Evaluation of anatomical and functional changes esophageal stump of patients with advanced megaesophagus submitted to subtotal laparoscopic esophagectomy

Management of Esophageal Dysphagia in Chagas Disease

Chagas disease, caused by the infection of the protozoan parasite Trypanosoma cruzi, has clinical consequences in the heart and digestive tract. The most important changes in the digestive tract occur in the esophagus (megaesophagus) and colon (megacolon). Esophageal dysfunction in Chagas disease results from damage of the esophageal myenteric plexus, with loss of esophageal peristalsis, partial or absent lower esophageal sphincter relaxation, and megaesophagus, which characterizes secondary esophageal achalasia. The treatment options for the disease are similar to those for idiopathic achalasia, consisting of diet and behavior changes, drugs, botulinum toxin, peroral endoscopic myotomy (POEM), pneumatic dilation of the lower esophageal sphincter, laparoscopic Heller myotomy, and esophagectomy. Chagas disease causes a life-threatening cardiopathy, and this should be considered when choosing the most appropriate treatment for the disease. While some options are palliative, for temporary relief of dysphagia (such as drugs, botulinum toxin, and pneumatic dilation), other therapies provide a long-term benefit. In this case, POEM stands out as a modern and successful strategy, with good results in more than 90% of the patients. Esophagectomy is the option in Chagas disease patients with advanced megaesophagus, despite the increased risk of complications. In these cases, peroral endoscopic myotomy may be an option, which needs further evaluation.

Evaluation of the effectiveness of preoperative outpatient pulmonary preparation in patients undergoing esophageal surgery

Abstract Introduction: Preoperative inspiratory muscle training (IMT) can minimize the occurrence of complications after esophagectomy. Objective: To evaluate the effects of preoperative IMT in patients undergoing esophageal surgery by determining respiratory muscle strength (PImax and PEmax), pulmonary function (FEV1, FVC, FEV1/FVC) and functional capacity by the 6-minute walk test (6MWT). Methods: Twenty-two patients were randomized into two groups: a control group (CG; n = 10) and an intervention group (IG; n = 12). Only IG performed IMT for a minimum period of 2 weeks. The assessments were conducted pre- and post-surgery. Results: An increase of PImax was observed in IG, but not in CG, in the second preoperative assessment (p = 0.014). Assessment on postoperative day 1 showed a reduction in maximal respiratory pressures in the two groups, but the reduction was more marked in IG (p < 0.05). Partial recovery of the variables evaluated was observed at discharge in the two groups. These variables had fully returned to initial values on postoperative day 30. The distance walked in the 6MWT was greater in IG, but the difference was not significant (p = 0.166). There was no difference in the frequency of pulmonary complications between groups. Conclusion: Preoperative IMT performed in our study improved inspiratory muscle strength but did not influence the postoperative pulmonary function or functional capacity of patients undergoing esophagectomy.

Esophagectomy with gastroplasty in advanced megaesophagus: late results of omeprazole use

Objective: To analyze the late results of advanced Chagasic megaesophagus treatment by esophagectomy associated with the use of proton pump inhibitor (omeprazole) as for the incidence of esophagitis and Barrett's esophagus in the remaining stump. Methods : We studied patients with advanced megaesophagus undergoing esophagectomy and transmediastinal esophagogastroplasty. Patients were divided into three groups: A (20) with esophageal replacement by full stomach, without the use of omeprazole; B (20) with esophageal replacement by full stomach, with omeprazole 40 mg/day introduced after the first postoperative endoscopy and maintained for six years; and C (30) with esophageal replacement by gastric tube with use of omeprazole. Dysphagia, weight loss and BMI were clinical parameters we analyzed. Upper gastrointestinal endoscopy was performed in all patients, and determined the height of the anastomosis, the aspect of the mucosa, with special attention to possible injuries arising from gastroesophageal reflux, and the patency of the esophagogastric anastomosis. Results : We studied 50 patients, 28 males (56%) and 22 (44%) females. All underwent endoscopy every year. In the first endoscopy, erosive esophagitis was present in nine patients (18%) and Barrett's esophagus, in four (8%); in the last endoscopy, erosive esophagitis was present in five patients (8%) and Barrett's esophagus in one (2%). When comparing groups B and C, there was no evidence that the manufacturing of a gastric tube reduced esophagitis and Barrett's esophagus. However, when comparing groups A and C, omeprazole use was correlated with reduction of reflux complications such as esophagitis and Barrett's esophagus (p <0.005). Conclusion : The use of omeprazole (40 mg/day) reduced the onset of erosive esophagitis and Barrett's esophagus during the late postoperative period.

Long-term results of the Modified Thal procedure in patients with chagasic megaesophagus

BACKGROUND

Chagas disease is a serious public health issue in South and Central America due to its high prevalence, morbidity, and mortality. The esophageal form of the disease leads to achalasia and consequent megaesophagus. In advanced or recurrent cases of megaesophagus, there is no consensus for which of three established techniques-the Serra-Dória procedure, subtotal esophagectomy, or Modified Thal cardioplasty-is best. Very few studies have investigated the average efficacy and long-term outcomes of the Thal procedure. The present study sought to bridge this gap.

METHODS

The Modified Thal procedure was performed in 29 patients at Hospital Universitário de Brasília between 1998 and 2008. All underwent clinical and nutritional evaluation, upper gastrointestinal endoscopy (UDE) with chromoscopy, esophageal manometry, and 24-h pH monitoring.

RESULTS

Overall, 86 % experienced resolution of all symptoms after surgery. Most patients were classified as Visick grade I, II, or III. The average body mass index was 22.7 kg/m(2). UDE showed normal mucosa in 76 % of patients, and 11 % had unstained areas on chromoscopy. Esophageal manometry demonstrated incomplete lower esophageal sphincter (LES) relaxation in 50 % of patients, complete LES relaxation in 21 %, and no LES relaxation in 29 %. All showed complete relaxation of the upper esophageal sphincter. On 24-h pH monitoring, reflux was pathological in 50 % of patients.

CONCLUSIONS

Overall, the modified Thal procedure improved symptoms-namely, dysphagia to liquids with resulting weight loss and malnutrition-in patients with megaesophagus. No correlations were found between clinical complaints, endoscopic findings, and degree of manometric abnormality in these patients.