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Lung diseases have a strong relationship with gastroesophageal reflux disease (GERD). It has been previously demonstrated that conditions such as tracheal stenosis, asthma and even lung transplantation may worsen with reflux and these patients have few symptoms of GERD. With the COVID-19 pandemic, the number of people who needed mechanical ventilation and tracheostomy increased. Our objective was to demonstrate the prevalence of gastro-oesophageal reflux in patients with tracheostomy and describe its characteristics. Methods Esophageal manometry and 24 h pH-metry was performed in 137 consecutive patients with a tracheostomy already in a chronic phase, independent of symptoms. Inquire on respiratory and digestive symptoms was also carried out at the time of the examination. Prevalence of gastroesophageal reflux was identified in this population and description of the groups with reflux and without it, as well as comparison between them. Results Of the 137 patients, 49 were male, the average age was 40.94 ± 17.3 and the body mass index was 26.3 ± 4.85. The prevalence of gastroesophageal reflux was 45.2%. Baseline characteristics were similar between the groups with and without reflux. In the reflux group, the mean DeMeester score was 36.5 ± 20.8 and the presence of lower sphincter hypotonia was found in only 31% of the patients and was not correlated with reflux between the groups (p = 0.285). Regarding the symptoms, 48% had heartburn symptoms and only 30% had a combination of typical symptoms (heartburn + regurgitation). Conclusion The presence of tracheostomy is related to an increased prevalence of reflux, even without typical symptoms most of the time. The mechanism for this is still unknown, perhaps the altered respiratory dynamics has a role. These patients should be investigated with functional exams if they develop any condition that may be affected by reflux.

Key Clinical Message This study describes a patient with symptomatic Killian‐Jamieson, a rare entity, successfully treated by cervical approach with diverticulum resection and esophagomyotomy.

Highlights • Heterotopic pancreas is a rare congenital anomaly. • Patients may present with complications such as inflammation and abscess. • The management depends on size, ability to exclude other etiologies and symptoms., Introduction Heterotopic pancreas is a rare congenital anomaly. We report a case of esophageal heterotopic pancreas complicated by recurrent mediastinal abscess and treated by minimally invasive resection. Presentation of case A 31-year-old woman was admitted with a history of recurrent chest pain, dysphagia, and heartburn. CT scan revealed focal confined collection in the lower mediastinum surrounding esophagus. Endoscopic ultrasound revealed a subepithelial lesion. The patient was treated by minimally invasive esophagectomy and made an uneventful postoperative recovery. Discussion The management of subepithelial lesions would depend on their size, ability to exclude other etiologies and their associated symptoms. The patient, in this case, was obviously symptomatic and accurate differentiation from malignant etiologies could not be accurately made. Conclusion Although pancreatic heterotopia is rare, it should be remembered in the differential diagnosis of various gastrointestinal lesions.

Duarte, A., Borralho, N., & Caetano, M. (2021). A Machine Learning Approach to Detect Dead Trees Caused by Longhorned Borer in Eucalyptus Stands Using UAV Imagery. In IGARSS 2021 - 2021 IEEE International Geoscience and Remote Sensing Symposium: Proceedings, 12 – 16 July, 2021 Virtual Symposium, Brussels, Belgium (pp. 5818-5821). IEEE. https://doi.org/10.1109/IGARSS47720.2021.9554947 ----------------- Funding Information: We would like to thank Terradrone and all colleagues of the RAIZ team. The presented work was also carried out with a research project financed by the MySustainableForest project, which has received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement No 776045. Publisher Copyright: © 2021 IEEE. Pest damages in eucalyptus plantations cause significant economic losses for the pulp and paper industry. Longhorned borers (ELB) outbreaks induce mortality in eucalyptus stands. In this study, multispectral imagery was obtained from unmanned aerial vehicles. We attempt to improve the classification process done in previous work. The local maxima of sliding a window and the Large-Scale Mean-Shift segmentation (LSMS) were applied to extract tree crows. Subsequently, the mean of spectral bands and twelve vegetation indices were calculated to characterize each segment. To classify tree canopies into dead and healthy trees, supervised machine learning using Random Forest (RF) and Support Vector Machine (SVM) were applied. The overall accuracy of Random Forests was 98.35% and Support Vector Machine of 97.7%. We concluded that SVM did not perform better than RF. Moreover, adding new vegetation indices in the classification process did not increase accuracy. authorsversion published

Barrett’ s esophagus (BE) is a complication of severe gastroesophageal reflux disease (GERD). The major concern aspect is its association to dysplasia and esophageal adenocarcinoma. The endoscopic treatment of the epithelium, as well as the follow-up (FU) period, should be guided according to the diagnosis and the worst degree of dysplasia found in the last endoscopies. However, we are aware of the great difficulty and variation among pathologists in diagnosing and grading dysplasia in BE. Methods Aim: Review new diagnoses of low- and high-grade dysplasia (LGD and HGD) in BE with specialized pathologists during long-term FU in clinical or surgical treatment for GERD From January 1980 to July 2019, 738 patients with BE were FU (average of 98 months), with routine endoscopic examination each 2 years with multiple biopsies, in patients with BE without dysplasia. 48 patients were diagnosed with any grade of dysplasia on FU endoscopic biopsies. The biopsies were reviewed by specialized pathologists and evaluated epidemiologic data, clinical or surgical treatment for the GERD and about the confirmation, downgrade or upgrade of dysplasia degree. Results 48 patients were reviewed, 32 males. The medium age was 61,9 YO (29 -93). Only 18 patients were in follow-up after surgical treatment for GERD. 9 patients had first diagnosis of in situ Adenocarcinoma, after review 8 were confirmed and treated and 1 were downgrade to HGD. 8 patients had first HGD and after review, 2 were upgrade to Adenocarcinoma, 4 were confirmed as HGD (endoscopic treatment) and 2 downgraded to no dysplasia BE. 31 patients had first LGD. 2 had upgrade to HGD/Adeno, 8 are in FU annually and 21 were downgrade to non dysplastic BE. Conclusion The diagnosis of dysplasia in BE remains a challenge. 23 of 48 (47%) of our patients once marked with any grade of dysplasia, were downgrade after pathological review and FU to non dysplasic BE. These difficulty of appropriate dysplasia degree diagnosis could make some mistakes in BE treatment and surveilance.

Systemic sclerosis (scleroderma) is frequently associated with both gastroesophageal reflux disease (GERD) and simultaneous esophageal dysmotility (ED). Antireflux surgery have to considerate the individual esophageal dysmotility degree of each patient. They need GERD treatment as a priority to help control worsening lung function, in patients developing pulmonary fibrosis or in lung transplantation patients. Another issue is the possibility that fundoplications in this patients can cause esophageal stasis, an event that can also disrupt lung function. Methods 113 patients were referred for surgical treatment of GERD, related with pulmonary impairment. SS patients are the most critical, once the ED may be an obstacle to fundoplication. We divided this patients in three groups regarding the esophageal function. A- Partial fundoplication—without important affection of ED, checked by manometry, confirmed with a complete emptying of esophagus in barium swallow test. B- Laparoscopic gastric bypass for treatment of GERD (RYGBP)—aperistalsis or atonic esophageal body, with normal esophageal empty at barium test. C- Esophagectomy—Atonic esophageal body with important delayed emptying of esophagus in barium swallow test. Results We could follow up 4 patients in group A, 3 patients in group B and 2 patients in group C. Median follow-up was 75, 30 and 18 months for Groups A,B and C respectively. All 3 patients in the RYGB group resolved all the symptoms including heartburn and regurgitation, with a sensitive improve in lung function. Only 1 patients in the fundoplication group reported symptom improvement or resolution. The Patients at Group C have no complain of Dysphagia but referred regurgitation and difficulty feedingtill first year. Conclusion Laparoscopic RYGB as an anti-reflux procedure is safe and may provide an alternative to fundoplication in the treatment of GERD for systemic sclerosis patients with esophageal dysmotility. Both reflux control and dysphagia rates were improved in the RYGBP group compared with fundoplication and esophagectomy.. This finding suggests that RYGBP may be an option for the primary manage- ment of scleroderma-associated gastroesophageal reflux in patients without importnat impairing of esophageal emptying.

Corrosive ingestion is a significant challenge for healthcare support. Limited data is available regarding the best treatment, and there is still a lack of consensus about the optimal surgical approach and its outcomes. This study aims to show a single-institution experience of surgical treatment of esophageal stenosis due to corrosive substance ingestion and review the current literature. Methods A retrospective review, including demographics, psychiatric profile, surgical procedures, and outcomes, is described. A systematic review of the literature was performed in PubMed. Results In total, 27 surgical procedures for esophageal stenosis due to corrosive substances ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. The incidence rate of cancer in patients with corrosive esophageal stenosis is 701.7–874.1 per 1,000,000 person-years, and the cancer latency between corrosion ingestion to carcinoma is 10–58 years. Esophagectomy and esophageal bypass were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded. Conclusion The surgical intervention either by esophagectomy or esophageal bypass seems to show a high success rate. However, the outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

Background Corrosive ingestion is a significant challenge for healthcare systems. Limited data are available regarding the best treatments, and there remains a lack of consensus about the optimal surgical approach and its outcomes. This study aims to review the current literature and show a single institution's experience regarding the surgical treatment of esophageal stenosis due to corrosive substance ingestion. Methods A retrospective review that accounted for demographics, psychiatric profiles, surgical procedures, and outcomes was performed. A systematic review of the literature was performed using PubMed. Results In total, 27 surgical procedures for esophageal stenosis due to corrosive substance ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. Esophagectomies and esophageal bypasses were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded. Conclusion Surgical intervention either by esophagectomy or esophageal bypass results in durable relief from dysphagia. However, successful clinical outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

Objective: to evaluate esophageal dysmotility (ED) and the extent of Barrett’s esophagus (BE) before and after laparoscopic Nissen fundoplication (LNF) in patients previously diagnosed with BE and ED. Methods: twenty-two patients with BE diagnosed by upper gastrointestinal (GI) endoscopy with biopsies and ED diagnosed by conventional esophageal manometry (CEM) were submitted to a LNF, and followed up with clinical evaluations, upper GI endoscopy with biopsies and CEM, for a minimum of 12 months after the surgical procedure. Results : sixteen patients were male (72.7%) and six were females (27.3%). The mean age was 55.14 (± 15.52) years old. and the mean postoperative follow-up was 26.2 months. The upper GI endoscopy showed that the mean length of BE was 4.09 cm preoperatively and 3.91cm postoperatively (p=0.042). The evaluation of esophageal dysmotility through conventional manometry showed that: the preoperative median of the lower esophageal sphincter resting pressure (LESRP) was 9.15 mmHg and 13.2 mmHg postoperatively (p=0.006). The preoperative median of the esophageal contraction amplitude was 47.85 mmHg, and 57.50 mmHg postoperatively (p=0.408). Preoperative evaluation of esophageal peristalsis showed that 13.6% of the sample presented diffuse esophageal spasm and 9.1% ineffective esophageal motility. In the postoperative, 4.5% of patients had diffuse esophageal spasm, 13.6% of aperistalsis and 22.7% of ineffective motor activity (p=0.133). Conclusion: LNF decreased the BE extension, increased the LES resting pressure, and increased the amplitude of the distal esophageal contraction; however, it was unable to improve ED.

Description Authors show the lessons learned after 50 robotic esophagectomies: the new positioning of the 4 robotic arms in the thorax avoiding collisions, fixation of the arches of the azygos vein arch (after section) and retraction of the trachea allowing the dissection of the left recurrent nerve lymph nodal chain, especially within the aortic arch. Abdominal dissection and cervical anastomosis are also presented. The film end with the results compared to Thoracoscopic Esophagectomy Disclosure All authors have declared no conflicts of interest.

INTRODUÇÃO: Instrumento eficiente para medição da disfagia, facilmente reprodutível e estatisticamente consistente, deveria fornecer dados mais consistentes sobre os resultados e acompanhamento de doenças com disfagia. As propostas existentes mostram ampla cobertura na avaliação do sintoma disfágico. OBJETIVOS: Analisar as escalas de disfagia disponíveis sugerindo as que permitem avaliação mais objetiva e estatisticamente consistente, e não apenas ferramenta de mensuração, e sugerir as que melhor quantificam o sintoma e úteis para seguimento dos pacientes. MÉTODO: Foram pesquisados os seguintes descritores no Pubmed: "disfagia", "escala", "index", "score". Dez artigos foram selecionados entre 1995 e 2012 com propostas de escalas para a disfagia. RESULTADOS: A maioria das escalas não atingiram os requisitos para serem classificadas como ferramenta completa na avaliação de qualquer disfagia. Muitas são específicas para uma única doença, e poucas com maior abrangência, não têm consistência estatística. Para disfagia orofaríngea (cervical), as escalas FOIS e ASHA são citadas com mais frequência. Na disfagia motora (cervical), a de Zaninotto e Youssef têm aplicabilidade prática, mas ambas necessitam de validação estatística. A de Zaninotto parece ser mais precisa por incluir mais variáveis (disfagia, dor no peito e azia). As escalas que cobrem as duas formas de disfagia (ASHA e DHI) são bem diferentes em seus objetivos. A DHI é escala publicada recentemente examina os dois tipos de disfagia e tem validação estatística bem estruturada. Importante passo no futuro seria testar essa nova proposta com amostra mais expressiva e representativa, provavelmente consagrando esse novo instrumento de avaliação. CONCLUSÃO: As escalas mais frequentes de disfagia relatadas nos últimos 17 anos têm propósito e estruturas diferentes. As escalas FOIS e ASHA são muitas vezes utilizadas para a avaliação da disfagia orofaringeana (região cervical), ambas focadas em terapia nutricional. Para a avaliação motora baixa, a escala de Zaninotto e Youssef tem aplicação prática, e a DHI parece representar a ferramenta mais promissora na avaliação global da disfagia. INTRODUCTION: An efficient instrument for dysphagia measurement, easily reproducible and statistically consistent, should provide consistent data on the outcomes and follow-up of diseases with dysphagia. Existent proposals do not show a global coverage in the evaluation of this symptom. OBJECTIVE: To analyze the available dysphagia scales determining those that allow a more objective and statistically consistent evaluation, and not only a measurement tool. Also, witch of the them achieve a better quantification of the symptom and useful in the follow-up. METHOD: Searching descriptors in the database Pubmed: "dysphagia", "scale", "index", "score", 10 papers were selected published between 1995 and June 2012 with proposals of dysphagia scales. RESULTS: Most scales do not reach the requirements to be classified as a complete tool in the evaluation of any dysphagia. Many are specific to a single disease and few, which have a global assessment, have no statistical consistency. In oropharyngeal (cervical) dysphagia, the FOIS and ASHA scales are the most often cited. In motor dysphagia (cervical), the Zaninotto and Youssef scale have extremely practical applicability, but both require statistical validation. Zaninotto´s seems to be more accurate by including more variables (dysphagia, chest pain and heartburn). The scales which cover the two forms of dysphagia (ASHA and DHI) are extremely different regarding the goal of their evaluation. The DHI is a scale of recent publication, which examines the two types of dysphagia and has a well-structured statistical validation. Future important step would be testing this new proposal with a more expressive and representative sample, probably enshrining this new assessment tool. CONCLUSION: The most frequent scales of dysphagia reported in the last 17 years have different purpose and structure.The FOIS and ASHA scales are often used for evaluation of oropharyngeal (cervical) dysphagia, both focused on nutritional therapy. For the evaluation of motor (low) dysphagia, the scale of Zaninotto and Youssef has practical application, and the DHI seems to represent the most promising tool in the overall assessment of dysphagia.

Background Ectopic pancreas is an extremely rare genetic malformation in the esophagus. It is defined by pancreatic tissue outside the pancreas and usually presents as a subepithelial lesion in the esophagus. To date, there are fewer than 15 patients reported in the literature. Methods We present 2 cases of pancreatitis in the esophageal ectopic pancreas with different presentation, treatment and development, as well as a review of the literature. Results 1. A 48-year-old woman admitted to the ER with acute dysphagia and chest pain. There were elevation of amylasemia and lipasemia, as well as presence of a tumor in the Gastroesophageal junction with hypersignal at the CT scan, suggesting acute inflammation. An echoendoscopy with biopsy, diagnosed ectopic pancreas in the distal esophagus. The patient was then submitted to laparoscopic resection of subepithelial tumor of the cardia, recovered by a fundoplication. The specimen confirmed pancreatic tissue with acute inflammation. 2. A 33-year-old woman with a history of episodic chest pain confused with GERD, nausea and vomiting pain episodes accompanied by elevated serum amylase and lipase levels. She was submitted to an ERCP without alterations to investigate the clinical complains. After some crisis she was hospitalized with a septic condition, where a CT scan revealed a cystic lesion in the lower mediastinum in the esophageal wall. Endoscopy was performed, showing a drainage orifice with purulent secretion in the cardia. She was treated with antibiotics and fasting. She had two more crises and was referred to our specialized service. Thoracoscopic subtotal esophagectomy with cervical anastomosis was performed for treatment of a suspected esophageal duplication cyst with recurrent infections. The specimen showed the presence of organized pancreatic tissue characterizing ectopic pancreas complicated with chronic pancreatitis. Conclusion The ectopic esophageal pancreas can be present as a differential of these lesions. The second case, was first admitted at a secondary care unit and the diagnosis was delayed, probably leading to a worse development and necessity of a esophagectomy. In the literature, there is only one description of 1 case of recurrent pancreatitis. We have shown that complications can range from dysphagia to abscess, requiring more invasive treatment. Disclosure All authors have declared no conflicts of interest.

Description Background: The concept of salvage esophagectomy after definitive chemoradiotherapy treatment has traditionally been recognized as a feasible option, but due to the associated unfavorable morbidity and mortality profile, this indication has been limited. Methods: The experience of 27 cases of salvage esophagectomy were summarized in this VIDEO. The thoracic field performed in the prone position and abdominal field performed laparoscopically. Lessons learned concerning improvement of safety and lymphadenectomy are particularly shown Results: The cases of thoracic and abdominal robotic esophagectomy summarized in this VIDEO were squamous cell mid third esophageal carcinoma post definitive chemo- radiotherapy. It this video, we particularly show the relationship to left broncqueal side and the effects of scars in mediastinum after the high dose of radiotherapy. Discussion: Salvage esophagectomy is feasible, but it still needs an intensive care during surgery to avoid secondary lesions, such as air way tree, vascular and pleural injuries. Disclosure All authors have declared no conflicts of interest.

Description One of the most frequent complication after esophagectomy is the anastomotic leakage, which is a determiming factor of morbidity and mortality after surgical treatment. The best location for the esophagogastric anastomosis (cervical or intra-thoracic) has been topic of discussion for many years, and surgical aspects as resected margins, recurrent nerve trauma and mainly the vascularization of the anastomosis. In this video we performed a cervical gastroplasty anastomosis (McKeown), side-to-side, stapled (linear stapler) with a thin gastric tube conduit, and after that we aimed to determine the feasibility and usefulness of indocyanine green (ICG) fluorescence imaging to evaluate the gastric conduit perfusion during an esophagectomy. After pulling up the gastric conduit trhought the mediastinum and after performing the cervical anastomosis, 5 mg of ICG was in jected as a bolus and visual assessment of the blood supply of the gastric conduit was seen. This patient was a 63 years old, male, with adenocarcinoma of esophago-gastric junction (Siewert II) underwent to neoadjuvant quimiotherapy (FOLFOX regimen) and submitted after 3 cycles to esophagectomy (thoracoscopy and laparoscopy). No fistula was found in post operative follow-up, and either complications. Disclosure All authors have declared no conflicts of interest.

Background Minimally invasive esophagectomy remains with high morbidity and mortality rates. The transhiatal technique has less surgical time, lower morbidity and an acceptable oncological surgical control for patients with adenocarcinoma of the esophagogastric junction (AGEJ), unfortunaly still infrequent by laparoscopy. The aim of this study is to present indications, technical aspects and results of the totally laparoscopic transhiatal esophagectomy (TLTE) comparing to open access (OA) Methods This study retrospectively reviewed esophageal cancer patients that were admitted at an oncology referral center between 2011 to 2016. The studied population was composed of 128 AEGJ, all of them characterized as Siewert I and II classification. Demographic, pathological and clinical characteristics were analyzed and compared to clinical stage and overall survival at 60 months, between TLTE and OA. Influence of prognostic variables was assessed by Cox regression. Results The mean age was 63,4 ys (55–80ys), 85,4% were male. The selection of this group of patients was related to good clinical condition, however most of T2-T3 tumors. 90 patients were submitted to OA and 38 to TLTE (p-value for Log-Rank 0.11). Average follow-up was 39.8 months. By univariate analysis, curative intention resection was related to only 22% of patients in 5 ys. By univariate Cox regression, only degree of cellular differentiation was related to poor clinical stage in TLTE (p-value = 0.05). Weight loss (kg), BMI variation (kg/m²) and percentage of weight loss from initial symptoms to the diagnosis of esophageal carcinoma are factors that predict indicate the TLTE. Considering only patients submitted to curative intent surgery, more than 21 node resection could reach a statistically significant improvement in survival rate by univariate analysis, but there were no difference between both groups.There was no mortality and morbidity rate about 7%. Comparing TLTE to OA there were no difference in survival and morbidity and mortality. Conclusion This is a preliminary study about low rate related to both access (TLTE and OA) in patients with AEGJ) with T2-T3 tumors, with low morbidity and no mortality series. TLTE is a safe and feasible alternative to the open approach, with decrease short-term morbidity with comparable oncological outcomes. Disclosure All authors have declared no conflicts of interest.

Organizations are struggling to move and manage their IT Services and/or IT-enabled Services to the Cloud, slowing the adoption of Cloud services. In our research we intend to help organizations adopt Cloud services and demystify fears and concerns. In order to accomplish this, we propose a method based on the Outsourcing Lifecycle and the continuous approach of the Capability Maturity Model Integrated (CMMI) models, resulting in a Cloud Maturity Model. The model allows organizations to know which processes need to be performed, and how they should be improved when moving and managing services in the Cloud. To evaluate the Cloud Maturity Model we performed a set of twelve semi-structured interviews with seven Cloud clients and five suppliers. Although some changes were suggested, the interviews allowed us to conclude that the model was accepted by the interviewees.