Search

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.

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.

Botulinum toxin is already in use to treat abdominal wall giant hernia. The concept is to reduce pressure e create new space in the abdominal compartiment after the surgey. We show a case that a similar aproach was used to treat giant hiatal hernia. Methods We used botulinum toxin 4 weeks prior the surgery to increase de abdominal compartment. it was checked in a ct scan. Results The surgey was performed with a hiatoplasty, fundoplication and a gastropexy. Conclusion The use of botulinum seens to be a new stragy for selected cases. Video https://www.dropbox.com/s/td7fr3a6buejqnd/Bianchi%20ET%20botox.wmv?dl=0.

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.

Diverticula of the thoracic esophagus are uncommon disorders and its most appropriate treatment continues unclear. The majority of these diverticula are results of underlying esophageal motility disorders, but some cases are results of periesophageal inflammation. The patients can be asymptomatic, or present dysphagia, regurgitation, aspirated pneumonia, retrosternal pain and weight loss. The barium esophagogram is considered the best study to show and evaluate these cases. Esophageal manometry allow study the esophageal motility abnormality. Methods Patients with small and asymptomatic diverticula could not require any treatment. Patients with symptomatic or big diverticula should be submitted a diverticulectomy and often with an esophageal myotomy. However the necessity, the esophageal extension and local of the myotomy are still unclear. We describe a case of a 70 yo woman with a intrathoracic esophageal diverticulum. She presented progressive dysphagia to solids in the last two years, associated to regurgitation, retrosternal pain, nausea and weight loss of 10 kilograms. She has no history of aspirated pneumonia. Results The upper GI endoscopy showed the diverticulum in middle esophagus (25 cm from superior dental arch) and the size in barium esophagogram was 6,5 x 4,8 cm. The high resolution esophageal manometry was normal and the patient had no tuberculosis history. She was submitted a thoracoscopic diverticulectomy with extend myotomy (intrathoracic and abdominal) and Dor’s fundoplication. She was able to resume a liquid diet by day 3, after a normal barium esophagogram, and was discharged at the 4 post-operative day. After 9 months the patient remains asymptomatic. Conclusion In our experience, the diverticulectomy associated with an extend myotomy bring excellent results at the esophageal function, allowing an adequate emptying of the esophagus, avoiding severe complications as mediastinitis or esophageal leakage even in patients without severe motility disorder. References 1. Altorki N K, Sunagawa M, Skinner D B. Thoracic esophageal diverticula. Why is operation necessary? J Thorac Cardiovasc Surg 1993 Feb; 105(2): 260–4. 2. Rice T W, Baker M E. Midthoracic esophageal diverticula. Semin Thorac Cardiovasc Surg 1999 Oct; 11(4): 352–7.

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.

Gastro-esophageal reflux disease (GERD) patients have a higher prevalence of airway symptoms, such as chronic cough, wheezing, and hoarseness. The therapeutic management of patients with these symptoms is controversial. Therefore, this study aims to perform a systematic review and meta-analysis evaluating the efficacy of anti-reflux surgery for controlling respiratory symptoms related to GERD. Methods A systematic review and meta-analysis was performed. Extraction of the data concerning proportions of participants who were not free of respiratory symptoms related to GERD (cough, wheezing, hoarseness) or not substantially improved at follow-ups (failure to cure) was performed. Results Of the screened articles, 61 were included for meta-analysis, with a cumulative sample size of 3,869 patients. Of all the included patients, after anti-reflux surgery, the general symptoms improvement was 80% (95% CI 75.2–84%). The numbers needed to harm (NNH) and the numbers needed to treat (NNT) were 15.21 and 1.23, respectively. Of the included patients, 83.4% (95% CI 78.3–87.5%) patients reported improvement in cough symptoms after surgery. For the wheezing symptom, 71.5% (95% CI 62.9–78.8%) reported improvement after surgery. Moreover, surgery presented better results in improving respiratory symptoms than medical therapy (risk difference: -0.46; 95% CI -0.77, −0.16). Conclusion Physicians should strongly consider surgical anti-reflux procedures for controlling respiratory symptoms in GERD patients after proper patient selection. Anti-reflux surgery has shown high efficacy in improving respiratory symptoms related to GERD, even when compared to medical therapy.

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.

Gastric tube fistula is a rare event, but very feared, as it invariably progresses with associated mediastinitis and can be fatal. We present a case in which this fistula occurred together with all diagnostic investigation of etiology and treatment, in addition to a brief review of this complication. Methods A 45-year-old patient underwent minimaly invasive esophagectomy due to end-stage achalasia. After 6 days, she presented acute multivisceral migration to the chest and needed to reintervation by open surgery and hiatoplasty. The patient evolved with outflow of bile through the chest drain. Conservative treatment was attempted. However, after 4 days, she underwent thoracotomy and suture of the orifice, and a nasal tube was maintained to drain the gastric tube. There was no suture dehiscence and in control a seriogram evidenced pyloric stenosis. After 2 months, she was submitted to GPOEM with improvement of gastric emptying and normal return to feeding. Results The risk factors for gastric tube fistula are the same as those for cervical or intrathoracic anastomosis fistula after esophagectomy. Some authors attribute the vascularization of the stomach and malnutrition. However, as shown in this case, impairment of gastric emptying is an important factor to increased pressure and consequent fistula. The patient experienced acute migration through the hiatus, which obstructed the tube for a few hours. And after the defect was corrected, he maintained an increased pressure due to pyloric achalasia, which was initially treated by depressurizing the tube by nasogastric tube and then GPOEM. Conclusion Gastric tube fistula can be avoided when we can establish a good gastric tube emptying condition.

Background Abnormal gastroesophageal acid reflux (GEaR) is often found in laryngeal diseases and tracheal stenosis. The study focuses on the prevalence of GEaR and the impact of anti-reflux surgery in the outcome of post-intubation tracheal stenosis Methods Prospective non-randomized study of patients with post-intubation tracheal stenosis. Inclusion criteria: adult with subglottic or recurrent tracheal stenosis. Exclusion criteria: previous gastroesophageal surgery. Patients were submitted to esophageal manometry and pH study. Patients were divided in 3 groups: one with pH study negative, one with pH study positive receiving treatment with proton pump inhibitor and one with pH study positive submitted to Nissen fundoplication. Follow-up was 24 months. Outcome was considered satisfactory when airway stenosis could be successfully managed by resection, no need for dilatation or definitive decannulation. In order to match the 3 groups, it was used a propensity score match (PSM) and them they were compared. Statistical significance was assumed for P Results Prevalence of GEaR was assessed in 175 patients. Abnormal pH study was found in 74 (42%) with a predominance of supine reflux. Typical GEaR symptoms were found in only 21%. Abnormal manometry was found in 37%, and hypotonic lower sphincter was the most frequent finding. Of the 124 patients who met the inclusion criteria, pH study was normal in 72 and abnormal in 52 (32 underwent clinical treatment and 20 nissen fundoplication). There were no peri-operative complications. After PSM, patients with abnormal pH study submitted to fundoplication had a higher chance of a satisfactory outcome of the stenosis compared to those treated with Omeprazole (OR 5.31; CI 2.41–11.07; P = 0.03) which was similar to those without GEaR (OR 1; CI 0.47–2.11; P = 0.99). Patients without GeAR had a higher chance of resolution of the tracheal stenosis compared to the patients treated with Omeprazole (OR 3.54; CI 2.02–6.19; P = 0.02). Conclusion Asymptomatic GEaR is a frequent finding in tracheal stenosis. Nissen fundoplication was safe and effective in selected patients with tracheal stenosis and GEaR. Control of the airway stenosis was superior after fundoplication if compared to medical treatment of GEaR. A larger prospective randomized multicenter trial is needed to confirm these findings Disclosure All authors have declared no conflicts of interest.

Achalasia of the cardia is associated with an increased risk of esophageal carcinoma. The real burden of achalasia at the malignancy genesis is still a controversial issue. Therefore, there are no generally accepted recommendations on follow-up evaluation for achalasia patients. This study aims to estimate the risk of esophageal adenocarcinoma and squamous cell carcinoma in achalasia patients. We searched for association between carcinoma and esophageal achalasia in databases up to January 2017 to perform a systematic review and meta-analysis. A total of 1,046 studies were identified from search strategy, of which 40 were selected for meta-analysis. A cumulative number of 11,978 esophageal achalasia patients were evaluated. The incidence of squamous cell carcinoma was 312.4 (StDev 429.16) cases per 100,000 patient-years at risk. The incidence of adenocarcinoma was 21.23 (StDev 31.6) cases per 100,000 patient-years at risk. The prevalence for esophageal carcinoma was 28 carcinoma cases in 1,000 esophageal achalasia patients (CI 95% 2, 39). The prevalence for squamous cell carcinoma was 26 cases in 1,000 achalasia patients (CI 95% 18, 39) and for adenocarcinoma was 4 cases in 1,000 achalasia patients (CI 95% 3, 6).The absolute risk increase for squamous cell carcinoma was 308.1 and for adenocarcinoma was 18.03 cases per 100,000 patients per year. To the best of our knowledge, this is the first meta-analysis estimating the burden of achalasia as an esophageal cancer risk factor. The high increased risk rate for cancer in achalasia patients points to a strict endoscopic surveillance for these patients. Also, the increased risk for developing adenocarcinoma in achalasia patients suggests fundoplication after myotomy, to avoid esophageal reflux and Barret esophagus, a known risk factor for adenocarcinoma.

Dysplasia and esophageal adenocarcinoma may arise in patients with Barrett's esophagus after fundoplication esophageal pH monitoring showing no acid in esophagus. This suggests the need to develop methodology to evaluate the occurrence of ultra-distal reflux (1cm above the LES). The objective of the study was to compare acid exposition in three different levels: 5cm above the upper border of the LES, 1cm above the LES and in the intrasphincteric region. Eleven patients with Barrett's esophagus after Nissen fundoplication with no clinical, endoscopic and radiologic evidence of reflux were selected. Four-channel pH monitoring took place: channel A, 5cm above the upper border of the LES; channel B, 1cm above the LES; channel C, intrasphincteric; channel D, intragastric. The results of channels A, B and C were compared. There was significant increase in number of reflux episodes and a higher fraction of time with pH

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.

Achalasia surgical treatment alters the esophagogastric junction anatomy (cardiomyotomy plus fundoplication or esophagectomy and gastric pull-up), thus favoring a certain degree of gastroesophageal reflux. Gastric secretory and hormonal functioning is not completely known in chagasic patients. The aim of this study was to evaluate the gastric secretory and hormonal response in patients with end-stage chagasic achalasia compared with normal subjects. Gastric secretion and hormonal response were assessed by estimation of gastric acid secretion (GAS) in basal condition and after pentagastrin stimulation, basal serum gastrin, and serum pepsinogen (SP) in basal condition and after betazole hydrochloride (Histalog; Eli Lilly and Company, Indianapolis, IN, USA) stimulation in 27 patients with chagasic achalasia. The results were then compared with those of 24 normal subjects. In the chagasic group, the mean basal and stimulated GAS were significantly lower than in the control group (basal: 1.277 vs. 3.13, P = 0.002; stimulated: 15.9 vs. 35.8, P = 0.0001). Chagasic patients' SG levels showed a significantly higher basal value than the control group (83.3 vs. 36.8, P = 0.0001). There was a significant increase of SP after stimulation compared with the basal levels in both chagasic and control groups. Although the chagasic patients' SP values were higher than the controls, this difference was not statistically significant, either in basal and stimulated conditions (basal: 122.0 vs. 108.9, stimulated 120 min: 177.1 vs. 158.9). In patients with chronic Chagas' disease (ChD), although autonomic denervation does not suppress the strength of the gastric mucosal cells' secretory response to stimulation, it reduces GAS (parietal cell) without, however, affecting SP production (chief cells). On the other hand, the gastrin-producing cells have continuously been stimulated by low GAS.

INTRODUÇÃO: O câncer de esôfago apresenta-se como uma das neoplasias mais freqüentes e letais. O acometimento linfático aparece como principal fator individual de pior prognóstico, sendo a esofagectomia com linfadenectomia extensa ainda seu tratamento de escolha. Ressecções mais extensas através da toracotomia estão associadas com maior sobrevida, mas apresentam altas taxas de morbimortalidade. O conceito de micrometástases pode nos trazer avaliação mais acurada do estadiamento dos tumores operados, com detecção através de imunoistoquímica ou reação em cadeia de polimerase de metástases não diagnosticadas pelos métodos convencionais. MÉTODOS: Realizou-se revisão bibliográfica de artigos científicos publicados e disponíveis no PubMed, através do site www.pubmed.gov. cruzando-se os descritores neoplasias esofágicas, biologia molecular, estadiamento de neoplasias, linfonodo sentinela, metástase linfática. REVISÃO DA LITERATURA: O conceito do linfonodo sentinela, onde se pesquisa durante a cirurgia os possíveis primeiros sítios de metástases, direcionando desta maneira a rota da ressecção linfática no intuito de permitir ressecções completas não necessariamente extensas, possibilita diminuir a morbimortalidade e restringir as indicações de procedimentos muitas vezes super-dimensionados que podem não trazer benefício aos pacientes. CONCLUSÃO: O estadiamento preciso através da procura de micrometástase e o tratamento mais regrado pelo método do linfonodo sentinela, podem trazer novas perspectivas no tratamento do câncer de esôfago, principalmente em casos de tumores precoces.

O refluxo do conteúdo duodenal através do piloro para o estômago é um evento fisiológico, que ocorre predominantemente à noite e no período pós-prandial; e raramente causa sintomas e doenças primárias. Entretanto, quando excessivo, pode ser patogênico, associando-se a complicações como gastrite, úlcera gástrica, carcinoma gástrico, síndromedispéptica e doença do refluxo gastro-esofágico (DRGE). A DRGE é altamente prevalente e incidente, representando a principal doença dentro das afecções gastroenterológicas. A fisiopatologia de suas complicações, como o esôfago de Barrett, é amplamente estudada e cada vez mais, modificações no epitélio esofágico são atribuídas ao refluxo duodeno-gastroesofágico(RDGE), principalmente após o advento de métodos diagnósticos específicos para o RDGE, como a espectrofotometria de bilirrubina (BilitecR). Até então, os métodos de diagnósticos se apresentavam com pouca sensibilidade e pouca especificidade, porém, com a bilimetria iniciaram-se grandes estudos, e ao mesmo tempo surgiram muitas controvérsias. Paralelamente, estudos experimentais relacionam cada vez mais a presença de excessivo RDGE com o desenvolvimento de esôfago de Barrett e adenocarcinoma de esôfago. Este trabalho discute as principais controvérsias desses estudos, avaliando os principais métodos de diagnóstico para o RDGE destacando suas vantagens, desvantagens, sensibilidade e especificidade. Discutiremos a real importância do RDGE na patogênese do esôfago de Barrette suas complicações.

BACKGROUND: Association between esophageal achalasia/ gastroesophageal reflux disease (GERD) and cholelithiasis is not clear. Epidemiological data are controversial due to different methodologies applied, the regional differences and the number of patients involved. Results of concomitant cholecistectomy associated to surgical treatment of both diseases regarding safety is poorly understood. AIM: To analyze the prevalence of cholelithiasis in patients with esophageal achalasia and gastroesophageal reflux submitted to cardiomyotomy or fundoplication. Also, to evaluate the safety of concomitant cholecistectomy. METHODS: Retrospective analysis of 1410 patients operated from 2000 to 2013. They were divided into two groups: patients with GERD submitted to laparocopic hiatoplasty plus Nissen fundoplication and patients with esophageal achalasia to laparoscopic cardiomyotomy plus partial fundoplication. It was collected epidemiological data, specific diagnosis and subgroups, the presence or absence of gallstones, surgical procedure, operative and clinical complications and mortality. All groups/subgroups were compared. RESULTS: From 1,229 patients with GERD or esophageal achalasia, submitted to laparoscopic cardiomyotomy or fundoplication, 138 (11.43%) had cholelitiasis, occurring more in females (2.38:1) with mean age of 50,27 years old. In 604 patients with GERD, 79 (13,08%) had cholelitiasis. Lower prevalence occurred in Barrett's esophagus patients 7/105 (6.67%) (p=0.037). In 625 with esophageal achalasia, 59 (9.44%) had cholelitiasis, with no difference between chagasic and idiopathic forms (p=0.677). Complications of patients with or without cholecystectomy were similar in fundoplication and cardiomyotomy (p=0.78 and p=1.00).There was no mortality or complications related to cholecystectomy in this series. CONCLUSIONS: Prevalence of cholelithiasis was higher in patients submitted to fundoplication (GERD). Patients with chagasic or idiopatic forms of achalasia had the same prevalence of cholelithiasis. Gallstones occurred more in GERD patients without Barrett's esophagus. Simultaneous laparoscopic cholecystectomy was proved safe. RACIONAL: São controversas as relações entre megaesôfago e doença do refluxo gastroesofágico (DRGE) com colelitíase, especialmente a forma mais adequada de conduzir pacientes com ambas. Dados epidemiológicos são díspares devido às diversas metodologias aplicadas, às diferenças regionais e à quantidade de pacientes envolvidos. OBJETIVO: Estudar a prevalência de colelitíase em pacientes submetidos às operações de refluxo gastroesofágico e megaesôfago (chagásicos ou não) e a segurança da colecistectomia estar associada. MÉTODO: Análise retrospectiva de 1410 pacientes operados entre 2000 e 2013. Eles foram divididos em dois grupos: os com DRGE e operados por hiatoplastia/fundoplicatura a Nissen laparoscópicas e os com acalásia por cardiomiotomia e fundoplicatura parcial laparoscópicas. Foram coletados dados epidemiológicos, diagnóstico, a presença ou não de litiase biliar, tratamento cirúrgico efetuado, complicações clínicas ou cirúrgicas e mortalidade. Todos os grupos e subgrupos foram comparados. RESULTADOS: Foram estudados 1229 pacientes portadores de megaesôfago e/ou DRGE, operados por fundoplicatura com hiatoplastia, nos casos de DRGE, e cardiomiectomia com fundoplicatura, nos casos de megaesôfago, no período de 2000 a 2013, verificando-se presença de colelítiase ou colecistectomia prévia. A colelítiase ocorreu mais no sexo feminino (2,38:1) e na faixa etária entre os 50 e 70 anos. A prevalência global foi de 11,43%; 13,08% na DRGE, menor nos portadores de esôfago de Barrett (6,67%) sendo a diferença significativa (p=0,037); e 9,44% no megaesôfago, não havendo diferença significativa entre os chagásicos e os idiopáticos (p=0,677). Não houve mortalidade ou complicações relacionadas à colecistectomia nesta série. CONCLUSÕES: A prevalência de colelitíase é maior nos pacientes com DRGE do que nos com megaesôfago. Não há diferenças na prevalência de colelitíase nos pacientes com megaesôfago chagásico e não chagásico. É mais frequente litíase biliar nos pacientes sem esôfago de Barrett em relação portadores. A colecistectomia videolaparoscópica simultânea se mostrou-se segura.

Woman with 53-years-old diagnosed with congenital esophageal atresia, underwent to several surgical procedures in childhood, the latest was a cervical retrosternal esophagocoloplasty at 11 years old. After 42 years she was evolved with cervical dysphagia, and an initial diagnosis of stenosis of the esophagocolic anastomosis was performed, treated with endoscopic dilation without improvement. Later, biopsies were performed in the area of stenosis in proximal colonic segment (Figure 1) and polypectomy of sessile polyp of 10 mm, 5 cm distal to the stenosis (Figure 2). The pathological assessment showed tubular-villous intramucosal adenocarcinoma at the resected polyp and the area of stenosis was a invasive adenocarcinoma in colonic mucosa. Colonoscopy of remained colon was normal. Staging performed with CT scan showed an eccentric wall thickening of proximal colon transposed with luminal reduction target of left innominate vein; densification of mediastinal fat plane adjacent and regional lymph nodes up to 1.9 cm.

RACIONAL: Displasia e adenocarcinoma esofágico surge em pacientes com esôfago de Barrett submetidos a tratamento cirúrgico (fundoplicatura) com pHmetria esofágica sem evidência de acidez, o que sugere existir refluxo distal ao cateter de pHmetria convencional. OBJETIVO: Desenvolver metodologia para avaliar refluxo ultra-distal (1 cm acima da borda superior de esfíncter inferior do esôfago). MÉTODO: Foram selecionados 11 pacientes com esôfago de Barrett previamente submetidos à fundoplicatura à Nissen, sem sintomas de refluxo, com endoscopia e estudo contrastado de esôfago sem sinais de recidiva. Foi realizada manometria esofágica para avaliar a localização e a extensão do esfíncter esofágico inferior (EIE). Realizou-se então pHmetria esofágica com quatro canais: canal A a 5 cm acima da borda superior do EIE; canal B a 1 cm acima; canal C intraesfincteriano; canal D intragástrico. Avaliou-se o escore de DeMeester no canal A. Comparou-se o número de episódios de refluxo ácido, o número de episódios de refluxo prolongado e a fração de tempo com pH

O esofago de Barrett e definido como a substituicao do epitelio escamoso do esofago distal por epitelio colunar. A metaplasia intestinal no esofago de Barrett e considerada por muitos como o principal fator de risco para o desenvolvimento do adenocarcinoma. Embora ja descrito, o adenocarcinoma do tipo difuso e o esofago de Barrett sem metaplasia intestinal, sao raros e pouco estudados. OBJETIVO E METODO: O presente estudo objetivou o calculo da prevalencia do adenocarcinoma no esofago de Barrett, assim como a analise macroscopica e microscopica detalhada de treze pacientes operados no periodo de 1990 a 2002, com realizacao de estudo imunohistoquimico do p53 e Ki67, correlacionando o tipo de tumor com o epitelio adjacente a este. RESULTADOS: Obtivemos uma prevalencia de 5,7% de adenocarcinoma em pacientes internados para tratamento cirurgico de esofago de Barrett . Encontraram-se tumores relativamente grandes, com media de 4,67 ± 2,28 cm, e sempre em esofago de Barrett longo, com media de 7,71 ± 1,5 cm. Observou-se tendencia de os tumores se localizarem proximos a transicao escamo-colunar. O estudo histologico mostrou dois pacientes (15,4%) que apresentavam esofago de Barrett adjacente ao tumor do tipo juncional sem presenca de metaplasia intestinal. Classificaram-se os tumores segundo a classificacao japonesa de Nakamura (23% de padrao diferenciado ou intestinal e 77% de padrao indiferenciado ou gastico) e pela classificacao de Lauren (61% intestinais e 39% difusos). A diferenca decorre da migracao dos tumores microtubulares e foveolares do padrao gastrico para o tipo intestinal de Lauren. O estudo do Ki67 foi fortemente positivo em todos os pacientes, mostrando o alto indice de proliferacao celular no epitelio colunar e no tumor. O p53 mostrou-se negativo em 66,7% dos pacientes no epitelio colunar e 41,7% no tumor, nao mostrando correlacao entre os dois materiais. CONCLUSAO: O adenocarcinoma se desenvolve sobre o esofago de Barrett a partir do epitelio colunar misto, intestinal, bem como do juncional, apresentando padrao tanto gastrico como intestinal; portanto tumores podem se desenvolver em epitelio colunar sem metaplasia intestinal o qual tambem deve ser seguido, principalmente quando for extenso.

Symptomatic gastroesophageal reflux disease (GERD) and Barrett's mucosa are risk factors for esophageal adenocarcinoma (ADC). The aim of this study was to analyze the anthropometric features and prevalence of GERD in patients with ADC compared with patients with squamous cell carcinoma (SCC) and control subjects. A total of 262 patients with ADC and 302 with SCC were enrolled consecutively. A control group of 262 individuals, sex and age matched to the ADC group, and an additional group of 138 patients with GERD confirmed by 24-h pH monitoring were used for comparison. The prevalence of symptomatic GERD was 32.4% in the subgroup of patients with Barrett's ADC (male-female=6.4:1; mean age=62 years) vs. 8% in those with gastric cardia carcinoma (P0.01), 3% in the SCC group (P0.01), and 10% in the control group (P0.01). ADC patients, controls and refluxers had similar body mass index (BMI) that was significantly higher than in the SCC group (P0.05). Whether surveillance endoscopy is indicated in men over 50 years with a long-lasting history of GERD and a BMI25 remains to be determined.