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The treatment of ingestion of caustic agents is controversial in the literature. Surgical therapy has been shown to be the best way to proceed, but the surgical methodology has been varied according to the patient's involvement. This study aims to expose the experience of a single institution in relation to the methodology used for the surgical treatment of esophageal stenosis by ingestion of a caustic substance. A retrospective study was carried out in which data were collected from 27 patients who underwent a surgical procedure for the treatment of esophageal stenosis due to alkali ingestion at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo between 2010 and 2019 and their subsequent comparison between the conduits used in the surgical intervention. Fisher's test was performed to compare the groups regarding cervical leakage and post-surgical symptoms with a significance level of 5%. Of the 27 surgical procedures for esophageal stenosis due to alkali ingestion, 12 performed gastric conduits and 15 colon conduits. When comparing the groups regarding cervical leaks, no statistically significant difference was noted (p = 0.7060). There were also no statistically significant differences regarding the presence of symptoms in the postoperative period (p > 0.99...) Surgical intervention by both gastric and colon conduits showed no differences in cervical leakage and symptom control. Surgical intervention by both gastric and colon conduits showed no differences in cervical leakage and symptom control.

Continuous episodes of Gastroesophageal reflux (GER) attack the esophageal mucosa and may lead to the unusual replacement of the squamous cell epithelium for the glandular columnar cell epithelium, with goblet cells. The intestinal metaplasia, in the esophageal mucosa characterizes Barrett's Esophagus (BE). BE occurs in 10 to 15% of chronic and long-term reflux patients. In addition, BE's epithelium is susceptible to chronic inflammation with risks for dysplasia and adenocarcinoma. We analyzed the impact of unconventional techniques on the evolution of Barrett's esophagus extension, as: Antrectomy (n = 1), Roux-en-Y Bypass (n = 5), Cardiomyotomy (n = 6), Esophagectomy (n = 10), Gastrectomy (n = 12), Lind fundoplication (n = 12). For this purpose, a retrospective study with BE patients treated at our service was carried out, evaluating the extension of Barrett's epithelium between the first and the last endoscopy of each patient. The greatest mean absolute regression of the BE extension was seen in esophagectomy, equivalent to 2.87 cm; esophagectomy combined with gastrectomy, 1.15 cm; and gastrectomy, with 0.97 cm. Antrectomy and procedures involving Roux-en-Y, in our series, did not reduce the extent of the columnar epithelium, actually showing progression or formation of Barrett's Esophagus. It is worth mentioning that Lind fundoplication, once the main treatment for GERD, obtained a mean regression of 0.37 cm in the BE extension, however it was not the treatment with the best result, and 17% of the evaluated patients showed lesion progression. The majority of evaluated procedures as alternative procedures for the treatment of reflux in patients with BE can be effective in controlling the evolution and even contributing to its regression.

Gastric volvulus is a rare clinical and occurs when the stomach rotates 180° in its transverse or longitudinal axis. Symptoms may range from mild abdominal pain to volvulus necrosis. Gastroesophageal reflux disease (GERD) is not very often associated with abdominal gastric volvulus. Usually, the volvulus is primary and results from anatomical ligament defects. Organoaxial volvulus is the most common type and is defined by the rotation of the stomach around the Pylorus or Gastroesophageal Junction. Two cases will be presented where the treatment of organo-axial gastric volvulus was performed by video laparoscopy. The literature revision will try to bring some aspects of the problems in missing the diagnosis of the volvulus before operation. Two male patients, 24 and 47 years old, underwent surgery, both with extra-esophageal symptoms of GERD associated with symptoms of gastroparesis. Endoscopy, barium swallow and gastrography, manometry, pHmetry, and scintigraphy gastric emptying test were performed, showing a delayed gastric emptying time leading to reflux in both patients. Both patients had a good evolution after surgery. The release of the gastric anatomical ligaments was performed, as well as the rotated gastric fundus. The gastric fundus was used to perform a partial fundoplication, with the stomach being fixed to the pillars and diaphragmatic surface, fixing the stomach in a normal anatomical position. Gastric volvulus can be an unexpected cause of GERD, and the symptoms usually are refractory without surgical treatment. The appropriate surgical technique can bring good results and symptom relief to patients.

Background: The present study aims to compare the effectiveness of surgical and medical therapy in reducing the risk of cancer in Barrett's esophagus in a long-term evaluation. Methods: A prospective cohort was designed that compared Barrett's esophagus patients submitted to medical treatment with omeprazole or laparoscopic Nissen fundoplication. The groups were compared using propensity score matching paired by Barrett’s esophagus length. A total of 398 patients met inclusion criteria. There were 207 patients in the omeprazole group (Group A) and 191 in the total fundoplication group (Group B). After applying the propensity score matching paired by Barrett’s esophagus length, the Groups were 180 (Group A) and 190 (Group B). Median follow-up was 80 months. Group B was significantly superior for controlling GERD symptoms, in promoting Barrett’s esophagus regression or blocking its progression. Also was more efficient in preventing the development of dysplasia and cancer. Logistic regression was performed for the outcomes of adenocarcinoma and dysplasia, using age and BMI as covariates. Even after regression analysis, Group B was still superior to Group A to prevent esophageal adenocarcinoma or dysplasia transformation (OR: 0.51; 95% CI: 0.27 to 0.97, for adenocarcinoma or any dysplasia; and OR: 0.26; 95% CI: 0.08 to 0.81, for adenocarcinoma or high-grade dysplasia). Surgical treatment is superior to medical management, allowing for better symptom control, less need for reflux medication use, higher regression rate of the columnar epithelium and intestinal metaplasia, and lower risk for progression to dysplasia and cancer.

Objetivo: Avaliação a longo prazo da evolução do epitélio colunar do esôfago de Barrett após tratamento clínico e cirúrgico através da fundoplicatura total do refluxo gastroesofágico. Métodos: Estudo prospectivo comparativo, incluindo 398 pacientes com esôfago de Barrett submetidos ao tratamento clínico com Omeprazol (seguimento médio de 67,8 meses) ou através de fundoplicatura laparoscópica a Nissen (147,7 meses). Foram colhidos dados de consultas anuais e endoscópicos a cada 2 anos. Os grupos foram comparados de forma geral e também utilizando Propensity Score Match (PSM), pareando a extensão do esôfago de Barrett, com variáveis de ocorrência para displasia e adenocarcinoma e quanto à evolução do epitélio e critérios clínicos, e significância estatística assumida para p

Introdução: O carcinoma espinocelular (CEC) anal é um tumor relativamente raro mas de incidência crescente. O tratamento padrão com quimiorradioterapia (QRT) concomitante permite que muitos pacientes evitem a amputação abdominoperineal de reto e a colostomia definitiva. No entanto, tumores avançados podem se apresentar com complicações locais que requerem uma derivação intestinal previamente ao início da QRT. O desfecho destes estomas é incerto e pouco estudado na literatura. O objetivo deste estudo é avaliar os pacientes com CEC anal submetidos à derivação intestinal previamente à QRT em relação ao desfecho do estoma e aos fatores de risco associados à sua permanência definitiva. Métodos: Foi realizado estudo de coorte retrospectivo através de análise de prontuários de pacientes tratados no Instituto do Câncer do Estado de São Paulo (ICESP-HCFMUSP) entre janeiro de 2008 e dezembro de 2020, diagnosticados com CEC anal e submetidos à derivação intestinal previamente ao início da QRT com intuito curativo. Foram excluídos pacientes tratados com intuito paliativo. Foram avaliados dados demográficos, clínicos, do estadiamento do tumor, do tratamento oncológico, sobre o desfecho do estoma e as suas complicações a curto e longo prazo. Foram analisados a taxa de reversão dos estomas pré-QRT e os fatores de risco relacionados à sua permanência definitiva. Resultados: No período estudado foram tratados 651 pacientes com CEC anal no ICESP-HCFMUSP. Destes, 82 foram submetidos à derivação intestinal previamente à QRT, mas 17 foram excluídos deste estudo, sendo 11 por doença metastática ao diagnóstico e 6 por óbito antes de iniciar o tratamento oncológico. Ao final, 65 pacientes foram avaliados. Os motivos para confecção da colostomia foram obstrução intestinal (n=28, 43,1%), fístula retovaginal (n=13, 20%) e infecção perianal (n=24, 36,9%). Após seguimento médio de 35,8 ± 27,6 meses, 9 pacientes (13,8%) reconstruíram o trânsito intestinal. Em análise univariada, sexo masculino (p=0,013), baixo status funcional (ECOG 2) (p=0,023), tumores volumosos (p=0,045), infecção perianal (p=0,010), QT com cisplatina (p=0,047) e interrupções na RT por período maior que sete dias (p=0,010) foram fatores de risco de permanência definitiva do estoma. Conclusão: A maioria das colostomias realizadas pré-QRT nos pacientes com CEC anal são definitivas. Os fatores de risco associados à sua permanência são: sexo masculino, baixo status funcional (ECOG 2), tumores volumosos, derivação intestinal por infecção perianal, QT com cisplatina e interrupções na RT por período maior que 7 dias Introduction: Squamous cell anal cancer (SCC) is a relatively rare gastrointestinal tumor although the incidence has increased over the last decades. The current standard of care is concurrent chemoradiation (CRT), which allows for tumor eradication while preserving the anal sphincter and possibly avoiding a definitive stoma. However, advanced tumors with local complications, such as intestinal obstruction, rectovaginal fistulas or perianal sepsis, may require pretreatment stomas in order to alleviate symptoms and avoid interruptions during CRT. The fate of pretreatment stomas is uncertain and limited data exist in the literature. The aim of this study is to evaluate the reversal rate of pretreatment stomas and the risk factors associated with a definitive stoma. Methods: This was a retrospective cohort study, which included patients treated at the Instituto do Câncer do Estado de São Paulo (ICESP-HCFMUSP) from January 2008 to December 2020, diagnosed with anal SCC, in whom a stoma was formed before CRT. Palliative patients were excluded. Demographic data, reason for stoma creation, tumor-related characteristics, chemotherapy regimen, radiotherapy dose and interruptions, reversal of the stoma, short- and long-term complications, and the risk factors associated with a definitive stoma were evaluated. Results: 651 patients with anal SCC were identified and 82 required pretreatment stomas. 17 were excluded, either due to metastatic disease (n=11) or death prior to initiating CRT (n=6). Finally, 65 patients were included. A stoma was needed for intestinal obstruction (n=28, 43.1%), rectovaginal fistula (n=13, 20%) and perianal sepsis (n=24, 36.9%). A total of 9 patients (13.8%) reversed their stomas after a mean follow-up of 35.8 ± 27.6 months. In univariate analysis, male gender (p=0.013), low performance status (ECOG 2) (p=0.023), large tumors (p=0.045), perianal sepsis (p=0.010), cisplatin-based chemotherapy (p=0.047) and interruptions during RT for more than 7 days (p=0.010) were associated with a definitive stoma. Conclusion: Pretreatment stomas are unlikely to be reversed and the risk factors for a definitive stoma are: male gender, perianal sepsis, low performance status (ECOG 2), large tumors, cisplatin-based chemotherapy and interruptions during radiotherapy for more than 7 days