F. A. M. Herbella

Resultados tardios da operação de Heller associada à fundoplicatura no tratamento do megaesôfago: análise de 83 casos

BACKGROUND: Retrospective study of the late results of the Hellers cardiomyotomy and fundoplication for the treatment of the megaesophagus. MATERIAL AND METHODS: Were studied 83 patients with a follow-up from one to 186 months (average 40.0±47.4 months). The fundoplications used were in three plans in 15.7% and posterior in 83.1%. The main pre-operatory complain was disphagia followed by regurgitation and loss of weight. Chagas, Disease as the etiology was confirmed in 72.3% of the patients. RESULTS: In the follow-up 55.4 % of the patients were assymptomatic, 34.9% complained of sporadic dysphagia, 14.4% of heartburn, 8.4% of regurgitation and 2.4% did not changed the dysphagia, these being re-operated and had improvement the symptoms. Gastro-esophageal reflux was noted in 8.4% of the patients. Other late complications were par-esophageal hernia, sliping of the fundoplication, Barrett esophagus and cancer. CONCLUSIONS: The necessity of a long-term clinical and endoscopical follow-up, even after surgery, owing to the possibility of late complications, especially cancer was emphasized. The late results are good in relation to the dysphagia. Myotomy is proposed as an alternative to patients with advanced megaesophagus with bad clinical conditions who can not be submitted to an esophagectomy.

Progression of diffuse esophageal spasm to achalasia: incidence and predictive factors

The progression of certain primary esophageal motor disorders to achalasia has been documented; however, the true incidence of this decay is still elusive. This study aims to evaluate: (i) the incidence of the progression of diffuse esophageal spasm to achalasia, and (ii) predictive factors to this progression. Thirty-five patients (mean age 53 years, 80% females) with a manometric picture of diffuse esophageal spasm were followed for at least 1 year. Patients with gastroesophageal reflux disease confirmed by pH monitoring or systemic diseases that may affect esophageal motility were excluded. Esophageal manometry was repeated in all patients. Five (14%) of the patients progressed to achalasia at a mean follow-up of 2.1 (range 1-4) years. Demographic characteristics were not predictive of transition to achalasia, while dysphagia (P= 0.005) as the main symptom and the wave amplitude of simultaneous waves less than 50u2003mmHg (P= 0.003) were statistically significant. In conclusion, the transition of diffuse esophageal spasm to achalasia is not frequent at a 2-year follow-up. Dysphagia and simultaneous waves with low amplitude are predictive factors for this degeneration.

Esophageal diverticula and cancer.

Esophageal diverticula are rare. The association of cancer and diverticula has been described. Some authors adopt a conservative non-surgical approach in selected patients with diverticula whereas others treat the symptoms by diverticulopexy or myotomy only, leaving the diverticulum in situ. However, the risk of malignant degeneration should be may be taken in account if the diverticulum is not resected. The correct evaluation of the possible risk factors for malignancy may help in the decision making process. We performed a literature review of esophageal diverticula and cancer. The incidence of cancer in a diverticulum is 0.3-7, 1.8, and 0.6% for pharyngoesophageal, midesophageal, and epiphrenic diverticula, respectively. Symptoms may mimic those of the diverticulum or underlying motor disorder. Progressive dysphagia, unintentional weight loss, the presence of blood in the regurgitated material, regurgitation of peaces of the tumor, odynophagia, melena, hemathemesis, and hemoptysis are key symptoms. Risk factors for malignancy are old age, male gender, long-standing history, and larger diverticula. A carcinoma may develop in treated diverticula, even after resection. Outcomes are usually quoted as dismal because of a delayed diagnosis but several cases of superficial carcinoma have been described. The treatment follows the same principals as the therapy for esophageal cancer; however, diverticulectomy is enough in cases of superficial carcinomas. Patients must be carefully evaluated before therapy and a long-term follow-up is advisable.

Comparison of idiopathic achalasia and Chagas' disease esophagopathy at the light of high-resolution manometry.

The comparison between idiopathic achalasia (IA) and Chagas disease esophagopathy (CDE) may evaluate if treatment options and their outcomes can be accepted universally. This study aims to compare IA and CDE at the light of high-resolution manometry. We studied 86 patients with achalasia: 45 patients with CDE (54% females, mean age 55 years) and 41 patients with IA (58% females, mean age 49 years). All patients underwent high-resolution manometry. Upper esophageal sphincter parameters were similar (basal pressure CDE = 72 ± 45u2009mmHg, IA = 82 ± 57u2009mmHg; residual pressure CDE = 9.9 ± 9.9u2009mmHg, IA = 9.8 ± 7.5u2009mmHg). In the body of the esophagus, the amplitude was higher in the IA group than the CDE group at 3u2009cm (CDE = 15 ± 14u2009mm Hg, IA = 42 ± 52u2009mmHg, P = 0.003) and 7u2009cm (CDE = 16 ± 15u2009mmHg, IA = 36 ± 57u2009mmHg, P = 0.04) above the lower esophageal sphincter (LES). The LES basal pressure (CDE = 17 ± 16u2009mmHg, IA = 40 ± 22u2009mmHg, P < 0.001) and residual pressure (CDE = 12 ± 11u2009mmHg, IA = 27 ± 13u2009mmHg, P < 0.001) were also higher in the IA group. Our results show that: (i) there is no difference in regards to the upper esophageal sphincter; (ii) higher pressures of the esophageal body are noticed in patients with IA; and (iii) basal and residual pressures of the LES are lower in patients with CDE. Our results did not show expressive manometric differences between IA and CDE. Some differences may be attributed to a more pronounced esophageal dilatation in patients with CDE.

Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery

Backgroundu2002 An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been demonstrated in normal individuals (NI) and patients with gastro‐esophageal reflux disease (GERD). The role of gastric anatomy and gastric motility in the physiology of the PPGAP remains elusive. This study aims to analyze the correlation of PPGAP with proximal gastric pressure after gastric surgery.

High resolution manometric findings in patients with Chagas' disease esophagopathy.

OBJECTIVEnTo describe high resolution manometry features of a population of symptomatic patients with Chagas disease esophagopathy (CDE).nnnMETHODSnSixteen symptomatic dysphagic patients with CDE [mean age (54.81±13.43) years, 10 women] were included in this study. All patients underwent a high resolution manometry.nnnRESULTSnMean lower esophageal sphincter (LES) extension was (3.02±1.17) cm with a mean basal pressure of (15.25±7.00) mmHg. Residual pressure was (14.31±9.19) mmHg. Aperistalsis was found in all 16 patients. Achalasia with minimal esophageal pressurization (type 1) was present in 25% of patients and achalasia with esophageal compression (type 2) in 75%, according to the Chicago Classification. Upper esophageal sphincter (UES) mean basal pressure was (97.96±54.22) mmHg with a residual pressure of (12.95±6.42) mmHg.nnnCONCLUSIONSnOur results show that LES was hypotensive or normotensive in the majority of the patients. Impaired relaxation was found in a minority of our patients. Aperistalsis was seen in 100% of patients. UES had impaired relaxation in a significant number of patients. Further clinical study is needed to investigate whether manometric features can predict outcomes following the studies of idiopathic achalasia.

Skin metastases from esophageal and esophagogastric junction cancer.

A large proportion of esophageal cancers present initially in an advanced stage (1). Extra-nodal metastases are seen in 20% of the patients (2),(3), the liver and lungs are the more common places (2),(3). Cutaneous metastases (CM) are rarely reported (4)-(12). n nWe report two cases of skin metastases from esophageal cancer.

Postprandial proximal gastric acid pocket and gastroesophageal reflux disease.

An unbuffered layer of acidity that escapes neutralization by food has been demonstrated in volunteers and gastroesophageal reflux disease patients. This postprandial proximal gastric acid pocket (PPGAP) is manometrically defined by the presence of acid reading (pH<4) in a segment of the proximal stomach between nonacid segments distally (food) and proximally (lower esophageal sphincter or distal esophagus). The PPGAP may have important clinical implications; however, it is still poorly understood. Gastric anatomy and physiology seem to be important elements for PPGAP genesis. Gastric operations and acid suppression medications may decrease distal - proximal intragastric acid reflux and help control gastroesophageal reflux.

Esophagectomy Perianesthetic Care from a Surgeon's Point of View

Esophagectomy is a distinctive and technically demanding operation. Perioperative care in patients to be submitted to esophagectomy should be individualized since intraoperative course may influence morbidity and mortality. W e reviewed esophagectomy-related concepts of interest to the anesthesiologist. Surgical technique, Perianesthetic monitoring, intubation, ventilation, aspiration prevention and extubation, fluid management, pain control, and intraoperative complications are discussed from a surgeon’s perspective. Important Esophagectomy-related concepts of interest to the anesthesiologist from a surgeon’s perspective are: (a) close communication between surgeons and anesthesiologists, especially during the mediastinal dissection, (b) fluid restriction, (c) thoracic epidural analgesia, and (d) extubation in the operating room.

Postprandial proximal gastric acid pocket in patients after distal gastrectomy

Backgroundu2002 An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in the majority of normal individuals and patients with gastroesophageal reflux disease. The role of gastric anatomy, specifically the antrum, in the physiology of the PPGAP is not yet fully elucidated. This study aims to analyze the presence of PPGAP in patients submitted to distal gastrectomy.