Francisco C. Seguro

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.

Prevalence of gallstones in 1,229 patients submitted to surgical laparoscopic treatment of GERD and esophageal achalasia: associated cholecystectomy was a safe procedure

Background Association between esophageal achalasia/ gastroesophageal reflux disease (GERD) and cholelithiasis is not clear. Epidemiological data are controversial due to different methodologies applied, the regional differences and the number of patients involved. Results of concomitant cholecistectomy associated to surgical treatment of both diseases regarding safety is poorly understood. Aim To analyze the prevalence of cholelithiasis in patients with esophageal achalasia and gastroesophageal reflux submitted to cardiomyotomy or fundoplication. Also, to evaluate the safety of concomitant cholecistectomy. Methods Retrospective analysis of 1410 patients operated from 2000 to 2013. They were divided into two groups: patients with GERD submitted to laparocopic hiatoplasty plus Nissen fundoplication and patients with esophageal achalasia to laparoscopic cardiomyotomy plus partial fundoplication. It was collected epidemiological data, specific diagnosis and subgroups, the presence or absence of gallstones, surgical procedure, operative and clinical complications and mortality. All groups/subgroups were compared. Results From 1,229 patients with GERD or esophageal achalasia, submitted to laparoscopic cardiomyotomy or fundoplication, 138 (11.43%) had cholelitiasis, occurring more in females (2.38:1) with mean age of 50,27 years old. In 604 patients with GERD, 79 (13,08%) had cholelitiasis. Lower prevalence occurred in Barretts esophagus patients 7/105 (6.67%) (p=0.037). In 625 with esophageal achalasia, 59 (9.44%) had cholelitiasis, with no difference between chagasic and idiopathic forms (p=0.677). Complications of patients with or without cholecystectomy were similar in fundoplication and cardiomyotomy (p=0.78 and p=1.00).There was no mortality or complications related to cholecystectomy in this series. Conclusions Prevalence of cholelithiasis was higher in patients submitted to fundoplication (GERD). Patients with chagasic or idiopatic forms of achalasia had the same prevalence of cholelithiasis. Gallstones occurred more in GERD patients without Barretts esophagus. Simultaneous laparoscopic cholecystectomy was proved safe.

Adenocarcinoma of transposed colon: first case of synchronous tumor

Woman with 53-years-old diagnosed with congenital esophageal atresia, underwent to several surgical procedures in childhood, the latest was a cervical retrosternal esophagocoloplasty at 11 years old. After 42 years she was evolved with cervical dysphagia, and an initial diagnosis of stenosis of the esophagocolic anastomosis was performed, treated with endoscopic dilation without improvement. Later, biopsies were performed in the area of stenosis in proximal colonic segment (Figure 1) and polypectomy of sessile polyp of 10 mm, 5 cm distal to the stenosis (Figure 2). The pathological assessment showed tubular-villous intramucosal adenocarcinoma at the resected polyp and the area of stenosis was a invasive adenocarcinoma in colonic mucosa. Colonoscopy of remained colon was normal. Staging performed with CT scan showed an eccentric wall thickening of proximal colon transposed with luminal reduction target of left innominate vein; densification of mediastinal fat plane adjacent and regional lymph nodes up to 1.9 cm.

Heller-Pinotti, a modified partial fundoplication associated with myotomy to treat achalasia: technical and final results from 445 patients

Aim: The need for an antireflux procedure after myotomy is no longer as controversial as it used to be. However, the choice of the best fundoplication after myotomy is still controversial. The authors present the results of laparoscopic myotomies associated with postero-latero-anterior fundoplications (Heller-Pinotti). Methods: Medical records and endoscopic findings were reviewed for achalasia patients that had submitted to the procedure following 5 years of followup. Results: In total, 445 patients were enrolled: 39 (8.7%) presented erosive esophagitis, the Los Angeles classification being A-21, B-12, C-2 and D-4 (2 with peptic substenosis and 2 Barret); 41 (9.2%) patients had dysphagia, 4 needed reinterventions; 49 (11%) presented a migration of the fundoplication wrap to the thorax due to hiatal hernia, this was correlated with a higher risk of present erosive esophagitis (P = 0.047) and dysphagia (P < 0.001). Conclusion: Laparoscopy myotomy postero-latero-anterior fundoplication (Heller-Pinotti) produces a good long-term outcome for dealing with dysphagia and in terms of reflux prevention.

Avaliação de refluxo ultra-distal com pHmetria de múltiplos canais

RACIONAL: Displasia e adenocarcinoma esofagico surge em pacientes com esofago de Barrett submetidos a tratamento cirurgico (fundoplicatura) com pHmetria esofagica sem evidencia de acidez, o que sugere existir refluxo distal ao cateter de pHmetria convencional. OBJETIVO: Desenvolver metodologia para avaliar refluxo ultra-distal (1 cm acima da borda superior de esfincter inferior do esofago). METODO: Foram selecionados 11 pacientes com esofago de Barrett previamente submetidos a fundoplicatura a Nissen, sem sintomas de refluxo, com endoscopia e estudo contrastado de esofago sem sinais de recidiva. Foi realizada manometria esofagica para avaliar a localizacao e a extensao do esfincter esofagico inferior (EIE). Realizou-se entao pHmetria esofagica com quatro canais: canal A a 5 cm acima da borda superior do EIE; canal B a 1 cm acima; canal C intraesfincteriano; canal D intragastrico. Avaliou-se o escore de DeMeester no canal A. Comparou-se o numero de episodios de refluxo acido, o numero de episodios de refluxo prolongado e a fracao de tempo com pH<4,0 nos canais A e B. Comparou-se a fracao de tempo de pH<4,0 nos canais B e C. A fracao de tempo com pH<4,0 acima de 50% no canal D foi usada como parâmetro para nao migracao proximal do cateter. RESULTADOS: Houve aumento significativo do numero de episodios de refluxo e da fracao de tempo com pH<4,0 no canal B em relacao ao canal A. Houve reducao do tempo de pH<4,0 no canal B em comparacao ao canal C. Dois casos de adenocarcinoma esofagico foram diagnosticados nos pacientes do grupo estudado. CONCLUSOES: A regiao 1 cm acima da borda superior do EIE esta mais exposta a acidez do que a regiao 5 cm acima, embora em niveis reduzidos. A regiao 1 cm acima da borda superior do EIE esta menos exposta a acidez do que a regiao intraesfincteriana, demonstrando eficacia da fundoplicatura.