Evaluation of urgent esophagectomy in esophageal perforation

Background

Esophageal trauma is considered one of the most severe lesions of the digestive tract. There is still much controversy in choosing the best treatment for cases of esophageal perforation since that decision involves many variables. The readiness of medical care, the patient''s clinical status, the local conditions of the perforated segment, and the severity of the associated injuries must be considered for the most adequate therapeutic choice.

Aim

To demonstrate and to analyze the results of urgent esophagectomy in a series of patients with esophageal perforation.

Methods

A retrospective study of 31 patients with confirmed esophageal perforation. Most injuries were due to endoscopic dilatation of benign esophageal disorders, which had evolved with stenosis. The diagnosis of perforation was based on clinical parameters, laboratory tests, and endoscopic images. ‪The main surgical technique used was transmediastinal esophagectomy followed by reconstruction of the digestive tract in a second surgical procedure. Patients were evaluated for the development of systemic and local complications, especially for the dehiscence or stricture of the anastomosis of the cervical esophagus with either the stomach or the transposed colon.

Results

Early postoperative evaluation showed a survival rate of 77.1% in relation to the proposed surgery, and 45% of these patients presented no further complications. The other patients had one or more complications, being pulmonary infection and anastomotic fistula the most frequent. The seven patients (22.9%) who underwent esophageal resection 48 hours after the diagnosis died of sepsis. At medium and long-term assessments, most patients reported a good quality of life and full satisfaction regarding the surgery outcomes.

Conclusions

Despite the morbidity, emergency esophagectomy has its validity, especially in well indicated cases of esophageal perforation subsequent to endoscopic dilation for benign strictures.     

Impact of minimally invasive surgery in the treatment of esophageal cancer

Background

Surgical treatment of esophageal cancer is associated to a high morbidity and mortality rate. The open transthoracic or transhiatal esophagectomy are considerably invasive procedures and have been associated to high rates of complications and operative mortality. In this way, minimally invasive esophageal surgery has been suggested as an alternative to the classic procedures because would produce improvement in clinical longterm postoperative outcomes.

Aim

To assess survival, mortality and morbidity results of esophagectomy due to esophageal cancer submitted to minimally invasive techniques and compare them to results published in international literature.

Method

An observational, prospective study. Between 2003 and 2012, 69 patients were submitted to a minimally invasive esophagectomy due to cancer. It was recorded postoperative morbidity and mortality according to the Clavien-Dindo classification. The survival rate was analyzed with the Kaplan-Meier method. The number of lymph nodes obtained during the lymph node dissection, as an index of the quality of the surgical technique, was analysed.

Results

63.7% of patients had minor complications (type I-II Clavien Dindo), while nine (13%) required surgical re-exploration. The most common postoperative complication corresponded to leak of the cervical anastomosis seen in 44 (63.7%) patients but without clinical repercusion, only two of them required reoperation. The mortality rate was 4.34%, and reoperation was necessary in nine (13%) cases. The average survival time was 22.59±25.38 months, with the probability of a 3-year survival rate estimated at 30%. The number of resected lymph nodes was 17.17±9.62.

Conclusion

Minimally invasive techniques have lower morbidity and mortality rate, very satisfactory lymphnodes resection and similar long term outcomes in term of quality of life and survival compared to results observed after open surgery.     

Surgical treatment of achalasia: A retrospective comparative study

A retrospective study carried out on 74 patients among 101 consecutive cases of achalasia of the esophagus operated from 1967 to 1989 is reported. On 21 patients observed between 1967 and 1975, a standard transabdominal Heller cardiomyotomy was performed (group A). From 1976 to 1989, the treatment of choice was a Heller myotomy associated with a modified Dor's fundoplication. In 80 consecutive cases (group B) the extension of myotomy was regulated by intraoperative monitoring of lower esophageal sphincter pressure. A 5-year follow-up with questionnaires, physical examination, and barium swallows was carried out on 16 patients in group A and on 58 patients in group B. In 75.6% of the cases (56 patients) follow-up examinations included esophageal manometry and 24-hour esophageal pH monitoring. Recurrence of dysphagia was recognized in 3 cases in group A (18.7%) and in 2 cases in group B (3.4%) (P=0.053); postoperative gastroesophageal reflux, measured as a percentage of total reflux time, showed a significantly lower mean value in group B than in group A (1.8% vs. 4.1%. P<0.01). This study suggests that an anti-reflux procedure lowers post-operative gastroesophageal reflux after Heller myotomy. Due to the low incidence of postoperative reflux and the negligible recurrence of dysphagia, Heller myotomy associated with a modified Dor's fundoplication may represent the surgical treatment of choice for achalasia of the esophagus.     

Cricopharyngeal myotomy for the treatment of cricopharyngeal achalasia

Three cases of cricopharyngeal achalasia are being presented. The preoperative diagnosis was established by a contrast swallow. Cricopharyngeal myotomy was performed in all patients. One child died in the postoperative period because of respiratory failure secondary to aspiration pneumonitis, whereas in the other two, symptoms were relieved, and they remain asymptomatic on follow-up.     

Surgical treatment of idiopathic megarectum in constipated children

BackgroundChronic constipation in children is associated with primary megarectum. This study investigated outcomes of surgical treatment of idiopathic megarectum in children.MethodsThis retrospective comparative study included 52 children with idiopathic megarectum (mean age, 9.4 ± 1.7 years) treated from 2007 to 2016. Patients were divided into 2 groups. Group 1 included 23 patients who underwent a Soave pull-through operation. Group 2 included 29 children who underwent laparoscopic low anterior resection with endorectal stapled anastomosis using laparoscopic ultrasound guidance. All patients had clinical and laboratory evaluations with anorectal manometry, colonoscopy and contrast enema studies.ResultsSix patients (26.1%) in Group 1 and one (3.5%) in Group 2 experienced anastomosis leakage requiring colostomy (χ² = 3.867, P = 0.049). In long-term follow-up, 3 children (13.1%) in Group 1 and 2 (6.9%) in Group 2 had ongoing constipation; this difference was not significant. Frequent loose stools with soiling were significantly more common in Group 1 (14 patients; 60.9%) than in Group 2 (4 patients; 13.8%) (χ² = 10.566, P = 0.001).ConclusionsOur experience shows that laparoscopic video-assisted low anterior resection of the colon with endorectal stapled anastomosis under laparoscopic ultrasound guidance to determine the level of colon resection is the better operation then Soave for children with idiopathic megarectum and chronic constipation. This approach provides good functional results and reduces complications.Type of studyTreatment study.Level of evidenceLevel III, retrospective comparative study.     

Prevalence of gallstones in 1,229 patients submitted to surgical laparoscopic treatment of GERD and esophageal achalasia: associated cholecystectomy was a safe procedure

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.     

腹腔镜治疗小儿贲门失弛缓症20例

目的：探讨腹腔镜治疗小儿贲门失弛缓症的临床安全性及可行性。方法回顾性分析2009年1月至2013年12月,新疆维吾尔自治区人民医院收治的20例贲门失弛缓症患儿临床资料,对患儿诊治过程中术前诊断、手术方式、恢复情况、术中术后并发症进行总结分析。结果腹腔镜治疗小儿贲门失弛缓症的20例患儿平均手术时间90 min,平均术中出血10 ml,术后观察1周,进食普食后未见有吞咽困难,未见有呕吐的情况。术后随访2-6个月,未见有复发,营养得到改善,生活质量提高,家属满意。结论腹腔镜治疗小儿贲门失弛缓症术中损伤小,并发症少,术后恢复好,安全,具有可行性,对改善患儿营养状况提高生活治疗具有重要意义。     

Surgical treatment of cardial achalasia

There was analyzed a 35-years experience of surgical treatment of 683 patients, suffering achalasia of cardia. Comparative analysis of different methods of operative interventions efficacy, including those, using laparoscopic access, was conducted. There was established, that esophagocardiomyotomy together with partial widening fundoplication guarantees good late results achievement in 96.6% of patients. Application of laparoscopic esophagocardiomyotomy and anterior widening fundoplication permits to secure all advantages of miniinvasive access and efficacy, comparable with such of the open access.     

介入治疗贲门失弛缓症

贲门失弛缓症是临床上较常见的食管良性狭窄性疾病,以往主要以外科手术治疗为主,介入放射学的开展为该病提供了一种新的治疗方法。我院自2000年以来采用球囊导管扩张术治疗18例贲门失弛缓症患者,取得一定的临床疗效,现报道如下。     

下咽及颈段食管癌的手术治疗

目的：探讨下咽及颈段食管癌的手术疗效及颈段食管重建的方法,方法：1980年至2000年6月对86例下咽及颈段食管鳞状细胞癌进行了外科治疗,下咽癌的切除率为97．4％（37／38例）,食管重建包括喉及肿瘤切除后食管与口底吻合4例,咽,喉及颈段食管切除后用颈阔肌皮瓣重建15例,游离空肠间插3例,全咽,全喉,全食管切除后用胃重建12例,3例未行喉切除者采用食管与咽部直接吻合,颈阔肌皮瓣及用胃重建食管各1例,颈段食管癌的切除率为91．7％（44／48例）,均采用非开胸食管拔脱后用胃重建食管,结果：术后发生并发症在胃重建组有57例（35％）,（包括1例术后死于心力衰竭）,游离空肠组1例（33．3％）,颈阔肌皮瓣重建组3例（18．8％）,随访6－108个月（平均57个月）,下咽癌的1,3,5年生存率分别为80．6％,60．0％和31．6％,颈段食管癌分别为70．7％,9．5％和0。结论：下咽及颈段食管癌的切除率甚高,但下咽癌的远期疗效明显优于颈段食管癌,咽,喉及颈段食管切除后采用颈阔肌皮瓣重建是一种安全,有效的手术方法,并发症少,远期效果优良。     

难治性特发性血小板减少型紫癜脾切除的临床分析

目的:探讨脾切除对难治性特发性血小板减少性紫癜的治疗效果及影响因素.方法:回顾15年中行脾切除术治疗难治性ITP患者62例的临床资料,分析年龄、性别、术前有无出血、术前对激素的反应、脾脏是否肿大、术后血小板峰值与脾切除疗效之间的关系.结果:62例中,显效34例,良效13例,进步10例,无效5例;有效率(显效+良效)为75.8％.性别和脾脏是否肿大与脾切除术疗效无关(均P＞0.05);有无出血症状、年龄、术后血小板峰值、骨髓巨核细胞数等因素分组间差异具有统计学意义(均P＜0.05);多因素分析表明,术前对激素的反应及术前血小板计数对脾切除疗效是主要的影响因素(均P＜0.05).结论:术前对激素的反应及术前血小板计数可作为脾切除术的疗效预测指标.     

Surgical management of tetralogy of fallot with idiopathic thrombocytopenic purpura

The association of cyanotic heart disease with Idiopathic Thrombocytopenic Purpura (ITP) may accentuate the hemorrhagic complications of cardiac surgery under cardiopulmonary bypass. A-5-year-old girl with Chronic Steroid Refractory Idiopathic Thrombocytopenic Purpura with Tetralogy of Fallot (TOF) underwent successful intracardiac repair under normothermic cardiopulmonary bypass and warm blood potassium cardioplegia. Presurgery she received immunoglobulins and perioperatively she was administered inj methylprednisolone, inj aprotinin, platelets and fresh frozen plasma.     

Surgical treatment of achalasia of pharyngoesophageal sphincter

Being a rather simple operation, cricoid-pharyngeal myotomy ensures restoration of deglutition in neurological patients. The article describes a method of the operation with plastics of the pharyngoesophageal junction. The operation was effective in 5 among 6 patients who had been subjected to it.     

Esophagocardioplasty with gastric patch in the treatment of achalasia

Result of operative treatment in 196 cases of achalasia was reviewed. The procedures employed include cardiolysis, Heller's extramucosal myotomy, Wendel's cardioplasty, Heyrovsky's esophagocardiostomy, with and without pyloroplasty, cardiac resection and esophagocardioplasty with gastric patch. Follow-up study on 166 cases revealed that the result was classified as good in 99 cases or 59.6 per cent and improved in 46 cases or 27.7 per cent. Overall satisfactory result was obtained in 87.3 per cent. When the result was broken down to groups following three classifications, i. e. according to X-ray, endoscopic and manometric findings, the interesting correlation emerged. Heller's myotomy and esophagocardioplasty with gastric patch gave best results in early stage of achalasia, while in later stage the latter procedure seems to be the operation of choice.     

Surgical treatment of stage IV cardial achalasia

An original method of surgical treatment of patients with stage IV cardial achalasia was developed. Seven patients aged 42 to 59 years underwent surgery according this method. Objective methods of examination and life quality study with GIQLI carried out 3 months to 5 years after surgery demonstrate satisfactory anatomic and functional results.     

低剂量利妥昔单抗治疗难治性特发性膜性肾病的临床疗效分析

目的 探讨低剂量利妥昔单抗(rituximab,RTX)治疗难治性特发性膜性肾病(idio-pathic membranous nephropathy,I N)的有效性及安全性.方法 回顾性收集2017年1月至2018年12月诊断的难治性IMN且抗磷脂酶A2受体(PLA2R)抗体阳性病例32例,接受低剂量RTX治疗方案...     

电视胸腔镜手术治疗特发性气胸38例临床分析

目的探讨电视胸腔镜手术治疗特发性气胸的优点、手术要点及疗效.方法对2000年11月至2005年10月收治的38例特发性气胸行胸腔镜手术治疗进行回顾性分析.结果手术时间平均45分钟,术后胸腔引流管平均引流量210ml,拔胸腔引流管时间平均为4.5天,术后住院时间平均为8天,全组治愈出院.随诊3个月至41个月,有1例复发,保守治疗后治愈.结论电视胸腔镜手术具有创伤小、康复快、住院时间短等优点,可作为本病的首选治疗方法.