Acalasia y su relación con el cáncer esofágico / Esophageal acalasia and its relationship with esophageal cancer

Resumen La acalasia es un trastorno motor primario de la musculatura lisa esofágica que se caracteriza por disfagia, pseudorregurgitación y baja de peso. El tratamiento puede ser endoscópico o quirúrgico. Sólo se conocen los resultados a largo plazo de la cirugía, mientras que los endoscópicos tienen aún un seguimiento muy corto y no permiten sacar conclusiones valederas. La acalasia es una lesión que tiene una probabilidad significativamente mayor de desarrollar un cáncer esofágico, ya sea de tipo epidermoide, por inflamación crónica y retención de comida en el esófago, o un adenocarcinoma, secundario a reflujo gastroesofágico, que aparece posterior a cualquier tratamiento. Las publicaciones muestran que alrededor de 3% a 4% de los pacientes presentan a largo plazo, sobre 10 a 15 años postratamiento, el desarrollo de un cáncer avanzado del esófago. Se concluye que es indispensable un seguimiento clínico y endoscópico en forma rutinaria a estos pacientes.

Achalasia is a primary motor disorder of the esophageal smooth muscle characterized by dysphagia, pseudoregurgitation, and weight loss. Treatment can be endoscopic or surgical. The long-term results are only known from surgery, while endoscopic results still have a very short follow-up and do not allow us to draw valid conclusions. Achalasia is a lesión that has a significantly higher probability of developing esophageal cancer, whether of the epidermoid type, due to chronic inflammation and food retention in the esophagus, or an adenocarcinoma, secondary to gastroesophageal reflux, which appears after any treatment. Publications show that about 3 to 4% of patients present in time, about 10 to 15 years after treatment, the development of advanced cancer of the esophagus. It is concluded that clinical and endoscopic follow-up is essential in these patients on a routine basis.

Complications After endoscopic balloon dilatation of esophageal strictures in children. Experience from a tertiary center in Shiraz - Iran (Nemazee Teaching Hospital) / Complicaciones posteriores a dilatación endoscópica con balón en niños con estenosis esofágica. Experiencia de un centro de referencia en Shiraz - Iran (Nemazee Teaching Hospital)

Background: Esophageal stricture is one of the most important complication of the caustic ingestion. Objective: The aim of this study was to evaluate complications of balloon dilatation among children with esophageal stenosis. Material and methods: In this retrospective study 82 children were included. Children who underwent balloon dilatation for esophageal stenosis were included in our study. Duration of study was 14 year starting from 2001. Mean age of the cases was 3.95±0.4 year (Min: 15 days, Max: 14 year). Chart review and telephone calling were the methods of data collection. Data was analyzed using SPSS. Results: In this study, 47% of the patients were male and 53% of the cases were female. Caustic ingestion (33.7%) was the most common etiology for the esophageal stricture. Vomiting (87.8%) was the most common presenting symptom. Among our cases, 76.8% had no compliant after esophageal dilatation. Chest pain was the most common compliant after esophageal dilatation. Response rate was similar among boys and girls. Toddler age had the best treatment response after esophageal dilatation. Conclusion: Among our cases, 76.8% had no post procedural compliant after esophageal dilatation. Esophageal perforation was seen in 4.9% of the cases. Chest pain was the most common post dilatation complication.

Antecedentes: La estenosis esofágica es una de las más importantes complicaciones de la ingesta de caústicos. Objetivo: El objetivo del estudio fue evaluar las complicaciones de la dilatación endoscópica con balón en niños con estenosis esofágica. Material y métodos: En este estudio retrospectivo se incluyeron 82 niños. Se incluyeron todos los niños que se sometieron a una dilatación endoscópica con balón por estenosis esofágica. La duración del estudio fue 14 años iniciando en el año 2001. La edad media de los pacientes fue 3,95 +/- 0,4 años (Min. 15 días, Máx. 14 años). La recolección de datos se realizó revisando las historias clínicas y con llamadas telefónicas. Los datos se analizaron con el Sistema SPSS. Resultados: En este estudio, 47% de los casos fueron varones y 53% fueron mujeres. La ingesta de caústicos fue la causa más frecuente de estenosis esofágica (33,7%). El síntoma más común fueron los vómitos (87,8%). Entre nuestros casos, 76,8% no presentaron molestias luego de la dilatación esofágica. El dolor torácico fue la molestia más común luego de la dilatación esofágica. La tasa de respuesta al tratamiento fue similar entre hombres y mujeres. Los niños pequeños tuvieron la mejor respuesta al tratamiento luego de la dilatación esofágica. Conclusiones: Entre nuestros casos, 76,8% no presentaron molestias luego de la dilatación esofágica. La perforación esofágica se presentó en 4,9% de los casos. El dolor torácico fue la complicación más común posterior a la dilatación.

Late evaluation of dysphagia after heller esophageal myotomy with dor fundoplication for achalasia / Avaliação tardia da disfagia após cardiomiotomia à heller com fundoplicatura a dor para acalásia

ABSTRACT Background: All available treatments for achalasia are palliative and aimed to eliminate the flow resistance caused by a hypertensive lower esophageal sphincter. Aim: To analyze the positive and negative prognostic factors in the improvement of dysphagia and to evaluate quality of life in patients undergoing surgery to treat esophageal achalasia by comparing findings before, immediately after, and in long follow-up. Methods: A total of 84 patients who underwent surgery for achalasia between 2001 and 2014 were retrospectively studied. The evaluation protocol with dysphagia scores compared preoperative, immediate (up to three months) postoperative and late (over one year) postoperative scores to estimate quality of life. Results: The surgical procedure was Heller-Dor in 100% of cases, with 84 cases performed laparoscopically. The percent reduction in pre- and immediate postoperative lower esophageal sphincter pressurewas 60.35% in the success group and 32.49% in the failure group. Regarding the late postoperative period, the mean percent decrease was 60.15% in the success group and 31.4% in the failure group. The mean overall drop in dysphagia score between the pre- and immediate postoperative periods was 7.33 points, which represents a decrease of 81.17%. Conclusions: Reduction greater than 60% percent in lower esophageal sphincter pressurebetween the pre- and postoperative periods suggests that this metric is a predictor of good prognosis for surgical response. Surgical treatment was able to have a good affect in quality of life and drastically changed dysphagia over time.

RESUMO Racional: Todos os tratamentos disponíveis para a acalásia são paliativos e visam eliminar a resistência ao fluxo causada por esfíncter esofágico inferior hipertenso. Objetivos: Avaliar os fatores prognósticos positivos e negativos na melhora da disfagia e avaliar a qualidade de vida em pacientes submetidos à cirurgia para tratar a acalásia esofágica, comparando os achados antes, imediatamente após e tardiamente à operação. Métodos : Foram estudados retrospectivamente 84 pacientes submetidos à operação de acalásia entre 2001 e 2014. O protocolo de avaliação com escores de disfagia comparou os escores pré-operatórios, do pós-operatório imediato (até três meses) e pontuação pós-operatória tardia (acima de um ano) para estimar a qualidade de vida. Resultados: O procedimento cirúrgico foi Heller-Dor em 100% dos casos, com 84 casos laparoscópicos. A redução percentual na pressão do esfíncter esofágico inferior pré e pós-operatório imediato foi de 60,35% no grupo de sucesso e de 32,49% no grupo de falha. Em relação ao período pós-operatório tardio, a redução percentual média foi de 60,15% no grupo de sucesso e 31,4% no grupo de falência. A queda média do escore de disfagia entre os períodos pré e pós-operatório imediato foi de 7,33 pontos, o que representa diminuição de 81,17%. Conclusões: A redução de mais de 60% da pressão do esfíncter esofágico inferior entre os períodos pré e pós-operatório sugere que ela é preditora de bom prognóstico cirúrgico. O tratamento cirúrgico foi capaz de contribuir na qualidade de vida e alterar em muito a disfagia em longo prazo.

Prevalence of gallstones in 1,229 patients submitted to surgical laparoscopic treatment of GERD and esophageal achalasia: associated cholecystectomy was a safe procedure / Prevalência de colelitíase em 1.229 pacientes submetidos ao tratamento cirúrgico laparoscópico de DRGE e megaesôfago: a colecistectomia associada mostra-se segura

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 ...

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 ...

Primary achalasia with pneumoesophagus and bronchopleural fistula causing right lung collapse and bronchiectasis.

A 35-year-old male non-smoker, presented with a history of recurrent respiratory tract infections, associated with intermittent haemoptysis and haematemesis since childhood. His vital parameters were normal with pulse oximetry saturation of 97% on room air. On physical examination, clubbing was observed. Chest auscultation revealed tubular type of bronchial breath sounds over the right hemithorax.

Achalasia and thyroid disease: possible autoimmune connection? / Acalasia e doença tireoidiana: uma conexão autoimune possível?

Many cases have been published showing a co-existence of autoimmune thyroid diseases (AITDs) and other autoimmune diseases. About a quarter of patients with achalasia have a concurrent thyroid disease, most commonly associated with hypothyroidism. Although relatively rare, the association of achalasia and hyperthyroidism requires attention. The physiopathology of Grave's Disease (GD) involves B- and T-mediator lymphocytes, which have an affinity for known thyroid antigens: thyroglobulin, thyroid-peroxidase, and thyrotrophin receptor. Currently, however, the real physiopathogenesis of achalasia continues to be unknown. Some important findings are suggestive of an autoimmune mechanism: significant infiltration of the myoenteric plexus by monocytes, presence of the class II-Human Histocompatibility Complex DQwl antigen and antibodies to myoenteric neurons. The present case reports a patient who, despite testing negative for Chagas' disease, had achalasia, progressed to developing significant wasting and worsening of his quality of life, was later diagnosed with hyperthyroidism. After endoscopic esophageal dilatation and radioiodine ablation of the thyroid gland, there was great improvement in the patient clinical condition. Arq Bras Endocrinol Metab. 2012;56(9):677-82.

Muitos casos têm sido publicados mostrando uma coexistência entre as doenças autoimunes da tireoide (DAIT) e outras doenças autoimunes. Cerca de um quarto dos pacientes com acalasia têm doenças da tireoide concomitantemente, sendo a mais comum a associação com hipotireoidismo. Apesar de ser relativamente rara, a associação da acalasia e hipertireoidismo requer atenção. A fisiopatologia da doença de Graves (DG) envolve os linfócitos B e T-mediados, os quais têm afinidade pelos antígenos da tireoide: tireoglobulina, tireoperoxidase e receptor de tireotrofina. Atualmente, a real fisiopatogenia da acalasia continua desconhecida. No entanto, alguns importantes achados em análise são sugestivos de mecanismo autoimune: infiltração significativa do plexo mioentérico pelos monócitos, presença do antígeno-DQwl do Complexo Humano de Histocompatibilidade classe II e presença de anticorpos contra neurônios mioentéricos. Este presente caso aborda um paciente que, apesar de testes negativos para doença de Chagas, tem acalasia que progrediu para o desenvolvimento de significativa perda ponderal e piora da sua qualidade de vida, posteriormente, diagnosticado com hipertireoidismo. Após dilatação endoscópica esofágica e ablação da glândula tireoide com radioiodo, houve grande melhora na condição clínica do paciente. Arq Bras Endocrinol Metab. 2012;56(9):677-82.

Evaluation of anatomical and functional changes esophageal stump of patients with advanced megaesophagus submitted to subtotal laparoscopic esophagectomy / Avaliação das alterações anatômicas e funcionais do coto esofágico de pacientes portadores de megaesôfago avançado submetidos à esofagectomia subtotal laparoscópica

PURPOSE: Evaluate anatomical and functional changes of the esophageal stump and gastric fundus of patients with advanced megaesophagus, submitted to laparoscopic subtotal esophagectomy. METHODS: Twenty patients with advanced megaesophagus, previously submitted to a videolaparoscopic subtotal esophagectomy , were evaluated. Were conducted: radiological evaluation of the stump esophagus with transposed stomach, electromanometric, endoscopic examination and histopathology of the esophageal stump and gastric fundus, without making gastric tube or pyloroplasty. RESULTS: It was observed that the average height and pressure of the anastomosis, in the electromanometric evaluation, were 23.45cm (±1.84cm) and 7.55mmHg (±5.65mmHg). In patients with megaesophagus III, the pressure of the anastomosis was 10.91mmHg (±6.33mmHg), and pressure from the UES, 31.89mmHg (±14.64mm Hg), were significantly higher than those in grade IV. The pathological evaluation detected mild esophagitis in 35% of patients, moderate in 20% and acanthosis glicogenica in 45%. The examination of the gastric fundus showed that 50% of patients were infected with Helicobacter pylori. Chronic gastritis occurred in 95% of the patients. CONCLUSIONS: The laparoscopic esophagectomy shown to be effective in the treatment of advanced achalasia. The cervical level anastomosis protects the esophageal stump from the aggression resulted from gastric reflux after the esophagectomy.

OBJETIVO: Avaliar as alterações anatômicas e funcionais do coto esofágico e fundo gástrico de pacientes com megaesôfago avançado, submetidos à esofagectomia subtotal laparoscópica. MÉTODOS: Vinte pacientes com megaesôfago avançado, previamente submetidos à esofagectomia subtotal videolaparoscópica, foram avaliados. Foram realizados: avaliação radiológica do coto esofágico com o estômago transposto, eletromanometria endoscopia e exame histopatológico do coto esofágico e fundo gástrico,sem fazer tubo gástrico ou piloroplastia. RESULTADOS: Observou-se que a altura média e pressão da anastomose, na avaliação eletromanométrica, foram: 23,45cm (± 1,84cm) e 7,55mmHg (± 5,65mmHg), Em pacientes com megaesôfago III, a pressão da anastomose foi de 10,91mmHg (± 6,33mmHg), e a pressão do ESE, 31,89mmHg (±14,64mmHg) foram significativamente mais elevados do que aqueles em grau IV. A avaliação patológica detectou esofagite leve em 35% dos pacientes, moderada em 20% e acantose glicogênica em 45%. O exame do fundo gástrico mostrou que 50% dos pacientes foram infectados com Helicobacter pylori. Gastrite crônica ocorreu em 95% dos pacientes. CONCLUSÕES: A esofagectomia laparoscópica mostrou-se eficaz no tratamento de acalasia avançada. A anastomose em nível cervical tem um papel protetor para o coto esofágico ao evitar a agressão resultante de refluxo gástrico após a esofagectomia.

Allgrove (AAA) Syndrome.

This is the first reported case of Allgrove Syndrome in Paediatric Department, S. C. B. MCH in a six years old male child who presented with convulsion and altered sensorium. He had no tears since birth, dysphagia with regurgitation of food and later developed skin hyperpigmentation. Allgrove syndrome is a rare autosomal recessive syndrome characterized by progressive loss of cholinergic function resulting in alacrimia, achalasia cardia, addison’s disease and autonomic neuropathy. Early diagnosis will lead to significant reduction of morbidity and mortality which is usually due to unrecognized adrenal crisis.

Prevalence of cholelithiasis in patients with chagasic megaesophagus / Prevalência de colelitíase em pacientes com megaesôfago chagásico

INTRODUCTION: The prevalence of cholelithiasis in the general population ranges from 9 to 18 percent. This prevalence is known to be higher in the presence of parasympathetic nerve damage of the biliary tract either due to surgery (vagotomy) or neuronal destruction (Chagas disease). The objective of this study was to evaluate the association of cholelithiasis and chagasic or idiopathic megaesophagus. METHODS: The ultrasound scans of 152 patients with megaesophagus submitted to cardiomyotomy and subtotal esophagectomy surgery were evaluated. The presence of cholelithiasis was compared between chagasic and idiopathic esophagopathy and ultrasound and clinical findings were correlated with age, sex and race. RESULTS: A total of 152 cases of megaesophagus, including 137 with chagasic megaesophagus and 15 with idiopathic megaesophagus, were analyzed. The mean age was 56.7 years (45-67) in the 137 patients with chagasic megaesophagus and 35.6 years (27-44) in the 15 cases of idiopathic megaesophagus, with a significant difference between the two groups (p < 0.0001). The group with chagasic megaesophagus consisted of 59 (43 percent) women and 78 (56.9 percent) men, while the group with idiopathic megaesophagus consisted of 8 (53.3 percent) women and 7 (46.6 percent) men, showing no significant difference between the groups. Of the 137 patients with confirmed chagasic megaesophagus, 39 (28.4 percent) presented cholelithiasis versus one case (6.6 percent) in the 15 patients with idiopathic megaesophagus. CONCLUSIONS: The prevalence of cholelithiasis is high in patients with chagasic megaesophagus and preoperative ultrasound should be performed routinely in these patients in order to treat both conditions during the same surgical procedure.

INTRODUÇÃO: A prevalência de colelitíase observada na população em geral varia de 9 a 18 por cento. Sabe-se que a prevalência de colelitíase é elevada quando existe lesão nervosa parassimpática das vias biliares, causada tanto por procedimentos cirúrgicos (vagotomias),quanto por destruição neuronal, como observado na forma digestiva da doença de Chagas. Propusemo-nos verificar a associação entre megaesôfago de etiologia chagásica e a presença de colelitíase. MÉTODOS: Avaliou-se prospectivamente o exame ultrassonográfico de 152 pacientes portadores de megaesôfago submetidos à cirurgia de cardiomiotomia e esofagectomia subtotal. Analisou-se comparativamente a esofagopatia chagásica e a idiopática com a presença de colelitíase, correlacionando os dados ultrassonográficos com os achados clínicos, idade, sexo e raça. RESULTADOS: Foram analisados 152 casos de megaesôfago, sendo 137 de etiologia chagásica e 15 idiopáticos. Entre os chagásicos, a idade média foi de 56,7 anos (45-67); e nos idiopáticos, a média de idade foi de 35,6 anos (27-44), verificando-se diferença significativa (p < 0,0001) em relação à média de idade. Dos 137 chagásicos, 78 (56,9 por cento) eram do sexo masculino; entre os 15 idiopáticos, 7 (46,6 por cento) eram do sexo masculino. A comparação entre os grupos em relação ao gênero não mostrou diferença significativa. Dentre os 137 chagásicos detectou-se 39 (28,4 por cento) casos de colelitíase e, dentre os 15 casos de megaesôfago idiopático, constatou-se colelitíase em apenas um (6,6 por cento). CONCLUSÕES: Conclui-se que portadores de megaesôfago chagásico possuem alta prevalência de colelitíase, e que a ultrassonografia deve ser realizada rotineiramente no pré-operatório, a fim de tratar ambas as afecções no mesmo ato cirúrgico.

Achalasia in the elderly patient: a comparative study / Acalásia no idoso: um estudo comparativo

CONTEXT: Achalasia is a primary esophageal motor disorder secondary to the degeneration of ganglion cells of the inhibitory intramural myenteric plexus. It affects both sexes similarly and has two peaks of incidence, one in the 3rd to 4th decades of life and the other after 60 years of age. The effect of age on esophageal motility of patients with achalasia is not well known. Studies have shown that healthy older people, when compared to the young, have: a) a lower number of ganglion cells in the intramural myenteric plexus; b) a reduced normal relaxation of the lower esophageal sphincter; and c) a reduced esophageal peristalsis. Thus, as both age and achalasia can produce comparable degenerative changes in the intramural myenteric plexus, it is possible that advanced age could be an important factor in enhancing the clinical and manometric abnormalities commonly found in patients with achalasia. OBJECTIVES: To compare the clinical, radiological and manometric findings in young as compared to elderly (>60 years old) achalasia patients. METHODS: A retrospective study of a group of patients with untreated achalasia separated into young and elderly patients. Demographic, clinical, serology for Chagas' disease, radiological and manometric data were compared between these groups. The level of significance was P<0.05. RESULTS: The study included 105 patients, 52 young (25 M/27 F, mean age 40 years old) and 53 elderly (21 M/32 F, mean age 70 years old). The elderly group had a higher prevalence of Chagas' disease (P = 0.004) and a lower pressure of the lower esophageal sphincter [26.4 mm Hg vs 31.9 mm Hg] P = 0.001, a difference that persisted when analyzed only elderly and young patients with idiopathic achalasia. Younger patients had a higher prevalence of heartburn (P = 0.001) and chest pain (P = 0.012) than the elderly. CONCLUSION: Elderly patients with achalasia had a lower esophageal sphincter pressure than the young, even when we excluded patients with Chagas' disease but, as a group, they were less symptomatic.

CONTEXTO: Acalásia é um distúrbio motor primário do esôfago, secundário à degeneração das células ganglionares do plexo mioentérico inibitório intramural. Afeta ambos os sexos da mesma forma e tem dois picos de incidência: um na 3ª e 4ª décadas de vida e outro após os 60 anos de idade. O efeito da idade na motilidade esofagiana em pacientes com acalásia não é bem conhecido. Estudos têm demonstrado que os idosos saudáveis quando comparados aos jovens apresentam: a) menor número de células ganglionares no plexo mioentérico intramural, b) redução no número de relaxamentos normais do esfíncter esofagiano inferior, e c) redução do peristaltismo esofagiano. Assim, se tanto a idade quanto a acalásia podem acarretar alterações degenerativas do plexo mioentérico intramural, é possível que a idade avançada possa ser fator importante no aumento das anormalidades clínicas e manométricas, comumente encontradas nos pacientes com acalásia. OBJETIVOS: Comparar os achados clínicos, radiológicos e manométricos dos pacientes jovens com acalásia (<60 anos), em relação aos pacientes idosos (>60 anos). MÉTODOS: Foi realizado estudo retrospectivo de um grupo de pacientes com acalásia não tratada, separando-os em pacientes jovens e idosos. Dados demográficos, clínicos, de sorologia para doença de Chagas, radiológicos e manométricos foram comparados entre os dois grupos. O nível de significância considerado foi P<0.05. RESULTADOS: O estudo incluiu 105 pacientes, 52 jovens (25 H/27 M, média de idade de 40 anos) e 53 idosos (21 H, 32 M, média de idade de 70 anos). O grupo idoso apresentou elevada prevalência de doença de Chagas (P = 0.004) e menor pressão do esfíncter esofagiano inferior [26,4 mm Hg x 31,9 mm Hg) P = 0.001, diferença esta que persistiu mesmo quando se analisou apenas os pacientes idosos e jovens com acalásia idiopática. Os pacientes jovens apresentaram elevada prevalência de pirose (P = 0.001) e dor torácica (P = 0.012), quando comparados aos idosos. CONCLUSÃO: Os pacientes idosos com acalásia apresentaram pressão do esfíncter esofagiano inferior mais baixa do que os jovens, mesmo quando excluídos com acalásia chagásica, entretanto como grupo eles foram menos sintomáticos.

Results of the surgical treatment of non-advanced megaesophagus using Heller-Pinotti's surgery: Laparotomy vs. Laparoscopy

INTRODUCTION: Dysphagia is the important symptom in achalasia, and surgery is the most common treatment. The Heller-Pinotti technique is the method preferred by Brazilian surgeons. For many years, this technique was performed by laparotomy, and now the laparoscopic method has been introduced. The objective was to evaluate the immediate and long-term results of patients submitted to surgery by either laparotomy or laparoscopy. MATERIALS AND METHODS: A total of 67 patients submitted to surgery between 1994 and 2001 with at least 5 years of follow-up were evaluated retrospectively and divided into two groups: laparotomy (41 patients) and laparoscopy (26 patients). Chagas was the etiology in 76.12 percent of cases. Dysphagia was evaluated according to the classification defined by Saeed et al. RESULTS: There were no cases of conversion to open surgery. The mean duration of hospitalization was 3.32 days for laparotomy and 2.54 days for laparoscopy (p<0.05). An improvement in dysphagia occurred with both groups reporting good or excellent results (laparotomy: 73.17 percent and laparoscopy: 73.08 percent). Mean duration of follow-up was 8 years. CONCLUSIONS: There was no difference between the two groups with respect to relief from dysphagia, thereby confirming the safety and effectiveness of the Heller-Pinotti technique, which can be performed by laparotomy or laparoscopy, depending on the surgeon's experience.

Robótica: tecnología de avanzada en cirugía abdominal / Robotic: advanced technology in abdominal surgery

Describir la utilidad y demostrar la seguridad del Robot Da Vinci®, en la cirugía general abdominal. Estudio realizado en el Hospital de Clínicas Caracas, Caracas-Venezuela. Estudio descriptivo, retrospectivo realizado entre junio 2006 y julio 2010, en pacientes que ameritaron cirugía abdominal y que fueron operados con el robot Da Vinci® (Intuitive Surgical, Sunnyvale, CA). Se incluyeron 61 pacientes, predominando el género femenino (82%), en edades comprendidas entre 21-80 años, que acudieron a la consulta y/o emergencia y que, accedieron a realizarse el abordaje laparoscópico asistido por el robot Da Vinci®. Entre las patologías mayormente operadas se encuentran: litiasis vesicular o colecistitis aguda y la hernia hiatal con reflujo gastroesofágico. Tuvimos 8% de complicaciones (entre mayores y menores). La cirugía abdominal laparoscópica asistida por robot, recupera la visión y la habilidad perdida con la cirugía laparoscópica convencional. En nuestra serie observamos no sólo los beneficios que el robot le brinda al cirujano, sino los que esta técnica le ofrece al paciente. La cirugía robótica ha probado ser de gran utilidad y segura.

To demostrate the safety and describe the benefits in abdominal general surgery. Study performed at the Hospital de Clínicas Caracas, Caracas-Venezuela. Retrospective study performed between 2006-2010 in patients who underwent abdominal surgery with the Da Vinci® robot (Intuitive Surgical, Sunnyvale, CA). Sixty one patients were included, 82% females, between 21-80 years. Elective and/or emergency abdominal surgery was performed after they agree to have the laparoscopic approach assited by the Da Vinci® robot. Gastroesophageal reflux disease with or withouth hiatal hernia, cholecistectomy were the frecuent pathologies. Minor and/or major complications where 8%. Laparoscopic approach with the Da Vinci® System, regains the tridimentional visión and the intuitive hand movements lost with the conventional laparoscopic approach. In our series robotic surgery is safe and brings benefits to the surgeon and the patients.

Acalasia en obesos mórbidos: reporte de casos / Achalasia in morbidly obese patients: report of two cases

Achalasia is uncommon in morbidly obese patients. We report two patients with both conditions. A 71 years old diabetic male with a body mass Índex (BMI) of 36 kg/m . He consulted for dysphagia and a manometry showed a lack of relaxation of the lower esophageal sphincter. He was subjected to unsuccessful pneumatic dilatations in two occasions. Finally the patient was subjected to a total gastrectomy and Roux en Y esophago-jejunal anastomosis. Eight months after surgery the patient reports slight dysphagia and lost 24 kg. A 66 years old male with a BMI of 44 kg/m² consulting for regurgitation. Manometry confirmed the diagnosis of achalasia. The patient was subjected to a esophagomyotomy, subtotal gastrectomy and Roux en Y gastro jejunal and jejuno-jejunal anastomosis. Two years after surgery the patient had a slight dysphagia and lost 20 kg.

La acalasia es un trastorno de la motilidad esofágica que tiende a producir baja de peso, siendo rara su presentación en obesos mórbidos. Existen pocos reportes de casos en la literatura. Se presentan 2 casos de pacientes con el diagnóstico de acalasia y obesidad mórbida, uno de ellos tratado con Gastrectomía total y el otro con Esofagomiotomía asociada a Bypass gástrico. Ambos pacientes evolucionaron en buenas condiciones. Finalmente se realiza un análisis de la literatura.

Miotomía de Heller con fundoplicatura de dor por laparoscopia para el tratamiento de la acalasia: resultado de 17 años de experiencia / Laparoscopic Heller myotomy with dor fundoplication for achalasia: result of 17 years experience

Exponer la experiencia en el manejo de la acalasia en el Servicio de Cirugía General del Centro Médico “Dr. Rafael Guerra Méndez”. Valencia-Venezuela. Estudio retrospectivo, descriptivo y analítico, basado en la revisión de los formatos de cirugía laparoscópica previamente diseñados para tal fin, de los pacientes ingresados entre el año 1992 y 2009, con el diagnóstico de acalasia. Se evaluaron las variables sexo, edad, síntomas, tiempo de evolución de los síntomas, tiempo quirúrgico y complicaciones. Los resultados se muestran en frecuencia absoluta y relativa. Se realizaron 27 procedimientos a predominio del sexo masculino (55.56%). El grupo de edad más frecuente fue la tercera y cuarta década (más del 70%). La sintomatología más frecuente fue disfagia, regurgitación y dolor torácico, presente en la mayoría de los casos. La distribución del tiempo quirúrgico promedio fue 158 minutos ± 32.35 minutos. Hubo 2 complicaciones intraoperatorias (7.4%), y complicaciones postoperatorias menores. No hubo mortalidad. Controles periódicos 3 pacientes (11.11%) necesitaron dilataciones postoperatorias pos disfagia. El abordaje laparoscópico para la acalasia es un método seguro y confiable para el tratamiento de la misma. Se necesita mayor seguimiento para evaluación de la técnica.

To expose the experience in the management of achalasia at General Surgery Service of Centro Médico “Dr. Rafael Guerra Mendez”. Valencia-Venezuela. This is a retrospective and analytical study based on the review of laparoscopic surgical records previously designed, of patients admitted between 1992 and 2009 with diagnosis of achafasia. We evaluated gender, age, symptoms and its evolution, surgical time and complications. The results are presented as absolute and relative frequency measurements. There were performed 27 procedures predominantely on male patients (55,56%). The age group more frequent affected was between 3rd and 4th decade (more than 70%). In most cases, symptomatology was dysphagia, regurgitation and thoracic pain, presented in 70% of patients, from 3 up to 9 years with this clinic. Average surgical time was 158 minutes ± 32,35. There were 2 intraoperative complications (7,4%), and minor postoperative complications. There was not mortality. Three patients (11,11%) need postoperative dilatations for dysphagia. Laparoscopic approach is a sale and reliable method in the treatment of achalasia. A longer follow-up is needed to evaluate this technique.

Autoimmune thyrotoxicosis with achalasia cardia.

We report a case of autoimmune thyrotoxocosis in an 11-year-old boy with achalasia cardia. This case explores autoimmunity as an etiological factor for achalasia based on several autoimmune conditions that have been associated with it.

Achalasia as a potential predisposing factor for lung allograft rejection

Microaspiration secondary to gastroesophageal reflux has been postulated to be a predisposing factor for development of bronchiolitis obliterans syndrome after lung transplantation. Esophageal manometry and ambulatory pH monitoring have been suggested as a screening test in patients with end-stage lung disease. We report a single lung transplant patient who developed allograft rejection presumed to be due to underlying achalasia as the patient's clinical status and lung function improved markedly following the treatment of achalasia

Alacasia en niños: análisis de casos relacionados con corrección laparoscópica por miotomía de Heller, Clínica Fundación Valle De Lili / Alacasia in children: analysis of cases related to alteration laparoscópica for miotomía of Heller Clínica Fundación Valle De Lili

CASO Nº 1 Paciente de 11 años de edad, sexo femenino, 24 kg de peso. Procedencia: Palmira, Valle. 8 meses de evolución de su enfermedad consistente en vómito, disfagia progresiva de sólidos a líquidos, regurgitación, asociado a desnutrición acentuada, motivo por el cual consulta al servicio de pediatría. Como antecedentes médicos de importancia, asma hasta los tres años de edad y estreñimiento. Al examen físico, muy comprometida nutricionalmente, afebril, hemodinámicamente estable, cardiopulmonar normal, abdomen blando depresible sin dolor a la palpación, peristaltismo normal Se realizaron los siguientes estudios: endoscopia de vías digestivas altas, esofagograma, manometría esofágica, gammagrafía esofágica, compatibles con acalasia esofágica Es llevada a cirugía el 16 de diciembre de 2004, realizándosele miotomía de Heller y fundoplicatura por laparoscopia. Paciente ASA II Monitoría básica: EKG, PANI, SO2, ETCO2 Acceso venoso en miembro superior izquierdo Inducción anestésica: fentanil, 50 mg; pentotal, 100 mg; B. pancuronio, 2 mg. Intubación: tubo orotraqueal Nº 5.5 Mantenimiento anestésico: isorane Ventilación mecánica: modo volumen control, VC: 235 cc, FR: 20 por minuto, PIM: 30 Reversión de relajación: prostigmine, 1 mg; atropina, 0,4 mg Tiempo quirúrgico: 1 hora 45 minutos Tiempo anestésico: 2 horas 15 minutos Se presentó vómito durante la inducción sin evidencia de broncoaspiración, pero quedando en broncoespasmo que cede en 30 minutos. Es trasladada a sala de recuperación posanestésica despierta y extubada Primer día posoperatorio sin complicaciones, recibiendo y tolerando vía oral progresivamente de líquida a sólida sin problemas. Se retira sonda nasogástrica y al día siguiente se da de alta con analgesia, metoclopramida y ranitidina. Controles posteriores por consulta externa, evidenciándose una evolución adecuada, ganancia de peso y adecuada tolerancia a la vía oral.