Laparoscopic total fundoplication is superior to medical treatment for reducing the cancer risk in Barrett's esophagus: a long-term analysis.

The present study aims to compare the effectiveness of surgical and medical therapy in reducing the risk of cancer in Barrett's esophagus in a long-term evaluation. A prospective cohort was designed that compared Barrett's esophagus patients submitted to medical treatment with omeprazole or laparoscopic Nissen fundoplication. The groups were compared using propensity score matching paired by Barrett's esophagus length. A total of 398 patients met inclusion criteria. There were 207 patients in the omeprazole group (Group A) and 191 in the total fundoplication group (Group B). After applying the propensity score matching paired by Barrett's esophagus length, the groups were 180 (Group A) and 190 (Group B). Median follow-up was 80 months. Group B was significantly superior for controlling GERD symptoms. Group B was more efficient than Group A in promoting Barrett's esophagus regression or blocking its progression. Group B was more efficient than Group A in preventing the development of dysplasia and cancer. Logistic regression was performed for the outcomes of adenocarcinoma and dysplasia. Age and body mass index were used as covariates in the logistic regression models. Even after regression analysis, Group B was still superior to Group A to prevent esophageal adenocarcinoma or dysplasia transformation (odds ratio [OR]: 0.51; 95% confidence interval [CI]: 0.27-0.97, for adenocarcinoma or any dysplasia; and OR: 0.26; 95% CI: 0.08-0.81, for adenocarcinoma or high-grade dysplasia). Surgical treatment is superior to medical management, allowing for better symptom control, less need for reflux medication use, higher regression rate of the columnar epithelium and intestinal metaplasia, and lower risk for progression to dysplasia and cancer.

The 2018 ISDE achalasia guidelines.

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Comparative evaluation of esophageal Barrett's epithelium through esophageal capsule endoscopy and methylene blue chromoendoscopy.

BACKGROUND: Patients presenting with Barrett's esophagus (BE) should be under life-long surveillance in an attempt to detect cancer in its early stages. Esophageal capsule endoscopy (ECE) is a new technique that enables a noninvasive evaluation of the esophagus. AIMS: To evaluate ECE effectiveness compared with methylene blue (MB) chromoendoscopy for the detection of esophageal lesions in which there was suspicion of cancer, the length and pattern of BE, and the presence of hiatal hernia. MATERIAL AND METHODS: Twenty-one patients with BE who underwent Nissen fundoplication and had a follow-up period of more than five years were prospectively enrolled in the study. The patients underwent ECE and chromoendoscopy with MB performed by different physicians who were blinded to each of the procedures. RESULTS: ECE sensitivity, negative predictive value, and accuracy were 100%, 100%, and 79%, respectively, for the detection of esophageal lesions suspected of cancer. ECE accuracy in assessing BE length was 89% and in the evaluation of finger-like projections, circumferential BE, and mixed BE was 74%, 79%, and 74%, respectively. In relation to hiatal hernia detection, ECE sensitivity was 43% and its accuracy was 74%. CONCLUSIONS: ECE appears to be a good method for detecting lesions in which there is suspicion of esophageal cancer and it had modest results in regard to the accurate identification of BE length and pattern. ECE is not a good method for detecting hiatal hernia. Further studies are needed in order to define the definitive role of ECE in BE monitoring.

Use of multiple channel pH monitoring for evaluation of ultra-distal reflux in patients after fundoplication for treatment of Barrett's esophagus.

Dysplasia and esophageal adenocarcinoma may arise in patients with Barrett's esophagus after fundoplication esophageal pH monitoring showing no acid in esophagus. This suggests the need to develop methodology to evaluate the occurrence of ultra-distal reflux (1cm above the LES). The objective of the study was to compare acid exposition in three different levels: 5cm above the upper border of the LES, 1cm above the LES and in the intrasphincteric region. Eleven patients with Barrett's esophagus after Nissen fundoplication with no clinical, endoscopic and radiologic evidence of reflux were selected. Four-channel pH monitoring took place: channel A, 5cm above the upper border of the LES; channel B, 1cm above the LES; channel C, intrasphincteric; channel D, intragastric. The results of channels A, B and C were compared. There was significant increase in number of reflux episodes and a higher fraction of time with pH <4.0 in channel B compared to channel A. There was significant decrease in fraction of time with pH <4.0 in channel B compared to channel C. Two cases of esophageal adenocarcinoma were diagnosed in the studied patients. The region 1cm above the upper border of the LES is more exposed to acid than the region 5cm above the upper border of the LES, although this exposure occurred in reduced levels. The region 1cm above the upper border of the LES is less exposed to acid than the intrasphincteric region.

Facial soft tissue changes after transverse palatal distraction in adult patients.

This longitudinal study investigated the 3-D facial soft-tissue response to transverse palatal bone-anchored osteodistraction in 18 adult patients. Laser-scanned facial surface data were obtained for all patients before (T(0)), 6 months (T(1)) and 1 year (T(2)) after transverse palatal distraction. The averaged facial morphologies at T(0), T(1) and T(2) were calculated and compared. Sagittal and vertical measurements were obtained from lateral cephalograms to evaluate skeletal and dental movements. Pre- and immediate post-distraction dental casts were used to investigate transverse maxillary movements. Cutaneous changes were mainly observed in the paranasal regions and cheeks, in the range 1-3 mm, reflecting the underlying increase in the maxillary width. A significant enlargement of the nasal base was also demonstrated. The absolute magnitude of these facial changes was limited but clinically relevant. Variable skeletal movements were observed. These were of low magnitude and no systematic tendency could be demonstrated statistically. Significant changes were documented only with regard to orthodontic repositioning of the upper and lower incisors. The mean transverse increases in the maxillary dental arch were 6.7 mm at the intercanine, 6.8 mm at the interpremolar, and 6.1 mm at the intermolar levels.

Diagnosis and treatment of retrobulbar haematomas following blunt orbital trauma: a description of eight cases.

Retrobulbar haematoma following blunt orbital trauma is a rare, but potentially serious, complication, since it can evolve rapidly from visual impairment to permanent loss of vision. This sight-threatening situation most commonly arises from orbital bleeding accompanying undisplaced fractures of the orbital walls, an event that increases the pressure inside the orbit and results in vascular damage to the optic nerve. The clinical presentation includes pain, exophthalmos with proptosis, and internal ophthalmoplegia, with impairment or loss of the pupillary reflex. A thin-layer orbital CT scan is an essential diagnostic aid. Any delay between the onset of symptoms and treatment can have a significant effect on functional recovery. Therapy is based on orbital decompression, via different surgical approaches, with the intention of reducing the pressure on the nerve and vascular structures inside the orbit. This paper presents eight cases of retrobulbar haematoma and their follow-up, in detail.

Intrasphincteric botulinum toxin injection in the treatment of chagasic achalasia.

According to the WHO, 16-18 million people in Central and South America are infected by Trypanosoma cruzi. Chagasic achalasia affects between 7.1% and 10.6% of the population. The aim of this study was to evaluate the effects of Botox injections in the clinical response and esophageal function of patients with dysphagia due to chagasic achalasia. In total, 24 symptomatic patients with chagasic achalasia were randomly chosen to receive Botulinum Toxin (BT) or saline injected by endoscopy in the lower esophageal sphincter (LES). Patients were monitored with a clinical score of dysphagia and an objective assessment (esophagograms, scintillography, manometry, and nutritional assessment) for a period of 6 months. Clinical improvement of dysphagia was statistically significant (P < 0.001) in patients receiving BT when compared with the placebo. There was no significant difference in the placebo group regarding clinical score, LES basal pressure and esophageal emptying time. Esophageal emptying time in the toxin group was significantly lower than in the placebo (P=0.04) after 90 days. There were non-significant increases in esophageal emptying of 25.36% and 17.39%, respectively, at 90 and 180 days, in the BT group (P=0.266). Gender, age, and baseline LES pressure did not influence the response to BT. Our data strongly suggests that intrasphincteric injection of BT in LES is clinically effective in the treatment of chagasic achalasia.

[Facial anthropometry and aesthetic perception in young italian subjects: their use for orthognatic surgery]. / Antropometria e percezione estetica del volto in un campione di popolazione italiana. Considerazioni ai fini della chirurgia ortognatica.

BACKGROUND: Aesthetic requests of patients undergoing orthognatic surgery have increased over time and represent nowadays the leading subjective motivation for the patient and a major aim of the treatment for the surgeon. In this regard, anthropometric evaluation has considerably improved the diagnostic capacity of the orthodontist and of the surgeon. Aim of the study is to provide the orthognatic surgeon with anthropometric normal values based on a sample of aesthetically pleasant Italian subjects and to discuss the use of a simplified aesthetical analysis in the set-up of the surgical plan and in the evaluation of treatment outcome. METHODS: The present study analyses 94 Italian subjects, by means of anthropometric measurements on photographic images, considering 28 facial proportions and 33 angular values. These figures were compared with the aesthetic judgement provided by 3 common observers and 3 orthodontists. The aesthetic score was attributed on a subjective discrete scale (common observer: above average/average/below average; orthodontist: eumorphic/ dismorphic). Data were also compared with similar evaluations on North-American and African subjects reported in the international literature. RESULTS: This study confirms the sexual dismorphism and the ethnic variability already reported by other Authors and documents specific morphological characters in the Italian population. CONCLUSIONS: The described method appears acceptably simple and consistent for clinical application. Its use in orthognatic surgery may provide objective and reproducible data for evaluating the aesthetic outcome of treatment.

Videolaparoscopic cholecystectomy. Analysis of the clinical and functional aspects of mechanical lifting of the abdominal wall.

BACKGROUND: Mechanical lifting of the abdominal wall, a method based on traction and consequent elevation of the abdominal wall, is an alternative procedure to create enough intra-abdominal space necessary for videolaparoscopic surgery, dispensing the need for intraperitoneal gas insufflation. OBJECTIVE: This study aims to evaluate the technical feasibility of this procedure to carry out a videolaparoscopic cholecystectomy, while analyzing the clinical and functional aspects of this technique. PATIENTS AND METHODS: In the Digestive Tract Surgery Discipline of the Medical School at the University of São Paulo, São Paulo, SP, Brazil, was created the equipment to perform videolaparoscopic surgery using this method. The equipment has two sections: an external part which consisted of a frame attached to the operating table, inside which there is a sliding steel cable, moved by a ratched which is located at the lower end of one of the frame rods; the internal rod, the support, has an "L" shape, and its horizontal branch is made up of three turning rods and which is connected to the steel cable after insertion into the abdominal cavity. Ten patients underwent videolaparoscopic cholecystectomy using this equipment. The time taken to install the equipment, the operating area characteristics, the interference from the lifting equipment on surgical movements and on the intra-operative cholangiography, the measurements made of the force used during traction and extension of the abdominal wall elevation, and the medication required for postoperative analgesia were all evaluated. RESULTS: There were no intra-operative complications, and in none of the cases was it found necessary to convert to open surgery. We considered the insertion a safe and uncomplicated procedure, and the traction system efficient. Apart from the elevation of the abdominal wall, the distribution of the viscera inside the abdominal cavity is fundamental for the operating area. Depending on the position of the epigastric trocar, the lifting equipment can interfere with the surgical instruments mobility. It may be necessary to reposition the support to perform the intra-operative cholangiography. The tensional force applied to the peritoneal surface by the lifting rods is small, and no additional postoperative pain was observed using this procedure. CONCLUSION: These results show that using the equipment described in this study, mechanical lifting of the abdominal wall is a feasible alternative for undertaking videolaparoscopic cholecystectomy.

Gastroesophageal reflux disease: clinical, endoscopic, and intraluminal esophageal pH monitoring evaluation.

One hundred and twenty-two patients with gastroesophageal reflux disease were studied (90 with and 32 without esophagitis) with the objective of analyzing possible differences between those with and without esophagitis. Evaluation consisted of clinical interview, endoscopy of the high digestive tract, esophageal manometry, and pH monitoring. There was no significant difference between the groups in age, sex, or symptoms. The incidence of hiatal hernia was greater in the group with esophagitis. Although the frequency of motor changes was similar, the type of anomaly was different. The reflux pattern was very similar in both groups. Therefore, the concept of reflux disease, esophagitis, and pathological reflux still needs a broader definition for greater diagnostic precision and for comparing the results of different studies on the subject. Normal reflux (confirmed using pH esophageal monitoring) in 12.2% of patients with esophagitis suggests that other factors are implicated in the etiology of the disease besides those measured using this examination.

[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.

Tumor necrosis factor (TNF alpha) in lymphadenopathy and bone marrow involvement: histopathological and serological study.

Serum samples were collected from 40 patients with enlarged lymph nodes. Lymph node and bone marrow biopsies were performed and processed as usual. Tumor necrosis factor-alpha (TNF alpha) was determined in the sera by factor test human TNF alpha ELISA kit. Histopathological studies of lymph node and bone marrow biopsies were evaluated. The data obtained from this study showed that bone marrow was involved in only 5 patients and their TNF showed the lowest level in this study with a mean level 50 pg/ml. The highest level of TNF occurred in cases with granulomatous lymphadenitis (124 pg/ml) followed by reactive lymphadenitis (105 pg/ml). It can be considered that TNF reflects the immune status of the patient and its study in the serum can be of help in evaluating the progress of the disease. An extended study is need to evaluate the role of TNF-alpha as a prognostic marker in malignancy.

Quimioprofilaxia da esquistossomose: atividade moluscicida de produtos naturais - ensaios com caramulos adultos e desovas. / Chemoprophylaxis of schistosomiasis: molluscacidal activity of natural products - assays with adult snails and oviposition

Sao apresentados os dados relativos a atividade moluscicida de 159 extratos, de 84 plantas brasileiras, sobre Biomphalaria glabrata, o mais importante hospedeiro intermediario do Schistosoma mansoni no Brasil. Setenta e oito (49,0%) dos extratos mostraram atividade contra caramujos ou desovas, porem, somente vinte e nove (18,2%)foram ativos sobre ambos. Os extratos de duas especies de vegetais (Mikania hirsutissima e Qualea multiflora) foram letais aos caramujos adultos, na concentracao de 10 ppm

Substituicao do esofago cervical por autotransplante de intestino delgado - aspectos tecnicos e experimentais. / Replacement of the cervical esophagus by autotransplantation of the small intestine - technical and experimental aspects

Os autores apresentam a sistematizacao tecnica do autotransplante do intestino delgado,em substituicao ao esofago cervical, em caes.Sao analisados 20 caes, nos quais a intervencao foi praticada, verificando-se apenas um caso de necrose do enxerto, com seguimento de 10 animais por um periodo de 30 a 60 dias. A incidencia de fistulas cervicais foi de 30%, e estenose a esse nivel de 10%. Conclui-se que esta modalidade tecnica e exequivel com recursos tecnicos rotineiros, abrindo-se amplas perspectivas para o seu emprego clinico

Esofagectomia sub-total no tratamento do acometimento esofagico pela esclerose sistemica progressiva (E.S.P.). / Subtotal esophagectomy in the treatment of progressive systemic sclerosis of the esophagus

Sao apresentados dois casos de esofagite de refluxo com extensa sub-estenose do esofago distal, em pacientes com esclerose sistemica progressiva. Os estudos radiologicos e o eletromanometrico indicaram intensas alteracoes nas funcoes do esofago, tanto na atividade de transporte de alimento (expressa pela ausencia de contracao do orgao em resposta a degluticao), como de contencao do refluxo gastro-esofagico (ausencia de registro ao exame eletromanometrico correspondente ao esfincter inferior do esofago), e pela prova de refluxo acido positiva. Considerando a impossibilidade de recuperacao da funcao do esofago, foi indicada a realizacao de esofagectomia sub-total,com reconstituicao do transito mediante gastro-esofago anastomose na regiao cervical, seguida de piloroplastia. O procedimento foi realizado sem toracotomia, pela abertura do diafragma e transposicao do estomago atraves do mediastino posterior. O ato cirurgico ocorreu sem incidentes e ao final do 10o dia, ambos os pacientes passaram a alimentar-se por via oral,sem qualquer dificuldade. Os autores comentam as razoes desta indicacao operatoria, assinalando as vantagens da tecnica empregada, que nao exige toracotomia, e utiliza o estomago para o restabelecimento do transito, o que evita a pratica de maior numero de anastomoses e de suas eventuais complicacoes