José Luis Braga de Aquino

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.

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

Objetivo: Avaliar as complicacoes da anastomose esofagogastrica cervical com sutura mecânica. Metodos: Foram estudados 20 pacientes com megaesofago graus III/IV submetidos a esofagectomia transmediastinal, com idade variavel de 31 a 68 anos. A reconstrucao do trânsito foi realizada pela transposicao gastrica e com anastomose na regiao cervical, realizada com o aparelho DHC no 25/29 mm. Resultados: Tres pacientes (15 porcento) apresentaram complicacoes clinicas, traduzidas por pneumonia, mas com boa evolucao com tratamento clinico. Outros tres pacientes (15 porcento) apresentaram deiscencia da anastomose esofago gastrico cervical, com boa evolucao sob tratamento conservador. Dois desses pacientes, mais um outro sem fistula, evoluiram com estenose da anastomose cervical; no entanto, com dilatacoes endoscopicas retornaram a apresentar degluticao normal. Conclusao: Neste estudo, chegou-se a conclusao de que a sutura mecânica e viavel por apresentar complicacoes de baixa morbidade e com boa resolucao. Entretanto, torna-se necessario realizar um estudo comparativo com a tecnica manual para avaliar qual procedimento seria o mais adequado. (AU)

Avaliação tardia da mucosectomia esofágica com conservação da túnica muscular em pacientes com megaesôfago avançado

BACKGROUND: To perform a long term evaluation the technique of the esophageal mucosectomy in patients with advanced mega esophagus. METHOD: 50 patients with advanced mega esophagus submitted the esophageal mucosectomy with conservation of muscular layer in period of January 1991 to December of 1997 underwent a late evaluation between 6 to 15 years after the surgical procedure. The age varied between 30 and 69 years (mean age of 53.5 years), 32 (64%) of them were males. The quality of deglution, the presence of regurgitation, alterations of the intestinal habit, the heavy evolution, the satisfaction with the surgery and with regard to normal work were assessed in all patients. Additionally, the morphological and functional evaluation with a contrast radiological study, upper digestive endoscopy and the thoracic CT scan were also performed. Each of the parameters were considered as good, excellent, regular and bad in accordance with total of the assigned points. RESULTS: In global clinical evaluation, 44 patients (88%) were considered as between excellent and good, while regular and bad in the others. In a global radiological evaluation, excellent and good had been presented in 47 patients (94%) and regular and bad in the others. In global endoscopic evaluation, 45 patients (90%) had excellent and good results, while regular and bad in the others. In relation the thoracic CT scan, 31 patients were considered good in all patients where the reconstruction of transit was carried through by the retroesternal route and excellent and good in all the patients where the reconstruction was through the transmediastinal route. CONCLUSION: The long term evaluation of patients submitted to esophageal mucosectomy for advanced mega esophagus showed excellent and good results in morphological, functional and clinical results in the majority of them.

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.

Tubo gástrico isoperistáltico de grande curvatura gástrica com sutura mecânica no tratamento cirúrgico do câncer de esôfago irressecável

BACKGROUND: The diagnose of esophageal cancer is in general done clinically late, remaining the palliative treatment the only possibility to improve the quality of life. The isoperistaltic gastric tube transposition may be used, however, if leakage happens, the swallow may be hindered, compromising deglutition. AIM: To evaluate the complications that can happen in the cervical esophagogastric anastomosis done with stapler, in patients with non resectable esophageal cancer. METHOD: Twenty two patients with non resectable esophageal cancer were submitted to an isoperistaltic gastric tube transposition. The esophagogastric anastomosis was made with circular stapler. Systemic and local complications were evaluated. RESULTS: Ten patients (45,5%) presented 1 to 3 complications, and in 6 (27,2%) of them, systemic ones. There were one (4,5%) case of lung embolism (with death), one miocardial infarction and four lung infections (all of them with good clinical evolution). Five had local complications; in three (13,6%), anastomotic leakage, and in four (18,2%), anastomotic stricture among the ones that had previous leakage. Twenty patients were followed through 11 months, and 16 (80%) of them maintained satisfactory swallow to solid and/or semi-solid meals. CONCLUSION: The isoperistaltic gastric tube of greater curvature with stapler suture seems to offer significant improvement on swallow with satisfactory quality of life and acceptable morbi-mortality.

Reconstrução esofágica pela esofagocoloplastia no megaesôfago avançado em pacientes gastrectomizados

RACIONAL: A necessidade de esofagocoloplastia em pacientes com megaesofago avancado, previamente submetidos a gastrectomia nao e frequente, mas quando executada traz consigo maior dificuldade tecnica, o que pode elevar o numero de complicacoes. OBJETIVO: Avaliar as complicacoes da reconstrucao de trânsito pela esofagocoloplastia em uma serie de pacientes submetidos a esofagectomia transmediastinal por megaesofago avancado com gastrectomia previa. METODOS: De julho de 1983 a abril de 2009, 204 pacientes com megaesofago grau III e IV foram submetidos a resseccao esofagica no Departamento de Cirurgia do Hospital Celso Pierro da Puc-Campinas. Em 92 pacientes a resseccao foi pela tecnica da mucosectomia esofagica; em 84 pela via transmediastinal; em 38 pela via transtoracica. Em 194 pacientes (95%) a reconstrucao do trânsito foi realizada pela transposicao gastrica e nos 10 restantes (5%), pela transposicao do colo transverso. O procedimento foi indicado pelo fato dos pacientes ja terem sido submetidos a gastrectomia previa. Todos eram do sexo masculino, com idade media de 47, 5 anos. RESULTADOS: Sete pacientes (70%) apresentaram uma ou mais complicacoes, sejam sistemicas ou locais. Das sistemicas, um paciente apresentou tromboflebite em membro inferior, com boa evolucao; outro, infarto do miocardio, com evolucao fatal; tres pacientes (30%) apresentaram infeccao pulmonar, com boa evolucao. Das complicacoes locais, quatro tiveram deiscencia da anastomose esofagocolonica cervical, tendo boa evolucao com tratamento conservador. Cinco pacientes evoluiram com estenose da anastomose esofagocolonica cervical entre o 35o e 63o dia do pos-operatorio, sendo realizadas dilatacoes endoscopicas com boa evolucao. De oito pacientes acompanhados neste periodo, seis (75%) apresentavam boa degluticao para solidos e/ou pastosos, referindo estarem satisfeitos com ato cirurgico por terem retornado aos habitos usuais. CONCLUSOES: A reconstrucao com o colo em pacientes submetidos a esofagectomia por megaesofago avancado nao deve ser a primeira opcao de tratamento, tendo somente indicacao quando for inviavel a transposicao gastrica, e ela deve ser considerada tecnica cirurgica com alta morbimortalidade em pacientes previamente gastrectomizados.

Risco nutricional no período pré-operatório

BACKGROUND: Bad nutricional status in preoperative period - mainly associated to weight loss -, may lead to grater number of postoperative complications. AIM: To investigate the nutritional risk indicators in preoperative period, stratified by disease groups treated at the site. METHODS: A total of 512 patients with the following conditions were assessed: acute abdomen, digestive tract diseases, biliary diseases, gynecological diseases, vascular diseases, hernias and traumas. The following data were analyzed: body mass index, recent weight loss, habitual energy intake, lymphocyte count and length of hospital stay. The data were compared among the disease groups. The chi-square test or Fishers exact test when necessary was used to compare proportions. The significance level was set at 5%. RESULTS: Trauma patients followed by those with digestive tract diseases and acute abdomen had significantly lower body mass index (P=0.0222), and the ones with acute abdomen presented recent weight loss at hospital admittance (P=0.0048). A greater percentage of severe and moderate immune depletion was seen in patients with acute abdomen (P<0.0001) and those with vascular diseases had a greater percentage of patients with energy intake below 1000 kcalories (P=0.0311). Trauma patients presented longer hospital stays (P<0.0001). CONCLUSION: Trauma and acute abdomen patients had greater nutritional risk during the preoperative period. Thus, nutritional care strategies should be oriented towards them since the hospital admittance.

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.

Predictors of Nutritional Risk According to NRS-2002 and Calf Circumference in Hospitalized Older Adults with Neoplasms

ABSTRACT Objectives: To investigate nutritional markers that better predict nutritional risk according to the Nutritional Risk Screening (NRS-2002), to verify agreement between indicators, and to identify the calf circumference cut-off point for diagnosing nutritional risk. Methods: Cross-sectional study with older patients hospitalized for neoplasms. The nutritional risk was assessed by NRS-2002 and the nutritional status by Subjective Global Assessment (SGA), Mini-Nutritional Assessment (MNA long form), calf circumference (CC), and body mass index (BMI). Statistical analyses included the chi-square and Mann–Whitney tests, Kappa coefficient, univariate and multiple logistic regression analyses to analyze the risk factors, and the receiver operator characteristic (ROC) curve to determine the cut-off point. Results: The NRS-2002 and MNA had good agreement (k = 0.5281), but the NRS-2002 did not agree with the other nutritional indicators. According to regression analysis, the predictors of nutritional risk were the MNA (p = 0.0010, OR = 28.270); BMI (p = 0.0419, OR = 4.681), and age (p = 0.0021, OR = 1.309). The best CC cut-off point for predicting nutritional risk according to the NRS-2002 was ≤32.25 cm. Conclusion: Both the NRS-2002 and MNA are useful for the nutritional diagnosis of older adults hospitalized for neoplasms. When the MNA, BMI, and age are used together, they can better predict nutritional risk according to the NRS-2002.