José Gonzaga Teixeira de Camargo

Avaliação da anastomose esofagogástrica cervical com sutura mecânica e manual em pacientes com megaesôfago avançado

OBJECTIVES The aim of the study is to evaluate cervical esophagogastric anastomosis complications between mechanical device versus manual suture. METHOD Thirty patients with megaesophagus with grade III/IV submitted to the esophagectomy transmediastinal approach were reviewed with average age from 31 to 68 years. The reconstruction was performed by gastric transposition and with anastomosis in the cervical region. The patients were divided in two groups: A) 15 patients had mechanical suture with the DHC 29 mm device, and B) 15 patients had manual suture in two layers. RESULTS Five patients (16.6%) presented pneumonia, and they were managed clinically. Three patients were in group B and two were in group A, and no statistical significance was found. Six patients (20%) presented leakage at the cervical esophagogastric anastomosis; one in group A (6.6%) and five in group B (33.3%), with no statistical significance. Anastomosis leakage with development of stricture occurred in five patients in group B, and in three in group A, as well in other two without leakage complications. All of them were managed successfully with endoscopic dilatation. Statistical evaluation was not significant for this complication between group B (33.3%) and group A (20%). There were no deaths in this study. CONCLUSION This study showed that mechanical suture is as adequate as manual suture by presenting anastomosis leakage incidence smaller, however, with no statistical significance, and with similar stricture incidence.

Mucosectomia esofágica no tratamento do megaesôfago avançado: análise de 60 casos

Partial ou total esophagectomy without thoracotomy has been used with greater frequency for the last few years to treat benign affections, specially advanced megaesophagus. Although this procedure presents the advantages of avoiding compromise of lung dynamics, it is not free complications. Among these, we have to emphasize the opening of pleura with hemopneumothorax, together with the potential aggression to other organs in the mediastinum, with a significant postoperative morbidity. On the other hand, in advanced megaesophagus, stasis esophagitis may lead to carcinoma. Based on these considerations, it was proposed, previously in animals and human beings, mucosal and submucosal removal by complete invagination, without thoracotomy. These results were satisfactory in experimental surgery and encouraged the beginning of the clinical experience area. Thus, the aim of the present work is to show, by a detailed analysis, the tecnique of esophageal mucosal and submucosa removal from the muscular layer, main taining it complete at the mediastinum. This procedure was performed by a cervicoabdominal approach in 60 patients with grade III and IV megaesophagus. The reconstruction of the gastrointestinal tract by the stomach transposition was performed through the posterior mediastinum inside the muscular layer or by retrosternal route. The study allowed us the following conclusions: 1) the mucosa removal by the submucosa, through invagination proved to be simple and seasible in 98,4% of the cases; 2) the absence of bleeding from the bed layer muscular esophagus, during or at immediate postoperative period; 3) The incidence of pleura and lung complications - (5,0%.) is low.

Clinical and nutritional status of surgical patients with and without malignant diseases: cross-sectional study

CONTEXT Malnutrition is frequently observed in inpatients with malignant diseases and may contribute to longer hospital stays. OBJECTIVE To compare the nutritional status, lymphocyte count, hemoglobin values and length of hospital stay of patients with and without malignant diseases. METHODS This comparative study assessed indicators of nutritional status, namely body mass index, recent weight loss, lymphocyte count, hemoglobin and length of hospital stay, of 928 surgical patients with and without malignant diseases (50.2% females and 49.8% males). The chi-square test was used to compare proportions and the Mann-Whitney test was used to compare continuous measurements between two groups. The significance level was set at 5%. RESULTS Patients with malignant diseases had longer hospital stays (P<0.0001), furthermore, a higher percentage of patients with malignant diseases had body mass index <18.5 (P<0.0001) and experienced recent weight changes (P<0.0002). Lymphocyte count also differed statistically between the groups (P = 0.0131), which lower levels were identified among patients with malignant diseases. CONCLUSION The lymphocyte count, hemoglobin values and weight loss are important findings of nutritional depletion in patients with malignant diseases.

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.

Dental and gastrointestinal changes as indicators of nutritional depletion in elderly inpatients

OBJECTIVE The objective of this study was to identify the associations between the nutritional status of elderly patients and length of hospital stay and presence of dental and gastrointestinal changes. CASUISTIC AND METHOD This cross-sectional study analyzed anthropometric and food intake indicators, dental and gastrointestinal changes and length of hospital stay of 441 elderly patients of both genders. The Pearsons correlation coefficient was used to verify the correlation between the nutritional status of the elderly patients and length of hospital stay and presence of dental and gastrointestinal changes. The significance level was set at P < 0.05. RESULTS Dietary and anthropometric variables as well as length of hospital stay were similar for patients with and without dental changes. Patients with gastrointestinal changes consumed less energy (P < 0.05) than patients without gastrointestinal changes. Length of hospital stay was inversely correlated with body mass index (r = -0.15; P < 0.05); arm circumference was inversely correlated with presence of dental changes (r = -0.12; P < 0.05) and mid-arm muscle circumference was inversely correlated with gastrointestinal changes (r = -0.12; P < 0.05). CONCLUSION Dental and gastrointestinal changes are important indicators of nutritional depletion and dietary intake of inpatients.

Carcinoma diferenciado da tireóide: a validade da complementação da tireoidectomia

OBJETIVO: Analisar a invasao tumoral do lobo contralateral da glândula tireoide no carcinoma diferenciado, correlacionando o risco/beneficio com as complicacoes decorrentes de uma segunda intervencao. METODO: De outubro/93 a dezembro/96 foram operados 20 pacientes com carcinomas diferenciados da glândula tireoide. Os parâmetros analisados foram sexo, idade, tipo de operacao, tipo de complicacoes, histopatologico da peca cirurgica e invasao do lobo contralateral. Eram dois pacientes do sexo masculino (10%) e 18 do feminino (90%); as idades variaram de 17 a 89 anos; o tipo histologico mais frequente foi o carcinoma papilifero (13 casos), seguido do folicular (seis casos) e carcinoma de celulas de Hurthle (um caso). Como primeiro procedimento cirurgico houve 11 lobectomias + istmectomias, quatro lobectomias subtotais e uma istmectomia. Cinco pacientes nao realizaram a totalizacao (um por fibrose, tres por perda de seguimento e um por ser microcarcinoma). RESULTADOS: Na analise do lobo contralateral realizada em 15 pacientes, 11 resultaram negativas e outras quatro positivas (26,6%). As complicacoes apresentadas foram rouquidao (dois casos revertidos com tratamento fonoterapico), hipoparatireoidismo (dois casos, um transitorio e um permanente). CONCLUSAO: A totalizacao da tireoidectomia e um procedimento importante no tratamento do tumor maligno da tireoide pela alta porcentagem de metastase contralateral (26,6%). Alem disso, e um procedimento com mortalidade nula e pequena incidencia de complicacoes.

Derivação retroesternal com tubo gástrico isoperistáltico no carcinoma irressecável de esôfago

OBJETIVO: Avaliar o beneficio do tratamento paliativo pela derivacao esofagica com o tubo gastrico isoperistaltico em pacientes com carcinoma de esofago irressecavel. METODO: Foram estudados 53 pacientes com carcinoma espino celular do esofago sem condicoes de ressecabilidade avaliados por criterios endoscopicos e radiologicos. A maioria dos pacientes era do sexo masculino com idade media de 56,8 anos. A operacao realizada foi a derivacao esofagica com o tubo gastrico isoperistaltico, de grande curvatura e transposto atraves do espaco retro esternal. RESULTADOS: Vinte e oito pacientes (52,0%) desenvolveram uma ou mais complicacoes, sendo a mais frequente a deiscencia e/ou estenose da anastomose cervical (15 pacientes - 28,3%). Em 48 pacientes que sobreviveram, 37 (77,0%) referiram alivio da disfagia no seguimento pos-operatorio. A media de sobrevida em 23 pacientes foi de sete meses e meio (seis a 13 meses) e 14 pacientes estao em seguimento com o tempo variavel entre dois e 16 meses, com boa evolucao, com perda de seguimento nos 11 pacientes restantes. CONCLUSOES: Tubo gastrico isoperistaltico tem aceitavel morbidade e mortalidade para a populacao em estudo, permitindo paliacao da disfagia na maioria dos casos.

Non-conventional surgical approach to achalasia: mucosectomy and endomuscular pull-through

Aim: Transhiatal esophagectomy is a therapeuthic option for the treatment of end-stage achalasia that avoids the complications of a thoracotomy. This technique; however, is still linked to some degree of morbimortality especially due to pleuromediastinal complications. Esophageal mucosectomy and endomuscular pull-through could avoid these complications. This study aims to evaluate the short and long-term outcomes of esophageal mucosectomy and endomuscular pull-through in a series of patients with advanced megaesophagus. Methods: We retrospectively studied 115 patients with end-stage achalasia that underwent esophageal mucosectomy and endomuscular pull-through. Digestive tract reconstruction was accomplished most times using the stomachthourgh the muscular tunnel. Outcomes were evaluated in a short and long-term follow-up based on clinical, endoscopic and tomographic evaluation. Results: Anastomotic leak or stenosis was present in 27%. Pleural efusion was noticed in 11% and pneumonia in 9%. Mortality was 1.7%. Long-term follow-up (over 10 years) was possible in 42 patients. Excellent and good clinical results were obtained in 83% of the patients. Conclusion: Esophageal mucosectomy and endomuscular pull-through is a valuable procedure for the treatment of end-stage achalasia. It shows a low rate of complications and good outcomes at long-term follow-up.

Avaliação dos resultados da cirurgia conservadora do câncer da laringe

OBJETIVO: Avaliar retrospectivamente os resultados de pacientes submetidos a laringectomias parciais por carcinoma epidermoide de laringe no servico do HMCP. METODOS: Dos doentes estudados, 28 eram do sexo masculino (93,5%) e dois do feminino (6,5%) com idade variavel de 42 a 66 anos, com media de 58 anos. Em relacao ao procedimento cirurgico, este foi variavel, dependendo do local da extensao tumoral e do estadio. A tecnica mais utilizada foi a laringectomia frontolateral em 12 pacientes (40%), seguido pela laringectomia vertical em oito (26,6%), laringectomia supraglotica em quatro (13,3%), laringectomia supracricoidea em quatro (13,3%), laringectomia near-total em um (3,3%) e cordectomia em um (3,3%). RESULTADOS: Na avaliacao pos-operatoria precoce, tres pacientes (10%) apresentaram complicacoes evidenciadas por fistula faringocutâneas em dois, com boa evolucao apos tratamento conservador, e pneumotorax no paciente restante com boa evolucao apos drenagem do torax. No que se refere a avaliacao da degluticao, cinco pacientes (16,6%) apresentaram dificuldade de ingestao oral devido a aspiracoes recorrentes com tempo variavel de 45 a 180 dias (media - 65 dias), o que obrigou a um paciente ser submetido a totalizacao da laringectomia devido a pneumonias recorrentes. Na avaliacao tardia, de seis a 125 meses e media de 29 meses, quatro pacientes (13,3%) apresentaram recidiva locorregional, sendo dois submetidos a laringectomia vertical, um a frontolateral e o restante a supracricoidea. Em todos foram realizadas totalizacao e/ou radioterapia, e dois evoluiram a obito pela doenca. Vinte e quatro pacientes (84%) apresentaram preservacao da voz. CONCLUSAO: Assim, os autores concluem que a cirurgia conservadora da laringe proporciona bom controle da doenca e com sobrevida aceitavel, ja que 90% dos pacientes estudados estao vivos e sem doenca ate o final da avaliacao. Alem disso, apresentam melhor qualidade de vida ja que a maioria dos pacientes demonstrou voz e ingestao oral bem satisfatorias.

Viabilidade do retalho miofascial (RMF) de grande peitoral em cabeça e pescoço: estudo de 14 casos

The great incidence of advanced squamous cell carcinoma of the mouth, pharynx, larynx and neck, justifies the extensive resections that are carried out by the authors at the Head and Neck Service of Hospital Celso Pierro PUCCAMP - Sao Paulo. Major pectoralis myofascial flap were used to manage 14 patients with advanced head and neck squamous cell carcinoma of the mouth (ten cases), pharynx (two cases); larynx (one case) and neck (one case). There was no complications in 81.2% and in 18.8% total necrosis of the flap was observed. We conclude that viability, age and necrosis or fibrosis were not associated with the success of this procedure (p=1.0), and previous treatment (chemoradiotheraphy and or radiotherapy alone) had no significant relation with flap viability (p=0.547).