Management of postoperative complications in gastric cancer.

Surgery is the only curative strategy for gastric cancer management and radical resection with free margins and extended lymphadenectomy seems to be the best option. Morbidity rate is usually associated with surgical treatment in about 24% of patients, and mortality in about 3%. These rates are influenced by tumor staging, patient condition, surgical strategies and surgeon experience. Their management is mostly conservative and outcome is favorable in the majority of cases. Improvement in gastric cancer treatment must consider experienced surgeons and adequate patient selection.

Larger amounts of nitrite and nitrate-reducing bacteria in megaesophagus of Chagas' disease than in controls.

In the megaesophagus of Chagas' disease, chronic esophagitis is caused by stasis of swallowed food and saliva. In this environment, the overgrowth of aerobic and anaerobic bacteria, including nitrate-reducing bacteria, is observed. The reduction of nitrate into nitrite by the action of these bacteria has been associated with the formation of volatile nitrosamines in different situations of gastric bacterial overgrowth. We have hypothesized that this phenomenon could occur in the esophageal lumen of patients with megaesophagus. To evaluate the concentration of nitrite, the presence of volatile nitrosamines and the concentration of nitrate-reducing bacteria in the esophageal lumen of patients with non-advanced megaesophagus of Chagas' disease and in a group of patients without esophageal disease. Fifteen patients with non-advanced megaesophagus [megaesophagus group (MG)] and 15 patients without any esophageal disease [control group (CG)] were studied. Saliva samples were taken for nitrate and nitrite quantitative determination and esophageal stasis liquid samples were taken for nitrate and nitrite quantitative determination, volatile nitrosamines qualitative determination and reductive bacteria quantitative determination. MG and CG were equivalent in nitrate and nitrite saliva concentration and in nitrate esophageal concentration. Significant difference was found in nitrite (p = 0.003) and reductive bacteria concentration (p < 0.0001), both higher in MG. Volatile nitrosamines were identified in three MG patients and in none of the CG patients, but this was not significant (p = 0.113). There is a higher concentration of reductive bacteria in MG, responsible for the rise in nitrite concentration at the esophageal lumen and, eventually, for the formation of volatile nitrosamines.

Robotic assisted spinal surgery--from concept to clinical practice.

After several years of product development, animal trials and human cadaver testing, the SpineAssist--a miniature bone-mounted robotic system--has recently entered clinical use. To the best of the authors' knowledge, this is the only available image-based mechanical guidance system that enables pedicle screw insertion with an overall accuracy in the range of 1 mm in both open and minimally invasive procedures. In this paper, we describe the development and clinical trial process that has brought the SpineAssist to its current state, with an emphasis on the various difficulties encountered along the way and the corresponding solutions. All aspects of product development are discussed, including mechanical design, CT-to-fluoroscopy image registration, and surgical techniques. Finally, we describe a series of preclinical trials with human cadavers, as well as clinical use, which verify the system's accuracy and efficacy.

Predicting recurrence after curative resection for gastric cancer: External validation of the Italian Research Group for Gastric Cancer (GIRCG) prognostic scoring system.

BACKGROUND: Most nomograms for Gastric Cancer (GC) were developed to predict overall survival (OS) after curative resection. The Italian Research Group for Gastric Cancer (GIRCG) prognostic scoring system (PSS) was designed to predict the recurrence risk after curative treatment based on pathologic tumor stage and treatment performed (D1-D2/D3 lymphadenectomy). This study was carried out to externally validate the GIRCG's PSS. PATIENTS AND METHODS: Adopting the same criteria used by GIRCG to build the PSS, 185 patients with GC operated with curative intention were selected. The median follow-up period was 77.8 months (1.93-150.8) for all patients and 102.5 months (60.9-150.8) for patients free of disease. The NRI (net reclassification improvement) was calculated to estimate the overall improvement in the reclassification of patients using the PSS in place of the TNM stage system. RESULTS: GC recurrence occurred in 70 (37.8%) patients. The mean time to recurrence was 22.2 (range 1.9-98.1) months. For patients with recurrence, the gain in the proportion of reclassification was 0.257 (p < 0.001), indicating an improvement of 26%. For patients without recurrence, the gain in the proportion of reclassification was -0.122 (p < 0.001), indicating a worsening of 12%. The NRI calculated was 0.135 (p = 0.0527). CONCLUSION: The GIRCG's PSS, which predicts the likelihood of recurrence after radical surgical treatment for GC, is more accurate than TNM system to predict recurrence mainly for high-risk patients. Yet, the PSS does not have the same effectiveness for low-risk patients, overestimating the chance of recurrence occurs even for disease-free patients.

Intermittent left bundle branch block (LBBB) as a clinical manifestation of myocardial contusion after blunt chest trauma.

Injury to the heart in blunt chest trauma is dependent on a number of factors. Symptoms are often non-specific, and there is no gold standard test for diagnosis. Injuries to small areas of the myocardium may only be identified at autopsy. We report a 38 year old man who sustained a number of injuries in a road traffic accident, and in whom the single clinical or ECG abnormality was a left bundle branch block (LBBB); he had a myocardial injury rated as grade II. The patient was treated for his injuries and later discharged. As this is a difficult diagnosis, algorithms of blunt chest trauma may save time and money by avoiding misleading diagnosis and unnecessary monitoring and admissions.

Resection for achalasia of the esophagus.

One hundred and twenty-two patients with advanced mega-esophagus managed by esophagectomy without thoracotomy and cervical gastroplasty were evaluated. Sixty-nine patients were followed up for periods of 6 months to 16 years. Clinical assessment included X-ray studies and endoscopy of the cervical esophagus and mobilized stomach. The most common postoperative complications were pleural effusion (22.1%) and cervical fistula (8.2%). Mortality was 4.18%. Regurgitation was the most frequent complaint in the late follow-up, followed by heartburn. Both symptoms were related to esophagitis and diffuse gastritis. Diarrhea and dumping also occurred due to vagotomy and pyloromyotomy performed at the same time as esophagectomy. The endoscopic study demonstrated esophagitis in 25.5% of the patients, and diffuse erosive gastritis in 12.7%. The symptoms and late complications were handled by clinical measures and careful endoscopic follow-up. Gastroplasty was considered a good procedure for replacing the esophagus, solving the serious problem of dysphagia and for providing nutritional improvement for the patient.

The treatment of portal hypertension by videolaparoscopy in situs inversus totalis.

A rare case of a 32-year-old male with situs inversus totalis viscerum admitted to hospital for hematemesis owing to portal hypertension of Laennec cirrhosis was treated for the first time by videolaparoscopic surgery. Situs inversus diagnosis was confirmed by thoracic radiography, electrocardiogram, echocardiogram, abdominal echography and computed tomography. Upper gastrointestinal endoscopy showed esophageal varices and large varices in the fundus of the stomach. A successful operation (azygo-portal disconnection, splenic artery ligation without splenectomy; transesophageal suturing of esophageal varices without opening the esophagus and cholecystectomy), was performed by videolaparoscopy. The uneventful postoperative evolution (4-day hospitalization) reinforces the viability of the videolaparoscopic approach and the possibility of the application of this procedure even to situs inversus totalis organorum.

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.

Pre-and postoperative nutritional evaluation in patients with chagasic megaesophagus.

Chagasic megaesophagus is a chronic disease that courses with progressive dysphagia, regurgitation and protein-calorie malnutrition. Advanced or recurrent megaesophagus can be treated with Serra Dória's operation (cardioplasty, partial gastrectomy and gastrojejunal Roux-en-Y anastomosis). A nutritional evaluation was performed on 27 patients (mean age 58 +/- 10 years) with chagasic megaesophagus at admission and after postoperative day 90. The nutritional state was assessed through global subjective nutritional evaluation (GSNE), anthropometry and laboratorial exams, besides the analysis of alimentary intake. In the preoperative period, GSNE pointed to malnutrition in 2/3 patients, while the anthropometric and laboratorial evaluation revealed that over 60% of the patients had protein-calorie malnutrition of the marasmic type. The preoperative nutritional state as evaluated by GSNE did not correlate with complications or postoperative mortality. The postoperative evaluation showed an increase in the intake of proteins, recovery in the body mass index and a reduction in the hemoglobin levels of the peripheral blood.

[The prognostic value of cholesterol levels in malnourished patients with esophageal carcinoma]. / Interés pronóstico de los niveles de colesterol en pacientes malnutridos con carcinoma esofágico.

A variety of clinical calculations, including serum cholesterol, have been used as parameters of prognostic value in surgical populations, but there are few studies aimed at patients with esophageal carcinoma. In a set of patients with established esophageal cancer, cholesterol and triglyceride levels were recorded, along with the following parameters: age, sex, body weight, serum albumin, total lymphocytes, and hemoglobin concentration. Manual grip strength was measured, along with delayed cutaneous hypersensitivity response, and the type of surgical treatment was distinguished (palliative versus radical). Total complications and postoperative hospitalisation time are the main indicators used in our study for the surgical results. Patients were divided into two groups: those with serum cholesterol levels over 150 mg/dl (Group I) and those under that figure (Group II). Most nutritional and functional values were lower in Group II patients, for whom the radical surgery rate was also lower, with greater postoperative morbidity. It was concluded that 1): Cholesterol depletion is associated with nutritional and immunological alterations and 2) post-surgical results are poorer in patients with levels below 150 mg/dl.

Laparoscopic cholecystectomy in children and adolescents.

During the period between August 1991 and November 1995, seven patients under age 17 were submitted to videolaparoscopic cholecystectomy (LC). Two were males and five females with ages ranging from 12 to 16 years (mean 13.8 years). The diagnosis of chronic cholecystitis with gallstones was made by the clinical history and physical and ultrasonographic examinations. There was no evidence of an association with hemolytic diseases, familial hyperlipidemia or Glucose-6-phosphate dehydrogenase (G6PD) deficiency. The surgery was performed under general anesthesia and the abdomen approached by four ports: a 10 mm umbilical incision, a 5 mm cystic, a 5 mm one at the xiphoid appendix and a 10 mm one at the left lateral margin of the left rectus abdominal muscle between the umbilical scar and the xiphoid appendix. Operative time averaged 120 minutes (105-150 min). One case required conversion to laparotomic approach because of Mirizzi's Syndrome, which was diagnosed by intraoperative cholangiography performed in all cases. There were no deaths or major postoperative complications. Hospital stays ranged from 1-3 days in the six patients submitted to LC. Thus LC in children can be considered a good method, requiring only more care regarding the use of proper equipment, complete and careful dissection of the biliary hilus, and intraoperative cholangiography. The latter is indispensable, as these children can present a higher rate of anatomic anomalies. The advantages of this techniques include a less painful postoperative period with a faster recovery, and it is especially recommended in children, who are less tolerant to physical restriction and pain than adults.

[The importance of age as determining factor in hiatus hernia and gastroesophageal reflux. Cross-sectional study]. / Importância do fator etário no determinismo da hérnia hiatal por deslizamento e a doença do refluxo gastroesofagiano. Estudo transversal.

This prospective study involve a total of 77 patients distributed according age. The patients were divided in three groups: Group A > or = 14 e < or = 24, Group B > or = 25 e < or = 54, and Group C > or = 55 e < or = 64 years old. Each group of patients had similar alterations in 24 h-pHmetry parameters such as total episodes number, number of episodes with duration more than 5 minutes, the longest episode, Johnson and DeMeester Score, reflux patterns (orthostatic or supine or combined) (P > 0.05 NS). The hiatal hernia was present in 10.00% of the patients between 14 and 24 years old, 43.40% between 25 and 54 years old, and 64.29% between 55 and 64 years old (P < 0.0001). The conclusion is that hiatal hernia do not participate in gastroesophageal reflux disease etiopathogenesis. Although the older age is a risk factor for development of gastroesophageal reflux disease complications, it is speculated if the continuous acid aggression in the distal esophagus in patients with gastroesophageal reflux disease is the only factor responsible for the higher incidence of hiatal hernia in patients with 55 and 64 years old than the younger groups of patients.

[Relationship between 24 h ambulatory esophageal pHmetry and upper digestive endoscopy in reflux esophagitis patients]. / Relação entre pHmetria esofagiana ambulatorial de 24 h e endoscopia digestiva alta em pacientes portadores de esofagite de refluxo.

The reflux gastroesophageal patients can be divided in three patterns, according with ambulatorial esophageal 24 h-pHmetry: orthostatic, which the reflux episodes occur when the patients are upright; supine, which the reflux episodes occur when the patients are sleeping; combined, when the reflux episodes are both observed in upright or lay down position. There are presented 56 patients with endoscopic reflux esophagitis who are divided according to the patterns of reflux by 24 h-pHmetry. The results are similar to those of international reports. Complicated esophagitis is more common in the combined refluxers following by supine refluxers. In the orthostatic refluxers were not observed complicated esophagitis. The 24 h-pHmetry is an useful tool for clinical use and prognosis in the gastroesophageal reflux disease.

[Histological criteria of esophagitis in the gastroesophageal reflux disease. Reevaluation of the sensitivity of the esophageal 24-hours pHmetry]. / Critérios histológicos de esofagite na doença do refluxo gastroesofágico. Reavaliação da sensibilidade da pHmetria esofágica de 24 horas.

Little change was observed in the histological criteria of reflux esophagitis since the studies of Ismail-Beiji, Pope (1970) and Weinstein (1975). The 24-hour esophageal pHmetry has been proposed as a high sensitivity method in diagnosis of gastroesophageal reflux disease patients. In this study we selected 35 patients with histological esophagitis and submitted them to 24-hour esophageal pHmetry. We determined histological differences according to reflux pattern, endoscopic esophagitis grades and age. The sensitivity of 24-hour esophageal pHmetry was 60.0% in our patients. There are higher histological alterations in patients with more severe patterns of reflux (supine and combined) and significant difference (P < 0.05) in observed quantitative exocytosis between moderate and severe endoscopic esophagitis. There are no difference between histological esophagitis criteria and age groups.

Histopathology of the common bile duct in choledocholithiasis.

The histology of the common bile duct was studied in 45 patients with choledocholithiasis and/or papillitis and compared with a control group of ten cadavers without hepatic or biliary disease. Choledochitis was diagnosed in 44. Only one patient presented a histologically normal duct. The inflammatory process was characterized by proliferation of connective tissue and loss of elastic fibers, cellular infiltration of lymphocytes and polymorphonuclear leukocytes, and atrophic dilatation or hyperplasic glandular changes. Choledochitis was divided in two types: chronic and acute-chronic, and according to the intensity of the inflammatory process was also classified in slight, moderate or severe. No correlation was found between choledocholithiasis and/or papillitis and type and intensity of choledochitis.

[Spontaneous perforation of the cecum without colonic obstruction. Report of 3 cases]. / Perfuração espontânea do ceco sem obstrução cólica. Relato de três casos.

Spontaneous perforation of the colon without obstruction is related to intestinal and extra intestinal diseases, mainly gynecological procedures. Its etiology is unknown, and there are many theories. Because of its diagnosis peculiarities, as well as its rarity, and mainly the severity of the disease, the authors describe three cases, relating the necessity of early diagnosis and correct surgical treatment.

[Gastroesophageal reflux disease: comparison between patients with and without esophagitis, concerning age, gender and symptoms]. / Doença do refluxo gastroesofágico: comparação entre as formas com e sem esofagite, em relação aos dados demográficos e às manifestações sintomáticas.

BACKGROUND: Patients with gastroesophageal reflux disease may or may not have endoscopic esophagitis; there are few studies comparing these groups among themselves. OBJECTIVES: This study was designed in order to evaluate differences between patients with gastroesophageal reflux disease with and without esophagitis. PATIENTS/METHODS: A hundred and twenty-two patients with gastroesophageal reflux disease characterized by esophageal endoscopy and pHmetry were included, 90 with and 32 without esophagitis. Assessment involved an anamnesis, including the following data: age, sex, heartburn, dysphasia, non-cardiac chest pain and respiratory symptoms. Heartburn was analyzed in more detail, its duration, intensity and periodicity being determined. RESULTS: No statistical significant difference was observed between the groups, regarding age, sex or presence of symptoms. However, in the group with esophagitis, heartburn classified as severe or very severe was more frequent. CONCLUSIONS: 1. The groups of patients with or without esophagitis analyzed were very similar concerning age, gender and presence of symptoms. However, regarding the heartburn's intensity, it was more intense in the group with esophagitis. 2. Among patients with gastroesophageal reflux disease, there is a large number of cases without esophagitis (26.2%) and that prolonged pH-monitoring is fundamental in its identification; 3. A better definition of reflux disease, esophagitis and pathological reflux is needed, in order to allow better diagnostic accuracy and comparisons in different studies on this subject.

Regeneration of esophageal epithelium in the presence of gastroesophageal reflux.

The esophageal mucosa in twelve dogs was excised from the distal third of the esophagus together with a surgical procedure to provoke gastroesophageal reflux. A longitudinal segment containing all the layers of the wall of the esophagogastric junction was removed intraoperatively in all dogs. It was determined that in this segment, the transition of the columnar and squamous epithelia and the apex of the inferior sphincter of the esophagus, which is perfectly individualized in the dog except for few variations, were at the same level. During the postoperative period, the dogs were randomly divided into two groups according to the time of sacrifice. Group I was killed after 30 days and Group II after 60. Serial sections of the autopsy specimen were taken at the level of the esophagogastric junction, in order to determine the way in which the esophageal epithelium regenerates in the presence of gastroesophageal reflux. The apex of the inferior sphincter of the esophagus was used as a fixed parameter of the esophagogastric transition, even in the absence of its epithelial lining. Postoperatively the dogs presented varying lengths of the inferior third of the esophagus relined with columnar epithelium. The epithelium originates either from the gastric epithelium itself, or from the ducts of the submucosal glands of the esophagus. The histologic aspect of the regenerated columnar epithelium varied from simple columnar epithelium to a well-differentiated epithelium resembling gastric mucosa. These studies reinforce the concept that columnar epithelium lining the terminal esophagus may be acquired due to reepithelization in an acid medium, of a previously injured esophageal epithelium.

Squamous cell carcinoma of the esophagus and multiple primary tumors of the upper aerodigestive tract.

Squamous cell carcinoma of the esophagus is frequently associated with other, synchronous or metachronous tumors, in the upper aerodigestive tract. All 264 patients with squamous cell carcinoma of the esophagus, treated in the Gastrointestinal Surgery, Esophagus section, of the "Hospital das Clínicas" (São Paulo University Medical School, Brazil), between 1979 and 1989 were analyzed retrospectively with regards to the occurrence of multiple primary tumors in the upper aerodigestive tract. Multiple primary tumors were encountered in 10 (3.8%) patients. All patients were male and the mean age at the time of the first primary was 52.2 years. Tobacco smoke and alcohol were the principal carcinogens in these patients (n = 10). The sites of the tumors were: larynx (n = 4), tongue (n = 4), lung (n = 2), and oral cavity (n = 1). Two simultaneous, three synchronous and five metachronous multiple primary carcinomas were detected. The esophagus was the second primary tumor in nine patients. The mean overall survival after the diagnosis of the second primary was 2.8 months (SD = 0.89). Inquiry regarding other malignancies, associated with panendoscopy should be carry out prior to the treatment of the first primary to diagnose simultaneous or synchronous primary tumors, and careful follow-up should be performed after treatment of the first primary to detect new tumors in these high-risk patients.