Comparative study of two modes of gastroesophageal reflux measuring: conventional esophageal pH monitoring and wireless pH monitoring / Estudo comparativo de duas modalidades de mensuração do refluxo gastroesofágico: pHmetria esofágica convencional e pHmetria sem cateter

CONTEXT: Esophageal pH monitoring is considered to be the gold standard for the diagnosis of gastroesophageal acid reflux. However, this method is very troublesome and considerably limits the patient's routine activities. Wireless pH monitoring was developed to avoid these restrictions. OBJECTIVE: To compare the first 24 hours of the conventional and wireless pH monitoring, positioned 3 cm above the lower esophageal sphincter, in relation to: the occurrence of relevant technical failures, the ability to detect reflux and the ability to correlate the clinical symptoms to reflux. METHODS: Twenty-five patients referred for esophageal pH monitoring and with typical symptoms of gastroesophageal reflux disease were studied prospectively, underwent clinical interview, endoscopy, esophageal manometry and were submitted, with a simultaneous initial period, to 24-hour catheter pH monitoring and 48-hour wireless pH monitoring. RESULTS: Early capsule detachment occurred in one (4%) case and there were no technical failures with the catheter pH monitoring (P = 0.463). Percentages of reflux time (total, upright and supine) were higher with the wireless pH monitoring (P < 0.05). Pathological gastroesophageal reflux occurred in 16 (64%) patients submitted to catheter and in 19 (76%) to the capsule (P = 0.355). The symptom index was positive in 12 (48%) patients with catheter pH monitoring and in 13 (52%) with wireless pH monitoring (P = 0.777). CONCLUSIONS: 1) No significant differences were reported between the two methods of pH monitoring (capsule vs catheter), in regard to relevant technical failures; 2) Wireless pH monitoring detected higher percentages of reflux time than the conventional pH-metry; 3) The two methods of pH monitoring were comparable in diagnosis of pathological gastroesophageal reflux and comparable in correlating the clinical symptoms with the gastroesophageal reflux.

CONTEXTO: A pHmetria esofágica é considerada o melhor método diagnóstico do refluxo ácido gastroesofágico. Contudo, é bastante incômoda e restringe consideravelmente as atividades cotidianas do paciente. A pHmetria sem cateter foi desenvolvida para contornar tais limitações. OBJETIVO: Comparar as primeiras 24 horas das pHmetrias convencional e sem cateter, posicionadas a 3 cm acima do esfíncter inferior do esôfago, em relação à: ocorrência de falhas técnicas relevantes, capacidade de detecção do refluxo e capacidade de relacionar as queixas clínicas com o refluxo. MÉTODOS: Foram estudados, de modo prospectivo, 25 pacientes encaminhados para pHmetria esofágica, com sintomas típicos da doença do refluxo gastroesofágico, submetidos a entrevista clínica, endoscopia digestiva, manometria esofágica e realização, com período inicial simultâneo, de pHmetrias com cateter por 24 horas e com cápsula por 48 horas. RESULTADOS: Houve queda precoce da cápsula em um paciente (4%) e nenhuma falha técnica na pHmetria com cateter (P = 0,463). As percentagens de tempo de refluxo (total, ortostático e supino) foram mais elevadas na pHmetria sem cateter (P<0,05). Refluxo gastroesofágico patológico foi diagnosticado em 16 (64,0%) pacientes com o cateter e em 19 (76,0%) com a cápsula (P = 0,355). O índice de sintomas foi positivo em 12 (48%) pacientes na pHmetria com cateter e em 13 (52%) na pHmetria sem cateter (P = 0,777). CONCLUSÕES: 1) Não há diferença significante entre as duas modalidades de pHmetria (cápsula vs cateter), em relação à ocorrência de falhas técnicas relevantes durante o exame; 2) A pHmetria sem cateter detecta refluxo em percentagens superiores às detectadas pela pHmetria convencional; 3) Os dois métodos de pHmetria têm capacidades semelhantes de diagnóstico de refluxo gastroesofágico patológico e capacidades semelhantes de relacionar as queixas clínicas com o refluxo gastroesofágico.

Clinical evaluation of oropharyngeal dysphagia in Machado-Joseph disease / Avaliação clínica da disfagia orofaríngea na doença de Machado-Joseph

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

CONTEXTO: Na doença de Machado-Joseph, a má postura, a distonia e a neuropatia periférica predispõem à disfagia orofaríngea, mais comumente associada à distrofia muscular. OBJETIVO: Avaliar as características clínicas da disfagia orofaríngea em pacientes com doença de Machado-Joseph. MÉTODOS: Quarenta indivíduos participaram do estudo, incluindo 20 sem quaisquer queixas clínicas e 20 disfágicos com doença de Machado-Joseph do tipo clínico 1, grupos similares em termos de sexo, média de idade e função cognitiva. Foi verificada a história clínica de cada paciente e todos os indivíduos passaram por avaliação clínica da deglutição. Ao final, a disfagia dos enfermos com doença de Machado-Joseph foi classificada de acordo com a Escala de Severidade da Disfagia. RESULTADOS: A comparação entre disfágicos e controles não revelou muitas diferenças significativas quanto à avaliação clínica da fase oral da deglutição, visto que os pacientes demonstraram déficits apenas relacionados à protrusão, retração e tônus linguais. Entretanto, em relação à fase faríngea, várias alterações relevantes, ausentes nos controles, foram notadas nos pacientes, tais como estase faríngea à deglutição de líquidos e sólidos, acompanhada de tosse e/ou engasgo, assim como de penetração e/ou aspiração laringotraqueal. CONCLUSÕES: Disfagia orofaríngea faz parte da doença de Machado-Joseph desde as primeiras manifestações neurológicas. Há maior comprometimento da fase faríngea, em relação à fase oral da deglutição. A disfagia desses pacientes é classificada entre leve e moderada.

Endobronchial ultrasound application for diagnosis of tracheobronchial tree invasion by esophageal cancer

INTRODUCTION: Esophageal cancer staging has been performed through bronchoscopy, computerized tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS). Whereas CT and PET scan provide assessments of distant metastasis, bronchoscopy importantly diagnoses tracheobronchial involvement, complementing chest CT findings. EUS is the most accurate examination for T and N staging but is technically limited when tumoral stenoses cannot be traversed. Endobronchial ultrasound (EBUS) appears to present greater accuracy than EUS, CT, and bronchoscopy for assessing tracheobronchial wall involvement. EBUS has been recently associated with EUS for esophageal cancer staging in our unit. OBJECTIVE: To compare EBUS findings in esophageal cancer patients without evident signs of tracheobronchial invasion on conventional bronchoscopy with EUS and CT. METHODS: Fourteen patients with esophageal cancer underwent CT, conventional bronchoscopy, EUS, and EBUS for preoperative staging. All patients underwent EBUS and EUS with an Olympus® MH-908 echoendoscope at 7.5 MHz. Seven patients were eligible for the study according to the inclusion criteria. RESULTS: The echoendoscope could not traverse tumoral esophageal stenosis to perform EUS in two patients, and invasion was effectively diagnosed by EBUS. In 4 (57%) of 7 patients EBUS revealed additional information to staging. In the remaining 3 cases the invasion findings were the same under both EUS and EBUS. CONCLUSION: EBUS showed signs of tracheobronchial invasion not observed by conventional bronchoscopy, adding information to staging in most of the cases when compared with CT and EUS.

Surgical Treatment of Liver Metastasis from Colorectal Cancer: Hospital A.C. Camargo Experience

Introduction: Colorectal cancer is the fourth leading cause of malignancy in Brazil, as well as in the US. Hepatic metastasis, occur in up to 50 of patients during the course of the disease. To date, surgical resection is the standard treatment, and is associated with the best survival outcome. Identifying prognostic factors is important for better patient selection. Patients and Methods: Data of 70 patients submitted to hepatic resection of colorectal metastasis with curative intent between January 1999 and June 2005 were reviewed Clinical data and surgical pathology features of all patients were analyzed. Results: 76 procedures were performed in 70 patients, Global estimated survival was 51 in 5 years. Prognostic significantly variables were number of metastasis, bilaterality and preoperative CEA. Postoperative death occurred only in one patient, due to infectionand sepsis. Conclusion: Surgical resection is the best treatment for colorectal hepatic metastasis, though prognostic factors imply worst outcome, survival is better than non surgical treatment. In this series we identified objective prognostic factors which might help the physician to select the best moment of resection and add systemic treatments.

Pancreatectomia distal videolaparoscópica em pacientes com cistadenoma de pâncreas / Laparoscopic distal pancreatectomy for pancreatic cystadenomas

RACIONAL: O diagnóstico de tumores císticos do pâncreas vem aumentando nos últimos anos. Estes tumores acometem geralmente pacientes do sexo feminino e apresentam poucos sintomas. Sua remoção por videolaparoscopia está indicada em pacientes selecionadas, principalmente quando localizados na região distal do pâncreas. OBJETIVOS: É apresentada a experiência inicial de um grupo de cirurgiões na realização de pancreatectomia distal por videolaparoscopia em pacientes com cistadenoma pancreático. MATERIAL E MÉTODOS: Três pacientes do sexo feminino (idade média, 55 anos) foram submetidas a ressecção pancreática por videolaparoscopia entre setembro de 2001 e dezembro de 2003. RESULTADOS: A ressecção pancreática por videolaparoscopia foi realizada com sucesso nas três doentes. O tempo cirúrgico variou de 4 a 6 horas. O sangramento operatório foi mínimo em todos os casos. A aplicação do grampeador endoscópico foi difícil em uma paciente devido à espessura do pâncreas. As três pacientes evoluíram bem, recebendo alta entre o 2° e o 5° dia pós-operatório. Duas apresentaram fístula pancreática com resolução após tratamento conservador. CONCLUSÃO: A pancreatectomia laparoscópica é factível, pode trazer benefícios aos pacientes portadores de neoplasia cística da porção distal do pâncreas, com pouca dor pós-operatória, curto tempo de permanência hospitalar, baixo índice de complicações e melhor resultado estético.