João de Souza Coelho Neto

O megaesôfago tratado cirurgicamente: perfil epidemiológico dos pacientes operados no Hospital de Clínicas da Universidade Estadual de Campinas entre 1989 e 2005

Megaesophagus is one of the manifestations of Chagas disease and surgical treatment is the approach that presents the best results. In this retrospective study, the epidemiological profile of patients operated in the Clinical Hospital of University of Campinas between 1989 and 2005 was evaluated with regard to: place of birth, place of residence, probable place of infection, age, degree of megaesophagus, etiology, duration and evolution of dysphagia, other diseases in association and the type of surgery chosen. The method used was to analyze the 390 medical files of these patients, at the hospitals medical archive service. The results made it possible to establish the endemic regions, place of birth and place of residence of the patients with Chagas disease attended at our clinic, and to characterize the group. After detailed analysis, it was found that the mean age was 47 years and the mean duration of dysphagia was 9.47 years. It was observed that: a) in 84.4% of the patients, dysphagia took hold progressively; b) 306 (78.5%) patients presented Chagas disease etiology; c) grade 2 was prevalent in 48%; d) 89.8% of the patients underwent cardiomyotomy; and e) there were frequent associations with gastritis, esophagitis, megacolon, arterial hypertension and cardiopathy.

Complicações pós-operatórias após gastrectomia total no câncer gástrico: análise de 300 doentes

BACKGROUND: A total gastrectomy is considered a procedure with a high level of complexity, has high complication rates, both local and general, because patients are mostly with clinical conditions and nutritional compromised by disease. AIM: To analyse the results and complications of the total gastrectomy in gastric cancer in the period from 1972 to 2007. METHODS: Were reviewed the medical records of 300 patients with gastric adenocarcinoma, divided into two periods: from 1972 to 1992 - comprising 108 patients (36%) and from 1993 to 2007 - comprising 192 patients (64%). They were 67.3% males, 70.7% whites, with ages ranging from 25 to 86 years (mean 63.4 years). The lesions were located in cardia - 40 cases (13.3%), gastric fundus - 83 cases (27.6%), gastric body - 77 cases (25.6%); plastic linitis- 45 cases (15%); gastric stump - 33 cases (11%) and antrum and body gastric - 22 cases (7.3%). A total gastrectomy with extended lymphadenectomy to level D2 was performed in 246 cases (82%). RESULTS: The reconstruction technique used was the esophagus-jejunal anastomosis end-to-side Roux-en-Y in 257 patients (86.7%). The general complications in the period from 1972 to 1992 totalized 47 cases (43.5%), mainly involving the respiratory (28 cases - 25.9%) and urinary tract (10 cases - 9.2%). In the period from 1993 to 2007 amounted to 48 cases (25%), mainly respiratory complications (27 cases - 14%), followed by urinary (12 cases - 6.2%). The local complications from 1972 to 1992 totalized 45 cases (30.8%) and in the period from 1993 to 2007 amounted to 28 cases (14.5%), being the most frequent the digestive fistulas. The operative mortality through 30 days was 18 cases (6%), while in the period from 1972 to 92 a total of 12 cases (11.1%) and in the period from 1993 to 2007 were 7 cases (3.6%). CONCLUSIONS: Total gastrectomy is a procedure that requires a skilled surgeon, his team, using an improved surgical technique to minimize postoperative complications. The postoperative complications requiring care in controlling infections, airway and nutritional care, reducing mortality, increasing survival and contributing to quality of life of patients.

Results of the surgical treatment of non-advanced megaesophagus using Heller-Pinotti's surgery: Laparotomy vs. Laparoscopy

INTRODUCTION: Dysphagia is the important symptom in achalasia, and surgery is the most common treatment. The Heller–Pinotti technique is the method preferred by Brazilian surgeons. For many years, this technique was performed by laparotomy, and now the laparoscopic method has been introduced. The objective was to evaluate the immediate and long‐term results of patients submitted to surgery by either laparotomy or laparoscopy. MATERIALS AND METHODS: A total of 67 patients submitted to surgery between 1994 and 2001 with at least 5 years of follow‐up were evaluated retrospectively and divided into two groups: laparotomy (41 patients) and laparoscopy (26 patients). Chagas was the etiology in 76.12% of cases. Dysphagia was evaluated according to the classification defined by Saeed et al. RESULTS: There were no cases of conversion to open surgery. The mean duration of hospitalization was 3.32 days for laparotomy and 2.54 days for laparoscopy (p<0.05). An improvement in dysphagia occurred with both groups reporting good or excellent results (laparotomy: 73.17% and laparoscopy: 73.08%). Mean duration of follow‐up was 8 years. CONCLUSIONS: There was no difference between the two groups with respect to relief from dysphagia, thereby confirming the safety and effectiveness of the Heller–Pinotti technique, which can be performed by laparotomy or laparoscopy, depending on the surgeons experience.

Aspectos atuais da terapêutica neo-adjuvante no carcinoma epidermóide do esôfago: revisão da literatura

INTRODUCAO: O câncer de esofago e o oitavo tipo de câncer mais incidente na populacao, com alta letalidade a despeito da melhora do tratamento cirurgico nas ultimas decadas. O carcinoma epidermoide tem maior prevalencia em varios paises em tambem no Brasil. Sendo assim, estrategias de tratamento neo-adjuvante tornaram-se objeto de estudo em varios centros mundiais de referencia. OBJETIVO: Identificar aspectos atuais da terapeutica neo-adjuvante no tratamento do carcinoma epidermoide do esofago. METODOS: Revisao bibliografica de artigos cientificos disponiveis no Medline e na base de dados Cochrane cruzando-se os descritores neoplasia esofagicas, cirurgia, quimioterapia, radioterapia. CONCLUSAO: A estrategia da terapeutica neo-adjuvante e cada vez mais utilizada como forma de oferecer melhores resultados tardios na sobrevida e na qualidade de vida dos pacientes portadores de carcinoma do esofago.

Eficácia local e complicações da terapêutica neoadjuvante no carcinoma epidermóide do esôfago: radioterapia versus radioterapia associada à quimioterapia

OBJECTIVE To evaluate tumor responses to neoadjuvant therapy, according to the histopathological findings of surgical specimens of patients operated and treated for squamous cell carcinoma of the middle third and distal esophagus. METHODS We conducted a retrospective nonrandomized study including 97 patients distributed as follows: Group I - 81 (83.5%) underwent neoadjuvant radiation therapy, and group II - 16 (16.5%) underwent neoadjuvant radiotherapy and chemotherapy. A third group of 26 patients undergoing esophagectomy alone was used for comparison of postoperative complications. The characteristics of each patient (age, gender and race), tumor site, staging, and histological evaluation of treatment modalities were reviewed and analyzed. Tumor response to neoadjuvant therapy was evaluated by histopathology of the specimen. RESULTS There was no statistically significant differences regarding race, gender, age, staging and postoperative complications in patients in the three groups. Patients undergoing radiotherapy and neoadjuvant chemotherapy showed more satisfactory tumor reduction, with improved local efficacy when compared to the group only submitted to neoadjuvant radiotherapy. CONCLUSION The study suggests that radiotherapy combined with chemotherapy was more efficient in reducing tumor site when compared to the group treated with radiotherapy. In addition, neoadjuvant therapy did not increase the postoperative complications when compared to patients undergoing surgery alone.OBJETIVO: avaliar por meio de um estudo retrospectivo nao randomizado as respostas tumorais a terapeutica neoadjuvante, conforme os achados histopatologicos das pecas cirurgicas dos pacientes operados e tratados por carcinoma espinocelular do terco medio e distal do esofago. METODOS: Foram incluidos no estudo 97 pacientes assim distribuidos: grupo I 81 (83,5%) submetidos a radioterapia neoadjuvante; e grupo II 16 (16,5%) submetidos a radioterapia e quimioterapia neoadjuvantes. Um terceiro grupo de 26 pacientes submetidos a esofagectomia exclusiva foi utilizado na comparacao das complicacoes pos-operatorias. As caracteristicas de cada paciente (idade, sexo e raca), o local do tumor, o estadiamento, e a avaliacao histologica das modalidades de tratamento foram revisadas e analisadas. A resposta tumoral a terapeutica neoadjuvante foi avaliada com estudos histopatologicos da peca cirurgica. RESULTADOS: Nao houve diferencas estatisticas significativas quanto a cor, sexo, idade, estadiamento e complicacoes pos-operatorias nos pacientes dos tres grupos analisados. Os pacientes submetidos a radioterapia e quimioterapia neoadjuvante apresentaram reducao tumoral mais satisfatoria, com melhor eficacia local, quando comparado ao grupo submetido apenas a radioterapia neoadjuvante. CONCLUSAO: o estudo sugere que a radioterapia associada a quimioterapia apresentou maior eficacia local na reducao tumoral em comparacao com o grupo tratado com radioterapia; alem disso, a terapeutica neoadjuvante nao elevou as complicacoes pos-operatorias em comparacao aos pacientes submetidos a cirurgia exclusiva.

Gastric Adenocarcinoma after Gastric Bypass for Morbid Obesity: A Case Report and Review of the Literature

Gastric adenocarcinoma after gastric bypass for morbid obesity is rare but has been described. The diet restriction, weight loss, and difficult assessment of the bypassed stomach, after this procedure, hinder and delay its diagnosis. We present a 52-year-old man who underwent Roux-en-Y gastric bypass 2 years ago and whose previous upper digestive endoscopy was considered normal. He presented with weight loss, attributed to the procedure, and progressive dysphagia. Upper digestive endoscopy revealed stenosing tumor in gastric pouch whose biopsy showed diffuse-type gastric adenocarcinoma. He underwent total gastrectomy, left lobectomy, distal pancreatectomy and splenectomy, segmental colectomy, and bowel resection with esophagojejunal anastomosis. The histopathological analysis confirmed the presence of gastric cancer. The pathogenesis of gastric pouch adenocarcinoma is discussed with a literature review.

Tratamento cirúrgico do megaesôfago no Hospital de Clínicas da UNICAMP - fatores associados a melhores ou a piores resultados

OBJECTIVES: To verify some possible factors, which would be associated with better or worse results for surgical treatment of megaesophagus. MEHTODS: There were 417 patients operated on for megaesophagus, but only 390 medical charts were analyzed between 1989 and 2005. The presence of intraoperative and postoperative complications and the maintenance of severe dysphagia complaints were evaluated in a directed questionnaire, studying association with: the surgical approach chosen, megaesophagus degree, etiology and presence of other digestive alterations. RESULTS: There were 360 cardiomiotomies, 20 esophagectomies and 11 mucosectomies. The results indicate that the cardiomiotomy is the safest surgery and the esophagectomy has more complications. The degree of megaesophagus is directed related with the results; more advanced megaesophagus has the worse results. The presence of digestive alterations has also a direct influence with worse results. CONLCUSION: The most important factor considering the results is the surgery chosen, and the best one were seen with cardiomiotomy. The degree of megaesophagus has also influenced the results. The etiology suggests better results with Chagas disease patients, maybe for the chronic course of this disease. The presence of digestive alteration is a factor which causes worse results, especially if associated with gastritis, esophagitis, megacolon and others.

The Rapunzel Syndrome: An Unusual Trichobezoar Presentation

The Rapunzel syndrome is an unusual form of trichobezoar found in patients with a history of psychiatric disorders, trichotillomania (habit of hair pulling) and trichophagia (morbid habit of chewing the hair), consequently developing gastric bezoars. The principal symptoms are vomiting and epigastric pain. In this case report, we describe this syndrome in a young girl.

Ranitidine is unable to maintain gastric pH levels above 4 in septic patients.

PURPOSE The study aimed to evaluate whether ranitidine and pantoprazole are able to maintain gastric pH >or=4 in septic patients. MATERIALS AND METHODS Twenty intensive care unit patients from a university teaching hospital with sepsis were included in this study. Ten patients received ranitidine (50 mg as an intermittent bolus 3 times a day) and 10 received pantoprazole (40 mg as an intermittent bolus twice a day). Gastric pH was measured continuously for 48 hours. Endoscopy of the upper digestive tract, gastric biopsy, and investigation for Helicobacter pylori were carried out before and at the end of the study. RESULTS pH values >or=4 were maintained for 46.27% +/- 38.21% and 81.57% +/- 19.65% of study time in the ranitidine and pantoprazole groups, respectively (P = .04). CONCLUSIONS Intravenous ranitidine was unable to maintain gastric pH above 4 in septic patients. All cases in the ranitidine group in whom pH remained above 4 had gastric hypotrophy or atrophy. Pantoprazole successfully maintained pH levels above 4.

Tratamento cirúrgico do divertículo de zenker

O diverticulo de Zenker (DZ) e uma doenca muito pouco frequente, cujo sintoma mais importante e a disfagia cervical. Os aspectos de sua etiopatogenia ainda sao motivos de varias pesquisas na literatura, atraves de estudos manometricos e cinerradiograficos. O tratamento mais empregado e o cirurgico, favorecendo quase a totalidade dos doentes, com indices de recidiva muito baixos. Porem, algumas publicacoes enfatizam as vantagens do tratamento endoscopico. Foram revisados 39 doentes, tratados no Servico nos ultimos 15 anos, sendo que 28 foram do sexo masculino (71,8%). A idade do grupo variou de 18 a 86 anos (media 54,5 anos). Os principais sintomas foram a disfagia cervical (89,8%), a regurgitacao alimentar (71,8%), a tosse repetitiva (30.7%) e o emagrecimento importante (25,6%). Dois pacientes apresentaram diverticulite aguda e perfuracao (5,1 %). O diagnostico foi estabelecido atraves de radiografias contrastadas em 37 pacientes (94,8%) e de endoscopia digestiva em 28 (71,7%). A eletromanometria foi realizada em 13 casos (33,3%). O tratamento consistiu de diverticulectomia seguida de miotomia do esfincter do musculo cricofaringeo em 24 pacientes (61,5%) e diverticulopexia seguida da mesma miotomia em 15 pacientes (38,5%). No seguimento a longo prazo de 35 pacientes (89,8%), variando de cinco meses a 12 anos (media 4,5 anos), ocorreu melhora importante com desaparecimento da disfagia em todos os casos. Tres pacientes (7,7%) persistiram sintomas disfagicos leves e inconstantes. Um paciente faleceu em decorrencia de complicacoes cardiacas e pulmonares. Os estudos histopatologicos dos diverticulos ressecados mostraram a presenca de tumor maligno neuroendocrino em um paciente (2,5%). Os doentes submetidos a diverticulopexia receberam alta hospitalar mais precocemente. Os autores discutem os aspectos atuais da fisiopatologia do DZ, analisam as opcoes de tratamento e os resultados da literatura, comparando com os obtidos neste estudo. Concluindo, os resultados mostram que tanto a diverticulectomia como a diverticulopexia podem ser utilizadas, ambas seguidas de miotomia do musculo cricofaringeo. A diverticulopexia mostrou ser uma opcao muito satisfatoria para os diverticulos de tamanhos pequenos e medios.