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.

MANAGEMENT OF SYMPTOMS RECURRENCE AFTER MYOTOMY FOR ACHALASIA. A PRACTICAL APPROACH.

BACKGROUND: Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases. AIMS: This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy. METHODS: A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy. RESULTS: To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics. CONCLUSIONS: A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.

Advanced Cancer-A Bad Consequence of a Missed Follow-Up after ESD in Barrett's Esophagus.

Barrett's esophagus(BE)is a precursor to adenocarcinoma of the esophagogastric transition. Thus, endoscopic surveillance is essential for the early diagnosis of dysplasia and neoplasm, allowing proper therapeutic. However, during the COVID-19 pandemic, surveillance frequently failed. We present a case of a male, caucasian, 65 years old, patient with early adenocarcinoma in BE. Submitted an endoscopic resection, but due to the COVID-19 pandemic patient lost the follow-up endoscopic exams. Returned with a T3N1 adenocarcinoma esophagus in resection area. The present report illustrates the consequences of the failure in follow-up after submucosal resection in COVID-19 pandemic context.

Management of symptoms recurrence after myotomy for achalasia. a practical approach / Manejo da recidiva de sintomas após miotomia para acalasia. uma abordagem prática

ABSTRACT BACKGROUND: Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases. AIMS: This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy. METHODS: A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy. RESULTS: To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics. CONCLUSIONS: A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.

RESUMO RACIONAL: A acalasia é um distúrbio da motilidade esofágica e a miotomia é uma das técnicas de tratamento mais utilizadas. No entanto, a persistência ou recorrência dos sintomas ocorre em 9 a 20%. OBJETIVOS: Este estudo visa fornecer uma abordagem prática para o manejo da recorrência ou persistência dos sintomas de acalasia após miotomia. MÉTODOS: Foi realizada uma revisão crítica para reunir evidências para uma abordagem racional no manejo da recorrência ou persistência dos sintomas de acalasia após miotomia. RESULTADOS: Para o manejo adequado de um paciente com acalásia com sintomas significativos após miotomia, como disfagia, regurgitação, dor torácica e perda de peso, é necessário classificar os sintomas, estratificar a gravidade, realizar exames adequados e definir uma estratégia de tratamento. Uma investigação diagnóstica diferencial sistemática é essencial para cobrir as principais etiologias de recorrência ou persistência dos sintomas após a miotomia. A endoscopia digestiva alta e a radiografia digital dinâmica são os principais exames que podem ser aplicados para investigação. As opções de tratamento incluem dilatação endoscópica, POEM (miotomia endoscópica oral), remiotomia e esofagectomia, e a decisão deve ser baseada nas características individuais do paciente. CONCLUSÕES: Uma boa avaliação clínica e a utilização de exames adequados, juntamente com uma avaliação racional, são essenciais para o manejo da recorrência ou persistência dos sintomas após miotomia por acalasia.

Anti-reflux surgery for controlling respiratory symptoms of gastro-esophageal reflux disease: A systematic review and meta-analysis.

Gastro-esophageal reflux disease (GERD) patients have a higher prevalence of airway symptoms, such as chronic cough, wheezing, and hoarseness. The therapeutic management of patients with these symptoms is controversial. Therefore, this study aims to perform a systematic review and meta-analysis evaluating the efficacy of anti-reflux surgery for controlling respiratory symptoms related to GERD. A systematic review and meta-analysis was performed. Extraction of the data concerning proportions of participants who were not free of respiratory symptoms related to GERD (cough, wheezing, hoarseness) or not substantially improved at follow-ups (failure to cure) was performed. Of the 3,424 initially screened articles, 68 studies were included for systematic review and 61 were included for meta-analysis, with a cumulative sample size of 3,869 patients. Of all the included patients, after anti-reflux surgery, the general symptoms improvement was 80% (95% CI 75.2-84%). The numbers needed to harm (NNH) and the numbers needed to treat (NNT) were 15.21 and 1.23, respectively. Of the included patients, 83.4% (95% CI 78.3-87.5%) patients reported improvement in cough symptoms after surgery. For the wheezing symptom, 71.5% (95% CI 62.9-78.8%) reported improvement after surgery. Moreover, surgery presented better results in improving respiratory symptoms than medical therapy (risk difference: -0.46; 95% CI -0.77, -0.16). Physicians should strongly consider surgical anti-reflux procedures for controlling respiratory symptoms in GERD patients after proper patient selection. Anti-reflux surgery has shown high efficacy in improving respiratory symptoms related to GERD, even when compared to medical therapy.

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.

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.

A case report of esophageal heterotopic pancreas presenting as recurrent mediastinal abscess, treated by minimally invasive esophagectomy.

INTRODUCTION: Heterotopic pancreas is a rare congenital anomaly. We report a case of esophageal heterotopic pancreas complicated by recurrent mediastinal abscess and treated by minimally invasive resection. PRESENTATION OF CASE: A 31-year-old woman was admitted with a history of recurrent chest pain, dysphagia, and heartburn. CT scan revealed focal confined collection in the lower mediastinum surrounding esophagus. Endoscopic ultrasound revealed a subepithelial lesion. The patient was treated by minimally invasive esophagectomy and made an uneventful postoperative recovery. DISCUSSION: The management of subepithelial lesions would depend on their size, ability to exclude other etiologies and their associated symptoms. The patient, in this case, was obviously symptomatic and accurate differentiation from malignant etiologies could not be accurately made. CONCLUSION: Although pancreatic heterotopia is rare, it should be remembered in the differential diagnosis of various gastrointestinal lesions.

Prevalence of gallstones in 1,229 patients submitted to surgical laparoscopic treatment of GERD and esophageal achalasia: associated cholecystectomy was a safe procedure.

BACKGROUND: Association between esophageal achalasia/ gastroesophageal reflux disease (GERD) and cholelithiasis is not clear. Epidemiological data are controversial due to different methodologies applied, the regional differences and the number of patients involved. Results of concomitant cholecistectomy associated to surgical treatment of both diseases regarding safety is poorly understood. AIM: To analyze the prevalence of cholelithiasis in patients with esophageal achalasia and gastroesophageal reflux submitted to cardiomyotomy or fundoplication. Also, to evaluate the safety of concomitant cholecistectomy. METHODS: Retrospective analysis of 1410 patients operated from 2000 to 2013. They were divided into two groups: patients with GERD submitted to laparocopic hiatoplasty plus Nissen fundoplication and patients with esophageal achalasia to laparoscopic cardiomyotomy plus partial fundoplication. It was collected epidemiological data, specific diagnosis and subgroups, the presence or absence of gallstones, surgical procedure, operative and clinical complications and mortality. All groups/subgroups were compared. RESULTS: From 1,229 patients with GERD or esophageal achalasia, submitted to laparoscopic cardiomyotomy or fundoplication, 138 (11.43%) had cholelitiasis, occurring more in females (2.38:1) with mean age of 50,27 years old. In 604 patients with GERD, 79 (13,08%) had cholelitiasis. Lower prevalence occurred in Barrett's esophagus patients 7/105 (6.67%) (p=0.037). In 625 with esophageal achalasia, 59 (9.44%) had cholelitiasis, with no difference between chagasic and idiopathic forms (p=0.677). Complications of patients with or without cholecystectomy were similar in fundoplication and cardiomyotomy (p=0.78 and p=1.00).There was no mortality or complications related to cholecystectomy in this series. CONCLUSIONS: Prevalence of cholelithiasis was higher in patients submitted to fundoplication (GERD). Patients with chagasic or idiopatic forms of achalasia had the same prevalence of cholelithiasis. Gallstones occurred more in GERD patients without Barrett's esophagus. Simultaneous laparoscopic cholecystectomy was proved safe.

Prevalence of gallstones in 1,229 patients submitted to surgical laparoscopic treatment of GERD and esophageal achalasia: associated cholecystectomy was a safe procedure / Prevalência de colelitíase em 1.229 pacientes submetidos ao tratamento cirúrgico laparoscópico de DRGE e megaesôfago: a colecistectomia associada mostra-se segura

BACKGROUND: Association between esophageal achalasia/ gastroesophageal reflux disease (GERD) and cholelithiasis is not clear. Epidemiological data are controversial due to different methodologies applied, the regional differences and the number of patients involved. Results of concomitant cholecistectomy associated to surgical treatment of both diseases regarding safety is poorly understood. AIM: To analyze the prevalence of cholelithiasis in patients with esophageal achalasia and gastroesophageal reflux submitted to cardiomyotomy or fundoplication. Also, to evaluate the safety of concomitant cholecistectomy. METHODS: Retrospective analysis of 1410 patients operated from 2000 to 2013. They were divided into two groups: patients with GERD submitted to laparocopic hiatoplasty plus Nissen fundoplication and patients with esophageal achalasia to laparoscopic cardiomyotomy plus partial fundoplication. It was collected epidemiological data, specific diagnosis and subgroups, the presence or absence of gallstones, surgical procedure, operative and clinical complications and mortality. All groups/subgroups were compared. RESULTS: From 1,229 patients with GERD or esophageal achalasia, submitted to laparoscopic cardiomyotomy or fundoplication, 138 (11.43%) had cholelitiasis, occurring more in females (2.38:1) with mean age of 50,27 years old. In 604 patients with GERD, 79 (13,08%) had cholelitiasis. Lower prevalence occurred in Barrett's esophagus patients 7/105 (6.67%) (p=0.037). In 625 with esophageal achalasia, 59 (9.44%) had cholelitiasis, with no difference between chagasic and idiopathic forms (p=0.677). Complications of patients with or without cholecystectomy were similar in fundoplication and cardiomyotomy (p=0.78 and p=1.00).There was no mortality or complications related to cholecystectomy in this series. CONCLUSIONS: Prevalence of cholelithiasis was higher in patients submitted to fundoplication (GERD). Patients with chagasic or idiopatic ...

RACIONAL: São controversas as relações entre megaesôfago e doença do refluxo gastroesofágico (DRGE) com colelitíase, especialmente a forma mais adequada de conduzir pacientes com ambas. Dados epidemiológicos são díspares devido às diversas metodologias aplicadas, às diferenças regionais e à quantidade de pacientes envolvidos. OBJETIVO: Estudar a prevalência de colelitíase em pacientes submetidos às operações de refluxo gastroesofágico e megaesôfago (chagásicos ou não) e a segurança da colecistectomia estar associada. MÉTODO: Análise retrospectiva de 1410 pacientes operados entre 2000 e 2013. Eles foram divididos em dois grupos: os com DRGE e operados por hiatoplastia/fundoplicatura a Nissen laparoscópicas e os com acalásia por cardiomiotomia e fundoplicatura parcial laparoscópicas. Foram coletados dados epidemiológicos, diagnóstico, a presença ou não de litiase biliar, tratamento cirúrgico efetuado, complicações clínicas ou cirúrgicas e mortalidade. Todos os grupos e subgrupos foram comparados. RESULTADOS: Foram estudados 1229 pacientes portadores de megaesôfago e/ou DRGE, operados por fundoplicatura com hiatoplastia, nos casos de DRGE, e cardiomiectomia com fundoplicatura, nos casos de megaesôfago, no período de 2000 a 2013, verificando-se presença de colelítiase ou colecistectomia prévia. A colelítiase ocorreu mais no sexo feminino (2,38:1) e na faixa etária entre os 50 e 70 anos. A prevalência global foi de 11,43%; 13,08% na DRGE, menor nos portadores de esôfago de Barrett (6,67%) sendo a diferença significativa (p=0,037); e 9,44% no megaesôfago, não havendo diferença significativa entre os chagásicos e os idiopáticos (p=0,677). Não houve mortalidade ou complicações relacionadas à colecistectomia nesta série. CONCLUSÕES: A prevalência de colelitíase é maior nos pacientes com DRGE do que nos com megaesôfago. Não há diferenças na prevalência de colelitíase nos pacientes com megaesôfago chagásico e não chagásico. É mais frequente litíase ...

Improvement in quality-of-life after laparoscopic Nissen fundoplication.

CONTEXT: Evaluating quality of life after surgery for gastroesophageal reflux is fundamental, since improvement of symptoms is the main goal of treatment. OBJECTIVE: To compare the satisfaction of patients operated for GERD, interviewed at the office, with patients interviewed by telephone. METHODS: One hundred and seventy-eight patients were submitted to laparoscopic Nissen fundoplication. Ninety patients were found, and 45 agreed to come to the hospital's office. The other 45 patients were interviewed by telephone. Quality of life was evaluated using three methods: The GERD-HRQL questionnaire, translated to Portuguese; question "If you could choose it today, would you do surgery again?"; and question "If you could classify your symptom improvement between 0 and 10, which grade would you give?" Patients were divided in group A (office interview) and B (telephone interview). Statistical analysis was performed. RESULTS: The average GERD-HRQL score in group A was 6.29, while in group B was 14.09(P = 0.002). There was no statistical difference between groups A and B regarding patients choice of doing the surgery again(P = 0.714) and their grade of postoperative symptom improvement (P = 0.642). CONCLUSION: The overall postoperative satisfaction was high. The GERD-HRQL questionnaire might not be suitable for application by telephone in our population, and based on other analyzes, the satisfaction and quality of life of patients interviewed at the office or by telephone was similar.

Improvement in uuality-of-life after laparoscopic nissen fundoplicatoon / Avaliação da qualidade de vida após fundoplicatura laparoscópica à Nissen

Context Evaluating quality of life after surgery for gastroesophageal reflux is fundamental, since improvement of symptoms is the main goal of treatment. Objective To compare the satisfaction of patients operated for GERD, interviewed at the office, with patients interviewed by telephone. Methods One hundred and seventy-eight patients were submitted to laparoscopic Nissen fundoplication. Ninety patients were found, and 45 agreed to come to the hospital’s office. The other 45 patients were interviewed by telephone. Quality of life was evaluated using three methods: The GERD-HRQL questionnaire, translated to Portuguese; question “If you could choose it today, would you do surgery again?”; and question “If you could classify your symptom improvement between 0 and 10, which grade would you give?” Patients were divided in group A (office interview) and B (telephone interview). Statistical analysis was performed. Results The average GERD-HRQL score in group A was 6.29, while in group B was 14.09(P = 0.002). There was no statistical difference between groups A and B regarding patients choice of doing the surgery again(P = 0.714) and their grade of postoperative symptom improvement (P = 0.642). Conclusion The overall postoperative satisfaction was high. The GERD-HRQL questionnaire might not be suitable for application by telephone in our population, and based on other analyzes, the satisfaction and quality of life of patients interviewed at the office or by telephone was similar. .

Contexto A avaliação da qualidade de vida após a cirurgia para a doença do refluxo gastroesofágico é fundamental, pois a melhora dos sintomas é o principal objetivo do tratamento. Objetivo Verificar a satisfação dos pacientes após a cirurgia para doença do refluxo gastroesofágico, e comparar a aplicação ambulatorial e telefônica do questionário GERD-HRQL. Métodos Cento e setenta e oito pacientes foram submetidos à fundoplicatura laparoscópica à Nissen. Noventa pacientes foram encontrados e 45 puderam comparecer ao ambulatório. Os demais 45 pacientes foram entrevistados por telefone. A qualidade de vida foi avaliada por três métodos: o questionário GERD-HRQL, traduzido para o Português; pergunta “Se você pudesse escolher hoje, faria a cirurgia novamente?”; e pergunta: “Se você pudesse classificar sua melhora dos sintomas entre 0 e 10, que nota você daria?” Os pacientes foram divididos em grupo A (entrevista ambulatorial) e B (entrevista telefônica). Resultados A pontuação média do grupo A no questionário GERD-HRQL foi de 6,29, enquanto que no grupo B foi de 14,09 (P = 0,002). Não houve diferença estatística entre os grupos A e B em relação a escolha de fazer a cirurgia novamente (P = 0,714) e o grau de melhora dos sintomas no pós-operatório (P = 0,642). Conclusão A satisfação geral dos pacientes no pós-operatório foi elevada. O questionário GERD-HRQL pode não ser adequado para aplicação por telefone na nossa população, e com base em outras análises, a satisfação e a qualidade de vida dos pacientes entrevistados no ambulatório ou por telefone foi semelhante. .

Avaliação de refluxo ultra-distal com pHmetria de múltiplos canais / Ultra-distal reflux evaluation with multiple channel pHmonitoring

RACIONAL: Displasia e adenocarcinoma esofágico surge em pacientes com esôfago de Barrett submetidos a tratamento cirúrgico (fundoplicatura) com pHmetria esofágica sem evidência de acidez, o que sugere existir refluxo distal ao cateter de pHmetria convencional. OBJETIVO: Desenvolver metodologia para avaliar refluxo ultra-distal (1 cm acima da borda superior de esfíncter inferior do esôfago). MÉTODO: Foram selecionados 11 pacientes com esôfago de Barrett previamente submetidos à fundoplicatura à Nissen, sem sintomas de refluxo, com endoscopia e estudo contrastado de esôfago sem sinais de recidiva. Foi realizada manometria esofágica para avaliar a localização e a extensão do esfíncter esofágico inferior (EIE). Realizou-se então pHmetria esofágica com quatro canais: canal A a 5 cm acima da borda superior do EIE; canal B a 1 cm acima; canal C intraesfincteriano; canal D intragástrico. Avaliou-se o escore de DeMeester no canal A. Comparou-se o número de episódios de refluxo ácido, o número de episódios de refluxo prolongado e a fração de tempo com pH<4,0 nos canais A e B. Comparou-se a fração de tempo de pH<4,0 nos canais B e C. A fração de tempo com pH<4,0 acima de 50 por cento no canal D foi usada como parâmetro para não migração proximal do cateter. RESULTADOS: Houve aumento significativo do número de episódios de refluxo e da fração de tempo com pH<4,0 no canal B em relação ao canal A. Houve redução do tempo de pH<4,0 no canal B em comparação ao canal C. Dois casos de adenocarcinoma esofágico foram diagnosticados nos pacientes do grupo estudado. CONCLUSÕES: A região 1 cm acima da borda superior do EIE está mais exposta à acidez do que a região 5 cm acima, embora em níveis reduzidos. A região 1 cm acima da borda superior do EIE está menos exposta à acidez do que a região intraesfincteriana, demonstrando eficácia da fundoplicatura.

BACKGROUND: Esophageal adenocarcinoma and dysplasia in patients with Barrett's esophagus are seen after surgical treatment of GERD (fundoplication).Esophageal pH monitoring shows no evidence of acidity, suggesting distal reflux to the conventional catheter positioning. AIM: To develop methodology for assessing ultra-distal reflux (1 cm above the top edge of the lower esophageal sphincter). METHOD: Were selected 11 patients with Barrett's esophagus previously submitted to Nissen fundoplication, without reflux symptoms and with endoscopy and contrasted study of esophagus without signs of relapse. Esophageal manometry was used to evaluate the location and length of the lower sphincter of the esophagus (LES). After that, esophageal pH monitoring with four channels was done: channel A at 5 cm above the top edge of the LES; channel B at 1 cm above; channel C, intra-sphincteric; channel D, intragastric. The DeMeester score was assessed on channel A. The number of episodes of acid reflux, the number of episodes of prolonged reflux and fraction of time pH<4.0 were compared on channels A and B. The fraction of time pH<4.0 was compared on channels B and C. The fraction of time with pH<4.0 above 50 percent on channel D was used as parameter of no proximal migration of the catheter. RESULTS: Significant increase in the number of reflux episodes and fraction of time pH<4.0 in channel B in relation to channel A. Reduced fraction of time pH<4.0 in channel B compared to channel C was seen. Two cases of esophageal adenocarcinoma were diagnosed in the group. CONCLUSIONS: The zone 1 cm above the top edge of the LES is more exposed to acidity than the one 5 cm above, although at reduced levels. The region 1 cm above the top edge of the LES is less exposed to acidity than the intrasphincteric zone, demonstrating efficacy of fundoplication.

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.

Mucin pattern reflects the origin of the adenocarcinoma in Barrett's esophagus: a retrospective clinical and laboratorial study.

BACKGROUND: Mucin immunoexpression in adenocarcinoma arising in Barrett's esophagus (BE) may indicate the carcinogenesis pathway. The aim of this study was to evaluate resected specimens of adenocarcinoma in BE for the pattern of mucins and to correlate to the histologic classification. METHODS: Specimens were retrospectively collected from thirteen patients who underwent esophageal resection due to adenocarcinoma in BE. Sections were scored for the grade of intestinal metaplasia. The tissues were examined by immunohistochemistry for MUC2 and MUC5AC antibodies. RESULTS: Eleven patients were men. The mean age was 61 years old (varied from 40 to 75 years old). The tumor size had a mean of 4.7 +/- 2.3 cm, and the extension of BE had a mean of 7.7 +/- 1.5 cm. Specialized epithelium with intestinal metaplasia was present in all adjacent mucosas. Immunohistochemistry for MUC2 showed immunoreactivity in goblet cells, while MUC5AC was extensively expressed in the columnar gastric cells, localizing to the surface epithelium and extending to a variable degree into the glandular structures in BE. Tumors were classified according to the mucins in gastric type in 7/13 (MUC5AC positive) and intestinal type in 4/13 (MUC2 positive). Two tumors did not express MUC2 or MUC5AC proteins. The pattern of mucin predominantly expressed in the adjacent epithelium was associated to the mucin expression profile in the tumors, p = 0.047. CONCLUSION: Barrett's esophagus adenocarcinoma shows either gastric or intestinal type pattern of mucin expression. The two types of tumors developed in Barrett's esophagus may reflect the original cell type involved in the malignant transformation.

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.

Novas perspectivas no estadiamento e tratamento do câncer de esôfago / New perspectives in esophageal cancer staging and treatment

INTRODUÇÃO: O câncer de esôfago apresenta-se como uma das neoplasias mais freqüentes e letais. O acometimento linfático aparece como principal fator individual de pior prognóstico, sendo a esofagectomia com linfadenectomia extensa ainda seu tratamento de escolha. Ressecções mais extensas através da toracotomia estão associadas com maior sobrevida, mas apresentam altas taxas de morbimortalidade. O conceito de micrometástases pode nos trazer avaliação mais acurada do estadiamento dos tumores operados, com detecção através de imunoistoquímica ou reação em cadeia de polimerase de metástases não diagnosticadas pelos métodos convencionais. MÉTODOS: Realizou-se revisão bibliográfica de artigos científicos publicados e disponíveis no PubMed, através do site www.pubmed.gov. cruzando-se os descritores neoplasias esofágicas, biologia molecular, estadiamento de neoplasias, linfonodo sentinela, metástase linfática. REVISÃO DA LITERATURA: O conceito do linfonodo sentinela, onde se pesquisa durante a cirurgia os possíveis primeiros sítios de metástases, direcionando desta maneira a rota da ressecção linfática no intuito de permitir ressecções completas não necessariamente extensas, possibilita diminuir a morbimortalidade e restringir as indicações de procedimentos muitas vezes super-dimensionados que podem não trazer benefício aos pacientes. CONCLUSÃO: O estadiamento preciso através da procura de micrometástase e o tratamento mais regrado pelo método do linfonodo sentinela, podem trazer novas perspectivas no tratamento do câncer de esôfago, principalmente em casos de tumores precoces.

BACKGROUND: The esophageal cancer presents as one of the most frequent and lethal neoplasia. Lymphatic involvement appears to be the principal individual factor for poor prognosis, thus esophagectomy with extensive lymphadenectomy still is the choice treatment. Thoracotomy for extensive resection is related to higher survival rate, as well as higher morbid-mortality rates. Micrometastasis concept involves a more accurate staging method for resected tumors, using immunohistochemistry or polymerase chain reaction techniques, which were not diagnosed by conventional methods. METHODS: A literature review was made over scientific articles published and available at PubMed site (www.pubmed.gov), crossing the following headings: esophageal neoplasm, molecular biology, neoplasm staging, sentinel lymph node, lymphatic metastasis. LITERATURE REVIEW: Sentinel lymph node concept consist of intraoperative identification of possible primary dissemination metastasis sites, thus guiding to a more complete and not so extensively lymphatic resection, decreasing morbid-mortality and restraining an over-dimensioned procedure that may not benefit the patient. CONCLUSION: Accurate staging by micrometastasis identification and precise treatment using sentinel lymph node method may bring new perspectives in the esophageal cancer treatment, especially on early-stages tumors.

Origin of adenocarcinoma in Barrett's esophagus: p53 and Ki67 expression and histopathologic background.

UNLABELLED: Barrett's esophagus is the substitution of squamous epithelium of the distal esophagus by columnar epithelium. Intestinal metaplasia in Barrett's esophagus is considered to be the main risk factor for the development of adenocarcinoma. Diffuse adenocarcinoma and Barrett's esophagus without intestinal metaplasia are rare, and reports on the subject are scarce. PURPOSE AND METHOD: To estimate the prevalence of adenocarcinoma in 297 patients with Barrett's esophagus, during the period of 1990 to 2002, and in 13 patients undergoing surgery, to conduct detailed macroscopic and microscopic analysis, with performance of immunohistochemical tests for p53 and Ki67, correlating the type of tumor with its adjacent epithelium. RESULTS: In our patients with Barrett's esophagus, there was a prevalence of 5.7% of adenocarcinoma. The tumors developed only when the Barrett's esophagus segment was long (>3.0 cm). Tumors were located close to the squamous-columnar junction. The histological study revealed 2 patients (15.4%) with Barrett's esophagus adjacent to a tumor with gastric metaplasia without the presence of intestinal metaplasia. Tumors were classified according to Nakamura's classification (23% differentiated pattern, and 77% undifferentiated pattern) and to Lauren's classification (61% intestinal and 39% diffuse). The difference is due to the migration of microtubular and foveolar tumors of undifferentiated (gastric) pattern in Nakamuras classification to the Lauren's intestinal type. The immunohistochemical test for Ki67 was strongly positive in all the patients, thus evidencing intense cell proliferation in both the columnar epithelium and tumor. Expression of p53 was negative in 67% of the adjacent columnar epithelia and 42% of the tumors, without any correlation between the tissue types. CONCLUSION: Adenocarcinoma develops from mixed columnar epithelium, either intestinal or gastric, showing both the gastric and the intestinal patterns; thus, tumors can also grow in columnar epithelium without intestinal metaplasia. Barrett's esophagus should be followed up for the possibility of progression to malignancy, especially when the segment is longer than 3 cm.