José Carlos Del Grande

'Raccoon eyes' (periorbital haematoma) as a sign of skull base fracture

This is a study of the relationship between skull base fracture and the raccoon eyes sign in a prospective study in cadavers. Fifty cadavers were analysed with cranio encephalic trauma and skull base fracture or the raccoon eyes sign. Both conditions were present in 24 (48.0%) cases. The association was significantly higher in cases with a frontal basal fracture and epidural haematoma. The raccoon eyes sign is easily recognised and can be associated with basal fractures.

Hiatal mesh repair--current status.

Most surgeons believe that cruroplasty (hiatoplasty) is an essential part of antireflux operations. One of the main causes of failure after antireflux operation is gastric (wrap) herniation through the hiatus that may be attributed to breakdown of the hiatal closure or a faulty repair. Surgeons are at present faced with the dilemma of choosing between a risk of recurrence and the fear of complications of prosthetic hiatal reinforcement. We reviewed the literature to evaluate the current status of hiatal mesh repair (HMR). Indication, technique, complications, and results are shown. Available data show a small number of mesh-related complications compared with the number of patients submitted to the procedure, and better results of HMR compared with simple hiatal closure. We support the use of HMR when performed by skilled foregut surgeons, as complications described occurred more frequently in the earliest cases of the series. In addition, HMR should be probably used selectively. However, studies to identify the patients at risk of hernia recurrence or mesh-related complications are still elusive. The ideal type of mesh and the ideal technique for mesh implantation are yet to be established.

Surgical Treatment of Primary Esophageal Motility Disorders

Named primary esophageal motility disorders (PEMD) present with specific manometric patterns classified as: (1) hypertensive lower esophageal sphincter, (2) nutcracker esophagus (also hypercontratile, hypertensive, or hypercontracting esophagus), (3) diffuse esophageal spasm, and (4) achalasia. These conditions, with the exception of achalasia, are rare, poorly understood, and inadequately studied. Treatment of these conditions is based on symptoms and aimed at symptomatic improvement. The authors reviewed current literature on surgical treatment of non-achalasia PEMD. The review shows that: (a) surgical therapy may be an attractive alternative in patients with PEMD; (b) proper selection of patients based on symptoms evaluation and esophageal function tests is essential; (c) laparoscopic myotomy with proximal extent tailored to manometric findings seems to be the ideal surgical therapy; and (d) esophagectomy may be necessary as a last resource due to multiple failures of surgical conservative treatment.

Randomized trial of total fundoplication and fundal mobilization with or without division of short gastric vessels: a short-term clinical evaluation

PURPOSE Evaluate short results after fundoplication procedure, concerning the division of short gastric vessels. METHODS A prospective randomization of 90 patients with indication for hiatoplasty and total fundoplication with fundus mobilization was performed. They were divided into two groups: no SGV division (group A, n= 46) and with SGV division (Group B, n=44), although in both groups the gastric fundus was mobilized to perform a floppy valve. Early outcome with clinical follow up (1 year) was observed. RESULTS Both groups were similar regarding preoperative parameters and severity of gastroesophageal reflux disease (GERD). No difference in morbidity was observed during hospital stay. Nevertheless, the median operating time was 80,2 minutes in group A and 94,1 minutes (p=0,021) in Group B. Transitory dysphagia during the first year was significantly lower in group B (46,6% versus 23,2%, p=0,012). However, in 12 months clinical outcome was similar in both groups (clinical symptoms of GERD, persistent dysphagia and reoperations). CONCLUSION There was no improvement in routine division of SGV in total fundoplication procedure when the gastric fundus was mobilized.

Short esophagus or bad dissected esophagus? An experimental cadaveric study

Short esophagus is defined as the inability to reduce the gastroesophageal junction below the diaphragm. One of the factors responsible for this inability can be inadequate esophageal mobilization. We evaluated esophageal lengthening achieved by means of dissection in a cadaveric model. Fifty-one cadavers were dissected (27 transthoracically and 24 transhiatally). Abdominal esophageal length was assessed before and after dissection of the esophagus from the hiatus to the carina. In the transthoracic group, a mean of 1.7 ± 1.3 cm (range0.3 to 5.0cm) was gained with dissection. In the transhiatal group, a mean of 1.8 ± 0.8 cm (range 0 to 3.0 cm) was gained with dissection. In a comparison of results of transthoracic and transhiatal approaches, the difference was not statistically significant. We concluded that a significant increase in esophageal length was achieved after dissection; however, the access route (thorax or abdomen) did not influence the results.

Anatomical analysis of the mediastinal lymph nodes of normal Brazilian subjects according to the classification of the Japanese Society for Diseases of the Esophagus.

Abstract.Purpose: Extended mediastinal lymphadenectomy is gaining popularity in the treatment of esophageal cancer, but lymph node nomenclature and classification is still not standardized. The normal mediastinal lymph node distribution according to the classification of the Japanese Society for Esophageal Diseases has never been studied. Methods: We dissected 20 fresh adult cadavers to examine the mediastinal lymph nodes. Results: We found an unpredictable and inconstant distribution. Conclusion: Previous papers have evaluated the number and distribution of normal mediastinal lymph nodes, clinically, radiologically, and anatomically, but the results are conflicting and inconsistent.

Helicobacter pylorihas no influence on distal gastric cancer survival

CONTEXT There is some evidence that Helicobacter pylori correlates with distal gastric cancer genesis. However, few studies analyzed the survival related to H. pylori infection. OBJECTIVE To correlate gastric cancer survival and H. pylori infection. METHODS Sixty-eight patients with distal gastric cancer that underwent subtotal gastrectomy were studied. Minimal follow-up was 1 month. H. pylori infection was confirmed by biopsy. RESULTS Thirty-four patients (19 males (55.9%), mean age 60.9 ± 14.03, range 33-82 years) were H. pylori positive. Thirty-four patients (16 males (47.1%), mean age 57.9 ± 13.97, range 27-85 years) were H. pylori negative. Groups were comparable in regards to age (P = 0.4), gender (P = 0.5), stage [T (P = 0.2), N (P = 0.6) and M (P = 0.9)]. Survival was not different when groups were compared [P = 0.1616 (hazard ratio 0.6834, 95% CI 0.4009 to 1.1647)]. CONCLUSIONS H. pylori infection does not affect distal gastric cancer survival.

High-Resolution and Conventional Manometry in the Assessment of the Lower Esophageal Sphincter Length

Dear Editor: High-resolution manometry (HRM) is a revolutionary tool in the field of esophageal function tests. It is a valuable and incomparable instrument to assess the esophageal sphincters and segmental defects of esophageal body peristalsis due to a “panoramic” and simultaneous view from the pharynx to the stomach. Furthermore, it is quicker, more comfortable, and does not share some of the limitations of conventional manometry such as motion artifacts. Ayazi et al. from DeMeester group recently presented an elegant paper on the value of HRM in the assessment of the lower esophageal sphincter (LES) in comparison to the conventional manometry. The authors reported an overestimation of the LES length with HRM. The paper raises two questions: (1) Which manometry is better to evaluate LES length?; (2) How should HRM assess LES length? When two methods are compared, the choice for which one should be considered the gold standard test may be sometimes difficult. Period of existence is not a guarantee that the older method is better. Ayazi et al. concluded in their study that HRM is associated to errors in the evaluation of the borders of the LES leading to detriment of accuracy in LES assessment. As a new method, HRM should be interpreted with open mind and new eyes. Old concepts must not necessary be valid for its interpretation. In regards to the evaluation of the borders of the LES and consequently of its length, motion artifacts must be carefully taken in consideration. It is known that LES is mobile with respiration (Fig. 1). This mobility is easily seen on HRM contours. It appears that the LES has a synchronous movement with the diaphragm, descending in average 0.85 cm during inspiration. Two points can explain the overestimation of the LES found. First, the borders of the LES must be defined in a fixed point, ignoring the oscillation seem on the HRM contours. If the borders are defined by the distance between its maximum and minimum amplitude, the amplitude of movement will be counted twice, as noticed on Fig. 3 of the referred paper. Second, this very group from the University of Southern California has educated all of us that the LES is defined by a constant rise in baseline of at least 2 mmHg. If we look at the area where the LES is intermittently present, a conventional manometry plot will not show a plateau of basal pressure expected for a sphincter, and it will not be incorporated in the calculation for the LES length (Fig. 2). In regards to pH catheter placement, also a concern of the authors, we recommend the use of the upper border of the area where the LES is constantly present F. A. M. Herbella : F. P. P. Vicentine : J. C. Del Grande Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil

Obesity and Symptomatic Achalasia

Weight loss is a frequent finding in achalasia because of the difficulty in swallowing. Although manometric findings compatible with achalasia have been found in morbidly obese patients, all of them were asymptomatic. The authors report a case of symptomatic achalasia and morbid obesity in a 38-year-old woman. A mental disorder become manifested after the patient was submitted to an esophageal myotomy and fundoplication. With weight gain, postoperative gastroesophageal reflux developed. Drawbacks of further operative procedures in such a patient are discussed.

Índice de publicação dos trabalhos apresentados no XXIV Congresso Brasileiro de Cirurgia

BACKGROUND: Analysis of the index of publication of the papers presented at the XXIV Brazilian Congress of Surgery. METHODS: Searches in a computerized database (Index Medicus-Medline-PubMed) of the papers presented at the Congress were done based on the names of authors and titles key words. RESULTS: Of the 1133 papers presented at the Congress, 29 (2.6%) were published-nine free papers (2.0%); one video (1.6%); two research forums (12.5%); and 17 posters (2.8%). Concerning authors, 2638 were identified and 71 (2.7%) had their papers published. CONCLUSIONS: The index of publication of the papers presented at the Brazilian Congress of Surgery is still low.