Treatment of achalasia: lessons learned with Chagas' disease.

Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.

[Esophagogastric acute injury caused by a chemical agent]. / Lesão aguda esôfago--gástrica causada por agente químico.

UNLABELLED: Treatment of chemical agent ingestion remain controversial. The incidence of these episodes has increased over the several last decades due to a variety reasons. PURPOSE: To analyze the occurrence, complications and results of the treatment of chemically induced esophagogastric injury. METHODS: Twenty-one adult patients with chemically induced esophagogastric injury were retrospectively studied. The patients were admitted up to 23 days after ingestion of a chemical agent to the Emergency Department of Santa Casa of Sao Paulo University Hospital from August, in a 12-year period. The mean age was 32.1 years. Eleven patients were of the female gender, which attempted suicide. Soda was the most ingested agent (76.2%), muriatic acid was present in three cases (14.3%) followed by one case of sulfur acid and another one of ammonia (4.8% each). RESULTS: Injuries of the Larynx and Pharynx were frequently associated with those of the esophagus, accounting for 18 cases (85.7%). Esophageal, gastric and duodenal injuries were assessed and classified according to endoscopic features. Five cases each of severe esophageal or gastric lesions were present. CONCLUSION: Treatment and outcome varied and suggested placement of esophageal tube to be harmful. Global mortality rate was 28.6% with the highest rate related to esophageal injuries of the third degree.

Lesäo aguda esôfago-gástrica causada por agente químico / Chemically induced esophagogastric acute injury

O tratamento da ingestão de agentes químicos corrosivos continua controverso. A incidência desses episódios tem aumentado nas últimas décadas por várias razões. OBJETIVO: Analisar a ocorrência, as complicações e os resultados do tratamento da lesão esôfago - gástrica causada por agentes químicos. MÉTODOS: Foram estudados retrospectivamente 21 pacientes adultos com lesão esôfago-gástrica, causada por ingestão de substância química, admitidos até 23 dias após o episódio, no Serviço de Emergência da Santa Casa de Misericórdia de São Paulo num período de 12 anos. A média de idade foi 32,1 anos e 11 doentes pertenciam ao sexo feminino, as quais mais freqüentemente tinham intenções suicidas. A soda cáustica foi o produto mais ingerido (76,2 por cento), ingestão de ácido muriático ocorreu em três casos (14,3 por cento), amoníaco e ácido sulfúrico em um caso (4,8 por cento) cada. RESULTADOS: As lesões faríngeas e laríngeas estiveram freqüentemente associadas às lesões de esôfago, presentes em 18 casos (85,7 por cento). As lesões esofágicas, gástricas e duodenais foram avaliadas e classificadas por endoscopia. Lesões graves esofágicas ou gástricas estiveram presentes em cinco casos cada. CONCLUSÃO: O tratamento e os resultados foram variados, mas sugeriram que a sondagem esofágica foi prejudicial. A mortalidade global foi 28,6 por cento, mais elevada na lesão esofágica grau 3.

Trauma in pregnant women: analysis of maternal and fetal mortality.

Twenty-seven traumatised pregnant women were analysed retrospectively over a period of 9 years. Mean age was 23.7 years (16-42 years). Gestational age ranged from 10 to 40 weeks (mean, 21.5 weeks), with most victims (46.1%) being in the second trimester. The predominant mechanism (65.3%) was blunt abdominal injury due to an automobile accident (the patient being run over or collision). At admission, 8 (30.7%) patients had haemodynamic alterations. 6 patients (23.0%) presented vaginal bleeding and 4 of these were haemodynamically normal. We analysed maternal mortality, fetal mortality and their causes. We also compared the median RTS and TRISS values for the groups with maternal-fetal survival and the group with maternal-fetal death. Fetal death occurred in all pregnant women admitted with vaginal bleeding. Maternal mortality due to haemorrhagic shock was 11.5%. Fetal mortality was 30.7%, with 37.5% of these deaths being caused by maternal death. The major cause of fetal mortality was a detached placenta (50.0%). The trauma indices, RTS and TRISS, were significantly lower (p = 0.0025 and p < 0.0001) in the group of maternal-fetal death but they were not of prognostic value in terms of fetal mortality.

Microbial flora of the normal esophagus.

The endogenous flora of the skin and some mucous membranes are well known, however, we were unable to find descriptions about normal esophageal flora in literature. We believe that knowledge about normal esophageal flora is important for therapeutic implications. We compiled data on 30 patients without infection of the oropharynx or esophagus who were admitted for an endoscopy of the upper digestive tract to determine normal esophageal flora. The samples were collected by injecting 10 ml of 0.9% physiological solution into the esophagus and oropharynx and removing it by suction. Esophageal samples from 30 patients and oropharingeal samples from 10 of these patients were collected. We identified mixed flora being Streptococcus viridans the most frequent microorganism found. Where samples from both the esophagus and oropharynx were collected, three occurrences of this same microorganism were found. We concluded that the isolation frequency of germs in the esophagus by the method used was high and the most frequently found germ was S. viridans. There is therefore a possible correlation between the flora from the oropharynx and the esophagus.

Esophageal schistosomiasis in a patient with megaesophagus.

The authors report a case of schistosomiasis of uncommon location. A patient submitted to esophagectomy for Chagas' megaesophagus was found to have eggs of Schistosoma mansoni upon pathologic examination of the surgical specimen. The authors discuss the anatomopathological aspects of schistosomiasis, as well as its occurrence in other rare sites. To date, no references in literature have been found on the existence of esophageal schistosomiasis, and its association to Chagas' megaesophagus has never been described.

[Cricopharyngeal dysfunction]. / Disfunção cricofaríngea.

The idiopathic dysfunction of the cricopharyngeal muscle is a rare disease. Limited understanding of the pharyngoesophageal physiology and physiopathology make the management of this disease complex. We have studied three patients with idiopathic crycopharyngeal dysfunction submitted to cricomyotomy. One patient did not present improvement after surgery. The authors discuss the difficulties in making the diagnosis., the treatment and the selection of patients who will benefit from this surgical procedure.

Lesäo esofágica provocada por ingestäo de pílula / Esophageal injury due to pill ingestion

Nos últimos anos, vários casos de lesao de esôfago provocada por drogas forma publicados. A causa primária aparente tem sido o retardo do trânsito e a aderência de drogas cáusticas à mucosa do esôfago. Neste trabalho é relatado um caso de úlcera com perfuraçao de esôfago associada a ingestao de analgésico, num paciente do sexo masculino, de 26 anos, sem queixas esofágicas anteriores. A revisao da literatura mostra que vários medicamentos têm sido implicados; e que o tamanho, a forma e a ingestao inadequada de pílula alteram o trânsito esofágico.

[Esophageal injury due to pill ingestion]. / Lesão esofágica provocada por ingestão de pílula.

In recent years, many case reports concerning esophageal injuries caused by drugs have been published. The primary cause has apparently been the delay in passage and the adherence of the caustic drugs on the esophageal mucosa. The authors report a case of esophageal ulceration caused by an analgesic in a 26-year-old male with no esophageal symptoms. A review of the literature shows that a variety of medications have been implicated; size, shape and improper ingestion of pills affect esophageal transit.

Emergency department thoracotomy.

The emergency department thoracotomy as a ressuscitative measure is a controversial subject in trauma surgery. Indiscriminate indication has occurred due to unclearness upon the real value of this procedure, but further critical evaluation has reduced initial enthusiasm rather emphasizing a more rational approach by systematization of criteria for selective indication. Clinical outcome is related to injury mechanism and patients conditions upon admission. According to vital signs the patients conditions are classified as fatal, agonic and shock; survival rates oscillate between 0 to 40%. This study presents a review of the literature discussing indications, technical aspects, complications and clinical outcome of emergency department thoracotomy in trauma patients.

[Incidence of symptomatic megacolon in patients with chagasic megaesophagus]. / Incidência de megacólon sintomático em portadores de megaesôfago chagásico.

The authors analyze the incidence of megacolon associated to megaesophagus during a 7 year period. Of the 192 patients with megaesophagus only 15 who presented associated intestinal symptoms were further investigated through barium enema. No statistically significant differences were found between the group with megaesophagus and the group presenting association of megaesophagus and megacolon as to sex and age of the individuals and severity of megaesophagus. The esophageal symptoms preceded the intestinal symptoms in 93.3% of the cases. Many treatments were used, but recently good results were obtained by the association of Heller's cardiomyotomy with modified Lortat-Jacob's technique and left hemicolectomy.