Impact of radiotherapy on adverse events of self-expanding metallic stents in patients with esophageal cancer.

Self-expanding metallic stents (SEMS) are considered the treatment of choice for the palliation of dysphagia and fistulas in inoperable esophageal neoplasms. However, the safety of SEMSs in patients who received or who will be submitted to radiotherapy (RT) is uncertain. The study aimed to evaluate the impact of RT on adverse events (AEs) in patients with esophageal cancer with SEMSs. This is a retrospective study conducted at a tertiary cancer hospital from 2009 to 2018. We collected information regarding RT, the histological type of the tumor, the model of SEMSs and AEs after stent placement. Three hundred twenty-three patients with malignant stenosis or fistula were treated with SEMSs. The predominant histological type was squamous cell carcinoma (79.6%). A total of 282 partially covered and 41 fully covered SEMSs were inserted. Of the 323 patients, 182 did not received RT, 118 received RT before SEMS placement and 23 after. Comparing the group that received RT before stent insertion with the group that did not, the first one presented a higher frequency of severe pain (9/118 7.6% vs. 3/182 1.6%; P = 0.02). The group treated with RT after stent placement had a higher risk of global AEs (13/23 56.5% vs. 63/182 34.6%; P = 0.019), ingrowth/overgrowth (6/23 26.1% vs. 21/182 11.5%; P = 0.045) and gastroesophageal reflux (2/23 8.7% vs. 2/182 1.1%; P = 0.034). Treatment with RT before stent placement in patients with inoperable esophageal neoplasm prolongs survival and is associated with an increased risk of severe chest pain. Treatment with RT of patients with an esophageal stent increases the frequency of minor, not life-threatening AEs.

Worldwide Techniques and Outcomes in Robot-assisted Minimally Invasive Esophagectomy (RAMIE): Results From the Multicenter International Registry.

OBJECTIVE: This international multicenter study by the Upper GI International Robotic Association aimed to gain insight in current techniques and outcomes of RAMIE worldwide. BACKGROUND: Current evidence for RAMIE originates from single-center studies, which may not be generalizable to the international multicenter experience. METHODS: Twenty centers from Europe, Asia, North-America, and South-America participated from 2016 to 2019. Main endpoints included the surgical techniques, clinical outcomes, and early oncological results of ramie. RESULTS: A total of 856 patients undergoing transthoracic RAMIE were included. Robotic surgery was applied for both the thoracic and abdominal phase (45%), only the thoracic phase (49%), or only the abdominal phase (6%). In most cases, the mediastinal lymphadenectomy included the low paraesophageal nodes (n=815, 95%), subcarinal nodes (n = 774, 90%), and paratracheal nodes (n = 537, 63%). When paratracheal lymphadenectomy was performed during an Ivor Lewis or a McKeown RAMIE procedure, recurrent laryngeal nerve injury occurred in 3% and 11% of patients, respectively. Circular stapled (52%), hand-sewn (30%), and linear stapled (18%) anastomotic techniques were used. In Ivor Lewis RAMIE, robot-assisted hand-sewing showed the highest anastomotic leakage rate (33%), while lower rates were observed with circular stapling (17%) and linear stapling (15%). In McKeown RAMIE, a hand-sewn anastomotic technique showed the highest leakage rate (27%), followed by linear stapling (18%) and circular stapling (6%). CONCLUSION: This study is the first to provide an overview of the current techniques and outcomes of transthoracic RAMIE worldwide. Although these results indicate high quality of the procedure, the optimal approach should be further defined.

Surgical anatomy of the upper esophagus related to robot-assisted cervical esophagectomy.

Robot-assisted cervical esophagectomy (RACE) enables radical surgery for tumors of the middle and upper esophagus, avoiding a transthoracic approach. However, the cervical access, narrow working space, and complex topographic anatomy make this procedure particularly demanding. Our study offers a stepwise description of appropriate dissection planes and anatomical landmarks to facilitate RACE. Macroscopic dissections were performed on formaldehyde-fixed body donors (three females, three males), according to the surgical steps during RACE. The topographic anatomy and surgically relevant structures related to the cervical access route to the esophagus were described and illustrated, along with the complete mobilization of the cervical and upper thoracic segment. The carotid sheath, intercarotid fascia, and visceral fascia were identified as helpful landmarks, used as optimal dissection planes to approach the cervical esophagus and preserve the structures at risk (trachea, recurrent laryngeal nerves, thoracic duct, sympathetic trunk). While ventral dissection involved detachment of the esophagus from the tracheal cartilage and membranous part, the dorsal dissection plane comprised the prevertebral compartment harboring the thoracic duct and right intercosto-bronchial artery. On the left side, the esophagus was attached to the aortic arch by the aorto-esophageal ligament; on the right side, the esophagus was bordered by the azygos vein, right vagus nerve, and cardiac nerves. The stepwise, illustrated topographic anatomy addressed specific surgical demands and perspectives related to the left cervical approach and dissection of the esophagus, providing an anatomical basis to facilitate and safely implement the RACE procedure.

Adverse events of self-expandable esophageal metallic stents in patients with long-term survival from advanced malignant disease.

BACKGROUND AND AIMS: Self-expandable metallic stents are considered the best palliative treatment of dysphagia for patients with advanced esophageal cancer. Adverse events (AEs) are a major concern, especially in patients with better prognosis and longer survival. The present study aimed to evaluate the AEs of patients who survived longer than 6 months with esophageal stents in place. METHODS: This is a retrospective analysis of a prospectively collected database including all patients submitted to esophageal stent placement for the palliation of malignant diseases during the period from February 2009 to February 2014 at a tertiary care academic center who had stents longer than 6 months. RESULTS: Sixty-three patients were included. Mean follow-up was 10.7 months. Clinical success was achieved in all patients, and the median stent patency was 7.1 months. AEs occurred in 40 patients (63.5%), totaling 62 AEs (mean, 1.5 AEs per patient). Endoscopic management of AEs was successful in 84.5% of cases, with a mean of 1.6 reinterventions per patient. The univariate analysis revealed that performance status, age, and post-stent radiotherapy presented a trend to higher risk of AEs. The multivariate analysis revealed that only performance status was associated with AEs (P = .025; hazard ratio, 4.1). CONCLUSIONS: AEs are common in patients with long-term esophageal stenting for malignancy. However, AEs were not related to higher mortality rate, and most AEs could be successfully managed by endoscopy. Only performance status was a risk factor for AEs. Our data suggest that metallic stenting is a valid option for the treatment of malignant esophageal conditions, even when survival longer than 6 months is expected.

Self-expandable metallic stent-induced esophagorespiratory fistulas in patients with advanced esophageal cancer.

BACKGROUND/AIMS: Self-expandable metallic stents (SEMSs) are widely adopted for the palliation of dysphagia in patients with malignant esophageal strictures. An important adverse event is the development of SEMS-induced esophagorespiratory fistulas (SEMS-ERFs). This study aimed to assess the risk factors related to the development of SEMS-ERF after SEMS placement in patients with esophageal cancer. METHODS: This retrospective study was performed at the Instituto do Cancer do Estado de São Paulo. All patients with malignant esophageal strictures who underwent esophageal SEMS placement between 2009 and 2019 were included in the study. RESULTS: Of the 335 patients, 37 (11.0%) developed SEMS-ERF, with a median time of 129 days after SEMS placement. Stent flare of 28 mm (hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.15-5.51; p=0.02) and post-stent chemotherapy (HR, 2.0; 95% CI, 1.01-4.00; p=0.05) were associated with an increased risk of developing SEMS-ERF, while lower-third tumors were a protective factor (HR, 0.5; 95% CI, 0.26-0.85; p=0.01). No difference was observed in overall survival. CONCLUSION: The incidence of SEMS-ERFs was 11%, with a median time of 129 days after SEMS placement. Post-stent chemotherapy and a 28 mm stent flare were associated with a higher risk of SEMS-ERF.

Diaphragmatic Hernia Repair After Esophagectomy: Technical Report and Lessons After a Series of Cases.

Introduction: Diaphragmatic hernia (DH) repair after esophagectomy is infrequent and technically challenging. Such hernias are mostly asymptomatic and have an estimated incidence of around 2.5%. Controversy continues over suture versus mesh cruroplasty. This article reports a series of cases and a description of the technique, showing this type of procedure being performed in the medical literature and its results. Methods: A DH was diagnosed, and repair was performed in eight out of 328 esophagectomies. All of them were performed through the following steps: (1) Pulling the hernia content down properly without handling the intestinal segment directly to not promote serosal lesions; (2) Lysis of adhesions-this should be done close to the diaphragmatic pillar, with precaution toward the vessels running in the epiplon and near the greater gastric curvature; and (3) Closure of the diaphragmatic hiatus achieved with anterior and posterior sutures. Mesh repair was performed across the DH defects that measured more than 5.5 cm. Results: The patients constituted five men (62.5%) with a mean age of 61.6 years. The main DH-related symptom was abdominal pain, reported by four patients (50%). The other symptoms mentioned were dyspnea (37.5%), thoracic pain (25%), and dysphagia (25%). The mean hospitalization period was 17.5 days and was related to the restoration of the respiratory function. Most of the DH repairs were performed by adopting a laparoscopic approach. Conclusions: DH is a rare complication following esophagectomy with most of the symptomatic manifestations. However, its repair is feasible and safe, with low morbidity (only respiratory complications) and no mortality.

Does the nissen fundoplication procedure improve esophageal dysmotility in patients with barrett's esophagus?

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.

Overview and perspectives about the robotic surgical certification process in Brazil: the new statement and a national web-survey.

OBJECTIVE: to appraise the general profile of the Brazilian robotic surgeon and the acknowledgment of the new certification process for robotic surgery upon the Associação Médica Brasileira (AMB - Brazilian Medical Association) statement. According to the AMB statement, medical societies and proctors have to achieve leading roles in training and certification of surgeons, acting in partnership with industry. METHODS: a national web-based survey was promoted by the Colégio Brasileiro de Cirurgiões (CBC - Brazilian College of Surgeons) among their members. RESULTS: the 294 answers were split into two groups: 133 (45.3%) who had robotic console certification, and 161 (54.8%) who did not have it. The overall median age was 46, but the non-robotic group presented more surgeons with at least 30 years of experience than to the robotic group (32.3% versus 23.3%, p=0.033). Surgeons with robotic certification more frequently work in a city with at least one million inhabitants than surgeons who were not certified (85.7 versus 63.4%, p<0.001). The majority of surgeons in both groups have similar positioning for all main points of the statement. However, the agreement proportions for the preceptors responsibility during the procedures were higher among non-robotic surgeons that expected the preceptor to assume co-responsibility for the procedure (85% versus 60.9%, p<0.001), and intervene during the procedure as much as necessary (97.5% versus 91.7%, p=0.033). CONCLUSION: the overall agreement of the answers to the AMB statement seems to be a promising pathway to increase the participation of the medical entities into the robotic certification in Brazil.

Evaluation of gene amplification and protein expression of HER-2/neu in esophageal squamous cell carcinoma using Fluorescence in situ Hybridization (FISH) and immunohistochemistry.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is the sixth most frequent neoplasia in Brazil. It is usually associated with a poor prognosis because it is often at an advanced stage when diagnosed and there is a high frequency of lymph node metastases. It is important to know what prognostic factors can facilitate diagnosis, optimize therapeutic decisions, and improve the survival of these patients. A member of the epidermal growth factor receptor (EGFR) family, c-erbB-2, has received much attention because of its therapeutic implications; however, few studies involving fluorescence in situ hybridization (FISH) analysis of HER-2/neu gene amplification and protein expression in ESCC have been conducted. The aim of this study was to verify the presence of HER-2/neu gene amplification using FISH, and to correlate the results with immunohistochemical expression and clinical-pathological findings. METHODS: One hundred and ninety-nine ESCC cases were evaluated using the Tissue Microarray (TMA) technique. A polyclonal antibody against c-erbB-2 was used for immunohistochemistry. Analyses were based on the membrane staining pattern. The results were classified according to the Herceptest criteria (DAKO): negative (0/1+), potential positive (2+) and positive (3+). The FISH reactions were performed according to the FISH HER2 PharmDx (DAKO) protocol. In each case, 100 tumor nuclei were evaluated. Cases showing a gene/CEN17 fluorescence ratio > or = 2 were considered positive for gene amplification. RESULTS: The c-erbB-2 expression was negative in 117/185 cases (63.2%) and positive in 68 (36.8%), of which 56 (30.3%) were 2+ and 12 (6.5%) were 3+. No significant associations were found among protein expression, clinicopathological data and overall survival. Among the 47 cases analyzed, 38 (80.9%) showed no gene amplification while 9 (19.1%) showed amplification, as demonstrated by FISH. Cases that were negative (0/1+) and potential positive (2+) for c-erbB-2 expression by immunohistochemistry showed no gene amplification. However, all cases with gene amplification were positive (3+) by immunohistochemistry. According to univariate analysis, there was a significant difference (p = 0.003) in survival rates when cases with and without HER-2/neu amplification were compared. CONCLUSION: Our data demonstrate the correspondence between gene amplification and protein expression of HER-2/neu. Gene amplification is an indicator of poor prognosis in ESCC.

Barrett's esophagus (BE) and carcinoma in the esophageal stump (ES) after esophagectomy with gastric pull-up in achalasia patients: a study based on 10 years follow-up.

BACKGROUND: Subtotal esophagectomy and gastric pull-up with cervical anastomosis is the main treatment for advanced achalasia. This surgical technique has been associated to esophagitis and also Barrett's epithelium following esophagectomy. AIM: To analyze late clinical, endoscopic, and pathologic findings in the esophageal stump (ES) mucosa after subtotal esophagectomy in patients treated for advanced chagasic achalasia. METHODS: 101 patients submitted to esophagectomy and cervical gastroplasty were followed-up prospectively for a mean of 10.5 +/- 8.8 years. All patients underwent clinical, endoscopic and histopathological evaluation every 2 years. Gastric acid secretion was also assessed. RESULTS: The incidence of esophagitis in the esophageal stump (45.9% at 1 year; 71.9% at 5 years, and 70.0% at 10 years follow-up); gastritis in the transposed stomach (20.4% at 1 year, 31.0% at 5 years, and 40.0% at 10 or more years follow-up), and the occurrence of ectopic columnar metaplasia and Barrett's Esophagus in the ES (none until 1 year; 10.9% between 1 and 5 years; 29.5% between 5 and 10 years; and 57.5% at 10 or more years follow-up), all rose over time. Gastric acid secretion returns to its preoperative values 4 years postoperatively. Esophageal stump cancer was detected in the setting of chronic esophagitis in five patients: three squamous cell carcinomas and two adenocarcinomas. CONCLUSION: (1) Esophagitis and Barrett's esophagus in the esophageal stump rose over time. (2) These mucosal alterations and the development of squamous cell carcinoma and adenocarcinoma are probably due to exposure to duodenogastric reflux, and progressively higher acid output in the transposed stomach.

Endoscopic polymer injection and endoluminal plication in treatment of gastroesophageal reflux disease: evaluation of long-term results.

BACKGROUND AND STUDY AIMS: Us of proton pump inhibitors (PPIs) has made endoscopic treatment of gastroesophageal reflux disease (GERD) more efficient, with reduction in morbidity and complications. However, some patients persist with symptoms despite medical treatment and some are not compliant with it or cannot afford it for financial reasons, and thus they require non-pharmacological therapeutic options such as surgical fundoplication. Surgery may be effective in the short term, but there is related morbidity and concern about its long-term efficacy. The possibility of minimally invasive endoluminal surgeries has resulted in interest in and development of newly endoscopic devices. Good short-term results with surgical fundoplication lack of studies of is with long follow-up justify our interest in this study. The aim of this study was to investigate the efficacy of endoscopic polymer injection and endoluminal full-thickness plication in the long-term control of GERD. PATIENTS AND METHODS: Forty-seven patients with GERD who underwent an endoscopic procedure were followed up for 60 months and evaluated for total response (RT), partial response (RP) and no response (SR) to endoscopic treatment with reintroduction of PPIs. RESULTS: Twenty-one patients received polymer injection (G0) and 26 endoluminal plication (G1). The number of patients with no response to endoscopic treatment with reintroduction of PPIs increased in time for both techniques (G0 P  = 0.006; G1 P  < 0.001). There was symptomatic improvement up to 12 months, with progressive loss of this trending up to 60 months in G0 and G1 ( P  < 0.001). Health-related quality of life score (GERD-HRQL) demonstrated TR in G0 and G1 at 1, 3, 6 and 12 months. The 60-month analysis showed an increased number of patients with SR in both groups. The quality of life assessment (SF-36) showed benefit in G0 up to 3 months. G0 showed a higher rate of complications. There were no deaths. There was healing of esophagitis at 3 months in 45 % of patients in G0 and 40 % in G1. There was no improvement in manometric or pH findings. CONCLUSION: Endoscopic therapies were ineffective in controlling GERD in the long term.

Expression profile of malignant and nonmalignant lesions of esophagus and stomach: differential activity of functional modules related to inflammation and lipid metabolism.

Adenocarcinomas of stomach and esophagus are frequently associated with preceding inflammatory alterations of the normal mucosa. Whereas intestinal metaplasia of the gastric mucosa is associated with higher risk of malignization, Barrett's disease is a risk factor for adenocarcinoma of the esophagus. Barrett's disease is characterized by the substitution of the squamous mucosa of the esophagus by a columnar tissue classified histopathologically as intestinal metaplasia. Using cDNA microarrays, we determined the expression profile of normal gastric and esophageal mucosa as well as intestinal metaplasia and adenocarcinomas from both organs. Data were explored to define functional alterations related to the transformation from squamous to columnar epithelium and the malignant transformation from intestinal metaplasia to adenocarcinomas. Based on their expression profile, adenocarcinomas of the esophagus showed stronger correlation with intestinal metaplasia of the stomach than with Barrett's mucosa. Second, we identified two functional modules, lipid metabolism and cytokine, as being altered with higher statistical significance. Whereas the lipid metabolism module is active in samples representing intestinal metaplasia and inactive in adenocarcinomas, the cytokine module is inactive in samples representing normal esophagus and esophagitis. Using the concept of relevance networks, we determined the changes in linear correlation of genes pertaining to these two functional modules. Exploitation of the data presented herein will help in the precise molecular characterization of adenocarcinoma from the distal esophagus, avoiding the topographical and descriptive classification that is currently adopted, and help with the proper management of patients with Barrett's disease.

[Laparoscopic distal pancreatectomy for pancreatic cystadenomas]. / Pancreatectomia distal videolaparoscópica em pacientes com cistadenoma de pâncreas.

BACKGROUND: Cystic neoplasms are an uncommon group among pancreatic tumors. These lesions are seen more frequently in recent surgical practice, probably because of advances in diagnostic and surgical techniques. Total tumor resection provides the best chance of cure and may remove the risk of malignant transformation of the cystadenomas, particularly of the mucinous type. Minimally invasive techniques have been revolutionary and provide clinical evidence of decreased morbidity and comparable efficacy to traditional, open surgery. However, laparoscopic pancreatic resection is not an established treatment for tumors of the pancreas. AIM: The authors present their initial experience with laparoscopic distal pancreatectomy for pancreatic cystadenomas. MATERIAL AND METHODS: Three female patients (mean age, 55 years) underwent laparoscopic pancreatic resection between September 2001 and December 2003. RESULTS: Laparoscopic pancreatic resection was successfully performed in all patients. Operative time varied between 4 and 6 hours. Intraoperative bleeding was minimal. Due to a thick pancreas, the application of vascular endoscopic stapler was difficult in one patient. Two patients presented postoperative pancreatic leakage with spontaneous resolution. CONCLUSIONS: Resection of the pancreas can be safely performed via the laparoscopic approach with all the potential benefits to the patients of minimally invasive surgery.

Does the nissen fundoplication procedure improve esophageal dysmotility in patients with barrett's esophagus? / A fundoplicatura a nissen melhora a dismotilidade esofágica em pacientes com esôfago de barrett?

ABSTRACT 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.

RESUMO Objetivo: avaliar a dismotilidade esofágica (DE) e a extensão do esôfago de Barrett (EB) antes e depois da fundoplicatura laparoscópica a Nissen (FLN) em pacientes previamente diagnosticados com EB e DE. Método: vinte e dois pacientes com EB diagnosticada por endoscopia digestiva alta (EDA) com biópsias e DE diagnosticada por manometria esofágica convencional (MEC) foram submetidos a FLN, e acompanhados por avaliações clínicas, endoscopia digestiva alta com biópsias e MEC, por no mínimo 12 meses após o procedimento cirúrgico. Resultados: dezesseis pacientes eram do sexo masculino (72,7%) e seis do feminino (27,3%). A média de idade foi de 55,14 (± 15,52) anos e o seguimento pós-operatório médio foi de 26,2 meses. A endoscopia digestiva alta mostrou que o comprimento médio do EB foi de 4,09 cm no pré-operatório e 3,91 cm no pós-operatório (p = 0,042). A avaliação da dismotilidade esofágica por meio da manometria convencional mostrou que a mediana pré-operatória da pressão de repouso do esfíncter esofágico inferior (PREEI) foi de 9,15 mmHg, e de 13,2 mmHg no pós-operatório (p = 0,006). A mediana pré-operatória da amplitude de contração esofágica foi de 47,85 mmHg, e de 57,50 mmHg no pós-operatório (p = 0,408). A avaliação pré-operatória do peristaltismo esofágico mostrou que 13,6% da amostra apresentava espasmo esofágico difuso e 9,1%, motilidade esofágica ineficaz. No pós-operatório, 4,5% dos pacientes apresentaram espasmo esofágico difuso, 13,6% de aperistalse e 22,7% de atividade motora ineficaz (p = 0,133). Conclusões: a FLN diminuiu a extensão do EB, aumentou a pressão de repouso do EEI e aumentou a amplitude da contração esofágica distal; no entanto, não foi capaz de melhorar a DE.

Overview and perspectives about the robotic surgical certification process in Brazil: the new statement and a national web-survey / Visão geral e perspectivas sobre o processo de certificação em cirurgia robótica no Brasil: o novo regimento e uma pesquisa nacional online

ABSTRACT Objective: to appraise the general profile of the Brazilian robotic surgeon and the acknowledgment of the new certification process for robotic surgery upon the Associação Médica Brasileira (AMB - Brazilian Medical Association) statement. According to the AMB statement, medical societies and proctors have to achieve leading roles in training and certification of surgeons, acting in partnership with industry. Methods: a national web-based survey was promoted by the Colégio Brasileiro de Cirurgiões (CBC - Brazilian College of Surgeons) among their members. Results: the 294 answers were split into two groups: 133 (45.3%) who had robotic console certification, and 161 (54.8%) who did not have it. The overall median age was 46, but the non-robotic group presented more surgeons with at least 30 years of experience than to the robotic group (32.3% versus 23.3%, p=0.033). Surgeons with robotic certification more frequently work in a city with at least one million inhabitants than surgeons who were not certified (85.7 versus 63.4%, p<0.001). The majority of surgeons in both groups have similar positioning for all main points of the statement. However, the agreement proportions for the preceptors responsibility during the procedures were higher among non-robotic surgeons that expected the preceptor to assume co-responsibility for the procedure (85% versus 60.9%, p<0.001), and intervene during the procedure as much as necessary (97.5% versus 91.7%, p=0.033). Conclusion: the overall agreement of the answers to the AMB statement seems to be a promising pathway to increase the participation of the medical entities into the robotic certification in Brazil.

RESUMO Objetivo: avaliar o perfil do cirurgião robótico brasileiro e seu reconhecimento sobre o novo processo de certificação para cirurgia robótica que consta na declaração da Associação Médica Brasileira (AMB). De acordo com a declaração da AMB, as sociedades médicas e os preceptores devem alcançar papéis de liderança no treinamento e certificação de cirurgiões, atuando em parceria com a indústria. Métodos: uma pesquisa nacional pela Internet foi promovida pelo Colégio Brasileiro de Cirurgiões com seus membros. Resultados: entre as 294 respostas, os cirurgiões foram divididas em dois grupos: 133 (45,3%) que possuíam certificação de console robótico e 161 (54,8%) que não possuíam. A média geral de idade foi de 46 anos, mas o grupo não robótico teve mais cirurgiões com pelo menos 30 anos de experiência (32,3% versus 23,3%, p = 0,033). Cirurgiões com certificação robótica trabalhavam mais frequentemente em cidades mais populosas, com pelo menos um milhão de habitantes (85,7 versus 63,4%, p <0,001). A maioria dos cirurgiões de ambos os grupos tem posicionamento semelhante para todos os pontos principais da declaração. No entanto, as proporções de concordância para a responsabilidade do preceptor durante os procedimentos foram maiores entre os cirurgiões não robóticos que esperavam que o preceptor assumisse corresponsabilidade pelo procedimento (85% versus 60,9%, p <0,001), e que intervenha , tanto quanto necessário (97,5% versus 91,7%, p = 0,033). Conclusão: a aceitação por parte da maioria dos profissionais em relação à declaraçãoda AMB parece ser caminho promissor para aumentar a participação das entidades médicas na certificação robótica no Brasil.

Exposure of splenic hilum increases safety of laparoscopic splenectomy.

Laparoscopic splenectomy is becoming the gold standard technique for the treatment of hematological disorders of the spleen. Hemostasis is a fundamental step during laparoscopic splenectomy leading some authors to develop several techniques to control splenic vessels such as hand assistance, preoperative splenic artery embolization, and the use of vascular linear staplers. However, intraoperative bleeding is usually due to inadequate exposure of the hilar splenic vessels itself. The authors describe a standardized technique for the exposure of splenic pedicle using an endoscopic triangular retractor. We have been used this technique in 16 consecutive laparoscopic splenectomies with minimal blood loss. The present technique may increase the safety of laparoscopic splenectomy with adequate exposure of the splenic hilum reducing the conversion rate and intraoperative blood loss.

Comparative study of two modes of gastroesophageal reflux measuring: conventional esophageal pH monitoring and wireless pH monitoring.

CONTEXT: Esophageal pH monitoring is considered to be the gold standard for the diagnosis of gastroesophageal acid reflux. However, this method is very troublesome and considerably limits the patient's routine activities. Wireless pH monitoring was developed to avoid these restrictions. OBJECTIVE: To compare the first 24 hours of the conventional and wireless pH monitoring, positioned 3 cm above the lower esophageal sphincter, in relation to: the occurrence of relevant technical failures, the ability to detect reflux and the ability to correlate the clinical symptoms to reflux. METHODS: Twenty-five patients referred for esophageal pH monitoring and with typical symptoms of gastroesophageal reflux disease were studied prospectively, underwent clinical interview, endoscopy, esophageal manometry and were submitted, with a simultaneous initial period, to 24-hour catheter pH monitoring and 48-hour wireless pH monitoring. RESULTS: Early capsule detachment occurred in one (4%) case and there were no technical failures with the catheter pH monitoring (P = 0.463). Percentages of reflux time (total, upright and supine) were higher with the wireless pH monitoring (P < 0.05). Pathological gastroesophageal reflux occurred in 16 (64%) patients submitted to catheter and in 19 (76%) to the capsule (P = 0.355). The symptom index was positive in 12 (48%) patients with catheter pH monitoring and in 13 (52%) with wireless pH monitoring (P = 0.777). CONCLUSIONS: 1) No significant differences were reported between the two methods of pH monitoring (capsule vs catheter), in regard to relevant technical failures; 2) Wireless pH monitoring detected higher percentages of reflux time than the conventional pH-metry; 3) The two methods of pH monitoring were comparable in diagnosis of pathological gastroesophageal reflux and comparable in correlating the clinical symptoms with the gastroesophageal reflux.

Clinical evaluation of oropharyngeal dysphagia in Machado-Joseph disease.

CONTEXT: In Machado-Joseph disease, poor posture, dystonia and peripheral neuropathy are extremely predisposing to oropharyngeal dysphagia, which is more commonly associated with muscular dystrophy. OBJECTIVE: To evaluate the clinical characteristics of oropharyngeal dysphagia in Machado-Joseph disease patients. METHOD: Forty individuals participated in this study, including 20 with no clinical complaints and 20 dysphagic patients with Machado-Joseph disease of clinical type 1, who were all similar in terms of gender distribution, average age, and cognitive function. The medical history of each patient was reviewed and each subject underwent a clinical evaluation of deglutition. At the end, the profile of dysphagia in patients with Machado-Joseph disease was classified according to the Severity Scale of Dysphagia, as described by O'Neil and collaborators. RESULTS: Comparison between dysphagic patients and controls did not reveal many significant differences with respect to the clinical evaluation of the oral phase of deglutition, since afflicted patients only demonstrated deficits related to the protrusion, retraction and tonus of the tongue. However, several significant differences were observed with respect to the pharyngeal phase. Dysphagic patients presented pharyngeal stasis during deglutition of liquids and solids, accompanied by coughing and/or choking as well as penetration and/or aspiration; these signs were absent in the controls. CONCLUSIONS: Oropharyngeal dysphagia is part of the Machado-Joseph disease since the first neurological manifestations. There is greater involvement of the pharyngeal phase, in relation to oral phase of the deglutition. The dysphagia of these patients is classified between mild and moderate.

Endobronchial ultrasound application for diagnosis of tracheobronchial tree invasion by esophageal cancer.

INTRODUCTION: Esophageal cancer staging has been performed through bronchoscopy, computerized tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS). Whereas CT and PET scan provide assessments of distant metastasis, bronchoscopy importantly diagnoses tracheobronchial involvement, complementing chest CT findings. EUS is the most accurate examination for T and N staging but is technically limited when tumoral stenoses cannot be traversed. Endobronchial ultrasound (EBUS) appears to present greater accuracy than EUS, CT, and bronchoscopy for assessing tracheobronchial wall involvement. EBUS has been recently associated with EUS for esophageal cancer staging in our unit. OBJECTIVE: To compare EBUS findings in esophageal cancer patients without evident signs of tracheobronchial invasion on conventional bronchoscopy with EUS and CT. METHODS: Fourteen patients with esophageal cancer underwent CT, conventional bronchoscopy, EUS, and EBUS for preoperative staging. All patients underwent EBUS and EUS with an Olympus(R) MH-908 echoendoscope at 7.5 MHz. Seven patients were eligible for the study according to the inclusion criteria. RESULTS: The echoendoscope could not traverse tumoral esophageal stenosis to perform EUS in two patients, and invasion was effectively diagnosed by EBUS. In 4 (57%) of 7 patients EBUS revealed additional information to staging. In the remaining 3 cases the invasion findings were the same under both EUS and EBUS. CONCLUSION: EBUS showed signs of tracheobronchial invasion not observed by conventional bronchoscopy, adding information to staging in most of the cases when compared with CT and EUS.

Preoperative gastric acid secretion and the risk to develop Barrett's esophagus after esophagectomy for chagasic achalasia.

INTRODUCTION: The aim of this study was to determine the contribution of preoperative gastric secretory and hormonal response, to the appearance of Barrett's esophagus in the esophageal stump following subtotal esophagectomy. METHODS: Thirty-eight end-stage chagasic achalasia patients submitted to esophagectomy and cervical gastric pull-up were followed prospectively for a mean of 13.6 +/- 9.2 years. Gastric acid secretion, pepsinogen, and gastrin were measured preoperatively in 14 patients who have developed Barrett's esophagus (Group I), and the results were compared to 24 patients who did not develop Barrett's esophagus (Group II). RESULTS: In the group (I), the mean basal and stimulated preoperative gastric acid secretion was significantly higher than in the group II (basal: 1.52 vs. 1.01, p = 0.04; stimulated: 20.83 vs. 12.60, p = 0.01). Basal and stimulated preoperative pepsinogen were also increased at the Group I compared to Group II (Basal = 139.3 vs. 101.7, p = 0.02; stimulated = 186.0 vs. 156.5, p = 0.07. There was no difference in preoperative gastrin between the two groups. Gastritis was present during endoscopy in 57.1% of the Group I, while it was detected in 16.6% of the Group II, p = 0.014. CONCLUSIONS: Barrett's esophagus in the esophageal stump was associated to high preoperative levels of gastric acid secretion, serum pepsinogen, and also gastritis in the transposed stomach.