Marcelo Manzano Said

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.

Tratamento cirúrgico do megaesôfago recidivado

BACKGROUND: To evaluate the surgical treatment results in a series of patients submitted to previous treatments for megaesophagus, which their symptoms recurred. METHOD: We analyzed the results of many different surgical techniques performed in 47 patients at the General and Thoracic Surgery Department of HMCP-PUC-Campinas. Our follow-up considered postoperative results as follows: development of new symptoms, relief of old symptoms, morbidity, and mortality. We divided the patients in three groups in accordance to the disease degree: Incipient (9 cases), not advanced (18 cases) and advanced (20 cases). The techniques used were Hellers modified cardiomyotomy, Thals esophagocardioplasty, Serra-Dorias esophagocardioplasty, subtotal esophagectomy with mucosectomy and conservation of the esophagus muscular layer. RESULTS: For incipient megaesophagus, the cardiomyotomy technique obtained good results, with low morbidity. For not advanced megaesophagus, the cardioplasty, in special the Serra Dorias esophagocardioplasty, was the best choice. The procedures used for advanced megaesophagus had the greatest morbidity rates; however, they also showed superiority for aggressive techniques comparing with the conservative operations, in special the mucosectomy with conservation of the esophagus muscular layer, being this the technique with less morbidity within this group. CONCLUSION: It is difficult to choose a standard procedure for megaesophagus with previous surgical treatment due to several available techniques, and different personal surgeon skills, in such way to create therapeutical protocols.

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.

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.

Análise da terapêutica cirúrgica da acalásia idiopática do esôfago

RACIONAL: A acalasia idiopatica do esofago e doenca inflamatoria de causa desconhecida, caracterizada por aperistalse do corpo do esofago e falha do relaxamento do esfincter esofagico inferior em resposta as degluticoes, com consequente disfagia. OBJETIVO: Demonstrar os resultados da terapeutica cirurgica desses pacientes, avaliando suas complicacoes locais e sistemicas. METODOS: Foram estudados retrospectivamente 32 pacientes portadores de acalasia idiopatica do esofago, sendo 22 com doenca nao avancada (Grau I/II) e 10 com doenca avancada (Grau III/IV); todos tinham condicoes clinicas de serem submetidos a terapeutica cirurgica. O diagnostico foi realizado por meio de analise clinica, endoscopica, cardiologica, radiologica e manometrica. Foi realizada avaliacao pre-operatoria com questionario baseado nos fatores mais predisponentes ao desenvolvimento da doenca, e a indicacao da tecnica cirurgica foi baseada no grau da lesao. RESULTADOS: Os pacientes com doenca nao avancada foram submetidos a cardiomiotomia com fundoplicatura, sendo que na avaliacao precoce do pos-operatorio apenas um deles (4,4%) apresentou infeccao pulmonar, mas com boa evolucao. Os pacientes com doenca avancada em sete foi realizada a mucosectomia esofagica com conservacao da tunica muscular, sendo que um paciente (14,2%) apresentou deiscencia da anastomose esofagogastrica cervical e tambem infeccao pulmonar, tendo ambas complicacoes sido resolvidas com tratamento especifico; os outros tres com doenca avancada foram submetidos a esofagectomia transmediastinal, sendo que dois apresentaram hidropneumotorax, com boa evolucao; um destes pacientes tambem apresentou fistula da anastomose esofagogastrica cervical, mas com fechamento espontâneo apos tratamento conservador e suporte nutricional. Os dois pacientes que apresentaram fistula da anastomose cervical, evoluiram com estenose, mas com boa evolucao apos dilatacoes endoscopicas. Na avaliacao a medio e longo prazos realizada em 23 pacientes, todos relataram acentuada melhora na qualidade de vida com retorno da degluticao. CONCLUSAO: O tratamento cirurgico proposto da acalasia idiopatica do esofago de acordo com grau da doenca foi de grande valia, devido as complicacoes pos-operatorias presentes serem de baixa morbidade, alem de proporcionar retorno adequado da degluticao.

Avaliação das complicações da esofagectomia de resgate na terapêutica cirúrgica do câncer de esôfago avançado

RACIONAL: Apesar das inumeras opcoes terapeuticas, o prognostico da neoplasia maligna de esofago continua sombrio. Devido a baixa taxa de cura da esofagectomia, foram desenvolvidas novas propostas de tratamento como a quimioterapia e radioterapia isoladas ou associadas, concomitante ou nao a cirurgia, alem da quimiorradiacao exclusiva. A esofagectomia de regaste surge como opcao terapeutica para aqueles pacientes com recorrencia ou persistencia da doenca apos tratamento clinico. OBJETIVO: Avaliar os resultados da esofagectomia de resgate em pacientes com câncer de esofago submetidos previamente a quimiorradiacao exclusiva, assim como descrever as complicacoes locais e sistemicas. METODO: Foram analisados retrospectivamente 18 pacientes com diagnostico inicial de carcinoma epidermoide de esofago irressecavel, submetidos previamente a quimiorradioterapia. Apos o tratamento oncologico eles foram examinados quanto as suas condicoes clinicas pre-operatorias. Foi realizada a esofagectomia por toracotomia direita e reconstrucao do trânsito digestivo por cervicolaparotomia. Os mesmos foram avaliados no periodo pos-operatorio tanto em relacao as complicacoes locais e sistemicas como em relacao a qualidade de vida. RESULTADOS: As complicacoes foram frequentes, sendo que cinco pacientes desenvolveram fistula por deiscencia da anastomose. Quatro desses evoluiram de maneira satisfatoria. Cinco tambem apresentaram estenose esofagogastrica cervical, mas responderam bem a dilatacao endoscopica. Infeccao pulmonar foi outra complicacao observada e presente em sete pacientes, sendo inclusive causa de obito em dois deles. Dentre os em que se conseguiu realizar seguimento com tempo medio de 5,6 anos, 53,8% estao vivos sem doenca. CONCLUSOES: Existe elevada morbidade da esofagectomia de regaste principalmente apos longo espaco de tempo entre quimiorradiacao e a cirurgia, propiciando maior dano tecidual e predisposicao a formacao de fistulas anastomoticas. No entanto, os resultados se mostram favoraveis aqueles que nao possuem mais opcoes terapeuticas.

Surgical treatment analysis of idiopathic esophageal achalasia

Background Idiopathic esophageal achalasia is an inflammatory disease of unknown origin, characterized by aperistalsis of the esophageal body and failure of the lower esophageal sphincter in response to swallowing, with consequent dysphagia. Aim To demonstrate the results of surgical therapy in these patients, evaluating the occurred local and systemic complications. Methods Were studied retrospectively 32 patients, 22 of whom presented non-advanced stage of the disease (Stage I/II) and 10 with advanced disease (Stage III/IV). All of them had the clinical conditions to be submitted to surgery. The diagnoses were done by clinical, endoscopic, cardiological, radiological and esophageal manometry analysis. Pre-surgical evaluation was done with a questionnaire based on the most predisposing factors in the development of the disease and the surgical indication was based on the stage of the disease. Results The patients with non-advanced stages were submitted to cardiomyotomy with fundoplication, wherein in the post-surgical early assessment, only one (4,4%) presented pulmonary infection, but had a good outcome. In patients with advanced disease, seven were submitted to esophageal mucosectomy preserving the muscular layer, wherein one patient (14,2%) presented dehiscence of gastric cervical esophagus anastomosis as well as pulmonary infection; all of these complications were resolved with proper specific treatment; the other three patients with advanced stage were submitted to transmediastinal esophagectomy; two of them presented hydropneumothorax with good evolution, and one of them also presented fistula of the cervical esophagogastric anastomosis, but with spontaneous healing after conservative treatment and nutritional support. The two patients with fistula of the cervical anastomosis progressed to stenosis, with good results after endoscopic dilations. In the medium and long term assessment done in 23 patients, all of them reported improvement in life quality, with return to swallowing. Conclusion The strategy proposed for the surgical treatment of idiopathic esophageal achalasia according to the stages of the disease was of great value, due to post-surgical low morbidity complications and proper recovery of swallowing.

Esofagocardioplastia no tratamento cirúrgico do megaesôfago não avançado recidivado

BACKGROUND It has always been very controversial to choose an ideal operation for patients with no advanced recurrent megaesophagus after previous treatment. The various existing techniques and the different degrees of disease are the major factors to this difficulty. AIM To evaluate the early and late results of the Serra-Doria esophagocardioplasty in patients who had recurrence of symptoms in non-advanced megaesophagus after having been submitted to cardiomyotomy. METHODS Were studied 32 patients. The age ranged from 32 to 63 years. Nineteen had mild and 13 moderate dysphagia, and 14 had some degree of regurgitation. These subjects underwent the Serra-Doria esophagocardioplasty and were evaluated the local and systemic complications occurred postoperatively. RESULTS After the procedure could be followed 27 patients, 22 began to show normal swallowing, five mild dysphagia and three remained with some regurgitation. No patient died. Three had early pneumonia and in one occurred anastomotic leak. CONCLUSIONS The Serra-Doria esophagocardioplasty is adequate procedure for the surgical treatment of relapsed non advanced megaesophagus.

Análise das complicações da esofagectomia transmediastinal no tratamento cirurgico do megaesôfago recidivado

BACKGROUND: The best option for the treatment of patients with achalasia and recurrent symptoms after previous treatment, has always been very controversial. In literature review, there is no surgical technique considered the best to deal with this condition. The idea to use a more selective treatment with transmediastinal esophagectomy without thoracotomy in patients with advanced megaesophagus in relapsed cases after prior cardiomyotomy can be considered. AIM: To evaluate the results of transmediastinal esophagectomy in recurrent megaesophagus regarding local and systemic complications. METHODS: Thrity two patients were treated with recurrent symptoms after previous surgery to achalasia and indication for esophagectomy with gastric transmediastinal transposition through the posterior mediastinum for grade IV megaesophagus. They were 25 men (78.1%) and seven women (21.9%), aged from 34 to 72 years. All underwent previous myotomy varying from five to 39 years to the day of transmediastinal esophagectomy. RESULTS: Some patients had complications. Among these, eight had pulmonary infection (25.0%) resulting in good outcome to the specific clinical treatment; two died due to hemodynamic effect caused by injury to the azygos vein and the other due to trachea injury; nine (28.1% ) had cervical esophagogastric anastomotic dehiscence doing well with conservative treatment. Of the 21 patients in whom monitoring was carried out in the long term - six months to 14 years -, 17 reported good swallowing solids and pastes, four (19.0%) had gastroesophageal reflux with clinical improvement with specific medical treatment. CONCLUSIONS: Transmediastinal esophagectomy, although providing adequate swallowing in most cases, is a procedure of high morbidity. This technique should not be recommended as first treatment option for relapsed megaesophagus.