Douglas Alexandre Rizzanti Pereira

Evaluation of urgent esophagectomy in esophageal perforation

Background Esophageal trauma is considered one of the most severe lesions of the digestive tract. There is still much controversy in choosing the best treatment for cases of esophageal perforation since that decision involves many variables. The readiness of medical care, the patients clinical status, the local conditions of the perforated segment, and the severity of the associated injuries must be considered for the most adequate therapeutic choice. Aim To demonstrate and to analyze the results of urgent esophagectomy in a series of patients with esophageal perforation. Methods A retrospective study of 31 patients with confirmed esophageal perforation. Most injuries were due to endoscopic dilatation of benign esophageal disorders, which had evolved with stenosis. The diagnosis of perforation was based on clinical parameters, laboratory tests, and endoscopic images. ‪The main surgical technique used was transmediastinal esophagectomy followed by reconstruction of the digestive tract in a second surgical procedure. Patients were evaluated for the development of systemic and local complications, especially for the dehiscence or stricture of the anastomosis of the cervical esophagus with either the stomach or the transposed colon. Results Early postoperative evaluation showed a survival rate of 77.1% in relation to the proposed surgery, and 45% of these patients presented no further complications. The other patients had one or more complications, being pulmonary infection and anastomotic fistula the most frequent. The seven patients (22.9%) who underwent esophageal resection 48 hours after the diagnosis died of sepsis. At medium and long-term assessments, most patients reported a good quality of life and full satisfaction regarding the surgery outcomes. Conclusions Despite the morbidity, emergency esophagectomy has its validity, especially in well indicated cases of esophageal perforation subsequent to endoscopic dilation for benign strictures.

Análise da terapêutica cirúrgica da acalásia idiopática do esôfago

RACIONAL: A acalasia idiopatica do esofago e doenca inflamatoria de causa desconhecida, caracterizada por aperistalse do corpo do esofago e falha do relaxamento do esfincter esofagico inferior em resposta as degluticoes, com consequente disfagia. OBJETIVO: Demonstrar os resultados da terapeutica cirurgica desses pacientes, avaliando suas complicacoes locais e sistemicas. METODOS: Foram estudados retrospectivamente 32 pacientes portadores de acalasia idiopatica do esofago, sendo 22 com doenca nao avancada (Grau I/II) e 10 com doenca avancada (Grau III/IV); todos tinham condicoes clinicas de serem submetidos a terapeutica cirurgica. O diagnostico foi realizado por meio de analise clinica, endoscopica, cardiologica, radiologica e manometrica. Foi realizada avaliacao pre-operatoria com questionario baseado nos fatores mais predisponentes ao desenvolvimento da doenca, e a indicacao da tecnica cirurgica foi baseada no grau da lesao. RESULTADOS: Os pacientes com doenca nao avancada foram submetidos a cardiomiotomia com fundoplicatura, sendo que na avaliacao precoce do pos-operatorio apenas um deles (4,4%) apresentou infeccao pulmonar, mas com boa evolucao. Os pacientes com doenca avancada em sete foi realizada a mucosectomia esofagica com conservacao da tunica muscular, sendo que um paciente (14,2%) apresentou deiscencia da anastomose esofagogastrica cervical e tambem infeccao pulmonar, tendo ambas complicacoes sido resolvidas com tratamento especifico; os outros tres com doenca avancada foram submetidos a esofagectomia transmediastinal, sendo que dois apresentaram hidropneumotorax, com boa evolucao; um destes pacientes tambem apresentou fistula da anastomose esofagogastrica cervical, mas com fechamento espontâneo apos tratamento conservador e suporte nutricional. Os dois pacientes que apresentaram fistula da anastomose cervical, evoluiram com estenose, mas com boa evolucao apos dilatacoes endoscopicas. Na avaliacao a medio e longo prazos realizada em 23 pacientes, todos relataram acentuada melhora na qualidade de vida com retorno da degluticao. CONCLUSAO: O tratamento cirurgico proposto da acalasia idiopatica do esofago de acordo com grau da doenca foi de grande valia, devido as complicacoes pos-operatorias presentes serem de baixa morbidade, alem de proporcionar retorno adequado da degluticao.

Avaliação das complicações da esofagectomia de resgate na terapêutica cirúrgica do câncer de esôfago avançado

RACIONAL: Apesar das inumeras opcoes terapeuticas, o prognostico da neoplasia maligna de esofago continua sombrio. Devido a baixa taxa de cura da esofagectomia, foram desenvolvidas novas propostas de tratamento como a quimioterapia e radioterapia isoladas ou associadas, concomitante ou nao a cirurgia, alem da quimiorradiacao exclusiva. A esofagectomia de regaste surge como opcao terapeutica para aqueles pacientes com recorrencia ou persistencia da doenca apos tratamento clinico. OBJETIVO: Avaliar os resultados da esofagectomia de resgate em pacientes com câncer de esofago submetidos previamente a quimiorradiacao exclusiva, assim como descrever as complicacoes locais e sistemicas. METODO: Foram analisados retrospectivamente 18 pacientes com diagnostico inicial de carcinoma epidermoide de esofago irressecavel, submetidos previamente a quimiorradioterapia. Apos o tratamento oncologico eles foram examinados quanto as suas condicoes clinicas pre-operatorias. Foi realizada a esofagectomia por toracotomia direita e reconstrucao do trânsito digestivo por cervicolaparotomia. Os mesmos foram avaliados no periodo pos-operatorio tanto em relacao as complicacoes locais e sistemicas como em relacao a qualidade de vida. RESULTADOS: As complicacoes foram frequentes, sendo que cinco pacientes desenvolveram fistula por deiscencia da anastomose. Quatro desses evoluiram de maneira satisfatoria. Cinco tambem apresentaram estenose esofagogastrica cervical, mas responderam bem a dilatacao endoscopica. Infeccao pulmonar foi outra complicacao observada e presente em sete pacientes, sendo inclusive causa de obito em dois deles. Dentre os em que se conseguiu realizar seguimento com tempo medio de 5,6 anos, 53,8% estao vivos sem doenca. CONCLUSOES: Existe elevada morbidade da esofagectomia de regaste principalmente apos longo espaco de tempo entre quimiorradiacao e a cirurgia, propiciando maior dano tecidual e predisposicao a formacao de fistulas anastomoticas. No entanto, os resultados se mostram favoraveis aqueles que nao possuem mais opcoes terapeuticas.

Surgical treatment analysis of idiopathic esophageal achalasia

Background Idiopathic esophageal achalasia is an inflammatory disease of unknown origin, characterized by aperistalsis of the esophageal body and failure of the lower esophageal sphincter in response to swallowing, with consequent dysphagia. Aim To demonstrate the results of surgical therapy in these patients, evaluating the occurred local and systemic complications. Methods Were studied retrospectively 32 patients, 22 of whom presented non-advanced stage of the disease (Stage I/II) and 10 with advanced disease (Stage III/IV). All of them had the clinical conditions to be submitted to surgery. The diagnoses were done by clinical, endoscopic, cardiological, radiological and esophageal manometry analysis. Pre-surgical evaluation was done with a questionnaire based on the most predisposing factors in the development of the disease and the surgical indication was based on the stage of the disease. Results The patients with non-advanced stages were submitted to cardiomyotomy with fundoplication, wherein in the post-surgical early assessment, only one (4,4%) presented pulmonary infection, but had a good outcome. In patients with advanced disease, seven were submitted to esophageal mucosectomy preserving the muscular layer, wherein one patient (14,2%) presented dehiscence of gastric cervical esophagus anastomosis as well as pulmonary infection; all of these complications were resolved with proper specific treatment; the other three patients with advanced stage were submitted to transmediastinal esophagectomy; two of them presented hydropneumothorax with good evolution, and one of them also presented fistula of the cervical esophagogastric anastomosis, but with spontaneous healing after conservative treatment and nutritional support. The two patients with fistula of the cervical anastomosis progressed to stenosis, with good results after endoscopic dilations. In the medium and long term assessment done in 23 patients, all of them reported improvement in life quality, with return to swallowing. Conclusion The strategy proposed for the surgical treatment of idiopathic esophageal achalasia according to the stages of the disease was of great value, due to post-surgical low morbidity complications and proper recovery of swallowing.

Early and late assessment of the surgical treatment of the pharyngoesophageal diverticulum by mechanical and manual suture

Rationale: The occurrence of the pharyngoesophageal, or Zenker diverticulum is not frequent in the national scenario, and the technique of the diverticulectomy with cricomyotomy in medium and great dimension diverticula is still the most indicated. Because the resection of the diverticulum requires the suture of the pharynx, dehiscence can occur, thereafter delaying swallowing. Hence, the idea to accomplish this surgical procedure, to compare the manual and mechanical suture in order to evaluate the actual benefit of the mechanical technique. Objectives: The objective of this study is to retrospectively evaluate the results of the pharyngoesophageal diverticulectomy with cricomyotomy using manual and mechanical suture in a series of patients with regard to local and systemic complications. Method: 57 patients with pharyngoesophageal diverticula diagnosed through high digestive endoscopy and pharyngeal esophagram were studied. The applied surgical technique was diverticulectomy with myotomy of the cricopharyngeal muscle, done in 24 patients (42.2%) the mechanical suture (Group A) with the mechanical linear suture device and in 33 (57.8%) a manual closure of the pharynx (Group B). Results: In the postoperative period, one patient of Group A (4.1%) presented fistula caused by dehiscence of the pharyngeal suture, and three of Group B (15.1%) presented the same complication, with a good outcome using a conservative treatment. In the same group, 3 patients (9.0%) presented stenosis of the suture of the pharynx, with good outcome and with endoscopic dilatations, and no patient from Group A presented such complication. Lung infection was present in five patients, being two (8.3%) of Group A and three (9.0%) of Group B, having good outcomes after specific treatment. In the late review, done with 18 patients (75.0%) of Group A and 25 (75.7%) of Group B, the patients declared to be pleased with the surgical procedure, because they were able to regain normal swallowing. Conclusion: The diverticulectomy with myotomy and pharyngeal closure using mechanical suture was proven appropriate, for having restored regular swallowing in most of the patients, and the mechanical closure of the pharynx proved to be more effective in comparison to the manual suture, because it provided a lower index of local post-surgical complications. Correspondence to: José Luis Braga de Aquino, Department of Surgery, Medical School of Pontifical Catholic University of Campinas and Chief of Thoracic Surgery Department of HMCP-FM-PUC, Brazil

Microsurgical head and neck reconstruction: retrospective analysis of 30 free flaps

Introduction: Reconstructive head and neck surgery is a challenge for the plastic surgeon and requires a large technical arsenal, in which microsurgery plays an essential role. The objective to retrospectively analyze microsurgical head and neck reconstruction performed at the Pontifical Catholic University of Campinas over a period of 2 years. Methods: The medical charts of patients who underwent microsurgical reconstruction after head and neck surgery between June 2014 and October 2016 were reviewed to determine which flap was used, the length of the vascular pedicle, recipient vessels, microvascular anastomoses, surgical time, length of hospital stay, complications, and success rate. Results: Thirty microsurgical reconstructions were performed using 3 types of flaps: anterolateral thigh (n = 15), antebrachial radial (n = 8), and fibula (n = 7). Recipient vessels: facial artery (70%) and facial vein (50%), as 92.4% of microvascular anastomoses were end-to-end. The average operative time was 10.1 hours. The average length of hospital stay was 10.7 days. Two flaps were lost due to arterial thrombosis, resulting in a success rate of 93.3%. Conclusions: The microsurgical reconstructions were effective for the repair of complex defects as well as to partially restore the shape and function of the affected tissues. Complications were observed in less than 50% of the cases, although these presented with significant morbidity. The success rate was similar to that reported by major centers of reconstructive microsurgery. The learning curve is long, although it tends to improve with staff training and the acquisition of experience over time. ■ ABSTRACT

EARLY AND LATE ASSESSMENT OF ESOPHAGOCARDIOPLASTY IN THE SURGICAL TREATMENT OF ADVANCED RECURRENT MEGAESOPHAGUS

Background Since Chagas disease has esophageal manifestations with different degrees of involvement, the best surgical option is controversial, especially for patients with advanced chagasic megaesophagus and recurrent symptoms after previous treatment. Objective To assess the early and late outcomes of esophagocardioplasty in a series of patients with advanced recurrent chagasic megaesophagus. Methods This descriptive study included 19 older patients with recurrent megaesophagus grade III/IV and positive immunofluorescence for Chagas disease. They had undergone cardiomyotomy with anterior fundoplication a mean of 16.5 years ago. Serra-Doria esophagocardioplasty was selected to treat the recurrence. The patients were followed to assess postoperative and late complications and the incidence of symptom recurrence. Results In early assessment, five (26.3%) patients presented clinical complications. One (5.2%) patient had a gastrointestinal fistula secondary to esophagogastric anastomotic leak, which responded well to conservative treatment. In the one-year follow-up, 18 (94.7%) patients could swallow normally and had no vomiting. Three years after surgery, 10 (62.5%) of 16 patients could swallow normally, and 3 (19.3%) patients complained of vomiting. Five years after surgery, only 5 (38.4%) of 13 patients could swallow normally and 7 (53.8%) had vomiting. Conclusion Serra-Doria esophagocardioplasty for the treatment of advanced recurrent megaesophagus had mild postoperative complications and good success rate in the short-term follow-up. In the long-term follow-up, it proved to be a poor surgery choice because of the high incidence of symptom recurrence, compromising quality of life. This procedure should be indicated only for patients with advanced recurrent megaesophagus without clinical conditions to undergo esophageal resection.

ASSESSMENT OF MECHANICAL AND MANUAL SUTURE IN THE SURGICAL TREATMENT OF THE PHARYNGOESOPHAGEAL DIVERTICULUM

Background: The occurrence of the pharyngoesophageal, or Zenker diverticulum is not frequent in the national scenario, and the technique of the diverticulectomy with cricomyotomy in medium and great dimension diverticula is still the most indicated. Because the resection of the diverticulum requires the suture of the pharynx, dehiscence can occur, thereafter delaying swallowing. Hence, the idea is to accomplish this surgical procedure, comparing the manual and mechanical suture, in order to evaluate the real benefit of the mechanical technique. Aim: To evaluate the results of the pharyngoesophageal diverticulectomy with cricomyotomy using manual and mechanical suture with regard to local and systemic complications. Method: Fifty-seven patients with pharyngoesophageal diverticula diagnosed through high digestive endoscopy and pharyngeal esophagogram were studied. The applied surgical technique was diverticulectomy with myotomy of the cricopharyngeal muscle, done in 24 patients (42.2%) the mechanical suture (group A) with the mechanical linear suture device and in 33 (57.8%) a manual closure of the pharynx (group B). Results: In the postoperative period, one patient of group A (4.1%) presented fistula caused by dehiscence of the pharyngeal suture, and three of group B (15.1%) presented the same complication, with a good outcome using a conservative treatment. In the same group, three patients (9.0%) presented stenosis of the suture of the pharynx, with good outcome and with endoscopic dilatations, and no patient from group A presented such complication. Lung infection was present in five patients, being two (8.3%) of group A and three (9.0%) on B, having good outcomes after specific treatment. In the late review, done with 43 patients (94.4%) of group A and 22 (88.0%) on B, the patients declared to be pleased with the surgical procedure, because they were able to regain normal swallowing. Conclusion: The diverticulectomy with myotomy and pharyngeal closure using mechanical suture was proven appropriate, for having restored regular swallowing in most of the patients, and the mechanical closure of the pharynx proved to be more effective in comparison to the manual one, because it provided a lower index of local post-surgical complications.

Case Report: Recurrent Thyroid Abscess Secondary to the Fistula of Pyriform Recess

Case Report: Recurrent Thyroid Abscess Secondary to the Fistula of Pyriform Recess Background: Acute suppurative thyroiditis is a rare event among the thyroid diseases, representing from 0, 1 to 0, 7% of the possible scenarios that can affect this organ. Pyriform recess fistula is the principal cause in children, presenting itself with an infectious process which is usually unilateral and recurrent. The authors report a case of a continuing thyroidal abscess due to pyriform recess fistula in a 16 year old patient, which is later than evidence describes. Clinical Case: In 2009, patient, 14 years old caucasian male, present hyperemia and cervical edema, on the left side and toxiinfectious signs. The ultrasound showed dense collection at the topography of the left thyroid lobe, and the diagnosis was settled in suppurative thyroiditis; treatment was conducted accordingly, through surgical drainage and antibiotics. The infectious process recurred in the following years, and further investigation of the trigger factor showed that there was a fistulous route of the left pyriform recess, setting a fourth brachial arch persistence, leading to a left thyroidal lobectomy and resection of the fistulous route. Discussion: as the main cause of suppurative thyroiditis in childhood, the pyriform recess fistula presents as an acute infectious process in an initial stage, and complementary exams will only show the consequences of this presentation, which are local collection and edema of adjacent structures, located in this case specifically more on the left side than the right. In the subacute stage of the disease, the diagnosis is determined through the pharyngo-esophagogram, which will reveal the fistulous tract, due to its contrast filling. The resection of the fistulous tract is the chosen surgical procedure, and it can partially resect the thyroid lobe or not. Conclusion: the authors conclude that the pyriform sinus fistula is a rare disease and the leading cause of childhood suppurative thyroiditis as shown in the literature review, and therefore should be investigated in cases of suppurative thyroiditis and should be treated with a thyroidectomy with resection of the tract.