Management of symptoms recurrence after myotomy for achalasia. a practical approach / Manejo da recidiva de sintomas após miotomia para acalasia. uma abordagem prática

ABSTRACT BACKGROUND: Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases. AIMS: This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy. METHODS: A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy. RESULTS: To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics. CONCLUSIONS: A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.

RESUMO RACIONAL: A acalasia é um distúrbio da motilidade esofágica e a miotomia é uma das técnicas de tratamento mais utilizadas. No entanto, a persistência ou recorrência dos sintomas ocorre em 9 a 20%. OBJETIVOS: Este estudo visa fornecer uma abordagem prática para o manejo da recorrência ou persistência dos sintomas de acalasia após miotomia. MÉTODOS: Foi realizada uma revisão crítica para reunir evidências para uma abordagem racional no manejo da recorrência ou persistência dos sintomas de acalasia após miotomia. RESULTADOS: Para o manejo adequado de um paciente com acalásia com sintomas significativos após miotomia, como disfagia, regurgitação, dor torácica e perda de peso, é necessário classificar os sintomas, estratificar a gravidade, realizar exames adequados e definir uma estratégia de tratamento. Uma investigação diagnóstica diferencial sistemática é essencial para cobrir as principais etiologias de recorrência ou persistência dos sintomas após a miotomia. A endoscopia digestiva alta e a radiografia digital dinâmica são os principais exames que podem ser aplicados para investigação. As opções de tratamento incluem dilatação endoscópica, POEM (miotomia endoscópica oral), remiotomia e esofagectomia, e a decisão deve ser baseada nas características individuais do paciente. CONCLUSÕES: Uma boa avaliação clínica e a utilização de exames adequados, juntamente com uma avaliação racional, são essenciais para o manejo da recorrência ou persistência dos sintomas após miotomia por acalasia.

MANAGEMENT OF SYMPTOMS RECURRENCE AFTER MYOTOMY FOR ACHALASIA. A PRACTICAL APPROACH.

BACKGROUND: Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases. AIMS: This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy. METHODS: A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy. RESULTS: To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics. CONCLUSIONS: A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.

Advanced Cancer-A Bad Consequence of a Missed Follow-Up after ESD in Barrett's Esophagus.

Barrett's esophagus(BE)is a precursor to adenocarcinoma of the esophagogastric transition. Thus, endoscopic surveillance is essential for the early diagnosis of dysplasia and neoplasm, allowing proper therapeutic. However, during the COVID-19 pandemic, surveillance frequently failed. We present a case of a male, caucasian, 65 years old, patient with early adenocarcinoma in BE. Submitted an endoscopic resection, but due to the COVID-19 pandemic patient lost the follow-up endoscopic exams. Returned with a T3N1 adenocarcinoma esophagus in resection area. The present report illustrates the consequences of the failure in follow-up after submucosal resection in COVID-19 pandemic context.

Effect of low-glucosinolate crambe meal in diet on lactational performance, efficiency of nutrient utilization, and hepatic function of crossbred Holstein × Zebu and Jersey cows.

Crambe meal (CM) is a potential dietary protein source for ruminant, but its effects in diets for lactating dairy cows remains unknown. We evaluated the effects of inclusion of the low-glucosinolates (GIs) CM (450 mg GIs/kg DM) in partial total mixed ration (pTMR) on performance, efficiency of nutrient utilization, and hepatic function of crossbred Holstein × Zebu and Jersey cows. Eight crossbred Holstein × Zebu cows and four Jersey cows were blocked by breed and days in milk, and randomly assigned in a replicated 4 × 4 Latin square design, and distributed in one of four isonitrogenous TMRs (130 g CP/kg DM): 0, 45, 90, and 135 g CM/kg DM pTMR. Crambe meal was included in pTMR replacing soybean meal (SBM) and ground corn grain (GCG). The pTMRs were offered ad libitum between 7:00 a.m. and 5:00 p.m. Cows were kept on pasture of Panicum maximum cv. Mombaça (90.4 g CP/kg DM) between 6:00 p.m. and 6:30 a.m. Pasture intake was measured from external and internal fecal excretion marker. Inclusion of CM did not affect (P ≤ 0.05) the DM intakes of pTMR and pasture, apparent total-tract digestibilities of organic matter, CP and NDF, ruminal outflow microbial protein, milk yield, milk composition, urinary N excretion, milk N efficiency, and level of plasm hepatic enzymes. The effects of CM inclusion in pTMR were independent of breed. Low-glucosinolates CM can be incorporated up to 135 g/kg DM in pTMR in replacement of SBM and GCG without affecting performance, efficiency of nutrient utilization, and hepatic function of crossbred Holstein × Zebu and Jersey cows.

Surgical management of esophageal stenosis due to ingestion of corrosive substances.

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

The SARS-CoV-2 receptor angiotensin-converting enzyme 2 (ACE2) in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: analysis of high-throughput genetic, epigenetic, and gene expression studies

Patients affected by Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) show specific epigenetic and gene expression signatures of the disease. However, it is unknown whether these signatures include abnormal levels of the human angiotensin-converting enzymes, ACE and ACE2, the latter being the main receptor described for the host-cell invasion by SARS-CoV-2. To investigate that, we first re-analyzed available case-control epigenome-wide association studies based on DNA methylation data, and case-control gene expression studies based on microarray data. From these published studies, we found an association between ME/CFS and 4 potentially hypomethylated probes located in the ACE locus. We also found another disease association with one hypomethylated probe located in the transcription start site of ACE2. The same disease associations were obtained for women but not for men after performing sex-specific analyses. In contrast, a meta-analysis of gene expression levels could not provide evidence for a differentially expression of ACE and ACE2 in affected patients when compared to healthy controls. In line with this negative finding, the analysis of a new data set on the gene expression of ACE and ACE2 in peripheral blood mononuclear cells did not find any differences between a female cohort of 37 patients and 34 age-matched healthy controls. Future studies should be conducted to extend this investigation to other potential receptors used by SARS-CoV-2. These studies will help researchers and clinicians to improve the understanding of the health risk imposed by this virus when infecting patients affected by this debilitating disease.

Machima itatiaia sp. nov.: a new species of lichen-mimic katydid (Orthoptera: Tettigoniidae: Phaneropterinae) from the Brazilian Atlantic Forest.

The Brazilian genus Machima Brunner von Wattenwyl, 1878 includes three valid species: M. paranensis Rehn, 1950 and M. scalprum Rehn, 1950 distributed on Southern and M. phyllacantha (Burmeister, 1838) from Northeastern Brazil. Herein we analyzed eleven male specimens of Machima from Parque Nacional de Itatiaia and propose a new species. Machima itatiaia sp. nov. is characterized by its main lobe of the cercus curving abruptly on apical two-thirds and accessory lobe as long as wide. The new species is the first record of the genus from Southeastern Brazil. Finally, we also present a key to species of Machima based on males.

Surgical treatment of Killian-Jamieson diverticulum: A case report and literature review.

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

Caetitus gen. nov.: a new genus of Neotropical Copiphorini (Tettigoniidae: Conocephalinae: Copiphorini) to include C. porteri (Bolivar, 1903).

Daedalellus porteri (Bolivar, 1903) was described based on a single broken female holotype collected in an undetermined locality in Brazil. This species is herein redescribed based on two males and one female collected in Caetité, Bahia State, Brazil, including its morphology of fastigium and male terminalia. Based on comparisons to other Daedalellus species and Neotropical Copiphorini genera, the new monotypic genus Caetitus gen. nov. is herein proposed. Caetitus porteri comb. nov. differs from species of Daedalellus and other related genera, such as Panacanthus, Copiphora, Borinquenula, and Lirometopum, mainly due to differences of the fastigium and male external terminalia.

Ontogenetic Variation in Biological Activities of Venoms from Hybrids between Bothrops erythromelas and Bothrops neuwiedi Snakes.

Lance-headed snakes are found in Central and South America, and they account for most snakebites in Brazil. The phylogeny of South American pitvipers has been reviewed, and the presence of natural and non-natural hybrids between different species of Bothrops snakes demonstrates that reproductive isolation of several species is still incomplete. The present study aimed to analyze the biological features, particularly the thrombin-like activity, of venoms from hybrids born in captivity, from the mating of a female Bothrops erythromelas and a male Bothrops neuwiedi, two species whose venoms are known to display ontogenetic variation. Proteolytic activity on azocoll and amidolytic activity on N-benzoyl-DL-arginine-p-nitroanilide hydrochloride (BAPNA) were lowest when hybrids were 3 months old, and increased over body growth, reaching values similar to those of the father when hybrids were 12 months old. The clotting activity on plasma diminished as hybrids grew; venoms from 3- and 6-months old hybrids showed low clotting activity on fibrinogen (i.e., thrombin-like activity), like the mother venom, and such activity was detected only when hybrids were older than 1 year of age. Altogether, these results point out that venom features in hybrid snakes are genetically controlled during the ontogenetic development. Despite the presence of the thrombin-like enzyme gene(s) in hybrid snakes, they are silenced during the first six months of life.

Revisão analítica das escalas de disfagia / Analytic review of dysphagia scales

INTRODUÇÃO: Instrumento eficiente para medição da disfagia, facilmente reprodutível e estatisticamente consistente, deveria fornecer dados mais consistentes sobre os resultados e acompanhamento de doenças com disfagia. As propostas existentes mostram ampla cobertura na avaliação do sintoma disfágico. OBJETIVOS: Analisar as escalas de disfagia disponíveis sugerindo as que permitem avaliação mais objetiva e estatisticamente consistente, e não apenas ferramenta de mensuração, e sugerir as que melhor quantificam o sintoma e úteis para seguimento dos pacientes. MÉTODO: Foram pesquisados os seguintes descritores no Pubmed: "disfagia", "escala", "index", "score". Dez artigos foram selecionados entre 1995 e 2012 com propostas de escalas para a disfagia. RESULTADOS: A maioria das escalas não atingiram os requisitos para serem classificadas como ferramenta completa na avaliação de qualquer disfagia. Muitas são específicas para uma única doença, e poucas com maior abrangência, não têm consistência estatística. Para disfagia orofaríngea (cervical), as escalas FOIS e ASHA são citadas com mais frequência. Na disfagia motora (cervical), a de Zaninotto e Youssef têm aplicabilidade prática, mas ambas necessitam de validação estatística. A de Zaninotto parece ser mais precisa por incluir mais variáveis (disfagia, dor no peito e azia). As escalas que cobrem as duas formas de disfagia (ASHA e DHI) são bem diferentes em seus objetivos. A DHI é escala publicada recentemente examina os dois tipos de disfagia e tem validação estatística bem estruturada. Importante passo no futuro seria testar essa nova proposta com amostra mais expressiva e representativa, provavelmente consagrando esse novo instrumento de avaliação. CONCLUSÃO: As escalas mais frequentes de disfagia relatadas nos últimos 17 anos têm propósito e estruturas diferentes. As escalas FOIS e ASHA são muitas vezes utilizadas para a avaliação da disfagia orofaringeana (região cervical), ambas focadas em terapia nutricional. Para a avaliação motora baixa, a escala de Zaninotto e Youssef tem aplicação prática, e a DHI parece representar a ferramenta mais promissora na avaliação global da disfagia.

INTRODUCTION: An efficient instrument for dysphagia measurement, easily reproducible and statistically consistent, should provide consistent data on the outcomes and follow-up of diseases with dysphagia. Existent proposals do not show a global coverage in the evaluation of this symptom. OBJECTIVE: To analyze the available dysphagia scales determining those that allow a more objective and statistically consistent evaluation, and not only a measurement tool. Also, witch of the them achieve a better quantification of the symptom and useful in the follow-up. METHOD: Searching descriptors in the database Pubmed: "dysphagia", "scale", "index", "score", 10 papers were selected published between 1995 and June 2012 with proposals of dysphagia scales. RESULTS: Most scales do not reach the requirements to be classified as a complete tool in the evaluation of any dysphagia. Many are specific to a single disease and few, which have a global assessment, have no statistical consistency. In oropharyngeal (cervical) dysphagia, the FOIS and ASHA scales are the most often cited. In motor dysphagia (cervical), the Zaninotto and Youssef scale have extremely practical applicability, but both require statistical validation. Zaninotto´s seems to be more accurate by including more variables (dysphagia, chest pain and heartburn). The scales which cover the two forms of dysphagia (ASHA and DHI) are extremely different regarding the goal of their evaluation. The DHI is a scale of recent publication, which examines the two types of dysphagia and has a well-structured statistical validation. Future important step would be testing this new proposal with a more expressive and representative sample, probably enshrining this new assessment tool. CONCLUSION: The most frequent scales of dysphagia reported in the last 17 years have different purpose and structure.The FOIS and ASHA scales are often used for evaluation of oropharyngeal (cervical) dysphagia, both focused on nutritional therapy. For the evaluation of motor (low) dysphagia, the scale of Zaninotto and Youssef has practical application, and the DHI seems to represent the most promising tool in the overall assessment of dysphagia.

Analytic review of dysphagia scales.

INTRODUCTION: An efficient instrument for dysphagia measurement, easily reproducible and statistically consistent, should provide consistent data on the outcomes and follow-up of diseases with dysphagia. Existent proposals do not show a global coverage in the evaluation of this symptom. OBJECTIVE: To analyze the available dysphagia scales determining those that allow a more objective and statistically consistent evaluation, and not only a measurement tool. Also, witch of the them achieve a better quantification of the symptom and useful in the follow-up. METHOD: Searching descriptors in the database Pubmed: "dysphagia", "scale", "index", "score", 10 papers were selected published between 1995 and June 2012 with proposals of dysphagia scales. RESULTS: Most scales do not reach the requirements to be classified as a complete tool in the evaluation of any dysphagia. Many are specific to a single disease and few, which have a global assessment, have no statistical consistency. In oropharyngeal (cervical) dysphagia, the FOIS and ASHA scales are the most often cited. In motor dysphagia (cervical), the Zaninotto and Youssef scale have extremely practical applicability, but both require statistical validation. Zaninotto´s seems to be more accurate by including more variables (dysphagia, chest pain and heartburn). The scales which cover the two forms of dysphagia (ASHA and DHI) are extremely different regarding the goal of their evaluation. The DHI is a scale of recent publication, which examines the two types of dysphagia and has a well-structured statistical validation. Future important step would be testing this new proposal with a more expressive and representative sample, probably enshrining this new assessment tool. CONCLUSION: The most frequent scales of dysphagia reported in the last 17 years have different purpose and structure.The FOIS and ASHA scales are often used for evaluation of oropharyngeal (cervical) dysphagia, both focused on nutritional therapy. For the evaluation of motor (low) dysphagia, the scale of Zaninotto and Youssef has practical application, and the DHI seems to represent the most promising tool in the overall assessment of dysphagia.

Esofagojejunostomia após gastrectomia total: anastomose mecânica ou manual? / Esophagojejunostomy after total gastrectomy: handsewn or stapler technique?

OBJETIVO: Os autores apresentam um estudo observacional, transversal, comparando a anastomose manual com a anastomose mecânica para reconstrução do trânsito digestivo em Y de Roux em pacientes submetidos à gastrectomia total para câncer gástrico. MÉTODOS: O estudo foi realizado no Hospital Governador Israel Pinheiro, no período de janeiro de 1997 a março de 2002. Um total de 40 pacientes neste período foram submetidos à gastrectomia total com reconstrução em Y de Roux. O Grupo I formado por 16 pacientes foi submetido à anastomose mecânica e o grupo II por 24 pacientes foi submetido à anastomose manual. Os dois grupos foram comparados quanto à incidência de complicações pós-operatórias, necessidade de re-operação, alta hospitalar e mortalidade per e pós-operatória. RESULTADOS: Quanto às complicações relacionadas à anastomose, fístula e abscesso intra-abdominal, elas ocorreram em nove pacientes do grupo com anastomose manual e em nenhum paciente no grupo com anastomose mecânica. (p= 0,006). A morbidade e a permanência hospitalar pós-operatória foram maiores no grupo submetido à sutura manual. Houve um óbito em cada grupo e 37 por cento dos pacientes em cada grupo não apresentaram quaisquer tipos de complicações. CONCLUSÃO: Considerando a fístula e o abscesso intra-abdominal juntamente como complicações da anastomose esôfago-jejunal, os resultados deste estudo sugerem uma maior viabilidade da sutura mecânica.

BACKGROUND: The authors report a observational study comparing the surgical outcomes in patients underwent total gastrectomy for gastric cancer and Roux-en-Y end-to-end esophagojejunostomy. METHODS: A mechanical EEA stapler or conventional manual suturing was used. The study was realized in Israel Pinheiro Governor Hospital from January 1997 to May 2002. The surgical outcomes of 16 patients in whom stapling was used (stapler group) and 24 patients in whom manual suturing was done (manual group) were compared. They were: complications incidence, re-operation, hospital stay and mortality. RESULTS: In each group, 37 percent of patients did not have any kind of complications. About anastomotic complications (leakage and intraabdominal abscess), there was 9 in manual group and anyone in mechanical group (p=0,006). Morbidity and hospital stay were higher in manual group. There was one obit in each group. CONCLUSION: Surgical complications, morbidity and hospital stay were higher in manual group. This study suggest a higher viability of mechanical suturing.

Ontogenetic Variation in Biological Activities of Venoms from Hybrids between Bothrops erythromelas and Bothrops neuwiedi Snakes

Lance-headed snakes are found in Central and South America, and they account for most snakebites in Brazil. The phylogeny of South American pitvipers has been reviewed, and the presence of natural and non-natural hybrids between different species of Bothrops snakes demonstrates that reproductive isolation of several species is still incomplete. The present study aimed to analyze the biological features, particularly the thrombin-like activity, of venoms from hybrids born in captivity, from the mating of a female Bothrops erythromelas and a male Bothrops neuwiedi, two species whose venoms are known to display ontogenetic variation. Proteolytic activity on azocoll and amidolytic activity on N-benzoyl-DL-arginine-p-nitroanilide hydrochloride (BAPNA) were lowest when hybrids were 3 months old, and increased over body growth, reaching values similar to those of the father when hybrids were 12 months old. The clotting activity on plasma diminished as hybrids grew; venoms from 3- and 6-months old hybrids showed low clotting activity on fibrinogen (i.e., thrombinlike activity), like the mother venom, and such activity was detected only when hybrids were older than 1 year of age. Altogether, these results point out that venom features in hybrid snakes are genetically controlled during the ontogenetic development. Despite the presence of the thrombin-like enzyme gene(s) in hybrid snakes, they are silenced during the first six months of life.

Biochemical and biological characterization of Bothriechis schlegelii snake venoms from Colombia and Costa Rica

Snakebites inflicted by the arboreal viperid snake Bothriechis schlegelii in humans are characterized by pain, edema, and ecchymosis at the site of the bite, rarely with blisters, local necrosis, or defibrination. Herein, a comparative study of Bothriechis schlegelii snake venoms from Colombia (BsCo) and Costa Rica (BsCR) was carried out in order to compare their main activities and to verify the efficacy of Bothrops antivenom produced in Brazil to neutralize them. Biochemical (SDS-PAGE and zymography) and biological parameters (edematogenic, lethal, hemorrhagic, nociceptive, and phospholipase A(2) activities) induced by BsCo and BsCR snake venoms were evaluated. The presence of antibodies in Bothrops antivenom that recognize BsCo and BsCR snake venoms by enzyme-linked immunosorbent assay and Western blotting, as well as the ability of this antivenom to neutralize the toxic activities were also verified. SDS-PAGE showed differences between venoms. Distinctive caseinolytic and hyaluronidase patterns were detected by zymography. BsCo and BsCR showed similar phospholipase A(2) activity. Strong cross-reactivity between BsCo and BsCR was detected using Bothrops antivenom with many components located between 150 and 35kDa. BsCR was more edematogenic and almost fourfold more hemorrhagic than BsCo, and both venoms induced nociception. BsCR (LD50 5.60mg/kg) was more lethal to mice than BsCo (LD50 9.24mg/kg). Bothrops antivenom was effective in the neutralization of lethal and hemorrhagic activities of BsCo and BsCR and was partially effective in the neutralization of edematogenic and nociceptive activities. In conclusion, geographic distribution influences the composition and activities of Bothriechis schlegelii venoms. Bothrops antivenom cross-reacted with these venoms and was partially effective in neutralizing some toxic activities of BsCo and BsCR