Manometric study of the upper esophageal sphincter before and after endoscopic management of Zenker's diverticulum.

BACKGROUND/AIM: Zenker's diverticulum treatment was done by endoscopic management of the elderly and debilitated patients without general anesthesia. MATERIALS/METHODS: With this technique, the septum between the diverticulum and the esophageal lumen is sectioned with a diathermic knife. Since the upper esophageal sphincter (UES) is certainly included in the mass sectioned, this accounts for the success of the procedure. RESULTS: Manometric assessment of the UES was done in 5 patients before the endoscopic treatment. The mean pressure was 54.6 cm H2O and the mean length of 3 cm. A significant (p < 0.05) reduction in maximum pressure occurred postoperatively--mean 26.8 cm H2O. There was no significant variation in length of the UES. CONCLUSION: The maintenance of this basal pressure may be explained by the preservation of the circular muscle structure of the region, with sphincter-like characteristics.

Achalasia: a prospective study comparing the results of dilatation and myotomy.

BACKGROUND/AIMS: In a prospective and randomized clinical study, the operative method and dilatation in the initial stage of megaesophagus were evaluated. METHODOLOGY: Forty patients in the initial stage of megaesophagus, managed by forced hydrostatic dilatation of the cardia (20 patients-DILAT Group) or by esophagocardiomyotomy associated with esophagofundopexy (20 patients-Group OP) were followed-up for three years, in terms of clinical, radiographic, endoscopic, manometric and pH monitoring. RESULTS: 1) Both procedures can be performed without significant morbidity or mortality. 2) The two procedures are similar regarding ongoing suppression of dysphagia. 3) Radiologically, the methods are equivalent, since they promote significant elimination of contrast stasis and maintenance of the esophageal diameter. 4) Endoscopic follow-up did not differentiate the procedures in terms of the development of reflux esophagitis, with a rate of only 5% for each group of patients. 5) Manometry demonstrated that surgery produced a significantly greater reduction of the LESP as compared to dilatation, although the latter also determined a marked drop in the maximum basal pressure of the LES. 6) Neither procedure altered the length of the LES. 7) With prolonged esophageal pH monitoring, dilatation demonstrated a greater propensity for reflux as compared to surgery. CONCLUSION: Both methods offer benefits in the treatment of the initial stage of megaesophagus, although esophageal pH monitoring indicates that dilatation provokes a greater index of esophageal acid exposition time.

Esophagogastric anastomosis with valvuloplasty: an experimental study.

Twenty dogs divided into two equal groups were studied by the authors in order to evaluate the functional activity and the occurrence of reflux and esophagitis after esophagogastrectomy followed by a simple esophagogastric anastomosis (group A) and associated with an anti-reflux valve mechanism (group B). The functional activity was studied by manometry at the esophagogastric junction and the occurrence of esophagitis by histologic examination of the esophagus after 25 days of histamine gastric acid stimulation. In group A, no high pressure zone between the gastric and esophageal tracings were verified. Reflux and esophagitis which, occurred in all animals, was severe in 70%. In group B, manometry demonstrated that esophagogastropexy creates a high pressure zone. At deglutition this zone showed positive deflections, corresponding to the propagation of the peristaltic wave in the segment of esophagus, encircled by the stomach. Esophagitis, which was detected in 30%, was less severe than that observed in group A.

[Esophageal manometry for the study of gastroesophageal reflux]. / Contribuições da manometria do esôfago para o estudo do refluxo gastroesofagiano.

In a medical literature revision, actual concepts about esophageal inferior sphincter's importance are presented. It is the principal object on studies about clinical and surgical therapeutic procedures for gastroesophageal reflux. Thus, esophageal manometric study, fundamental for physiological knowledge of the organ, conducts the reflux esophagitis therapy.

[Importance of esophageal pH monitoring in the screening of gastroesophageal reflux in children]. / A importância da pHmetria esofágica prolongada na pesquisa do refluxo gastroesofágico patológico em crianças.

In the past 20 years the association between gastroesophageal reflux and otorhinolaryngological and/or respiratory affections became more evident by many studies. At the same time it is known that regurgitation, abdominal pain, growth retard, among others signs, could be generated by gastroesophageal reflux in infants, and when these signals are present the suspicious must be considered and they could be referred to perform pH studies. Sixty children were referred to our center to perform pH monitoring with gastroesophageal reflux suspicious, with digestive symptoms, respiratory problems or otorhinolaryngological manifestations. The patients were divided in two groups: the first, with 25 children, suffering from digestive manifestations. The second, 35 patients, including otorhinolaryngological or pulmonary symptoms. The children with digestive manifestations and with otorhinolaryngological or pulmonary symptoms were included in the first group. The pH analysis were considered positive for reflux when Boix-Ochoa Index (for 8 months of age or less) or DeMeester index (for 9 months or more) were above 11.99 or 14.72, respectively. The data were also compared to the results of scintigraphic studies for reflux or endoscopic findings in 22 patients. The pH monitoring test were positive in 62% patients with digestive manifestations. In the group with otorhinolaryngological or pulmonary symptoms the positivity was only 29%. In the group of children with both affections, the positivity was 66%. In patients that performed scintigraphic test or endoscopy, the pH test positivity were similar, 63%, without correlation if these other tests were positive or not. Patients with abnormal endoscopy or positive scintigraphic tests for gastroesophageal reflux presented 37% of positivity in pH test. We conclude that pH monitoring tests could be altered mainly when referred to investigate digestive manifestations when compared to primary otorhinolaryngological or pulmonary indications. Digestive endoscopy or scintigraphic study altered do not mean positive pH test and the inverse situation could be find too. Digestive symptoms coexisting with otorhinolaryngological or pulmonary afections do not increase the positivity frequency of the pH tests when compared with digestive manifestations exclusively.

[Surgical treatment of megaesophagus. Effect of myotomy and fundoplication on the lower esophageal sphincter]. / Tratamento cirúrgico do megaesôfago. Efeito da miotomia e da valvuloplastia sobre o esfíncter inferior do esôfago.

Details about the structure of the lower esophageal sphincter and the function of fundoplication are yet unknown. New study is presented about electromanometric examination of the lower esophageal sphincter in 20 chagasic patients with megaesophagus operated on by cardiomyotomy complemented with His angle agudization (Group A-10 patients) or fundoplication (Group B-10 patients). On the 30th postoperative day, the patients, without dysphagia, were submitted to radiologic study, demonstrating valvuloplasty integrity (Group B), and electromanometric study of the esophagus. The comparison between the groups demonstrated: -myotomy does not modify the lower esophageal sphincter extension, but decrease its pressure, not to zero; -fundoplication does not increase the lower esophageal sphincter pressure after myotomy, under resting conditions. These conclusions suggest that: -lower esophageal sphincter is formed by muscular fibers interlacing, configuration that maintains residual regional pressure after myotomy; - in resting state, after myotomy, fundoplication exerts exclusively mechanical function, without increase of the lower esophageal sphincter pressure.

Suture of the diaphragmatic esophageal hiatus (an experimental study).

Eighty rabbits were submitted to different procedures on the esophageal hiatus of the diaphragm. The authors concluded that section of the peritoneal lining, removal of the perimysium of the crura of the medial diaphragmatic limb and abrasion of its borders, do not cause local adhesions. On the other hand, the approximation of these muscular structures with interrupted nylon sutures, determines the formation of the scar uniting them. The resistance of the scar varies in different animals but the average values recorded, showed the efficiency of the suture used.

[Controversial aspects in traumatic lesions of the pancreas]. / Aspectos controversos na lesão traumática do pâncreas.

The pancreatic anatomo-functional characteristics explain the traumatic gravidity and the problems in diagnostic. Its lesion is treated surgically, with controversial aspects. In terms of literature and analytic description of a case, were established: the initial course of trauma can be uncharacteristic, with normal amilasemia and abdomen Rx; the ultrasonography can determine the diagnosis; in cases of proximal transection of pancreas, the surgical treatment can include pancreatic derivation, in early operations, under favourable conditions.

The surgical treatment of megaesophagus and megacolon.

The effect of Chagas' disease on the digestive tract is evaluated based on the experience acquired in the surgical management of 929 cases of megaesophagus: 807 in the nonadvanced state of the disease and 122 with dolichomegaesophagus. The 807 subjects with nonadvanced megaesophagus were submitted to wide esophagocardiomyectomy on the anterior esophagogastric junction combined with an antireflux valvuloplasty procedure. There was no mortality. On the other hand, dolichomegaesophagus was always resected, with an esophagogastroplasty through the esophageal bed. The index of mortality of the series was 4.1% (5/122) and the main postoperative complications were pleural effusion (22.1%) and fistula of the esophagogastric anastomosis (8.2%). Over the long term the patients adapted well to the operation and gained weight. For the treatment of the megacolon, an easier technique has been employed: resection of the dilated sigmoid colon and colorectal anastomosis just above the anorectal ring. In 30 patients, no leakages, infection or other major complications were seen. The patients, after 1 year of follow-up, had a normal bowel transit.

[Pharyngoesophageal dysfunction: report of case and review of literature]. / Disfunção faringoesofagiana: relato de caso e revisão de literatura.

Buccopharyngeal motor disorders causing difficulties in swallowing are frequently encountered in clinical medicine. Affected patients manifest distinctive clinical features and pose special problems in their management. A case report is described and summarize the pathogenesis, consequences, evaluation, treatment and some selected clinical conditions that are associated with buccopharyngeal dysphagia.

Removal of a foreign body from the upper gastrointestinal tract with a flexible endoscope: a prospective study.

BACKGROUND AND STUDY AIMS: There have so far been no prospective studies on the value of flexible endoscopy for removing foreign bodies in the upper gastrointestinal tract. This study presents a clinical analysis of accidents with foreign bodies and prospectively evaluates the effectiveness of flexible endoscopy for removing them. PATIENTS AND METHODS: A total of 105 cases of foreign-body ingestion in the upper gastrointestinal tract were evaluated, 29 (27.6 %) in children and 76 (72.4 %) in adults. Thirty patients (28.5 %) had esophageal strictures. RESULTS: Thirty-nine of the foreign bodies (37.1 %) consisted of food and 66 (62.9 %) were not food-related. The success rate of foreign-body extraction using only a conventional flexible endoscope and accessories for treatment was 98.0 %, and with only a polypectomy snare and rat-toothed forceps it was 91.2 %. Complications at the moment of foreign-body removal occurred in nine patients (8.6 %); there was only one (1 %) esophageal perforation. The incidence of complications related to the duration of foreign-body impaction was six (10.5 %) with foreign bodies impacted for up to 24 h, 13 (52.0 %) for those impacted for 24-48 h, and three (60.0 %) for those impacted for 48-72 h ( P < 0.05). CONCLUSIONS: The flexible endoscope is an effective and safe device for removing foreign bodies from the upper gastrointestinal tract, with a high success rate using only the polypectomy snare and the rat-toothed forceps as accessories. If foreign-body impaction lasts for more than 24 h, there is a significant increase in the incidence of complications.

Surgical complications of Chagas' disease: megaesophagus, achalasia of the pylorus, and cholelithiasis.

Three surgical complications of Chagas' disease--megaesophagus, achalasia of the pylorus, and cholelithiasis--were evaluated within the framework of the experience acquired in the management of 840 cases of megaesophagus--722 in the nonadvanced stage of the disease and 118 with advanced disease (dolichomegaesophagus). In the group of the 722 patients with nonadvanced disease, achalasia of the pylorus was present in 140 (19.4%), and in the total of 840 patients, uncomplicated cholelithiasis without chagasic involvement of the gallbladder and/or papilla was observed in 58 (6.9%). The 722 subjects with nonadvanced megaesophagus were submitted to wide esophagocardiomyectomy performed at the level of the anterior esophagogastric junction, combined with an antireflux valvuloplasty procedure. We recorded no mortality, and 95% excellent and good results in long-term follow-up. On the other hand, dolichomegaesophagus required esophageal resection with reconstruction by means of an esophagogastroplasty placed in the esophageal bed. The mortality rate was 4.2% (5/118); the main postoperative complications were pleural effusion (22%) and fistulas of the esophagogastric anastomosis (8.4%). Postoperatively, the patients adapted well to their new anatomy and gained weight. Achalasia of the pylorus was confirmed by delayed gastric emptying time. This entity was managed by concomitant antropyloromyectomy without mortality. Cholelithiasis was managed by cholecystectomy and radiologic exploration of the bile ducts.

[Reapplication of myotomy and fundoplication in the surgical treatment of recurrent dysphagia after incomplete myotomy]. / Reaplicação de miotomia e fundoplicatura para tratamento cirúrgico da recidiva de disfagia nos casos de miotomia incompleta.

Twelve patients presenting dysphagia due to incomplete myotomy were evaluated. Clinic, endoscopic, radiographic and manometric studies were performed before and after a new operation, esophagocardiomyotomy and esophagofundogastropexy, by laparotomy and phrenotomy. There was no morbiletality and it was achieved control of dysphagia in all patients, as well as weight gain and significant reduction of the esophageal emptying time. Only one patient presented moderate esophagitis in the postoperative period. Reduced resting pressure of the LES was noted, but with no alteration of its lenght. The operation proved be factible and able to constitute good option to treat these cases.

Esophageal endoscopic aspects after forceful dilation of the gastric cardia in patients with achalasia of Chagas' disease.

The purpose of this study was to evaluate the clinical results and to observe endoscopically the distal esophagus in a series of chagasic adults with incipient megaesophagus and normal endoscopic aspect of the mucosa, who underwent forced hydrostatic dilatation of the cardia, 48 h after the procedure. Twenty patients were submitted to a careful specific pattern of forced dilatation, changing forceful and rapid standardized injection of water to slow distension of the balloon until the patient felt pain. The procedure was repeated three times with the same volume and was maintained each time for 5 min, with intervals of about 3 min. The dysphagia was practically immediately controlled and there were no severe complications or mortality in the series. Five patients complained of pyrosis, mild in two of them. The endoscopic examination revealed mucosal edema in 11 patients (55%), hyperemia in nine (45%) and superficial fissures of the mucosa in six (30%), with seven patients (35%) presenting all the signs simultaneously. These observations characterize 'traumatic esophagitis' due to forced dilatation of the cardia as being frequently asymptomatic. Extreme care with the method can produce effective dilatation of the cardia, avoiding severe complications but not some degree of mucosal injuries.

[Cervical esophageal membrane and Plummer-Vinson syndrome: report of a caseload and review of the literature]. / Membrana esofágica cervical e síndrome de Plummer-Vinson: apresentação de casuística e revisão da literatura.

Esophageal webs are an uncommon group among esophageal diseases. We report our findings in ten patients with membranes in the upper esophagus; seven of them were women. The median age was 48.5 years (range 24 to 73 years). Dysphagia was the main symptom in all patients and anemia was found in six cases. Radiologic and endoscopic studies provided the diagnosis. All patients underwent endoscopic dilatation and/or debridement and good results with this management were achieved. A review of literature of this condition and a discussion about the diagnosis, treatment and etiopathogenesis are presented.