Leiomiomatosis esofágica difusa gigante. Reporte de caso / Giant Diffuse Esophageal Leiomyomatosis. Case Report

Introducción: La leiomiomatosis esofágica es una neoplasia benigna con una incidencia dentro de los tumores del esófago extremadamente baja y en ocasiones difícil de categorizar como neoplasia o miopatía. Caso clínico: Se reporta el caso de una joven de 24 años que consultó por disfagia pro- gresiva de un año de evolución y antecedente de haberle descubierto una "mancha" en el pulmón diez años atrás. Las imágenes muestran masa que ocupa el tercio medio e inferior del esófago y megaesófago proximal por obstrucción a nivel de cardias. Se rea- lizó esofagectomía total, tubulización y ascenso gástrico con piloroplastía más anastomosis esófago gástrica latero lateral a nivel cervical. La patología confirmó la histología de leiomiomatosis esofágica. Conclusión: Es una patología muy rara con pocos casos reportados.

Introduction: Esophageal leiomyomatosis is a benign neoplasm with an extremely low incidence of esophageal tumors and is sometimes difficult to categorize as a neoplasm or myopathy. Clinical Case: The case of a 24-year-old girl, who consulted for progressive dysphagia of one year of evolution and a history of having discovered a "spot" on her lung ten years ago, is reported. The images show a mass that occupies the middle and lower third of the esophagus and proximal megaesophagus due to obstruction at the level of the cardia. Total esophagectomy, tubulization and gastric ascent with pyloroplasty plus lateral esophagogastric anastomosis at the cervical level were performed. The pathology confirms the histology of esophageal leiomyomatosis. Conclusion: It is a very rare pathology with few reported cases.

Experiencia en el tratamiento de la perforación de esófago cervical por cuerpo extraño en población adulta en el Hospital de San José, Bogotá durante un período de 5 años / Experience in the treatment of cervical esophageal perforation due to foreign body in the adult population at the Hospital de San José, Bogotá over a 5-year period

Introducción. La perforación esofágica cervical por cuerpos extraños es una entidad clínica poco frecuente, pero con un potencial alto de complicaciones, incluyendo la muerte como desenlace. Su tratamiento sigue siendo discutible, sin evidencia suficiente para definir el mejor abordaje entre el quirúrgico y el conservador. Métodos. Mediante un estudio de tipo observacional, retrospectivo, con componente analítico, se evaluaron los pacientes adultos con diagnóstico de perforación de esófago cervical por cuerpo extraño, tratados en el hospital de San José, Bogotá, D.C., Colombia, entre enero de 2018 y junio de 2023. Resultados. La población consistió en 22 pacientes, donde predominaron las mujeres (59 %), con una media de edad de 61,32 ± 9,04 años. Siete pacientes (31,8 %) recibieron manejo quirúrgico y 15 (68,2 %) manejo conservador. Para los desenlaces, el 90,9 % de los pacientes fueron dados de alta (domicilio) y el 9,1 % pasaron de manejo conservador a manejo quirúrgico; no se reportó ninguna muerte derivada de la perforación. Según el análisis multivariado, no hubo diferencias en los desenlaces asociadas con la edad (p=0,189), el tipo de tratamiento (p=0,095), los hallazgos tomográficos (p=0,371) o los hallazgos intraoperatorios (p= 0,515). Conclusiones. En este estudio se identificaron similares desenlaces clínicos con el tratamiento quirúrgico y conservador. El manejo conservador va tomando relevancia al no tener desventajas frente al tratamiento quirúrgico, sobre todo por ser menos invasivo.

Introduction. Cervical esophageal perforation due to foreign bodies is a rare clinical entity, but with a high potential for complications, including death as an outcome. Its treatment remains debatable, without sufficient evidence to define the best surgical or conservative approach. Methods. Through an observational, retrospective study, with an analytical component, adult patients with a diagnosis of cervical esophageal perforation due to a foreign body, treated at the Hospital San José, Bogotá, D.C., Colombia, between January 2018 and June 2023, were evaluated. Results. The population consisted of 22 patients, where women predominated (59%), with a mean age of 61.32 ± 9.04 years. Seven patients (31.8%) received surgical management and 15 (68.2%) conservative management. For the outcomes, 90.9% of the patients were discharged home and 9.1% went from conservative to surgical management. No deaths resulting from perforation were reported. According to the multivariate analysis, there were no differences in outcomes associated with age (p=0.189), type of treatment (p=0.095), tomographic findings (p=0.371), or intraoperative findings (p=0.515). Conclusions. Similar clinical outcomes with surgical and conservative treatment were identified in this study. Conservative management is becoming more relevant as it has no disadvantages compared to surgical treatment, especially because it is less invasive.

Esofagectomía mínimamente invasiva: Resultados posoperatorios en 99 pacientes intervenidos en un hospital universitario / Minimally invasive esophagectomy: Postoperative results in 99 patients operated at a university hospital

Introducción. La esofagectomía mínimamente invasiva (EMI) ha venido ganando popularidad debido a los resultados obtenidos en términos de seguridad, mortalidad, complicaciones y calidad de vida, así como los resultados oncológicos comparables a los obtenidos con la cirugía por vía abierta. Métodos. Estudio de cohorte de pacientes en quienes se llevó a cabo una EMI en la Sociedad de Cirugía de Bogotá Hospital de San José, en Bogotá, D.C., Colombia, entre enero de 2008 y diciembre de 2020. Resultados. Se incluyeron 99 pacientes, 52 hombres y 47 mujeres, con una edad media de 56 años; 58 tenían enfermedades benignas y 41 neoplasias del esófago. En 76 se llevó a cabo un abordaje de McKeown y en 23 una esofagectomía transhiatal por laparoscopia con anastomosis cervical. El tiempo quirúrgico promedio fue de 240 minutos y la media del sangrado de 140 ml. Seis pacientes fallecieron (6 %) y hubo 21 complicaciones en 14 pacientes (14 %), con 8 fugas de la anastomosis esofagogástrica (8 %) y 4 pacientes con neumonía (4 %). Conclusiones. Los resultados obtenidos confirman que la EMI es un procedimiento factible y seguro, cuyos beneficios la han convertido en el abordaje de elección para la resección y reconstrucción del esófago. No obstante, se trata de una cirugía compleja, con una curva de aprendizaje prolongada, que debe ser realizada en centros con altos volúmenes y por cirujanos expertos. La selección de los pacientes debe hacerse de manera individual teniendo en cuenta las comorbilidades, los recursos disponibles y la experticia del grupo quirúrgico.

Introduction. Minimally invasive esophagectomy (MIE) has been gaining popularity due to the results obtained in terms of safety, mortality, complications and quality of life, as well as oncologic results comparable to those obtained with open surgery. Methods. Cohort study of patients in whom MIE was performed at Hospital de San José, in Bogotá, D.C., Colombia, between January 2008 and December 2020. Results. Ninety-nine patients were included, 52 men and 47 women, with a mean age of 56 years; 58 had benign diseases and 41 had neoplasms of the esophagus. A McKeown approach was performed in 76 and a laparoscopic transhiatal esophagectomy with cervical anastomosis in 23. The average surgical time was 240 minutes and the average bleeding was 140 ml. Six patients died (6%) and there were 21 complications in 14 patients (14%), with eight esophagogastric anastomosis leaks (8%) and four patients with pneumonia (4%). Conclusions. The results obtained confirm that MIE is a feasible and safe procedure, whose benefits have made the approach of choice for resection and reconstruction of the esophagus. However, it is a complex surgery, with a long learning curve, which must be performed in centers with high volumes and by expert surgeons. Patient selection must be done individually taking into account comorbidities, available resources and expertise of the surgical group.

Esofagectomía mínimamente invasiva: impacto de la curva de aprendizaje. Experiencia en un centro de alto volumen / Minimally invasive esophagectomy: Impact of the learning curve. Experience in a high volume center

Introducción. El tratamiento del cáncer de esófago ha evolucionado notablemente en los últimos años. Los nuevos abordajes permiten preservar el esófago en tumores tempranos, mediante técnicas endoscópicas, y en aquellos localmente avanzados, es posible realizar resecciones mínimamente invasivas en combinación con tratamiento oncológico. La innovación quirúrgica es necesaria para aumentar la eficacia terapéutica, sin embargo, ésta requiere un aprendizaje cuya curva impacta en los resultados obtenidos. El objetivo de este trabajo fue mostrar cómo incide la curva de aprendizaje en la morbimortalidad asociada al procedimiento. Métodos. Se tomó una cohorte de 128 pacientes con esofagectomía mínimamente invasiva por cáncer de esófago, realizadas entre enero de 2014 y diciembre de 2023. Se agruparon en dos etapas de manera cronológica, creando dos grupos de 64 pacientes cada uno. Se evaluaron variables demográficas, tipo de anastomosis realizada, tasa de complicaciones, anatomía patológica, días de internación y seguimiento. Resultados. No hubo una diferencia significativa entre los dos grupos en factores demográficos, como edad y sexo, tipos histológicos o sitio de la anastomosis. La morbilidad (complicaciones tipo III y IV de Clavien-Dindo) fue del 43,7 % en la primera etapa y del 23 % en la segunda, con una diferencia significativa (p=0,02). Conclusiones. En nuestra cohorte mostramos una diferencia estadísticamente significativa en cuanto a la morbilidad entre la primera y la segunda etapa, sin embargo, no hubo diferencias en la mortalidad. Los hallazgos sugieren así que la curva de aprendizaje de un procedimiento tiene un impacto negativo transitorio sobre los resultados.

Introduction. The treatment of esophageal cancer has evolved significantly in recent years. New approaches allow preserving the esophagus in early tumors, using endoscopic techniques, and in locally advanced tumors, it is possible to perform minimally invasive resections in combination with an oncological treatment. Surgical innovation is necessary to increase therapeutic efficacy; however, it requires learning curve whose impacts the results obtained. The objective of this work was to show how the learning curve affects the morbidity and mortality associated with the procedure. Methods. A cohort of 128 patients with minimally invasive esophagectomy due to esophageal cancer was included, performed between January 2014 and December 2023. They were grouped into two stages chronologically, creating two groups of 64 patients each. Demographic variables, type of anastomosis performed, complication rate, pathology types, hospital stay and follow-up were analyzed. Results. There was no significant difference between both groups in demographic variables, such as age and sex, histological types, or anastomosis site. Morbidity (Dindo-Clavien types III and IV complications) was 43.7% on the first stage and 23% in the second one, with a significant difference (p=0.02). Conclusions. In our cohort, we showed a statistically significant difference in morbidity between the first and second stages; however, there were no differences in mortality. The findings thus suggest that the learning curve of a procedure has a temporary negative impact on the results.

Alternativas de reemplazo esofágico: Revisión de tema / Esophageal replacement alternatives: A literature review

Introducción. Posterior a una esofagectomía parcial o total, el reemplazo del esófago representa un reto para los cirujanos. La selección del sustituto dependerá de diferentes factores, tanto del paciente como del cirujano. Las alternativas disponibles son el estómago, segmentos del colon, el yeyuno supercargado o colgajos libres miocutáneos. Métodos. Se realizó una búsqueda de la literatura en las bases de datos de Medline, Embase y Lilacs, utilizando las palabras claves descritas y aplicando una técnica en bola de nieve, y se seleccionaron los artículos más relevantes. Resultados. El órgano seleccionado debe asegurar una adecuada red vascular, mantener la función deglutoria y tener los menores riesgos posibles. Cada sustituto tiene ventajas particulares, pero todos generan complicaciones a corto y largo plazo. El estómago es el más frecuentemente usado, sin embargo, el reflujo gastroesofágico y la gastroparesia pueden presentarse en un número importante de pacientes. El colon requiere diversos estudios preoperatorios y cada segmento tiene sus características particulares para el ascenso; a largo plazo puede alargarse, tornarse dilatado y tortuoso, afectando la calidad de vida. El yeyuno supercargado permite un adecuado ascenso sin tensión, pero implica una técnica quirúrgica más compleja. Conclusiones. El tubo gástrico es la primera opción, por su menor complejidad técnica y buenos desenlaces. De no estar disponible, se cuenta como alternativas con los diferentes segmentos del colon, el yeyuno supercargado o los colgajos musculocutáneos. Las complicaciones asociadas a estos procedimientos no son despreciables, por lo que se debe tener muy en cuenta la experiencia del grupo quirúrgico.

Introduction. After partial or total esophagectomy, replacement of the esophagus represents a challenge for surgeons. The selection of the substitute will depend on different factors, both from the patient and the surgeon. The available alternatives are the stomach, the different segments of the colon, the supercharged jejunum or free myocutaneous flaps. Methods. A literature review was carried out in the Medline, Embase and Lilacs databases, using the keywords described and applying a snowball technique, and the most relevant articles were selected. Discussion. The selected organ must ensure an adequate vascular network, maintain swallowing function and have the lowest possible risks. Each substitute has particular advantages, but all generate complications in the short and long term. The stomach is the most frequently used, but gastroesophageal reflux and gastroparesis can occur in a significant number of patients. The colon requires different preoperative studies and each segment has its particular characteristics for the ascent; in the long term, the colon can lengthen, become dilated and tortuous, affecting quality of life. The supercharged jejunum allows adequate ascent without tension, but involves a more complex surgical technique. Conclusions. The gastric tube is the first option, due to its lower technical complexity and good outcomes. If it is not available, different segments of the colon, the supercharged jejunum or musculocutaneous flaps are good alternatives. The complications associated with these procedures are not negligible, so the experience of the surgical group must be taken into account.

Primary adenoid cystic carcinoma in the esophagus.

Esophageal adenoid cystic carcinoma (EACC) is an exceedingly rare malignant tumor constituting only 0.2% of all esophageal tumors. The tumor exhibits aggressive behavior, composed histologically of ductal and modified myoepithelial cells. We report a case of a 69-year-old female with a diagnosis of an EACC by preoperative endoscopic biopsy. Thoracoscopy esophagectomy was carried out. However, pleural metastasis was found. Therefore, surgical resection of the esophageal tumor was not carried out. The patient underwent an uneventful recovery, followed by palliative treatment and ongoing chemoradiotherapy. EACC is uncommon but exhibits a more aggressive nature compared to its counterparts in the head and neck region. Dysphagia associated with gastroesophageal reflux disease is a common symptom. The duration from symptom onset to diagnosis is typically short. Treatment options include surgical resection, chemotherapy, and radiotherapy, with surgery being the preferred initial approach despite high operative mortality. Prognosis remains inconclusive, with some studies associating poor outcomes with lymph node metastasis and vascular invasion, while others report better survival rates. EACC presents diagnostic and therapeutic challenges due to its rarity and aggressive nature. Prognostic considerations remain unclear, emphasizing the need for further research and accumulated cases to delineate optimal treatment. The presented case demonstrates a 1-year survival with systemic palliative care, contributing to the evolving knowledge surrounding EACC.

El carcinoma adenoide quístico primario de esófago (EACC) es un tumor maligno excepcionalmente raro que constituye solo el 0.2% de todos los tumores esofágicos. El tumor exhibe un comportamiento agresivo, compuesto histológicamente por células ductales y mioepiteliales modificadas. Presentamos el caso de una mujer de 69 años con diagnóstico de un EACC mediante biopsia endoscópica preoperatoria. Se realizó una esofagectomía por toracoscopia. Sin embargo, se encontró metástasis pleural. Por lo tanto, no se llevó a cabo la resección quirúrgica del tumor esofágico. La paciente tuvo una recuperación sin complicaciones, seguida de tratamiento paliativo y radioquimioterapia continua. El EACC es poco común, pero exhibe una naturaleza más agresiva en comparación con sus contrapartes en la región de la cabeza y el cuello. La disfagia asociada con la enfermedad por reflujo gastroesofágico es un síntoma común. La duración desde el inicio de los síntomas hasta el diagnóstico suele ser corta. Las opciones de tratamiento incluyen la cirugía, quimio y radioterapia, siendo la cirugía la preferida a pesar de la alta mortalidad operatoria. El pronóstico es inconcluso, algunos estudios asocian resultados pobres con metástasis e invasión vascular, mientras que otros informan mejores tasas de supervivencia. El EACC presenta desafíos diagnósticos y terapéuticos debido a su rareza y naturaleza agresiva. El pronóstico sigue siendo poco claro, lo que enfatiza la necesidad de más investigación para delinear el tratamiento óptimo. El caso presentado demuestra una supervivencia de un año con cuidados paliativos sistémicos, contribuyendo al conocimiento en evolución sobre el EACC.

[Multidisciplinary management of esophageal affections: Two challenging cases]. / Manejo multidisciplinario de la enfermedad esofágica: dos casos complejos.

Esophageal pathologies can exhibit extremely low incidence and prevalence rates. Therefore, it is essential to have multidisciplinary teams including surgeons specialized in esophageal pathology, with a high caseload, to ensure proper diagnosis and management. This manuscript presents a series of esophageal pathology cases with favorable outcomes and atypical resolution for non-specialized groups. However, failure to refer to specialists in a timely manner can result in missed diagnoses or poor quality of life for patients. These findings underscore the importance of having surgeons specialized in esophageal pathology and multidisciplinary teams to provide the best possible care for patients. Lusoria dysphagia (LD) is a condition caused by vascular compression of the esophagus, resulting from the most common embryological vascular abnormality of the aortic arch: the aberrant right subclavian artery (ARSA) or lusoria artery (LA). This variant occurs in 0.5 to 2.5% of individuals. Necrosis of the gastric tube following an esophagectomy is a rare complication with a high mortality rate. Esophageal replacement with coloplasty is the preferred technique for a second attempt at reconstruction. However, this remains a complex surgery with a high rate of complications.

Las enfermedades del esófago pueden presentar una incidencia y prevalencia extremadamente baja. Por lo tanto, es fundamental contar con equipos multidisciplinarios que incluyan cirujanos especializados en afecciones esofágicas, con un alto volumen de casos, para garantizar un diagnóstico y manejo adecuados. En este estudio, se analizan casos de enfermedad esofágica con resultados satisfactorios y una resolución atípica. La falta de derivación a especialistas a tiempo puede llevar a una ausencia de diagnóstico o una baja calidad de vida para los pacientes. Estos hallazgos subrayan la importancia de disponer de cirujanos especializados en esófago y equipos multidisciplinarios para asegurar la mejor atención posible para los pacientes.

Study on Analgesic Effects of Combined Thoracic Paravertebral Block Anesthesia or Erector Spinae Plane Block with Ultrasound Guided Transversus Abdominis Plane Block in Endoscopic Esophagectomy: A Clinical Anatomical Approach / Estudio sobre los Efectos Analgésicos de la Anestesia Combinada con Bloqueo Paravertebral Torácico o el Bloqueo del Plano del Erector de la Columna con Bloqueo del Plano Transverso del Abdomen Guiado por Ultrasonido en la Esofagectomía Endoscópica: Un Enfoque Anatómico Clínico

SUMMARY: The application effect of transversus abdominis plane block (TAPB) combined with thoracic paravertebral block (TPVB) or erector spinae plane block (ESP) under ultrasound guidance in endoscopic radical resection of esophageal cancer under general anesthesia was studied. From March 2021 to February 2022, patients who underwent endoscopic radical resection of esophageal cancer in our hospital were selected as the research object, and 90 patients were selected as the samples. Patients were divided into groupA and group B according to the difference of blocking schemes. Group A received ESP and Group B received TPVB. The dosage of sufentanil, nerve block time, awakening time and extubation time of the two groups were counted. The postoperative pain, sedation effect, sleep satisfaction and analgesia satisfaction of the two groups were compared, and the complications of the two groups were observed. The nerve block time and extubation time in group A were shorter than those in group B (P0.05). At T2, T3 and T4, the visual analogue scale (VAS) scores of group A at rest and cough were significantly lower than those of group B (P0.05). The satisfaction of sleep and analgesia in group A was higher than that in group B (P0.05). The analgesic effect of ultrasound-guided TAPB combined with ESP is better than that of ultrasound-guided TAPB combined with TPVB, and it can shorten the time of nerve block and extubation, which is worth popularizing.

Se estudió el efecto de la aplicación del bloqueo del plano transverso del abdomen (TAPB) combinado con el bloqueo paravertebral torácico (TPVB) o el bloqueo del plano del erector de la columna (ESP) bajo guía ecográfica en la resección radical endoscópica del cáncer de esófago bajo anestesia general. Desde marzo de 2021 hasta febrero de 2022, en nuestro hospital, se seleccionaron como objeto de investigación pacientes sometidos a resección radical endoscópica de cáncer de esófago, y como muestra se seleccionaron 90 pacientes. Los pacientes se dividieron en el grupo A y el grupo B según la diferencia de esquemas de bloqueo. El grupo A recibió ESP y el grupo B recibió TPVB. Se contaron la dosis de sufentanilo, el tiempo de bloqueo nervioso, el tiempo de despertar y el tiempo de extubación de los dos grupos. Se compararon el dolor posoperatorio, el efecto de la sedación, la satisfacción del sueño y la satisfacción de la analgesia de los dos grupos y se observaron las complicaciones de los dos grupos. El tiempo de bloqueo nervioso y el tiempo de extubación en el grupo A fueron más cortos que los del grupo B (P0,05). En T2, T3 y T4, las puntuaciones de la escala visual analógica (EVA) del grupo A en repo- so y tos fueron significativamente más bajas que las del grupo B (P 0,05). La satisfacción del sueño y la analgesia en el grupo A fue mayor que en el grupo B (P0,05). El efecto analgésico de la TAPB guiada por ecografía combinada con ESP es mejor que el de la TAPB guiada por ecografía combinada con TPVB, y puede acortar el tiempo de bloqueo nervioso y extubación, lo que vale la pena popularizar.

Prevalence of postoperative complications in oncologic gastro-esophageal surgeries: a cross-sectional study

Purpose: This study evaluated the prevalence of complications in the postoperative period of esophagogastric oncological surgeries. Methods: We conducted a retrospective cross-sectional study, adhering to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The study size implied 163 patients who underwent surgical treatment for esophageal and gastric cancer and experienced postoperative complications between January 2018 and December 2022. These patients were treated at the Liga Norte Riograndense Contra o Câncer, a high-complexity oncology center and a reference for cancer treatment in Northeast Brazil. Results: The prevalence found was 88.3%. The most prevalent complications were Clavien-Dindo I and II, and infection was the most common. According to our statistics analysis, hypoalbuminemia showed a positive correspondence with the occurrence of postoperative complications (odds ratio = 8.60; 95% confidence interval 1.35-54.64, p = 0.0358). Conclusions: Postoperative complications of gastroesophageal surgeries increase patient morbidity and mortality.

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.

Reemplazo esofágico mínimamente invasivo con tubo de Akiyama en un paciente pediátrico con quemadura esofágica / Minimally invasive esophageal replacement with Akiyama tube in a pediatric patient with esophageal burn

Introducción. La ingesta de cáusticos continúa siendo un problema de salud pública en los países en vía de desarrollo, por lo que a veces es necesario realizar un reemplazo esofágico en estos pacientes. Aún no existe una técnica estandarizada para este procedimiento. Caso clínico. Masculino de 10 años con estenosis esofágica por ingesta de cáusticos, quien no mejoró con las dilataciones endoscópicas. Se realizó un ascenso gástrico transhiatal por vía ortotópica mediante cirugía mínimamente invasiva como manejo quirúrgico definitivo .Discusión. Actualmente existen varios tipos de injertos usados en el reemplazo esofágico. La interposición colónica y gástrica son las que cuentan con mayores estudios, mostrando resultados similares. Conclusiones. La elección del tipo y posición del injerto debe ser individualizada, tomando en cuenta las características de las lesiones y la anatomía de cada paciente para aumentar la tasa de éxito.

Introduction. The ingestion of caustics continues to be a public health problem in developing countries, which is why sometimes is necessary to perform an esophageal replacement in these patients. There is still no standardized technique for this procedure. Clinical case. A 10-year-old male with esophageal stricture due to caustic ingestion, who did not improve with endoscopic dilations. A laparoscopic transhiatal gastric lift was performed orthotopically as definitive surgical management using minimally invasive surgery. Discussion. Currently there are several types of grafts used in esophageal replacement. Colonic and gastric interposition are the ones that have the most studies, showing similar results. Conclusions. Choice of type and position of the graft must be individualized, taking into account the characteristics of the lesions and anatomy of each patient, in order to increase the success rate.

The impact of sarcopenia on esophagectomy for cancer: a systematic review and meta-analysis.

BACKGROUND: Esophagectomy is the gold-standard treatment for locally advanced esophageal cancer but has high morbimortality rates. Sarcopenia is a common comorbidity in cancer patients. The exact burden of sarcopenia in esophagectomy outcomes remains unclear. Therefore, this systematic review and meta-analysis were performed to establish the impact of sarcopenia on postoperative outcomes of esophagectomy for cancer. METHODS: We performed a systematic review and meta-analysis comparing sarcopenic with non-sarcopenic patients before esophagectomy for cancer (Registration number: CRD42021270332). An electronic search was conducted on Embase, PubMed, Cochrane, and LILACS, alongside a manual search of the references. The inclusion criteria were cohorts, case series, and clinical trials; adult patients; studies evaluating patients with sarcopenia undergoing esophagectomy or gastroesophagectomy for cancer; and studies that analyze relevant outcomes. The exclusion criteria were letters, editorials, congress abstracts, case reports, reviews, cross-sectional studies, patients undergoing surgery for benign conditions, and animal studies. The meta-analysis was synthesized with forest plots. RESULTS: The meta-analysis included 40 studies. Sarcopenia was significantly associated with increased postoperative complications (RD: 0.08; 95% CI: 0.02 to 0.14), severe complications (RD: 0.11; 95% CI: 0.04 to 0.19), and pneumonia (RD: 0.13; 95% CI: 0.09 to 0.18). Patients with sarcopenia had a lower probability of survival at a 3-year follow-up (RD: -0.16; 95% CI: -0.23 to -0.10). CONCLUSION: Preoperative sarcopenia imposes a higher risk for overall complications and severe complications. Besides, patients with sarcopenia had a lower chance of long-term survival.

EARLY POSTOPERATIVE OUTCOMES OF THE ESOPHAGECTOMY MINIMALLY INVASIVE IN ESOPHAGEAL CANCER.

BACKGROUND: The incidence of esophageal cancer is high in some regions and the surgical treatment requires reference centers, with high volume, to make surgery feasible. AIMS: To evaluate patients undergoing minimally invasive esophagectomy by thoracoscopy in prone position for the treatment of esophageal cancer and to recognize the experience acquired over time in our service after the introduction of this technique. METHODS: From January 2012 to August 2021, all patients who underwent the minimally invasive esophagectomy for esophageal cancer were retrospectively analyzed. In order to assess the factors associated with the predefined outcomes as fistula, pneumonia, and intrahospital death, we performed univariate and multivariate logistic regression analyses, accounting for age as an important factor. RESULTS: Sixty-six patients were studied, with mean age of 59.5 years. The main histological type was squamous cell carcinoma (81.8%). The incidence of postoperative pneumonia and fistula was 38% and 33.3%, respectively. Eight patients died during this period. The patient's age, T and N stages, the year the procedure was performed, and postoperative pneumonia development were factors that influenced postoperative death. There was a 24% reduction in the chance of mortality each year, associated with the learning curve of our service. CONCLUSIONS: The present study presented the importance of the team's experience and the concentration of the treatment of patients with esophageal cancer in reference centers, allowing to significantly improve the postoperative outcomes.

Nutrition management by a multidisciplinary team for prevention of nutritional deficits and morbidity following esophagectomy.

This study evaluated the effects of perioperative nutrition management by a multidisciplinary team on nutrition and postoperative complications of patients with esophageal cancer. A total of 239 patients with esophageal cancer who underwent esophagectomy and gastric conduit reconstruction for esophageal or esophagogastric junction cancer between February 2019 and February 2020 were included in the study. They were divided into the experimental group (120 patients) and the control group (119 patients) using the random number table method. Control group patients received routine diet management and experimental group patients received perioperative nutrition management by a multidisciplinary team. The differences of nutriture and postoperative complications between the two groups were compared. At 3 and 7 days after surgery, the experimental group patients had higher total protein and albumin levels (P<0.05), shorter postoperative anal exhaust time (P<0.05), lower incidence of postoperative gastrointestinal adverse reactions, pneumonia, anastomotic fistula, hypoproteinemia (P<0.05), and lower hospitalization costs (P<0.05) than the control group. Nutrition management by a multidisciplinary team effectively improved the nutriture of patients, promoted the rapid recovery of postoperative gastrointestinal function, reduced postoperative complications, and reduced hospitalization costs.

Implementation of Staging Guidelines in Early Esophageal Cancer: A Study of the Society of Thoracic Surgeons General Thoracic Surgery Database.

OBJECTIVE: To evaluate the adoption and clinical impact of endoscopic resection (ER) in early esophageal cancer. BACKGROUND: Staging for early esophageal cancer is largely inaccurate. Assessment of the impact of ER on staging accuracy is unknown, as is the implementation of ER. METHODS: We retrospectively reviewed 2608 patients captured in the Society of Thoracic Surgeons General Thoracic Surgery Database between 2015 and 2020. Patients with clinical T1 and T2 esophageal cancer without nodal involvement (N0) who were treated with upfront esophagectomy were included. Staging accuracy was assessed by clinical-pathologic concordance among patients staged with and without ER. We also sought to measure adherence to National Comprehensive Cancer Network staging guidelines for esophageal cancer staging, specifically the implementation of ER. RESULTS: For early esophageal cancer, computed tomography/positron emission tomography/endoscopic ultrasound (CT/PET/EUS) accurately predicts the pathologic tumor (T) stage 58.5% of the time. The addition of ER to staging was related to a decrease in upstaging from 17.6% to 10.8% ( P =0.01). Adherence to staging guidelines with CT/PET/EUS improved from 58.2% between 2012 and 2014 to 77.9% between 2015 and 2020. However, when ER was added as a staging criterion, adherence decreased to 23.3%. Increased volume of esophagectomies within an institution was associated with increased staging adherence with ER ( P =0.008). CONCLUSIONS: The use of CT/PET/EUS for the staging of early esophageal cancer is accurate in only 56.3% of patients. ER may increase staging accuracy as it is related to a decrease in upstaging. ER is poorly utilized in staging of early esophageal cancer. Barriers to the implementation of ER as a staging modality should be identified and corrected.

Comparison of robotic-assisted minimally invasive esophagectomy versus minimally invasive esophagectomy: A propensity-matched study from a single high-volume institution.

OBJECTIVE: Robotic-assisted minimally invasive esophagectomy accounts for a growing proportion of esophagectomies, potentially due to improved technical capabilities simplifying the challenging aspects of standard minimally invasive esophagectomy. However, there is limited evidence directly comparing both operations. The objective is to evaluate the short-term and long-term outcomes of robotic-assisted minimally invasive esophagectomy in comparison with the minimally invasive esophagectomy approach for patients with esophageal cancer over a 7-year period at a high-volume center. The primary end points of this study were overall survival and disease-free survival. Secondary end points included operation-specific morbidity, lymph node yield, readmission status, and in-hospital, 30-day, and 90-day mortality. METHODS: Patients who underwent robotic-assisted minimally invasive esophagectomy or standard minimally invasive esophagectomy over a 7-year period were identified from a prospectively maintained database. Inclusion criteria were patients with stage I to III disease, operations performed past the learning curve, and no evidence of scleroderma or cirrhosis. A 1:3 propensity match (robotic-assisted minimally invasive esophagectomy:minimally invasive esophagectomy) for multiple clinical covariates was performed to identify the final study cohort. Perioperative outcomes were compared between the 2 operations. RESULTS: A total of 734 patients undergoing minimally invasive esophagectomy (n = 630) or robotic-assisted minimally invasive esophagectomy (n = 104) for esophageal cancer were identified. After exclusions and matching, a total cohort of 246 patients undergoing robotic-assisted minimally invasive esophagectomy (n = 65) or minimally invasive esophagectomy (n = 181) were identified. There was no difference in overall survival (P = .69) or disease-free survival (P = .70). There were no significant differences in rates of major morbidity: pneumonia (17% vs 17%, P = .34), chylothorax (8% vs 9%, P = .95), recurrent laryngeal nerve injury (0% vs 1.5%, P = 1), anastomotic leak (5% vs 4%, P = .49), intraoperative complications (9% vs 8%, P = .73), or complete resection rates (99% vs 96%, P = .68). There was no difference in in-hospital (P = .89), 30-day (P = .66) or 90-day mortality (P = .73) between both cohorts. The robotic-assisted minimally invasive esophagectomy cohort yielded a higher median lymph node harvest in comparison with the minimally invasive esophagectomy cohort (32 vs 29, P = .02). CONCLUSIONS: Robotic-assisted minimally invasive esophagectomy may improve lymphadenectomy in patients undergoing esophagectomy for cancer. Minimally invasive esophagectomy and robotic-assisted minimally invasive esophagectomy are otherwise associated with similar mortality, morbidity, and perioperative outcomes. Further prospective study is required to investigate whether improved lymph node resection may translate to improved oncologic outcomes.

Exactitud diagnóstica en el cáncer de esófago localizado. Estudio observacional retrospectivo.

OBJECTIVE: To assess the accuracy of the diagnostic tests for a correct clinical tumor staging in localized esophageal cancer (EC). METHOD: Retrospective observational study of patients who underwent esophagectomy for cancer in a referral hospital between January 2003 and September 2019. Those patients who received neoadjuvant treatment were excluded in order to avoid bias from downstaging effects. The preoperative stage was compared with the pathological stage of the surgical specimen. Computed tomography (CT) , endoscopic ultrasound (EUS) and positron emission tomography (PET) were evaluated. The pT stage was correlated with the tumor length described in the esophagram (EG). RESULTS: Among the 63 patients included, the clinical staging was correct in 16 (global accuracy 25.4%), it was overstaged in 21 (33.2%) and understaged in 26 (41.3%). For cT staging, the accuracy of EUS was higher than that of CT (46.6% and 34.9%, respectively), specially for early stages. EG tumor length correlated with pT stage (p < 0.05). For cN staging, PET had the highest sensitivity (50.0%) and negative predictive value (75.0%). CONCLUSIONS: Despite the multiple diagnostic tools used, the global accuracy of clinical staging in localized EC is still a challenge. The lack of a test that stands out significantly from the others reinforces the need to use them in a complementary way.

OBJETIVO: Evaluar la exactitud diagnóstica para el estadiaje clínico del cáncer de esófago (CE) localizado. MÉTODO: Estudio observacional retrospectivo de los pacientes esofagectomizados por CE en un hospital de referencia entre enero de 2003 y septiembre de 2019. Se excluyeron aquellos que recibieron neoadyuvancia para evitar sesgos de infraestadiaje. Se comparó el estadio preoperatorio con el estadio patológico de la pieza quirúrgica. Se evaluaron la tomografía computarizada (TC), la ecoendoscopia (EUS) y la tomografía por emisión de positrones (PET). El estadio pT se correlacionó con la longitud tumoral descrita en el esofagograma (EG). RESULTADOS: De los 63 pacientes incluidos, el estadiaje clínico fue correcto en 16 (exactitud 25.4%), con sobreestadiaje en 21 (33.2%) e infraestadiaje en 26 (41.3%). Para el estadiaje cT, la EUS fue superior a la TC (exactitud 46.6% y 34.9%, respectivamente), en especial para estadios precoces. La longitud tumoral del EG se correlacionó con el estadio pT (p < 0.05). Para el estadiaje cN, la PET tuvo la mayor sensibilidad (50.0%) y el mayor valor predictivo negativo (75.0%). CONCLUSIONES: A pesar de las múltiples herramientas diagnósticas empleadas, la exactitud diagnóstica en el CE localizado es limitada. La ausencia de una prueba que destaque de manera significativa refuerza la necesidad de emplearlas de forma complementaria.

Caracterización clinicoepidemiológica, diagnóstica e histopatológica de pacientes tratados con esofagectomía por cáncer de esófago / Clinical epidemiological, diagnostic, histological and pathological characterization of patients treated with esophagectomy due to esophagus cancer

Introducción: El cáncer de esófago se manifiesta clínicamente en etapas avanzadas y presenta gran letalidad. Objetivo: Caracterizar a los pacientes operados de cáncer de esófago según variables epidemiológicas, clínicas, diagnósticas e histopatológicas. Métodos: Se realizó un estudio observacional, descriptivo y transversal de 87 pacientes con cáncer de esófago, operados en el Servicio de Cirugía General del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora de Santiago de Cuba, en el periodo 2014-2018. Resultados: Dicha afección predominó en pacientes del sexo masculino (94,2 %) entre los 65 y 74 años de edad (37,9 %); el tipo histológico más frecuente fue el carcinoma epidermoide (89,6 %) y la localización en el tercio medio (49,4 %). Los hábitos tóxicos que primaron fueron el tabaquismo (87,4 %) y el consumo de alcohol (75,8 %). La disfagia y la pérdida de peso se manifestaron en 73,5 y 66,6 % de la serie, respectivamente. El diagnóstico se realizó mediante imágenes, tales como esofagograma, tomografía contrastada de tórax, abdomen y pelvis; así como por medio de endoscopia y biopsia. Conclusiones: Se demostró que los hombres son los más afectados y es más frecuente el diagnóstico en mayores de 60 años de edad. Se observó el vínculo con el hábito de fumar y el consumo de alcohol. La disfagia es el síntoma más común y tardío de la enfermedad. El estudio de las características clínico-histológicas de los pacientes con cáncer de esófago permite un adecuado enfoque diagnóstico de esta afección, así como el desarrollo de acciones de salud preventivas sobre los principales factores de riesgo identificados.

Introduction: The esophagus cancer is clinically manifested in advanced stages and presents great lethality. Objective: To characterize the patients operated on esophagus cancer according to epidemiological, clinical, diagnostic, histological and pathological variables. Methods: An observational, descriptive and cross-sectional study of 87 patients with esophagus cancer was carried out; they were operated in the General Surgery Service of Saturnino Lora Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba, in the period 2014-2018. Results: This affection prevailed in patients from the male sex (94.2 %) between the 65 and 74 years (37.9 %); the most frequent histhologic type was the squamous cell carcinoma (89.6 %) and the localization in the mean third (49.4 %). The toxic habits that prevailed were nicotine addiction (87.4 %) and consumption of alcohol (75.8 %). The dysphagia and loss of weight showed in 73.5 and 66.6 % of the series, respectively. The diagnosis was carried out by means of images, such as esophagogram, chest, abdomen and pelvis contrast tomography, as well as by means of endoscopy and biopsy. Conclusions: It was demonstrated that men are the most affected and it is more frequent the diagnosis in those over 60 years. The link with the habit of smoking and consumption of alcohol was observed. The dysphagia is the most common and late symptom of the disease. The study of clinical, histological and pathological characteristics of patients with esophagus cancer allows an appropriate diagnostic approach of this affection, as well as the development of preventive health actions about the main identified risk factors.

Evidence for Better Results of Combined General and Epidural Anaesthesia in Esophagectomy.

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Ongoing Controversies in Esophageal Cancer II: Gastrectomy versus Esophagectomy for Siewert Type II Esophageal Adenocarcinoma.

The optimal management of Siewert Type II or Junction AEG II adenocarcinoma remains a point of debate. Surgical options include an extended total gastrectomy or esophagectomy. Accurately identifying the location of the esophagogastric junction (GEJ) is important as the epicenter of the lesion is defined in reference to the GEJ. Type II tumors, in the most recent iteration of the AJCC, describe these lesions as being within 1 cm cephalad and 2 cm caudal to GEJ. Accurate staging of the location and identification of nodal metastasis is vital to guide the optimal surgical approach. Endoscopy, endosonography, CT, and PET help guide decision-making as to what junctional subtype is present. The extent of resection and lymphadenectomy remains contestable. Both surgical approaches remain viable, as each has its own advantages and issues. The key to the management of these cancers is that the surgeon has the capability to operate on both sides of the diaphragm to manage these oftentimes challenging malignancies.