Frequency of Human Papillomavirus Detection in Chagasic Megaesophagus Associated or Not with Esophageal Squamous Cell Carcinoma.

BACKGROUND: Chagasic megaesophagus (CM) as well as the presence of human papillomavirus (HPV) has been reported as etiological factors for esophageal squamous cell carcinoma (ESCC). OBJECTIVE: We assessed the prevalence of HPV DNA in a series of ESCCs associated or not with CM. Data obtained were further correlated to the pathological and clinical data of affected individuals. METHODS: A retrospective study was performed on 92 formalin-fixed and paraffin-embedded tissues collected from patients referred to 3 different hospitals in São Paulo, Brazil: Barretos Cancer Hospital, Barretos, São Paulo; Federal University of Triângulo Mineiro, Uberaba, Minas Gerais; and São Paulo State University, Botucatu, São Paulo. Cases were divided into 3 groups: (i) 24 patients with CM associated with ESCC (CM/ESCC); (ii) 37 patients with ESCC without CM (ESCC); and (iii) 31 patients with CM without ESCC (CM). Detection of HPV DNA was assessed in all samples by a genotyping assay combining multiplex polymerase chain reaction and bead-based Luminex technology. RESULTS: We identified a high prevalence of high-risk HPV in patients in the CM group (12/31, 38.8%) and CM/ESCC (8/24, 33.3%), compared to individuals in the ESCC group (6/37, 16.3%). The individuals in the groups with cancer (ESCC and CM/ESCC) had a higher frequency of HPV-16 (4/9, 44.5% and 2/8, 25.0%). The other types of high-risk HPVs detected were HPV-31, 45, 51, 53, 56, 66, and 73. We also observed in some samples HPV coinfection by more than one viral type. Despite the high incidence of HPV, it did not show any association with the patient's clinical-pathological and molecular (TP53 mutation status) characteristics. CONCLUSION: This is the first report of the presence of HPV DNA in CM associated with ESCC. HPV infection was more presence in megaesophagus lesions. Further studies are needed to confirm and better understand the role of persistent HPV infection in patients with CM.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT.

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

Ten years of IRCAD, Barretos, SP, Brazil.

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

Transcutaneous electrical nerve stimulation is superior than placebo and control for postoperative pain relief.

Aim: To determine whether transcutaneous electrical nerve stimulation (TENS) is more efficient than placebo TENS and control groups for pain relief. Design: Randomized, single-blinded, placebo-controlled trial. Setting & participants: A total of 78 adults with postoperative pain, after cholecystectomy, at the University Hospital. They were randomized into active TENS, placebo TENS and control. Intervention: A total of 30-min interventions applied in the first 24 h after the surgery. Outcome: Pain intensity. Results: Pain significantly decreased for both TENS; however, the active TENS was better. A decrease of 2 points or more on the visual analog scale for 53.8% active TENS and 11.5% placebo. Conclusion: There was a greater reduction in pain of important clinical relevance in the active TENS group. Clinical Trial registration: Brazilian Clinical Trial (REBEC): RBR-6cgx2k.

Biliary tract reconstruction using jejunal tube: an experimental study in dogs.

BACKGROUND: To physiologically reconstruct the biliary tract, Crema et al suggested the application of the Monti principle to the biliary tract, already used in humans for the urinary tract. With this technique, a jejunal segment is transversely retubularized. This study aimed to evaluate the efficacy of jejunal tube interposition between the common bile duct and duodenum in dogs. METHODS: Thirteen dogs underwent a laparoscopic common bile duct ligature, followed by a biliodigestive connection by jejunal tube interposition after one week. The levels of glutamic-pyruvic and glutamic-oxalacetic transaminases, total bilirubins, alkaline phosphatase and gamma-glutamyltransferase were assessed before surgery and thereafter weekly until euthanasia, which was performed 6 weeks after biliodigestive connection. RESULTS: Data on 9 dogs were analyzed statistically. The dogs presented with obstructive jaundice after common bile duct ligature, as confirmed by biochemical examination. They showed a statistically significant reduction in cholestasis after biliodigestive connection by jejunal tube interposition and were healthy until the end of the experiment. CONCLUSION: A statistically significant reduction was seen in total bilirubin and canalicular enzymes (alkaline phosphatase and gamma-glutamyltransferase) in the 9 dogs 6 weeks after biliodigestive connection by jejunal tube interposition.

COMPARATIVE EVALUATION OF MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY AND PERIOPERATIVE CHOLANGIOGRAPHY IN PATIENTS WITH SUSPECT CHOLEDOCHOLITHIASIS.

BACKGROUND: Cholelithiasis is a highly prevalent condition, and choledocholitiasis is a high morbidity complication and requires accurate methods for its diagnosis. AIM: To evaluate the population of patients with suspected choledocholitiasis and check the statistical value of magnetic resonance cholangiopancreatography, ultrasonography, the laboratory and the clinic of these patients comparing them to the results obtained by perioperative cholangiography. METHODS: This is a retrospective cohort study, which were evaluated 76 patients with cholelithiasis and suspected choledocholithiasis. RESULTS: It was observed that the presence of dilatation of the biliary tract or choledocholithiasis in the ultrasonography was four and eight times increased risk of perioperative cholangiography for positive choledocholithiasis, respectively. For each unit increased in serum alkaline phosphatase was 0.3% increased the risk of perioperative cholangiography for positive choledocholithiasis. In the presence of dilatation of the bile ducts in the ultrasonography was four times greater risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. In the presence of pancreatitis these patients had five times higher risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. On the positive magnetic resonance cholangiopancreatography presence to choledocholithiasis was 104 times greater of positive perioperative cholangiography for choledocholithiasis. CONCLUSIONS: The magnetic resonance cholangiopancreatography is a method with good accuracy for propedeutic follow-up for the diagnosis of choledocholithiasis, consistent with the results obtained from the perioperative cholangiography; however, it is less invasive, with less risk to the patient and promote decreased surgical time when compared with perioperative cholangiography.

Analysis of the cellular immune response in patients with the digestive and indeterminate forms of Chagas' disease.

The commitment of the digestive organs observed in patients during the chronic phase of Chagas' disease is mainly attributed to neuronal damage induced by immune and inflammatory processes elicited by the presence of Trypanosoma cruzi. Here we compare the cellular immune response in patients with the digestive and indeterminate forms of Chagas' disease on the basis of lymphocyte proliferation and cytokine production after antigen or mitogen stimulation. No significant differences between patients groups were observed on proliferative response or on tumor necrosis factor (TNF)-alpha and interleukin (IL)-10 levels, although IL-10 achieves higher levels than TNF-alpha after T. cruzi antigen stimulation. Interferon (IFN)-gamma basal production was significantly higher in the digestive form and IL-4 was significantly higher in patients with megaesophagus when compared with patients with megacolon. These results indicated that patients with the digestive form of Chagas' disease do not suffer immune suppression and that the cytokine balance favors a strong inflammatory reaction in patients with the digestive form, which may contribute to lesions of the mioenteric nervous system.

Leiomyosarcoma of the inferior vena cava: a case report.

Leiomyosarcoma of the inferior vena cava is an extremely rare tumor that is characterized by a poor prognosis and nonspecific symptoms, a fact that may delay the diagnosis for several years. The only therapeutic modality proven to prolong the survival of patients is total surgical resection of the tumor. In this study, the authors report the case of a 50-year-old patient with a diagnosis of leiomyosarcoma of the inferior vena cava, affecting the middle and distal thirds, who was submitted to surgical treatment.

Innovative technique for the study of pneumoperitoneum in the evaluation of abdominal pain after chemical irritation with zymozan.

PURPOSE: To assess the influence of pneumoperitoneum in mice submitted to peritoneal irritation provoked by the biological agent Saccharomyces cerevisae, by counting the number of abdominal contractions elicited. METHODS: To study the effects of pneumoperitoneum analgesic action, 60 mice were divided into two groups: the experimental group, subjected to pneumoperitoneum; and the control group, without pneumoperitoneum. The both groups received intraperitoneal injection of zymosan at a dose of 1mg/0,2ml/mouse. RESULTS: The sum of the number of abdominal contractions of the experimental group (with pneumoperitoneum) was significantly lower than that of the control group (without pneumoperitoneum). In the experimental group, a lower number of contractions occurred in each min compared to the control. CONCLUSION: The observation of the analgesic effect of pneumoperitoneum using CO2 in mice submitted to peritoneal irritation by zymosan was verified.

PREVALENCE OF BACTERIOBILIA IN PATIENTS UNDERGOING ELECTIVE COLECYSTECTOMY.

BACKGROUND: Cholelithiasis is one of the diseases with greater surgical indication. Currently, laparoscopic cholecystectomy is the gold standard in the treatment of cholelithiasis. AIM: To analyze the culture of bile from patients with cholelithiasis, mainly in the occurrence of brown and mixed stones. METHODS: Was carried out a prospective study with 246 cases with biliary lithiasis who underwent elective laparoscopic cholecystectomy. Bile culture was performed in all. During anesthetic induction the patients received a single dose of intravenous cefazolin 1 g. At the end of the surgery, the gallbladder was punctured, its contents extracted and immediately placed in a sterile 20 ml propylene flask and promptly sent to bacterioscopy with Maconkey and blood agars. Incubation at 37° C for 24 h was carried out. A protocol was elaborated to include the main factors potentially related to cholelithiasis and the possible presence of associated bacterial infection. RESULTS: Of the 246 patients, 201 had negative bile culture and 45 positive. Of the 45 patients with bacteriobilia, 34 had growth of a single type of bacterium in bile culture and 11 more than one. CONCLUSIONS: It was observed a relationship between bacteriobilia and age, suggesting that age is a risk factor for bacteriobilia. The use of antibiotic prophylaxis in the elderly is therefore recommended.

Preservation of the vagus nerves in subtotal esophagectomy without thoracotomy.

PURPOSE: To evaluate the outcome of transhiatal esophagectomy without thoracotomy and with preservation of the vagal trunks for the treatment of advanced megaesophagus. METHODS: Between March 2006 and September 2017, it was performed 136 transhiatal esophagectomies without thoracotomy by laparoscopy, with preservation of the vagus nerves. All patients were evaluated pre and postoperatively for respiratory and nutritional aspects Post operatively, some surgical aspects were evaluated like radiology and endoscopy of the digestive tract. RESULTS: Follow-up for 7 months to 12 years by clinical, radiologic, endoscopic and pH monitoring revealed satisfactory and encouraging outcomes of the procedure. CONCLUSION: The laparoscopic transhiatal esophagectomy is a feasible and safe technique with good postoperative outcomes.

Combination of preoperative pulmonary and nutritional preparation for esophagectomy.

PURPOSE: To compare pulmonary and nutritional parameters before and after inspiratory muscle training (IMT) and enteral feeding support in patients with esophageal disease undergoing preoperative outpatient follow-up. METHODS: Thirty patients with a mean age of 55.83 years, 16 men and 14 women, were included. Pulmonary assessment consisted of the measurement of MIP, MEP, and spirometry. Anthropometric measurements and laboratory tests were performed for nutritional assessment. After preoperative evaluation, inspiratory muscle training and enteral nutrition support were started. A p<0.05 was considered statistically significant. RESULTS: After an outpatient follow-up period of 4 weeks, a significant increase in MIP (-62.20 ± 25.78 to -81.53 ± 23.09), MEP (73.4 ± 31.95 to 90.33 ± 28.39), and FVC (94.86 ± 16.77 to 98.56 ± 17.44) was observed. Regarding the anthropometric variables, a significant increase was also observed in BMI (20.18 ± 5.04 to 20.40 ± 4.69), arm circumference (23.38 ± 3.28 to 25.08 ± 4.55), arm muscle circumference (21.48 ± 3.00 to 22.07 ± 3.36), and triceps skinfold thickness (5.62 ± 2.68 to 8.33 ± 6.59). CONCLUSION: Pulmonary and nutritional preparation can improve respiratory muscle strength, FVC and anthropometric parameters. However, further studies are needed to confirm the effectiveness of this preoperative preparation.

Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy.

OBJECTIVE: to evaluate the pulmonary function of women submitted to conventional and single-port laparoscopic cholecystectomy. METHODS: forty women with symptomatic cholelithiasis, aged 18 to 70 years, participated in the study. We divided the patients into two groups: 21 patients underwent conventional laparoscopic cholecystectomy, and 19, single-port laparoscopic cholecystectomy. We assessed pulmonary function through forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the FEV1/FVC ratio, measured before and 24 hours after the procedure. RESULTS: in both groups, FVC and FEV1 were lower in the postoperative period than those obtained in the preoperative period, with a greater reduction in the group undergoing conventional laparoscopic cholecystectomy. Regarding the FEV1/FVC (%) values, there was no statistically significant difference in any of the groups or times analyzed. CONCLUSION: there was a greater decline in FVC and FEV1 in the postoperative group of patients submitted to conventional laparoscopic cholecystectomy.

PIK3CA mutations are frequent in esophageal squamous cell carcinoma associated with chagasic megaesophagus and are associated with a worse patient outcome.

BACKGROUND: Chronic diseases such as chagasic megaesophagus (secondary to Chagas' disease) have been suggested as etiological factors for esophageal squamous cell carcinoma; however, the molecular mechanisms involved are poorly understood. OBJECTIVE: We analyzed hotspot PIK3CA gene mutations in a series of esophageal squamous cell carcinomas associated or not with chagasic megaesophagus, as well as, in chagasic megaesophagus biopsies. We also checked for correlations between the presence of PIK3CA mutations with patients' clinical and pathological features. METHODS: The study included three different groups of patients: i) 23 patients with chagasic megaesophagus associated with esophageal squamous cell carcinoma (CM/ESCC); ii) 38 patients with esophageal squamous cell carcinoma not associated with chagasic megaesophagus (ESCC); and iii) 28 patients with chagasic megaesophagus without esophageal squamous cell carcinoma (CM). PIK3CA hotspot mutations in exons 9 and 20 were evaluated by PCR followed by direct sequencing technique. RESULTS: PIK3CA mutations were identified in 21.7% (5 out of 23) of CM/ESCC cases, in 10.5% (4 out of 38) of ESCC and in only 3.6% (1 case out of 28) of CM cases. In the CM/ESCC group, PIK3CA mutations were significantly associated with lower survival (mean 5 months), when compared to wild-type patients (mean 2.0 years). No other significant associations were observed between PIK3CA mutations and patients' clinical features or TP53 mutation profile. CONCLUSION: This is the first report on the presence of PIK3CA mutations in esophageal cancer associated with chagasic megaesophagus. The detection of PIK3CA mutations in benign chagasic megaesophagus lesions suggests their putative role in esophageal squamous cell carcinoma development and opens new opportunities for targeted-therapies for these diseases.

Presence of microsatellite instability in esophageal squamous cell carcinoma associated with chagasic megaesophagus.

AIM: The molecular pathogenesis of esophageal squamous cell carcinoma (ESCC) has been increasingly studied, but there is no report on the role of MSI in ESCC development associated with chagasic megaesophagus (CM).Results/methodology: In four ESCC/CM (4/19) we found microsatellite instability (MSI) alterations (21.1%), being three MSI-L (15.8%) and one MSI-H (5.3%). Four out of 35 ESCC cases showed MSI-L (11.4%) and only one out of 26 CM cases presented MSI-L (3.9%). The MSI-H was observed in an ESCC/CM patient that presents lack of MSH6 immunostaining corroborating deficiency in MMR pathway. Interestingly, the MSI-H ESCC/CM case also presented a deletion the HSP110 poly(T)17 gene. DISCUSSION/CONCLUSION: Taking together, we concluded that MSI is a rare event in esophageal squamous cell carcinoma, but can be associated with CM.

Gallbladder neuron count in cholelithiasis patients with and without Chagas disease.

Various investigators agree that the incidence of cholelithiasis is greater in patients with Chagas disease. The most plausible explanation for this is based on the parasympathetic denervation that occurs over the whole digestive tract due to Chagas disease. In order to analyze the occurrence of this alteration, gallbladder neuron counts were performed on cholelithiasis patients with and without Chagas disease who were being treated at the Department of Digestive Surgery, Universidade Federal do Triângulo Mineiro, Uberaba, Brazil. In the present study, a notable reduction in the number of neurons in the gallbladder wall was observed in Chagas patients, in comparison with non-Chagas subjects.

Proposal of a new technique for bile duct reconstruction after iatrogenic injury: study in dogs and review of the literature.

PURPOSE: Interposition of a jejunal tube between the common bile duct and duodenum. METHODS: Five adult mongrel dogs of both sexes, weighing on average 22.3 kg (18 to 26.5 kg), were used. Obstructive jaundice was induced by ligation of the distal common bile duct. After one week, a 2.5-cm long jejunal tube was fabricated from a segment of the loop removed 15 cm from the Treitz angle and interposed between the common bile duct and duodenum. RESULTS: The animals presented good clinical evolution and no complications were observed. After 6 weeks, complete integration was noted between the bile duct mucosa, tube and duodenum and a significant reduction in total bilirubin and alkaline phosphatase was observed when compared to the values obtained one week after ligation of the common bile duct. CONCLUSION: The jejunal tube interposed between the dilated bile duct and duodenum showed good anatomic integration and reduced total bilirubin and alkaline phosphatase levels in the animals studied.

Comparative analysis of preparation of human hepatocytes by the ethylenediamine tetraacetic acid and collagenase technique.

PURPOSE: To compare the viability of human hepatocytes dissociated by the ethylenediaminetetraacetic acid and collagenase techniques. METHODS: Hepatocytes were prepared by dissociation of liver fragments obtained from hepatectomies performed for therapeutic purposes at the Service of Digestive Tract Surgery, Federal University of Triângulo Mineiro. RESULTS: During the first 4 days of the experiment, 70% of the cells presented birefringent membranes and were not stained with 2% erythrosine, and were therefore considered to be viable. During the first 3 days, hepatocyte viability was on average 71% in the EDTA group and 76% in the collagenase group, with no significant difference between groups. No significant difference was observed between groups at any time. The secretion of albumin by the cultured hepatocytes was preserved up to the seventh day. Mean albumin secretion during the first 3 days was 50 microg/ml in the two groups and a reduction of albumin production was observed from the fourth to the seventh day. Again, no significant difference was observed between groups at any time. CONCLUSION: Cell viability and preservation of albumin secretion by hepatocytes are similar for the EDTA and collagenase techniques.

Ten years of IRCAD, Barretos, SP, Brazil

Minimally invasive surgery represented a significant milestone in modern surgery; however, continuous innovation and the emergence of new technologies pose new challenges in terms of surgical learning curves since new interventions are associated with increased surgical complexity and a higher risk of complications. For this reason, surgeons are aware of the beneficial effects of "learning before doing" and the importance of safely implementing new surgical procedures in order to obtain better patient outcomes. Considered the largest Latin American training center in minimally invasive surgery, IRCAD Barretos, São Paulo, Brazil, makes it possible to acquire surgical skills through training in different and the most complex areas of medicine, providing the experience of real and simulated situations, with focus on innovation. The center possesses state-of-the-art infrastructure and technology, with a very high-level teaching staff and an affectionate and hospitable reception. Since its inauguration, in 2011, the center has already qualified numerous professionals and has placed the country in a privileged position in terms of surgical knowledge. The present article describes the activities developed over these ten years of the institute in Brazil as the largest training center for surgeons of the continent in order to address the importance of surgical skills training.

Comparative study of respiratory muscle strength in women undergoing conventional and single-port laparoscopic cholecystectomy.

PURPOSE: To evaluate respiratory muscle strength (PImax and PEmax) before and 24 and 48 h after conventional and single-port laparoscopic cholecystectomy. METHODS: Forty women with symptomatic cholelithiasis (18 to 70 years) participated in the study. The patients were divided into two groups: 21 patients undergoing conventional laparoscopic cholecystectomy and 19 patients undergoing single-port laparoscopic cholecystectomy. Differences were considered to be significant when p<0.05. RESULTS: The results showed a greater decline in PImax after 24 h in the group submitted to conventional laparoscopic cholecystectomy, with a significant difference between groups (p=0.0308). CONCLUSION: Recovery of the parameters studied was more satisfactory and respiratory muscle strength was less compromised in the group submitted to single-port laparoscopic cholecystectomy.