Nelson Ary Brandalise

Diagnosis of superficial esophageal cancer and dysplasia using endoscopic screening with a 2% lugol dye solution in patients with head and neck cancer

Head and neck cancer (HNC) has a high incidence in Brazil, with cancer of the oral cavity being one of the five most common cancers among Brazilians. Alcohol and tobacco consumption may contribute to synchronous or metachronous HNC and esophageal cancer. The early detection of superficial esophageal cancer and dysplasia in asymptomatic patients with HNC, after successfully treating the primary cancer, may provide an effective cure.

Antireflux surgery followed by bipolar electrocoagulation in the treatment of Barrett’s esophagus

BACKGROUND Management of Barretts esophagus requires reduction of gastric acid secretion and screening for the development of adenocarcinoma. However, the current therapeutic options are ineffective in reducing the Barretts mucosa. The aim of this study was to evaluate the effectiveness of endoscopic thermal coagulation of Barretts mucosa as an alternative therapeutic approach and the recurrence of the disease in the long term. METHODS Fourteen patients (11 men, 3 women; mean age 45.7 years) with Barretts esophagus participated in the study. They underwent laparoscopic fundoplication and were symptom free with no defective fundoplication wraps before therapeutic endoscopy. Endoscopic thermocoagulation was performed with a flexible videoendoscope and a bipolar probe. Mucosal areas were treated once a month until the Barretts mucosa disappeared. Endoscopy was performed 1 and 7 months after completion of the treatments and once a year thereafter. RESULTS The mean follow-up period was 21.6 months (range 18 to 30 months). The mean length of Barretts esophagus was 4.8 cm. Successful ablation of the columnar epithelium was achieved in 3.7 sessions, as defined by demonstration of normal squamous epithelium at histologic examination of biopsy samples collected after completion of the treatments and at follow-up evaluations. Three patients experienced short-term (10 days) odynophagia or dysphagia. All patients were symptom free with no evidence of Barretts esophagus at the end of the study. CONCLUSIONS Bipolar electrocoagulation after antireflux operations is effective in promoting regression of Barretts esophagus and has few complications. Endoscopic thermal coagulation might reduce risk for adenocarcinoma among these patients.

Use of corticosteroids after esophageal dilations on patients with corrosive stenosis: prospective, randomized and double-blind study

OBJECTIVE To determine triancinolone intralesional injections effects in association with esophageal dilations in corrosive stenosis cases, by means of a double-blind and randomized study. METHOD Fourteen adults patients (6 men and 8 women) with severe esophageal corrosive stenosis were randomized in two groups: Group A: treated by esophageal dilations and posterior triancinolone 10 mg/ml intralesional injection; Group B: treated by esophageal injections and posterior saline solution 0,9% injection (placebo). New applications were made based on the patient symptomatology. It had been analysed dilation frequency, obtained diameters and dysphagia before and after the research, for 12 months. RESULTS Eleven patients had ingested sodium hydroxide, two had ingested ammoniac and one had taken muriatic acid. There was no statistic difference (p > 0.05) in dilation frequency and dysphagia between the groups. However, an improvement in obtained diameter was observed in the corticosteroids group in comparison with control group (p < 0.05). By comparing groups before and after steroids, the final results were very favorable in group A CONCLUSION: Multiple intralesional injections of triancinolone hexacetonide 10 mg/ml in association with esophageal dilations increase obtained diameters in succeeding sessions.

Absolute ethanol and 5% ethanolamine oleate are comparable for sclerotherapy of esophageal varices

BACKGROUND Endoscopic sclerotherapy is widely accepted as an effective treatment for the eradication of esophageal varices in patients with portal hypertension and a history of upper gastrointestinal bleeding. The objective of this study was to assess the effectiveness and safety of absolute ethanol as an alternative sclerosing agent to the commonly used 5% ethanolamine oleate. METHODS One hundred fifty-seven patients with portal hypertension and a history of variceal bleeding were randomly assigned to sclerotherapy with absolute ethanol (n = 66) or 5% ethanolamine oleate (n = 91) between January 1992 and July 1994. Once eradication was achieved, these patients were prospectively followed until September 1998. RESULTS Sclerotherapy with both sclerosants resulted in similar eradication rates (approximately 90%), with comparable numbers of sessions required for eradication (5.4 and 5.9 sessions for absolute ethanol and 5% ethanolamine oleate, respectively). Similar complication and recurrent bleeding rates were observed among both groups. CONCLUSION Sclerotherapy with absolute ethanol is as effective as with 5% ethanolamine oleate in preventing further bleeding in patients with portal hypertension.

Avaliação tardia de doentes gastrectomizados por úlcera péptica: aspectos clínicos, endoscópicos e histopatológicos

BACKGROUND The gastrectomy is an uncommon procedure because the proton bomb inhibitors associated to the antibiotic outlines used to eradicate the Helicobacter pylori changed the focus of the peptic ulcer treatment. AIMS Later evaluation on those patients who underwent partial gastrectomy as a treatment for peptic ulcer, at that time when any drug to eradicate the Helicobacter pylori was not used. The clinical evaluation included the late postoperative symptoms and postgastrectomy syndromes like dumping, diarrhea, alkaline gastritis and nutritional aspects. The upper digestive endoscopy analysed the surgery reconstruction and the gastric stump, the duodenum and the jejunum mucosa aspects. The histopathological evaluation included looking for Helicobacter pylori by using two different methods: histology and urease test. CASUISTIC AND METHODS Fifty-nine patients, 44 (74.6%) male, median age 55.5 years old (range from 31 to 77 years old), who underwent a clinical interview and an upper digestive endoscopy. Paraffin blocks from the surgical specimen were reviewed in order to find out if the patients did have or did not have Helicobacter pylori before surgery. RESULTS The final results show that most of the patients had very good and good clinical evolution (Visick I e II) in 96%. The most common symptoms on late postoperative are mild dyspepsia with or without Helicobacter pylori, and diarrhea, anemia and dumping occurred in, respectively, 11 (18.6%), 2 (3.4%) and 2 (3.4%) cases. The Billroth I reconstruction had the best clinical results on statistical rate. The endoscopic finding showed normal results in the most number of cases, and reflux alkaline gastritis or erosive gastritis in a few cases. Ulcer recurrences were diagnosed in two patients (3.4%), and both had positive Helicobacter pylori. Most of the patients had Helicobacter pylori (86%) before surgery and also in the postoperative time (89.9%). CONCLUSIONS The patients had a very good clinical evolution after the gastrectomy. The Billroth I reconstruction had the best clinical results. The Helicobacter pylori is still present on gastric stump in late postoperative time, and we believe that it does not bring any negative influence to surgical results.

Use of omentum pedicled graft to protect great vessels in gastric transposition for pharyngoesophageal cancer.

Transmediastinal gastric transposition and pharyngogastric anastomosis is perhaps one of the most widely accepted methods for restoration of the alimentary continuity after pharyngoesophageal resection. The need of neck dissection, mediastinal tracheostomy, and previous radiotherapy may favor exposure and rupture of major vessels. Protection with omentum may prevent this complication. A comprehensive review of omentum flap use in surgery was undertaken.

Regression of childhood Barrett's esophageal mucosa by antireflux surgery and bipolar electrocoagulation

The authors report a case of a 13-year-old girl with Barretts esophagus who underwent antireflux surgery and was subsequently treated with endoscopic thermal coagulation using bipolar electrocoagulation. Follow-up endoscopy 15 months after completion of the endoscopic therapy showed normal esophageal mucosa without intestinal metaplasia. Longer follow-up is needed to assess the long-term effects of endoscopic treatment of the Barretts mucosa with thermal coagulation, and this procedure should still be considered under investigation.

Fat absorption after total gastrectomy in rats submitted to Roux-en-Y or Rosanov-like double-transit technique

PURPOSE Steatorrhea is one of the most common complications in reconstruction after total gastrectomy. Many reconstruction techniques after total gastrectomy have been developed in order to avoid these undesirable effects, but each one of them has some inconvenience. In this experiment, a modified Rosanov technique that keeps duodenal transit, evaluation of fat absorption after gastrectomy was tested. METHODS Three groups of rats with the same characteristics were used. Total gastrectomy was performed in two groups: one was operated on and transit was reestablished by the Roux-en-Y technique (group Y), while the other was submitted to the modified Rosanov technique (group R). Following surgery, a handmade hyper fatty diet (11% of fat) was offered. A third group (control - group C) was not operated but was submitted to the same conditions of the other groups, and used for reference steatocrit values. The animals underwent laparotomy 14 days after surgery and had their feces collected from cecum to determine their steatocrit by analysis of their values. RESULTS Steatocrit values for groups R and C (mean 5.16% and 4.15% respectively) were similar (p > 0.1), while group Y had significantly higher values (mean = 28.18%, p = 0.0001 - p < 0,05). This was attributed to the fact that group R animals had their duodenal transit patent, decreasing the complications expected in the Roux-en-Y reconstruction. CONCLUSIONS Steatorrhea in the modified Rosanov technique was similar to the control group, while Roux-en-Y reconstruction presented higher steatorrhea and fat malabsorption.

Tratamento cirúrgico do divertículo de Zenker: diverticulopexia versus diverticulectomia

RACIONAL: Diverticulo faringoesofagico, conhecido como de Zenker, e herniacao adquirida na mucosa faringea atraves de um defeito muscular entre as fibras obliquas do musculo constritor inferior da faringe e as transversas do musculo cricofaringeo. OBJETIVO: estudo retrospectivo, nao randomizado, compararando os resultados da diverticulopexia e diverticulectomia, ambas associadas a miotomia do musculo cricofaringeo, no tratamento do diverticulo de Zenker. METODOS: Quarenta pacientes foram submetidos a tratamento cirurgico entre 1989 e 2003, dos quais 38 (95%) foram seguidos. Vinte e oito eram do sexo masculino (70%) e 12 femininos, com media de idade de 62,5 anos (21 a 85 anos). Vinte e quatro pacientes (60%) foram submetidos a diverticulopexia ou elevacao, e 16 a diverticulectomia ou resseccao, atraves de cervicotomia esquerda, com miotomia do musculo cricofaringeo. RESULTADOS: Resultados excelentes (Visick I), foram verificados em 84,6% dos pacientes submetidos a diverticulectomia e 66,6% dos pacientes submetidos a diverticulopexia. Na analise global de todos os casos estudados, 27 (11 resseccoes e 16 elevacoes - 72,9%) apresentaram Visick I; 8 (2 resseccoes e 6 elevacoes - 21,6%) apresentaram Visick II; e 2 (elevacoes - 5,4%) apresentaram Visick III. Nao foi registrado nenhum caso na classificacao de Visick IV. A incidencia de complicacoes pos-operatorias registrada nos dois grupos foi semelhante (P>0,05). Foi verificado a presenca de neoplasia maligna em um caso submetido a resseccao (2,5%). CONCLUSAO: A diverticulopexia com miotomia do musculo cricofaringeo e mais indicada em doentes geriatricos, pequenos diverticulos e doentes com risco operatorio elevado. A diverticulectomia e boa opcao em grandes diverticulos e doentes jovens, para prevenir o risco de transformacao maligna. Esta casuistica mostrou melhores resultados com a diverticulectomia em comparacao com a diverticulopexia.

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.