Post-operative giant hiatal hernia: A single center experience

To verify the results of the treatment of post-operative giant hiatal hernia (POGH).The POGH becomes each time more frequent after surgical treatment of the gastroesophageal reflux.Fifteen patients (6 females and 9 males; 43.66 ± 5.05 years old; BMI 22.13 ± 1.92) were referred to our Service, for surgical treatment of a type III POGH 30.4 ± 1.76 months after treatment of gastroesophageal reflux disease. The need for a reoperation was determined mainly by dysphagia.Reoperation was completed laparoscopically in all patients and the mean postoperative hospital stay was 3.2 ± 1.2 days (range, 1-6 days). Mortality was 0% and there were not postoperative complications. They became asymptomatic along follow-up of 2.86 ± 1.40 years. Around 1 year from the procedure, patients were submitted to control exams and barium esophagogram revealed well positioned esophago-gastric junction and signs of intact fundoplicature, the same observation having been done at esophageal endoscopy. Esophageal manometry showed preserved peristaltism, increase of resting pressure and extension of the intra-abdominal LES and significant raise of amplitude of deglutition waves at distal third of the esophagus. No reflux was observed at post-operative 24-hour pH testing.The corrective surgery of POGH can often be completed laparoscopically in experienced hands. Successful results can be obtained performing reduction of the hernia, sac excision, crural repair, anti-reflux procedure and long anterior gastropexy.

LAPAROENDOSCOPIC TRANSGASTRIC RESECTION OF SUBEPITHELIAL JUXTACARDIAC TUMORS

Background:

With a prevalence of 0.4-3.5%, subepithelial lesions of the upper digestive tract are discovered during endoscopic procedures. Treatment depends on etiological and pathophysiological information, ability to diagnose and the different technical resources available.

Aim:

To demonstrate the effectiveness of a surgical technique that combines endoscopy and videolaparoscopy in the transgastric resection of subepithelial juxtacardic lesions.

Method:

The patients were assisted with a technical combination between endoscopy and laparoscopy. After diagnosis of subepithelial tumor, intraoperative endoscopy was performed after pneumoperitoneum and placement of laparoscopic tweezers. Through endoscopy, the following steps were performed: demarcation of surgical margins, visualization of the intragastric image for the laparoscopic procedure and removal of the surgical specimen. By laparoscopy the following steps were performed: intragastric intra-abdominal access, resection of the part and closure of the gaps.

Results:

This technique was applied in two cases in order to evaluate its initial results. There were two videolaparoendoscopic resections of juxtacardiac gastric tumors of the posterior wall. Both had their endoscopic diagnosis confirmed. After laparoendoscopic and tomographic and/or ecoendoscopic diagnostic complementation and preoperative performance, the laparoendoscopic procedure was indicated. The patients had a good recovery, with a short hospitalization time and no complications.

Conclusion:

The combined use of videolaparoscopy and endoscopy is a safe and effective technique for transgastric resection of juxtacardiac subepithelial lesions. It may be important for definitive diagnosis of the tumor.

Results of pneumatic dilation in treating achalasia: predictive factors

Forced pneumatic dilatation (PD) of the cardia is one of the most consecrated therapeutic measures for esophageal achalasia. The procedure only achieved better standardization with the appearance of the Rigiflex balloon. Results and predictive factors of success and failure of PD are reviewed, right after the description of the main technical aspects of the procedure. The success rates, providing control of dysphagia for about 1 year from the procedure using the Rigiflex balloon, are quite satisfactory, with success in more than 75% of patients. It is generally observed that good responses sustained for more than 5 years appear in at least 40% of cases. However, approximately half of the patients submitted to PD require additional dilation and a subgroup of them will undergo surgical treatment to attain adequate control of dysphagia. PD is a method with a low rate of acute complications, with esophageal perforation, the most severe of them, not affecting more than 5% of the cases. The best results could be potentially obtained when predictive factors of success were considered before choosing PD as a therapeutic option, but prospective studies in this field are missing until now.

COLONOSCOPY: RANDOMIZED COMPARATIVE STUDY OF INSUFFLATION WITH CARBON DIOXIDE VERSUS AIR

Background:

In Brazil, an increasing number of people are submitted to colonoscopy, either for screening or for therapeutic purposes.

Aim:

To evaluate whether there are advantages of using carbon dioxide (CO₂) over air for insufflation.

Methods:

Two hundred and ten of 219 patients were considered eligible for this study and were randomized into two groups according to the gas insufflation used: Air Group (n=104) and CO₂ Group (n=97). The study employed a double-blind design.

Results:

The Air and CO₂ Groups were similar in respect to bowel preparation evaluated using the Boston scale, age, gender, previous surgery, maneuvers necessary for the advancement of the device, and presence of polyps, tumors or signs of diverticulitis. However, “waking up with pain” and “pain at discharge” were more prevalent in the Air Group, albeit not statistically significant, with post-exam bloating seen only in the Air Group. The responses to a questionnaire, applied to analyze the late post-exam period, showed more comfort with the use of CO₂.

Conclusions:

The use of CO₂ is better than air as it avoids post-examination bloating, thereby providing greater comfort to patients.

Surgical treatments for esophageal cancers

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Discussing the influence of electrode location in the result of esophageal prolonged pH monitoring

Background

There is a large consensus to preserve the distance of 5 cm above the proximal border of the lower esophageal sphincter (PBLES) as appropriate to the location of the electrode of the pH-metry. The main objective of this study is to determine whether placement of the electrode below the recommended location achieves a significant difference in the calculation of the DeMeester score.

Methods

The study was made up of 60 GERD patients and 20 control subjects. They were submitted to esophageal manometry and to pH-metric examination with two pH-metric catheters contained antimony electrodes - the distal was positioned 3 cm above the PBLES, leaving the other 5 cm away from it.

Results

LES pressure (LESP) in the GERD group was significantly lower than in the control group (P = 0.005). Normal mean DeMeester score was observed simultaneously in the control group, by both the electrodes, but abnormal DeMeester score was much more expressive when observed by the distal electrode in the GERD group. There were significant differences as for DeMeester score, of patients with GERD from that of the control group and of distal from the proximal electrode in the GERD group.

Conclusions

Acid reflux is directly related to lower levels of LESP. Lower location of the catheter may strongly affect the results of prolonged esophageal pH monitoring in GERD patients.

Causes and treatments of achalasia, and primary disorders of the esophageal body

The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high-resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

New therapeutic strategies for squamous cell cancer and adenocarcinoma

This paper presents commentaries on neoadjuvant treatment esophagectomy; the prognostic and predictive effects of single nucleotide polymorphisms (SNP) in the multimodality therapy of esophageal cancer; optimal preoperative treatment prior to surgery for esophageal cancer; a possible role for trastuzumab in treating esophageal adenocarcinoma or any esophageal dysplasia/intra-epithelial neoplasia; surgery after chemoradiation in resectable esophageal cancer; whether para-aortic lymph node dissection should be performed in esophagogastric junction (EGJ) tumors; and transhiatal esophagectomy in treatment of the esophageal cancer.

Barrett's esophagus: progression to adenocarcinoma and markers

The following on progression to adenocarcinoma and markers of Barrett's esophagus includes commentariess on the expression of claudin 4 in Barrett's adenocarcinoma; the role of acid and bile salts; the role of insulin-like growth factor; the value of reactive oxygen species; the importance of abnormal methylation; genetic alterations in stromal cells and genomic changes in the epithelial cells; the value of confocal laser endomicroscopy for the subsurface analysis of the mucosa; indications for statins as adjuvant chemotherapeutic agent; the sequence of molecular events in malignant progression in Barrett's mucosa; and the value of the macroscopic markers and of p53 mutations.

Barrett's esophagus: surveillance and reversal

The following on surveillance and reversal of Barrett's esophagus (BE) includes commentaries on criteria for surveillance even when squamous epithelium stains normally with a variety of biomarkers; the long-term follow-up of surgery versus endoscopic ablation of BE; the recommended surveillance intervals in patients without dysplasia; the sampling problems related to anatomic changes following fundoplication; the value of tissue spectroscopy and optical coherence tomography; the cost-effectiveness of biopsy protocols for surveillance; the quality of life of Barrett's patients; and risk stratification and surveillance strategies.

Clinical evaluation of oropharyngeal dysphagia in Machado-Joseph disease

CONTEXT: In Machado-Joseph disease, poor posture, dystonia and peripheral neuropathy are extremely predisposing to oropharyngeal dysphagia, which is more commonly associated with muscular dystrophy. OBJECTIVE: To evaluate the clinical characteristics of oropharyngeal dysphagia in Machado-Joseph disease patients. METHOD: Forty individuals participated in this study, including 20 with no clinical complaints and 20 dysphagic patients with Machado-Joseph disease of clinical type 1, who were all similar in terms of gender distribution, average age, and cognitive function. The medical history of each patient was reviewed and each subject underwent a clinical evaluation of deglutition. At the end, the profile of dysphagia in patients with Machado-Joseph disease was classified according to the Severity Scale of Dysphagia, as described by O'Neil and collaborators. RESULTS: Comparison between dysphagic patients and controls did not reveal many significant differences with respect to the clinical evaluation of the oral phase of deglutition, since afflicted patients only demonstrated deficits related to the protrusion, retraction and tonus of the tongue. However, several significant differences were observed with respect to the pharyngeal phase. Dysphagic patients presented pharyngeal stasis during deglutition of liquids and solids, accompanied by coughing and/or choking as well as penetration and/or aspiration; these signs were absent in the controls. CONCLUSIONS: Oropharyngeal dysphagia is part of the Machado-Joseph disease since the first neurological manifestations. There is greater involvement of the pharyngeal phase, in relation to oral phase of the deglutition. The dysphagia of these patients is classified between mild and moderate.

A therapeutic maneuver for oropharyngeal dysphagia in patients with Parkinson's disease

OBJECTIVE

This study investigates resources to provide better conditions for oropharyngeal swallowing for improvement in the quality of life of Parkinson's disease patients.

METHOD

Three men and one woman with an average age of 70.25 years had been afflicted with Parkinson's disease for an average of 9.25 years. The patients were submitted to a rehabilitation program for oropharyngeal dysphagia after a clinical evaluation of swallowing. The rehabilitation program consisted of daily sessions for two consecutive weeks during which a biofeedback resource adapted especially for this study was used. The patients were then reevaluated for swallowing ability at follow-up.

RESULTS

The patients presenting difficulties with swallowing water displayed no such problems after rehabilitation. Only one patient exhibited slow oral transit of food and other discrete oropharyngeal food remnants when swallowing a biscuit. The sample variance was used to analyze the pressure measurements, demonstrating a numerical similarity of the results obtained with the swallowing of saliva or of biscuits (VAR = 4.41). A statistical difference was observed between the swallowing of saliva and biscuits, showing a significant pressure increase at the end of the rehabilitation program (p < 0.001).

CONCLUSION

The effortful swallow maneuver reinforced by using biofeedback appears to be a therapeutic resource in the rehabilitation of oropharyngeal dysphagia in Parkinson's disease patients.

Helicobacter pylori e doença péptica: estudo comparativo de métodos diagnósticos

Foram estudados, prospectivamente, 150 pacientes. Estudo endoscópico revelou gastrite crônica em 109 pacientes (72,6%), úlcera gástrica em 6 (4%), duodenite crônica em 9 (6%) e úlcera duodenal em 26 (17,4%). Quanto à avaliação metodológica para pesquisa do Helicobacter pylori, 103 (68,67%) apresentaram teste da urease positivo, 104 (69,33%), positividade histopatológica e 98 (65,33%), positividade sorológica. Não houve diferença estatística entre os métodos. Pela facilidade de realização, o teste da urease credencia-se como o de melhor indicação nos pacientes que também se beneficiarão com o diagnóstico endoscópico. Caso a endoscopia digestiva alta não possa ou não deva ser realizada, está recomendado o teste sorológico.

[Terlipressin as a new therapeutic agent in septic shock]

BACKGROUND AND OBJECTIVES

The hemodynamic support of sepsis is now formulated trying to insert terlipressin as salvage drug in catecholamine resistant shock, justifying a broad critical analysis.

CONTENTS

The analysis included hemodynamic therapies with defined specific goals and new recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult and pediatric patients.

CONCLUSIONS

Terlipressin appears as a new but controversial alternative for vasopressor therapy in sepsis.

Simultaneous bilimetry and pHmetry in GERD and Barrett's patients

BACKGROUND/AIMS

Despite the progressive development of technology and better knowledge of physiopathology, GERD diagnosis remains a medical problem. The aim of the study is to verify whether the measurement of bile reflux can increase the diagnostic accuracy of GERD.

METHODOLOGY

6 healthy volunteers adhered to a standard protocol, 11 Barrett's patients and 15 GERD patients (endoscopic erosive esophagitis) were fasted for 6 h before any examinations and the patients ceased acid suppression medications 72 h earlier. Manometric study was performed to localize the LES. Then The Bilitec 2000 fiberoptic probe (Synectics, Medtronics) and an antimony pH probe attached to a Digitrapper Mark III pH recorder (Synectics, Medtronics), together, were inserted through the nostril and positioned 5cm above the LES. They received an uncolored diet and after around 24 h, both Bilitec and pH data were downloaded simultaneously to a personal computer for analysis, using the Synectics software. Absorbance threshold was set at 0.14 absorbance units and acceptable esophageal pH at 4, to verify fraction of time of bile reflux (absorbance > 0.14) and DeMeester score.

RESULTS

Except controls, in whom DeMeester and Johnson scoring and fraction time of absorbance were always normal, all patterns of combined results were observed in GERD and Barrett's patients, showing possibilities of "normal" pHmetry in patients with detectable bile reflux, normal fraction time of absorbance with pathologic pH recording and both normal in GERD (40%) and Barrett's patients (only 18%).

CONCLUSIONS

This study showed that Bilitec measurements combined with 24-hour monitoring of intraluminal pH can offer other diagnostic and screening contributions in GERD and Barrett's patients, but cases of normal pHmetry and spectrophotometry demonstrate that none is definitive in characterization of reflux.

[Recommended diet for reflux spectrophotometry]

BACKGROUND

The spectrophotometric probe, which uses bilirubin as a marker for the detection of duodenoesophagic reflux is subject to interference from strongly colored foods, which can cause erroneously high bilirubin absorbance readings. To overcome this problem it is necessary to ingest a diet that is free from such substances.

OBJECTIVE

To test the absorbance of 48 different food substances in an in vitro environment.

MATERIAL AND METHOD

Dry foods were blended with water or milk and non-dry solid foods were blended undiluted. It was utilized the proper calibration recipient to test them.

RESULTS

The absorbance of weakly colored foods was usually lesser than the commonly accepted threshold of 0.14, and the absorbance of strongly colored foods was usually above this. Thirty-two from the 48 substances tested are suitable when the absorbance threshold is set at 0.14, but scrambled eggs, lacteous flour mush, green beans, beetroot, carrot, chayote, squash, "baroa" potato, boiled corn, orange, cashew, purple grape, avocado, mango, papaya and peach can alter the results and must be avoided.

CONCLUSION

From the foods evaluated, enough are suitable at the 0.14 threshold to enable a suitable diet to be constructed for most patients during Bilitec studies.

Surgical treatment of the non-complicated gastroesophageal reflux: fundoplication without division of the short gastric vessels

BACKGROUND

There is today a significant greater number of laparoscopic antireflux procedures for the surgical treatment of gastroesophageal reflux disease and there are yet controversies about the necessity of division of the short gastric vessels and full mobilization of the gastric fundus to perform an adequate fundoplication.

AIM

To verify the results of the surgical treatment of non-complicated gastroesophageal reflux disease performing Rossetti modification of the Nissen fundoplication. Patients and Methods - Fourteen patients were operated consecutively and prospectively (mean age 44.07 years); all had erosive esophagitis without Barrett's endoscopic signals (grade 3, Savary-Miller) and they were submitted to the Rossetti modification of the Nissen fundoplication. Endoscopy, esophageal manometry and pHmetry were performed before the procedure and around 18 months postoperatively.

RESULTS

There was no morbidity, transient dysphagia average was 18.42 days; there was no register of dehiscence or displacement of the fundoplication and only one patient revealed a light esophagitis at postoperative endoscopy; the others presented a normal endoscopic view of the distal esophagus. All noticed a marked improvement of preoperative symptoms. Lower esophageal sphincter pressure changed from 5.82 mm Hg (preoperative mean) to 12 mm Hg (postoperative mean); lower esophageal sphincter relaxing pressure, from 0.38 mm Hg to 5.24 mm Hg and DeMeester score, from 16.75 to 0.8.

CONCLUSION

Rossetti procedure (fundoplication without division of the short gastric vessels) is an effective surgical method to treat gastroesophageal reflux disease.

Esophageal endoscopic aspects after forceful dilation of the gastric cardia in patients with achalasia of Chagas' disease

The purpose of this study was to evaluate the clinical results and to observe endoscopically the distal esophagus in a series of chagasic adults with incipient megaesophagus and normal endoscopic aspect of the mucosa, who underwent forced hydrostatic dilatation of the cardia, 48 h after the procedure. Twenty patients were submitted to a careful specific pattern of forced dilatation, changing forceful and rapid standardized injection of water to slow distension of the balloon until the patient felt pain. The procedure was repeated three times with the same volume and was maintained each time for 5 min, with intervals of about 3 min. The dysphagia was practically immediately controlled and there were no severe complications or mortality in the series. Five patients complained of pyrosis, mild in two of them. The endoscopic examination revealed mucosal edema in 11 patients (55%), hyperemia in nine (45%) and superficial fissures of the mucosa in six (30%), with seven patients (35%) presenting all the signs simultaneously. These observations characterize 'traumatic esophagitis' due to forced dilatation of the cardia as being frequently asymptomatic. Extreme care with the method can produce effective dilatation of the cardia, avoiding severe complications but not some degree of mucosal injuries.

[Importance of esophageal pH monitoring in the screening of gastroesophageal reflux in children]

In the past 20 years the association between gastroesophageal reflux and otorhinolaryngological and/or respiratory affections became more evident by many studies. At the same time it is known that regurgitation, abdominal pain, growth retard, among others signs, could be generated by gastroesophageal reflux in infants, and when these signals are present the suspicious must be considered and they could be referred to perform pH studies. Sixty children were referred to our center to perform pH monitoring with gastroesophageal reflux suspicious, with digestive symptoms, respiratory problems or otorhinolaryngological manifestations. The patients were divided in two groups: the first, with 25 children, suffering from digestive manifestations. The second, 35 patients, including otorhinolaryngological or pulmonary symptoms. The children with digestive manifestations and with otorhinolaryngological or pulmonary symptoms were included in the first group. The pH analysis were considered positive for reflux when Boix-Ochoa Index (for 8 months of age or less) or DeMeester index (for 9 months or more) were above 11.99 or 14.72, respectively. The data were also compared to the results of scintigraphic studies for reflux or endoscopic findings in 22 patients. The pH monitoring test were positive in 62% patients with digestive manifestations. In the group with otorhinolaryngological or pulmonary symptoms the positivity was only 29%. In the group of children with both affections, the positivity was 66%. In patients that performed scintigraphic test or endoscopy, the pH test positivity were similar, 63%, without correlation if these other tests were positive or not. Patients with abnormal endoscopy or positive scintigraphic tests for gastroesophageal reflux presented 37% of positivity in pH test. We conclude that pH monitoring tests could be altered mainly when referred to investigate digestive manifestations when compared to primary otorhinolaryngological or pulmonary indications. Digestive endoscopy or scintigraphic study altered do not mean positive pH test and the inverse situation could be find too. Digestive symptoms coexisting with otorhinolaryngological or pulmonary afections do not increase the positivity frequency of the pH tests when compared with digestive manifestations exclusively.

[Reapplication of myotomy and fundoplication in the surgical treatment of recurrent dysphagia after incomplete myotomy]

Twelve patients presenting dysphagia due to incomplete myotomy were evaluated. Clinic, endoscopic, radiographic and manometric studies were performed before and after a new operation, esophagocardiomyotomy and esophagofundogastropexy, by laparotomy and phrenotomy. There was no morbiletality and it was achieved control of dysphagia in all patients, as well as weight gain and significant reduction of the esophageal emptying time. Only one patient presented moderate esophagitis in the postoperative period. Reduced resting pressure of the LES was noted, but with no alteration of its lenght. The operation proved be factible and able to constitute good option to treat these cases.

Achalasia: a prospective study comparing the results of dilatation and myotomy

BACKGROUND/AIMS

In a prospective and randomized clinical study, the operative method and dilatation in the initial stage of megaesophagus were evaluated.

METHODOLOGY

Forty patients in the initial stage of megaesophagus, managed by forced hydrostatic dilatation of the cardia (20 patients-DILAT Group) or by esophagocardiomyotomy associated with esophagofundopexy (20 patients-Group OP) were followed-up for three years, in terms of clinical, radiographic, endoscopic, manometric and pH monitoring.

RESULTS

1) Both procedures can be performed without significant morbidity or mortality. 2) The two procedures are similar regarding ongoing suppression of dysphagia. 3) Radiologically, the methods are equivalent, since they promote significant elimination of contrast stasis and maintenance of the esophageal diameter. 4) Endoscopic follow-up did not differentiate the procedures in terms of the development of reflux esophagitis, with a rate of only 5% for each group of patients. 5) Manometry demonstrated that surgery produced a significantly greater reduction of the LESP as compared to dilatation, although the latter also determined a marked drop in the maximum basal pressure of the LES. 6) Neither procedure altered the length of the LES. 7) With prolonged esophageal pH monitoring, dilatation demonstrated a greater propensity for reflux as compared to surgery.

CONCLUSION

Both methods offer benefits in the treatment of the initial stage of megaesophagus, although esophageal pH monitoring indicates that dilatation provokes a greater index of esophageal acid exposition time.

[Surgical treatment of megaesophagus. Effect of myotomy and fundoplication on the lower esophageal sphincter]

Details about the structure of the lower esophageal sphincter and the function of fundoplication are yet unknown. New study is presented about electromanometric examination of the lower esophageal sphincter in 20 chagasic patients with megaesophagus operated on by cardiomyotomy complemented with His angle agudization (Group A-10 patients) or fundoplication (Group B-10 patients). On the 30th postoperative day, the patients, without dysphagia, were submitted to radiologic study, demonstrating valvuloplasty integrity (Group B), and electromanometric study of the esophagus. The comparison between the groups demonstrated: -myotomy does not modify the lower esophageal sphincter extension, but decrease its pressure, not to zero; -fundoplication does not increase the lower esophageal sphincter pressure after myotomy, under resting conditions. These conclusions suggest that: -lower esophageal sphincter is formed by muscular fibers interlacing, configuration that maintains residual regional pressure after myotomy; - in resting state, after myotomy, fundoplication exerts exclusively mechanical function, without increase of the lower esophageal sphincter pressure.

Manometric study of the upper esophageal sphincter before and after endoscopic management of Zenker's diverticulum

BACKGROUND/AIM

Zenker's diverticulum treatment was done by endoscopic management of the elderly and debilitated patients without general anesthesia.

MATERIALS/METHODS

With this technique, the septum between the diverticulum and the esophageal lumen is sectioned with a diathermic knife. Since the upper esophageal sphincter (UES) is certainly included in the mass sectioned, this accounts for the success of the procedure.

RESULTS

Manometric assessment of the UES was done in 5 patients before the endoscopic treatment. The mean pressure was 54.6 cm H2O and the mean length of 3 cm. A significant (p < 0.05) reduction in maximum pressure occurred postoperatively--mean 26.8 cm H2O. There was no significant variation in length of the UES.

CONCLUSION

The maintenance of this basal pressure may be explained by the preservation of the circular muscle structure of the region, with sphincter-like characteristics.

[Cervical esophageal membrane and Plummer-Vinson syndrome: report of a caseload and review of the literature]

Esophageal webs are an uncommon group among esophageal diseases. We report our findings in ten patients with membranes in the upper esophagus; seven of them were women. The median age was 48.5 years (range 24 to 73 years). Dysphagia was the main symptom in all patients and anemia was found in six cases. Radiologic and endoscopic studies provided the diagnosis. All patients underwent endoscopic dilatation and/or debridement and good results with this management were achieved. A review of literature of this condition and a discussion about the diagnosis, treatment and etiopathogenesis are presented.

The surgical treatment of megaesophagus and megacolon

The effect of Chagas' disease on the digestive tract is evaluated based on the experience acquired in the surgical management of 929 cases of megaesophagus: 807 in the nonadvanced state of the disease and 122 with dolichomegaesophagus. The 807 subjects with nonadvanced megaesophagus were submitted to wide esophagocardiomyectomy on the anterior esophagogastric junction combined with an antireflux valvuloplasty procedure. There was no mortality. On the other hand, dolichomegaesophagus was always resected, with an esophagogastroplasty through the esophageal bed. The index of mortality of the series was 4.1% (5/122) and the main postoperative complications were pleural effusion (22.1%) and fistula of the esophagogastric anastomosis (8.2%). Over the long term the patients adapted well to the operation and gained weight. For the treatment of the megacolon, an easier technique has been employed: resection of the dilated sigmoid colon and colorectal anastomosis just above the anorectal ring. In 30 patients, no leakages, infection or other major complications were seen. The patients, after 1 year of follow-up, had a normal bowel transit.

Surgical complications of Chagas' disease: megaesophagus, achalasia of the pylorus, and cholelithiasis

Three surgical complications of Chagas' disease--megaesophagus, achalasia of the pylorus, and cholelithiasis--were evaluated within the framework of the experience acquired in the management of 840 cases of megaesophagus--722 in the nonadvanced stage of the disease and 118 with advanced disease (dolichomegaesophagus). In the group of the 722 patients with nonadvanced disease, achalasia of the pylorus was present in 140 (19.4%), and in the total of 840 patients, uncomplicated cholelithiasis without chagasic involvement of the gallbladder and/or papilla was observed in 58 (6.9%). The 722 subjects with nonadvanced megaesophagus were submitted to wide esophagocardiomyectomy performed at the level of the anterior esophagogastric junction, combined with an antireflux valvuloplasty procedure. We recorded no mortality, and 95% excellent and good results in long-term follow-up. On the other hand, dolichomegaesophagus required esophageal resection with reconstruction by means of an esophagogastroplasty placed in the esophageal bed. The mortality rate was 4.2% (5/118); the main postoperative complications were pleural effusion (22%) and fistulas of the esophagogastric anastomosis (8.4%). Postoperatively, the patients adapted well to their new anatomy and gained weight. Achalasia of the pylorus was confirmed by delayed gastric emptying time. This entity was managed by concomitant antropyloromyectomy without mortality. Cholelithiasis was managed by cholecystectomy and radiologic exploration of the bile ducts.

[Controversial aspects in traumatic lesions of the pancreas]

The pancreatic anatomo-functional characteristics explain the traumatic gravidity and the problems in diagnostic. Its lesion is treated surgically, with controversial aspects. In terms of literature and analytic description of a case, were established: the initial course of trauma can be uncharacteristic, with normal amilasemia and abdomen Rx; the ultrasonography can determine the diagnosis; in cases of proximal transection of pancreas, the surgical treatment can include pancreatic derivation, in early operations, under favourable conditions.

Esophageal manometry and vectorcardiography study of asymptomatic patients with Chagas' disease

The indeterminate form of Chagas' disease is characterized by positive serology for the disease in the absence of clinical findings and in the presence of both normal esophagogram and electrocardiogram. When more sensitive methods were used, abnormalities have been described either in the esophagus or in the heart. The authors have studied simultaneously the esophagus and the heart in the same subjects. In thirteen adults with diagnosis of indeterminate form and nine adult controls, the esophageal manometry both in basal conditions and after stimulus (bethanecol) and vectorcardiogram were performed. In the control group none of the subjects presented concomitant esophageal and cardiac alterations while in the chagasic group 92,3% of the patients presented results simultaneously altered. It is concluded that the studied patients showed indications of parasympathetic denervation manifested by simultaneously esophageal and heart alterations.

[Esophageal manometry for the study of gastroesophageal reflux]

In a medical literature revision, actual concepts about esophageal inferior sphincter's importance are presented. It is the principal object on studies about clinical and surgical therapeutic procedures for gastroesophageal reflux. Thus, esophageal manometric study, fundamental for physiological knowledge of the organ, conducts the reflux esophagitis therapy.

Suture of the diaphragmatic esophageal hiatus (an experimental study)

Eighty rabbits were submitted to different procedures on the esophageal hiatus of the diaphragm. The authors concluded that section of the peritoneal lining, removal of the perimysium of the crura of the medial diaphragmatic limb and abrasion of its borders, do not cause local adhesions. On the other hand, the approximation of these muscular structures with interrupted nylon sutures, determines the formation of the scar uniting them. The resistance of the scar varies in different animals but the average values recorded, showed the efficiency of the suture used.

Esophagogastric anastomosis with valvuloplasty: an experimental study

Twenty dogs divided into two equal groups were studied by the authors in order to evaluate the functional activity and the occurrence of reflux and esophagitis after esophagogastrectomy followed by a simple esophagogastric anastomosis (group A) and associated with an anti-reflux valve mechanism (group B). The functional activity was studied by manometry at the esophagogastric junction and the occurrence of esophagitis by histologic examination of the esophagus after 25 days of histamine gastric acid stimulation. In group A, no high pressure zone between the gastric and esophageal tracings were verified. Reflux and esophagitis which, occurred in all animals, was severe in 70%. In group B, manometry demonstrated that esophagogastropexy creates a high pressure zone. At deglutition this zone showed positive deflections, corresponding to the propagation of the peristaltic wave in the segment of esophagus, encircled by the stomach. Esophagitis, which was detected in 30%, was less severe than that observed in group A.