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.

Esophageal achalasia: a risk factor for carcinoma. A systematic review and meta-analysis.

Achalasia of the cardia is associated with an increased risk of esophageal carcinoma. The real burden of achalasia at the malignancy genesis is still a controversial issue. Therefore, there are no generally accepted recommendations on follow-up evaluation for achalasia patients. This study aims to estimate the risk of esophageal adenocarcinoma and squamous cell carcinoma in achalasia patients. We searched for association between carcinoma and esophageal achalasia in databases up to January 2017 to perform a systematic review and meta-analysis. A total of 1,046 studies were identified from search strategy, of which 40 were selected for meta-analysis. A cumulative number of 11,978 esophageal achalasia patients were evaluated. The incidence of squamous cell carcinoma was 312.4 (StDev 429.16) cases per 100,000 patient-years at risk. The incidence of adenocarcinoma was 21.23 (StDev 31.6) cases per 100,000 patient-years at risk. The prevalence for esophageal carcinoma was 28 carcinoma cases in 1,000 esophageal achalasia patients (CI 95% 2, 39). The prevalence for squamous cell carcinoma was 26 cases in 1,000 achalasia patients (CI 95% 18, 39) and for adenocarcinoma was 4 cases in 1,000 achalasia patients (CI 95% 3, 6).The absolute risk increase for squamous cell carcinoma was 308.1 and for adenocarcinoma was 18.03 cases per 100,000 patients per year. To the best of our knowledge, this is the first meta-analysis estimating the burden of achalasia as an esophageal cancer risk factor. The high increased risk rate for cancer in achalasia patients points to a strict endoscopic surveillance for these patients. Also, the increased risk for developing adenocarcinoma in achalasia patients suggests fundoplication after myotomy, to avoid esophageal reflux and Barret esophagus, a known risk factor for adenocarcinoma.

Gastric secretory and hormonal patterns in end-stage chagasic achalasia.

Achalasia surgical treatment alters the esophagogastric junction anatomy (cardiomyotomy plus fundoplication or esophagectomy and gastric pull-up), thus favoring a certain degree of gastroesophageal reflux. Gastric secretory and hormonal functioning is not completely known in chagasic patients. The aim of this study was to evaluate the gastric secretory and hormonal response in patients with end-stage chagasic achalasia compared with normal subjects. Gastric secretion and hormonal response were assessed by estimation of gastric acid secretion (GAS) in basal condition and after pentagastrin stimulation, basal serum gastrin, and serum pepsinogen (SP) in basal condition and after betazole hydrochloride (Histalog; Eli Lilly and Company, Indianapolis, IN, USA) stimulation in 27 patients with chagasic achalasia. The results were then compared with those of 24 normal subjects. In the chagasic group, the mean basal and stimulated GAS were significantly lower than in the control group (basal: 1.277 vs. 3.13, P = 0.002; stimulated: 15.9 vs. 35.8, P = 0.0001). Chagasic patients' SG levels showed a significantly higher basal value than the control group (83.3 vs. 36.8, P = 0.0001). There was a significant increase of SP after stimulation compared with the basal levels in both chagasic and control groups. Although the chagasic patients' SP values were higher than the controls, this difference was not statistically significant, either in basal and stimulated conditions (basal: 122.0 vs. 108.9, stimulated 120 min: 177.1 vs. 158.9). In patients with chronic Chagas' disease (ChD), although autonomic denervation does not suppress the strength of the gastric mucosal cells' secretory response to stimulation, it reduces GAS (parietal cell) without, however, affecting SP production (chief cells). On the other hand, the gastrin-producing cells have continuously been stimulated by low GAS.

[Laparoscopic treatment of common bile duct lithiasis]. / Tratamento laparoscópico de coledocolitíase.

With the advances of videolaparoscopic surgery, this approach had become the treatment of choice for cholelithiasis. However, about 5% to 10% may present common bile duct lithiasis. Most surgeons have still difficulties to deal with this situation and do prefer resolve with open surgery or with further endoscopic approach. We present a case of a 60-year-old man, with 18 months history of right upper quadrant pain, weight loss and jaundice. He was referred with diagnostic of pancreatic cancer. Laboratory investigation showed increased bilirubin (10 mg/dL), alkaline phosphatase and GGT. Abdominal ultrasound showed atrophic gallbladder with dilated intra and extrahepatic biliary tree. Computerized tomography scan disclosed enlarged biliary tree with 3 cm stone in the distal common bile duct. The patient underwent a laparoscopic cholecystectomy followed by choledochotomy and retrieval of the large stone. A latero-lateral choledochoduodenum anastomosis was then performed to decompress the biliary tree. The patient had an uneventful recovery being discharged at the 6th postoperative day. Laparoscopic management of choledocholithiasis is feasible in many patients, specially those with dilated biliary tree. The retrieval of stones may be followed by biliary drainage with T-tube. In some elderly patients with chronically dilated common bile duct, as in the present case, a choledochoduodenal anastomosis is the procedure of choice.

[Videolaparoscopy gastrectomy for complicated peptic ulcer: technique and case report]. / Gastrectomia videolaparoscópica no tratamento da úlcera péptica complicada: técnica e relato de caso.

Since the introduction of H2 receptor antagonists and inhibitors of the acid pump, the indications for the surgical management of peptic disease have decreased significantly. However some patients presenting bleeding, perforation, gastric outlet obstruction and intractable peptic ulcer still need surgical treatment. The first laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world. The aim of this study was to present a case of totally laparoscopic Billroth II gastrectomy and to describe an alternative technique using endoscopic stapling devices. We present a case of a 48-year-old man, complaining of severe epigastralgia, who had a 20-year history of peptic ulcer. Gastroscopy had revealed a duodenal ulcer and a deformity of the bulbus. A diagnosis of intractable peptic ulcer was made, and the patient underwent laparoscopic Billroth II gastrectomy with side-to-side intracorporeal gastrojejunostomy using endoscopic stapling devices. On postoperative day 1, he was able to walk. On postoperative day 3, he started on a clear liquid diet and was discharged on postoperative day 6. During his postoperative recovery, the patient experienced little pain and did not request narcotic analgesia. Laparoscopic gastric resection is an alternative to open procedure in well selected cases.

[Laparoscopic treatment of non-advanced esophageal achalasia: technical aspects]. / Tratamento laparoscópico do megaesôfago não-avançado: aspectos técnicos.

Laparoscopic cardiomyotomy has recently became a popular alternative to traditional laparotomy in the management of patients with nonadvanced achalasia. The laparoscopic approach for this disease is encouraging due to the low rate of complications associated with a shorter recovery period and reduced postoperative pain. This article describes an alternative technique in the laparoscopic treatment of achalasia with introduction of a supplementary 5 mm port in order to facilitate the cardiomyotomy and the construction of the valvuloplasty.

An alternative technique for open laparoscopy.

Laparoscopic cholecystectomy has become a routine surgical procedure. Complications related to use of the laparoscope frequently result from insertion of a Veress needle or blind introduction of the primary cannula on its trocar. This risk is clearly higher in patients who have undergone previous surgical operations. Open insertion with visualisation of abdominal cavity before the introduction of the primary cannula reduces the risk of major vascular and visceral injury. Nevertheless, open laparoscopy has rarely been adopted mainly due to gas leak from the wound and because it is time-consuming. A simple, quick and effective technique is described. The authors experience with this technique in the last 500 cases has shown that it has no effect on the duration of operation, and does not involve a larger skin incision. This technique has been associated with no operative difficulty.

[Contribution to the study of devascularization of esophagogastric transition in the treatment of esophageal bleeding varices]. / Contribuição ao estudo da desvascularização da transição esofagogástrica no tratamento das varizes sangrantes do esôfago.

The usual techniques of esophagogastric desvascularization associated with splenectomy are reviewed and a new one is presented. It is a variant of EGDS technique described by Espíndula (1978) with the following modifications: A) In order to get a possible reduction of the transudation at the dissected area, on reperitonize: 1) the lesser curvature of stomach, naked during proximal gastric vagotomy (PGV). Fig. 1a and 1b; 2) the area of peritoneum concerning splenic hilum and tail of pancreas; 3) the dissected area of distal esophagus, performing a fundoplication (Lind, 1965) that also serves to obtain a good anti-reflux procedure. The EGDS was complemented with endoscopic sclerosis of varices, three to six months after operation. On consider that endoscopic sclerosis substitutes the surgical suture of the varices and reduces the surgical time and morbidity. From 1987 to 1989, eight patients with esophageal varices and gastrointestinal bleeding secondary to mansonic schistosomiasis were operated upon. Based on Child classification, two of these patients (25%) were graded B, six (75%) were graded A. None of the patients had post-operative esophageal bleeding or reflux esophagitis. There were no mortality. Two patients had postoperative ascitis that disappeared with clinic measures. The patients were followed during a period of six months to two years.

[True splenic cyst treated with++videolaparoscopy. Case report and review of the literature]. / Cisto esplênico verdadeiro tratado por videolaparoscopia. Relato de caso e revisão da literatura.

True non-parasitic splenic cysts are uncommon, their real incidence is difficult to determine since over 30% are asymptomatic. Preoperatively these cysts are rarely diagnosed correctly and they are often findings on examinations. Partial or total splenectomy is the treatment of choice after ruling out splenic hydatidosis, since it is responsible for two thirds of global incidence. Currently, with the technological advances of surgery, especially of videolaparoscopy, some authors have proposed its use for partial cystectomy or splenectomy. The authors present the case of a true splenic cyst (epidermoid) which was resected videolaparoscopically and they discuss aspects of diagnosis and management.

[Laparoscopic treatment of duodenal obstruction in a patient with pancreatic cancer]. / Tratamento laparoscópico de obstrução duodenal em paciente portador de câncer avançado de pâncreas.

We present a case report of laparoscopic gastrojejunostomy in a patient with duodenal obstruction from unresectable cancer. We performed an side-to-side intracorporeal gastrojejunostomy using endoscopic stapling devices. The patient had no morbidity and he was discharge on fourth postoperative day. Laparoscopic gastric bypass is an alternative to open procedure in well selected cases.

[Video laparoscopic splenectomy in a patient with splenomegaly due to hereditary spherocytosis: report of two cases]. / Esplenectomia videolaparoscópica em paciente portador de esplenomegalia por esferocitose hereditária: relato de dois casos.

We present a case report of laparoscopic splenectomy in two patients with congenital spherocytosis. A 23-year-old man and a 25-year-old woman with splenomegaly due to congenital spherocytosis underwent laparoscopic splenectomy. Their postoperative course was uncomplicated and they were discharged on the second and fourth postoperative day, respectively.

[Spinal subdural empyema. A case report]. / Empiema espinhal subdural. Relato de um caso.

Spinal subdural empyema is a very unusual condition. About 40 cases have been previously reported. The authors describe another case, mentioning the difficulties in diagnosis particularly when no primary infection is known. In these circumstances, the neurological signs and MRI are important; MRI demonstrates the level of the lesion and its subdural localization. Surgical treatment and antibiotics are clearly indicated and the earliest it is done, the better the results.

[Barrett esophagus in the esophageal stump after subtotal esophagectomy with cervical esophagogastroplasty]. / Esôfago de Barrett no coto esofagiano após esofagectomia subtotal com esofagogastroplastia cervical.

In 48 patients that suffered subtotal esophagectomy and were submitted to esophagogastroplasty a long term follow-up study was carried out. In four of these patients (8.3%) pathological changes that characterize Barrett's esophagus were found in the esophageal stump. As far as we could verify, such changes were never reported at this localization before. The Barrett's esophagus seems to be intimately linked to reflux esophagitis resulting from the action of acid-peptic and biliary secretions.