The Clinical Efficacy, and Long-Term Outcomes Between Pneumatic Dilation and Laparoscopic Heller Myotomy in Achalasia.

Introduction: Achalasia is the most well-known motility disorder, characterized by the lack of optimal relaxation of the lower esophageal sphincter during swallowing and the absence of peristalsis of the esophageal body. Laparoscopic Heller esocardiomyotomy (LHM) and pneumatic dilation (PD) were the main treatment options for achalasia. Currently, the therapeutic methods are complemented by per-oral endoscopic myotomy (POEM). Materials and Methods: we performed a retrospective study, analyzing the data and evolution of 98 patients with achalasia, admited and treated in the General and Esophageal Surgery Clinic of the St. Mary Clinical Hospital-Bucharest between January 2016 and June 2023. The treatment was performed by PD in 25 cases and the majority LHM. The average duration of symptoms in the case of PD was 48 months, and 24 months in LHM. The patients were evaluated before and after the treatment procedures by the Eckardt clinical score and investigations such as timed barium esophagogram (TBO) and esophageal manometry. Results: Although patients had the same Eckardt score before treatment, a statistically significant decrease of the Eckardt score was obtained at the post-therapeutic evaluation after undergoing LHM compared to PD. Recurrence of symptoms was more frequent in the case of PD, requiring another therapeutic intervention. The cost of treatment, as well as the number of hospitalization days were reduced in the case of PD. Conclusions: The treatment of achalasia with LHM is more effective regarding recurrence of symptoms, even if it involves higher costs and a longer hospital stay compared to DP.

Management of Chylothorax in Esophageal Surgery by Minimally Invasive Thoracoscopic Approach: Case Series.

Chylothorax is a rare complication, especially after esophageal cancer surgery. It may occur mainly in the thoracic stage of esophagectomy. The management of chylothorax is usually conservative, surgical reoperation with thoracic duct ligation being reserved for those cases refractory to that treatment. We discuss issues of diagnosis and therapeutic attitude, as evidenced by the literature, although a general consensus has not been established, most likely due to the low frequency of this complication. We emphasize the minimally invasive thoracoscopic approach, as it has been applied for two cases with this type of complication. A high rate of suspicion for thoracic duct injury should be maintained in all patients after esophageal surgery, with any pleural effusion entering the differential diagnosis of chylothorax.

Management of Esophageal Perforations During Achalasia Treatment Experience of the General and Esophageal Surgery Clinic, Sf Maria Hospital.

Introduction: Achalasia is a motility disorder characterized by the absence of optimal relaxation of the lower esophageal sphincter (LES) with swallowing and lack of peristalsis of the esophageal body. Excepting temporary medical options, the treatment aims to lower the LES pressure by endoscopic or surgical means. Either method involves a risk of perforation. We analyzed the management of esophageal perforations in patients who received treatment for achalasia. Material and Method: we conducted a retrospective study of patients with achalasia hospitalized and treated in the Clinic of General and Esophageal Surgery within the Sf. Maria Clinical Hospital in Bucharest between January 2016 and December 2021. Results: There were 57 patients, 35 men, with a mean age of 50 years and a mean duration of symptoms of 35 months. Almost all (91.89%) patients presented with dysphagia. Preoperative manometry was performed in 52 patients, of whom 17 were type I, 35 were type II. The treatment was laparoscopic Heller eso-cardiomyotomy (LHM) in most cases (55), with Dor anterior fundoplication. There were 10 recurrent cases after dilation or surgery in another medical unit. There were 3 mucosal perforations after LHM. The treatment varied from simple suture to a combined endoscopic and surgical approach, involving the use of esophageal stent, abscess drainage, and feeding jejunostomy. We also present the management of two cases of esophageal perforation after endoscopic dilation, in which the support of the surgical team was necessary. Conclusion: Esophageal perforation in the treatment of achalasia, either endoscopic or surgical, requires immediate identification and treatment to provide the best chance of favorable evolution. The treatment of achalasia is indicated to be performed in dedicated centers, prepared even in case of complications.

Paracolostomy Evisceration: Short Review and a New Case Report.

Introduction: Diverting ostomy is a commonly perfomed procedure but may be associated to its own morbidity (early or late complications). Colostomy-related evisceration is a rare but potentially life threatening condition (requiring emergency surgery), relatively undocumented for its mechanisms. Case report: A male aged 84 was admited for chronic low digestive occlusion due to a locally advanced, stenosing, rectal adenocarcinoma. Prior to neoadjuvant therapy, a loop sigmoidostomy was indicated using a left iliac open aproach, with no preparation of the colic content. The sigmoid was loaded with hard stools. The parietal breach was reaproximated by 2 monofilament nylon sutures, fascial and colocutaneus fixation. Colostomy was opened two days later, but was not functional (postoperative paralytic ileus). Parastomal evisceration of ileum in day 3, dehiscence of parietal suture. Emergency operation, using the same aproach. Results: Favourable outcome. Thoraco-abdominal CT scan: N0,M0. Pelvic MRI: proliferative mass of inferior and middle rectum, involving mesorectum fascia, levator ani and a few regional lymphatic nodes. Radio-chemotherapy and abdomino-perineal resection. Pathologic result: colorectal adenocarcinoma, G2, ypT1ypN0, ICD-O: 8140/3. Conclusions: We rewiewed 8 case reports published since 2011, equally distributed as late or early complications. There was no connection with the princeps indication (colorectal cancer in half of cases); neither related to topography (transverse or sigmoid) or type of colostomy (loop or end). Occurence of the complication is not time-dependent (5 to18 months in late, 3 to 12 days for early eviscerations). The main premise is colostomy itself (a place of reduced parieto-abdominal resistence), stressed by increassed intra-abdominal pressure (eg. bronchopulmonary disease, digestive obstruction). Predisposing factors for late evisceration seems to be related to spontaneous rupture of parastomal hernia/colostomy prolapse. As for early evisceration, both technical details and surgical strategy must be considered (indequate fixation; creation of a larger than necessary colostomy aperture).

Diagnosis and Therapeutic Management in Postcholecistectomy Alithiasic Cholangitis.

Introduction:The objective of the current retrospective study is to present the results of a personal research on the prevalence and treatment of alithiasic cholangitis in hospitalized patients. Material and methods:The research was based on the following criteria: case selection according to gender, age and diagnosis, anamnesis information, clinical, paraclinical, imagery and laboratory investigation methods, therapeutic approach. Results:Between 2016-2018, 109 cases had a discharge diagnosis of postcholecystectomy cholangitis following clinical and paraclinical examinations. In a large percentage, cholangitis was alithiasic, imagery assessments showing only a dilation of the intra- and/or extra-hepatic biliary ducts (81 cases, 91.01%). Conclusions:Alithiasic cholangitis has been the main biliary cause in the postcholecystectomy pathology in this reference study (91.01%). In hospitalized people with alithiasic cholangitis as main diagnosis, highlighted endoscopic retrograde cholangiopancreatography (ERCP) represented a modern therapeutic approach; this allows the improvement of sphincter Oddi functional disorders through sphincterotomy/sphincteroplasty (6.75%).

The suspensory apparatus and digital flexor muscles of the llama (Lama glama) 1: The thoracic limb / El aparato suspensorio y los músculos flexores digitales de la llama (Lama glama) 1: El miembro torácico

The digital flexor muscles of the thoracic limb of four llamas were dissected and illustrated to provide data about the suspensory (support) apparatus and weight bearing structures. An extensive literature search was performed and yielded incomplete information about these anatomical structures. The popularity of the llama world wide as a domesticated animal used for show and fiber has increased in the recent years. It is helpful to describe the anatomy fully to aid in understanding of the species and treatment of pathologic conditions. The description of the anatomical structures and the original illustrations demonstrate genuine peculiarities and differences between the llama and domestic ruminants. In llamas, the three heads of the deep digital flexor muscle (DDF) originate and connect with each other in a very peculiar combination, with one tendon receiving an attachment from the flexor carpi ulnaris muscle (FCU). The superficial digital flexor muscle (SDF) has a thin tendon which is fused with the palmar fascia and then broadens. There are no interflexor muscles. Additionally, unexpected lumbricalis muscles are found in the distal limb and vary in number between the fore and hind limb. The anatomy of the suspensory apparatus in the thoracic limb is evaluated in this paper.

Fueron disecados e ilustrados los músculos flexores digitales del miembro torácico de cuatro llamas con la finalidad de aportar datos sobre el aparato suspensor (de apoyo) que soportan estas estructuras. Se realizó una extensa búsqueda bibliográfica dada la incompleta información existente de estas estructuras anatómicas. La popularidad de la llama en todo el mundo como uno de los animales domésticos utilizados ha aumentado en los últimos años. Es importante describir detalladamente la anatomía de esta especie para su tratamiento en condiciones patológicas. La descripción de las estructuras anatómicas y las ilustraciones originales demuestran peculariedades genuinas y diferencias entre la llama y los rumiantes domésticos. En llamas, las tres cabezas del músculo flexor profundo de los dedos se originan y se conectan entre ellas en una muy peculiar combinación, con uno de los tendones recibiendo un fascículo del músculo flexor ulnar del carpo. El músculo flexor superficial de los dedos tiene un tendón delgado el cual se fusiona con la fascia palmar y luego se amplía. No existen músculos interflexores. Adicionalmente, fueron encontrados músculos lumbricales en la extremidad distal y variaban en número entre los miembros. Finalmente, en este trabajo se evalúa el aparato suspensorio del miembro torácico.

The suspensory apparatus and digital flexor muscles of the llama (Lama glama) 2: The pelvic limb / El aparato suspensorio y los músculos flexores digitales de la llama (Lama glama) 2: El miembro pélvico

This paper provides data (text and illustrations) about the digital flexor muscles of the pelvic limb and the / metatarsophalangeal joint, evaluating the suspensory (support) apparatus and weight bearing structures. Similar to the above mentioned paper, a literature search provided incomplete information about these anatomical structures. As in the thoracic limb, unique anatomically variations exist in the pelvic limb of the llama. The caudal tibial muscle is fused with the lateral head of the deep digital flexor muscle (DDF), and the soleus muscle is missing. A symmetrical unexpected lumbricalis pedis muscle was found; the tendons are fusing with the axial branches of the lateral tendon of the long digital extensor muscle. A quadratus plantae muscle, also unexpected is present on the medial aspect of the tarsal region. The superficial digital flexor muscle (SDF) resembles that of the domestic ruminants. The metacarpo/ metatarsophalangeal joints, referred to as the fetlock joints (FJ) are very different from those of the domestic ruminants. Particular structures were found and they will be described and illustrated in the text. The anatomy of the suspensory (support) apparatus in the pelvic limb is evaluated in this paper.

El presente artículo ofrece datos (texto e ilustraciones) sobre el músculo flexor digital del miembro pélvico y la articulación metatarsofalángica, evaluando el aparato suspensorio (de apoyo) y el peso que soportan estas estructuras. La literatura proporciona información incompleta acerca de estas estructuras anatómicas. Al igual que en el miembro torácico, existen variaciones anatómicamente únicas en el miembro pélvico de la llama. El músculo tibial caudal se fusiona con la cabeza lateral del músculo flexor digital profundo (FDP), y el músculo soleo no existía. Fue encontrada una simetría inesperada del músculo lumbrical del pie; los tendones se encontraban fusionados con las ramas axiales del tendón lateral del músculo extensor digital largo. Un músculo cuadrado plantar, se encontraba presente en la cara medial de la región tarsal. El músculo flexor digital superficial (FDS) se asemeja al de rumiantes domésticos. Las articulaciones metacarpo/metatarsofalángicas, denominadas articulaciones del nudillo (AN) son muy diferentes de las de rumiantes domésticos. Fueron encontradas estructuras particulares que se describen e ilustran en el texto. Se evalúa la anatomía del aparato suspensorio (de apoyo) en el miembro pélvico.