10.1016/j.mpmed.2007.01.011
11. Fass R, Fennerty B, Vakil N. Nonerosive reflux disease -current conceps and dilemas. Am J Gastroenterol. 2001;96:303-14.
https://doi.org/10.1111/j.1572-0241.2001.03511.x
12. Patti MG. Advances in diagnostic testing for gastroesophageal reflux disease. World J Gastroenterol. 2010;16:3750-6.
https://doi.org/10.3748/wjg.v16.i30.3750
13. Fiocca R, Mastracci L, Ridell R, Takubo K, Vieth M, Yerian L, et al. Development of consensus guidelines for the histologic recognition of microscopic esophagitis in patients with gas- troesophageal reflux disesase: The Esohisto Project. . Human Pathology. 2010;41:223-31.
https://doi.org/10.1016/j.humpath.2009.07.016
14. Hirano I, Richter JE, Practice Parameters Committee of the American College of Gastroenterology. ACG practice guidelines: Esophageal reflux disease. Am J Gastroenterol. 2007;102:668-85.
https://doi.org/10.1111/j.1572-0241.2006.00936.x
15. Katz PO. Review article: Intragastric and oesophageal pH moni- toring in patients with gastro-esophageal reflux disease. Aliment Pharmacol Ther. 2006;23(Suppl.1):3-11.
https://doi.org/10.1111/j.1365-2036.2006.02801.x
16. DeVault KR, Caastell DO. Update guidelines for the diagnosis and treatment of gastroesophaegeal reflux disease. Am J Gas- troenterol. 2005;100:190-200.
https://doi.org/10.1111/j.1572-0241.2005.41217.x
17. Tutuian R, Castell DO. Review article: Complete gastro- oesophageal reflux monitoring -combined pH and impedance. Aliment Pharmacol Ther. 2006;24(Suppl.2):27-37.
https://doi.org/10.1111/j.1365-2036.2006.03039.x
18. Sifrim D, Castell D, Dent J, Kharilas PJ. Gastro-oesophageal reflux monitoring: Review and consensus report on detec- tion and definitions of acid, non-acid, and gas reflux. Gut. 2004;53:1024-31.
https://doi.org/10.1136/gut.2003.033290
19. Galli J, Volante M, Parrilla C, Rigante M, Valenza V. Oropharyn- goesophageal scintigraphy in the diagnostic algorithm of laryn- gopharyngeal reflux disease: A useful exam? J Otolaryngol Head Neck Surg. 2005;132:717-21.
https://doi.org/10.1016/j.otohns.2005.01.043
20. Richter JE. Diagnostic test for gastroesophageal reflux disease. Am J Med Sci. 2003;326:300-8.
https://doi.org/10.1097/00000441-200311000-00006
21. Hani A. Pruebas diagnósticas en enfermedad por reflujo gas- troesofágico (ERGE). Revista Colombiana de Gastroenterología. 2009;24210-22.
22. Ozin Y, Dagli U, Kuran S, Sahin B. Manometric findings in patients with isolated distal gastroesophageal reflux. World J Gastroenterol. 2009;15:5461-4.
https://doi.org/10.3748/wjg.15.5461
23. Frazzoni M, De Micheli E, Savarino V. Different patterns of oe- sophageal acid exposure distinguish complicated reflux disease from either erosive reflux oesophagitis or non-erosive reflux disease. Aliment Pharmacol Ther. 2003;18:1091-8.
https://doi.org/10.1046/j.1365-2036.2003.01768.x
24. Lemme EM, Abrahao-Junior LJ, Manhaes Y, Shechter R, Carvalho BB, Alvariz A. Ineffective esophageal motility in gastroesophageal erosive reflux disease and in nonerosive reflux disease: Are they different? J Clin Gastroenterol. 2005;39:224-7.
https://doi.org/10.1097/01.mcg.0000152782.22266.7c
25. Martinek J, Benes M, Hucl T, Drastich P, Stirand P, Spicak J. Non-erosive and erosive gastroesophageal reflux diseases: No difference with regard to reflux pattern and motility abnorma- lities. Scand J Gastroenterol. 2008;43:794-800.
https://doi.org/10.1080/00365520801908928
26. Ho SC, Chang CS, Wu CY, Chen GH. Ineffective esophageal motility is a primary motility disorder in gastroesophageal reflux disease. Dig Dis Sci. 2002;47:652-6.
https://doi.org/10.1023/A:1017992808762
27. Nagpal AP, Soni H, Haribhakti S. Is oesophageal manometry a must before laparoscopic fundoplication? Analysis of 46 consecutive patients treated without preoperative manometry. J Minim Access Surg. 2010;6:66-9.
https://doi.org/10.4103/0972-9941.68581
28. Haack HG, Hansen RD, Malcolm A, Kellow JE. Ineffective oesophageal motility: Manometric subsets exhibit different symptom profiles. World J Gastroenterol. 2008;14:3719-24.
https://doi.org/10.3748/wjg.14.3719
29. Patiño JF. Reflujo gastroesofágico. En: Patiño JF. Lecciones de cirugía, Primera edición, Bogotá; Editorial Médica Panameri- cana; 2000. p. 421-32.
30. Camilleri M, Thompson DG, Malagelada JR. Functional dyspep- sia. Symptoms and underlying mechanism. J Clin Gastroenterol. 1986;8:424-9.
https://doi.org/10.1097/00004836-198608000-00008
31. Greydanus MP, Vassallo M, Camilleri M, Nelson DK, Hanson RB, Thomforde GM. Neurohormonal factors in functional dyspepsia: Insights on pathophysiological mechanisms. Gas- troenterology. 1991;100:1311-8.
https://doi.org/10.1016/0016-5085(91)70018-S
32. Rodríguez A, Zuleta J. De la fisiología del vaciamiento gástrico al entendimiento de la gastroparesia. Rev Col Gastroenterol. 2010;25:219-25.
33. Abell TL, Bernstein RK, Cutts T, Farrugia G, Forster J, Hasler WL, et al. Treatment of gastroparesis: A multidisciplinary clinical review. Neurogastroenterol Motil. 2006;18:263-83.
https://doi.org/10.1111/j.1365-2982.2006.00760.x
34. Koskenpato J, Korppi-Tommola T, Kareima K, Farkkila M. Long term follow up study of gastric emptying and Helicobacter pylori eradication among patients with functional dyspepsia. Dig Dis Sci. 2000;45:1763-8.
https://doi.org/10.1023/A:1005582211673
35. DeVault KR, Castell DO. Guidelines for the diagnosis and treatment of gastroesophagal reflux disease. Arch Intern Med. 1995;155:2165-73.
https://doi.org/10.1001/archinte.1995.00430200044008
36. Kahrilas PJ, Quigley EMM. Clinical esophageal pH recording: A technical review for practice guideline development. Gas- troenterology. 1996;110:1982-96.
https://doi.org/10.1053/gast.1996.1101982
37. Bansal A, Wani S, Rastogi A. Impact of measurement of esopha- geal acid exposure close to the gastroesophageal junction on diagnostic accuracy and event-symptom correlation: A prospecti- ve study using wireless dual pH monitoring. Am J Gastroenterol. 2009;104:2918-25.
https://doi.org/10.1038/ajg.2009.506
38. Shay S, Tutuian R, Sifrim D, Vela M, Wise J, Blaji N, et al. Twenty-four hours ambulatory simultaneous impedance and pH monitoring: A multicenter report of normal values from 60 healthy volunteers. Am J Gastroenterol. 2004;99:1037-43.
https://doi.org/10.1111/j.1572-0241.2004.04172.x
39. Sifrim D, Castell D, Dent J, Kahrilas PJ. Gastro-oesophageal reflux monitoring: Review and consensus report on detec- tion and definitions of acid, nonacid, and gas reflux. Gut. 2004;53:1024-31.
https://doi.org/10.1136/gut.2003.033290
40. Pandolfino JE, Richter JE, Ours T, Guardino JM, Chapman J, Kahrilas PJ. Ambulatory esophageal pH monitoring using a wireless system . Am J Gastroenterol. 2003;98:740-9.
https://doi.org/10.1111/j.1572-0241.2003.07398.x
41. Mekapati J, Knight LC , Maurer AH, Fisher RS, Parkman HP. Trans-sphincteric pH profile at the gastroesophageal junction. Clin Gastroenterol Hepatol. 2008;6:630-4.
https://doi.org/10.1016/j.cgh.2008.01.003
42. Pandolfino JE, Zhang Q , Ghosh SK, Post J, Kwiatek M, Kahrilas PJ. Acidity surrounding the squamocolumnar junction in GERD patients: 'Acid pocket' versus 'acid film'. Am J Gastroenterol. 2007;102:2633-41.
https://doi.org/10.1111/j.1572-0241.2007.01488.x
43. Wenner J, Hall M , Hoglund P, Johansson J, Johnsson F, Oberg S. Wireless pH recording immediately above the squamocolumnar junction improves the diagnostic performance of esophageal pH studies. Am J Gastroenterol. 2008;103:2977-85.
https://doi.org/10.1111/j.1572-0241.2008.02174.x
44. Bredenoord AJ, Weusten BL, Timmer R, Conchillo JM, Smout AJ. Addition of esophageal impedance monitoring to pH mo- nitoring increases the yield of symptom association analysis in patients off PPI therapy. Am J Gastroenterol. 2006;101:453-9.
https://doi.org/10.1111/j.1572-0241.2006.00427.x
45. Wenner J, Johnsson F, Johansson J, Oberg S. Acid reflux im- mediately above the squamocolumnar junction and in the distal esophagus: Simultaneous pH monitoring using the wireless capsule pH system. Am J Gastroenterol. 2006;101:1734-41.
https://doi.org/10.1111/j.1572-0241.2006.00653.x
46. Sgromo B, Irvine LA, Cuschieri A. Long-term comparative outcome between laparoscopic total Nissen and Toupet fundo- plication: Symptomatic relief, patient satisfaction and quality of life. Surg Endosc. 2008;22:1048-53.
https://doi.org/10.1007/s00464-007-9671-4
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2011-07-01
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Hazbón, H. R.; Junca Burgos, E. G. Manejo quirúrgico Del Reflujo gastroesofágico En La Universidad Nacional De Colombia, Sede Bogotá. Rev Colomb Cir 2011, 26, 196-206.
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