Esophagocele due to two times caustic ingestions: resection through videothoracoscopy / Esofagocele por duas ingestões cáusticas: ressecção por videotoracoscopia

ABSTRACT BACKGROUND: Caustic ingestion is still a health problem of utmost importance in the West. In developing countries, this incident remains at increase and it is associated with unfavorable factors like social, economic, and educational handicaps, besides a lack of prevention. Esophagocele is a rare consequence of caustic ingestion. AIM: We aimed to describe a patient with multiple caustic ingestions who presented an esophagocele resected by videothoracoscopy. METHODS: A woman ingested caustic soda when she was only 17 years old in a suicidal attempt during a depressive crisis. Initially, she was submitted to a retrosternal esophagocoloplasty with the maintenance of her damaged esophagus. After 1 year of this first surgery, she ingested caustic soda again in a new suicidal attempt. Her transposed large bowel in the first surgery became narrow, being replaced in a second surgery by a retrosternal esophagogastroplasty. Still, at the second surgery, her damaged esophagus remained in its original position in the posterior mediastinum. However, after 5 years, she developed an esophagocele. RESULTS: The esophagocele was resected through videothoracoscopy in a prone position, employing four trocars. The postoperative was uneventful. CONCLUSION: Esophageal exclusion must always be recorded because esophagocele presents unspecific symptoms. The videothoracoscopy in a prone position is an excellent technical option to resect esophagoceles.

RESUMO RACIONAL: A ingestão de produtos cáusticos ainda é um problema de saúde de extrema importância no Ocidente. Nos países em desenvolvimento, este incidente continua em ascensão e está associada a fatores desfavoráveis como sociais, econômicos e educacionais, além da falta de prevenção. A esofagocele é uma consequência rara da ingestão de cáusticos. OBJETIVO: Nosso objetivo é descrever um paciente com múltiplas ingestões cáusticas que apresentou uma esofagocele ressecada por videotoracoscopia. MÉTODOS: Doente feminina que ingeriu soda cáustica com 17 anos de idade, como tentativa de suicídio, durante uma crise depressiva. Inicialmente, foi submetida a esofagocoloplastia retroesternal com manutenção do esôfago lesado. Após um ano desta primeira cirurgia, voltou a ingerir soda cáustica, em nova tentativa de suicídio. Seu intestino grosso transposto na primeira cirurgia tornou-se estenosado, sendo substituído em uma segunda cirurgia, por esofagogastroplastia retroesternal. Ainda assim, nesta segunda cirurgia, o esôfago lesado permaneceu em sua posição original no mediastino posterior. No entanto, após cinco anos, ela desenvolveu uma esofagocele. RESULTADOS: A esofagocele foi ressecada por videotoracoscopia, em decúbito ventral, empregando-se quatro trocartes. O pós-operatório transcorreu sem intercorrências. CONCLUSÕES: A exclusão esofágica deve ser sempre registrada, pois a esofagocele apresenta sintomas inespecíficos. A videotoracoscopia em posição prona é uma excelente opção técnica para ressecção de esofagoceles.

Thoracoscopy Approach in Prone Position for Esophagoplasty in Children.

Congenital esophageal stenosis (CES) is a very rare clinical condition found in 1 per 25,000 to 50,000 live births. There are three histological types of CES described: tracheobronchial remnants, fibromuscular stenosis (FMS), and membranous stenosis. The first-line treatment in most cases is the conservative treatment (dilatation with a Savary bougie or balloon), but in some CES types, dilatation may be ineffective or result in esophageal perforation with serious complications or lethal outcome. Resection of the stenotic segment and end-to-end esophageal anastomosis was formerly presented as the most common surgical treatment option for CES. However, esophagoplasty is a safe and feasible alternative for surgical treatment of esophageal stenosis in children. Our aim is to report two cases of FMS submitted to thoracoscopic esophagoplasty. Both cases started with dysphagia and refusal after transition to solid diet, at 6 months old, and the radiological examination showed stricture of the distal esophagus. Esophagoplasty was performed with the patients in prone position. The stenotic esophageal wall was incised longitudinally and transverse synthesis was performed. After surgery, the patients had prompt recovery, without recurrent stenosis, remaining asymptomatic, with good diet acceptance.

Esophageal substitution or esophageal elongation procedures in patients with complicated esophageal atresia? Results of a comparative study.

BACKGROUND: In newborns with complex esophageal atresia, there are situations in which a primary anastomosis cannot be safely performed. The alternative is performing a late anastomosis after the esophageal ends have gone through a period of spontaneous growth or after elongations of the distant ends of the esophagus and create an anastomosis under tension which causes risks of morbidity. An alternative to the elongation procedures is to perform a cervical esophagostomy with a gastrostomy for nutritional support and later on an esophageal replacement. The purposes of this retrospective chart review study are to report on our experience with esophageal substitution procedures in such cases, address the quality of life of a group of patients, and compare our results with those of patients who underwent esophageal elongation procedures as reported in the literature. METHODS: Patients with esophageal atresia underwent esophageal replacement procedures and quality of life was assessed in a group of esophagocoloplasty patients. RESULTS: From February 1978 to July 2019, 276 children (232 colonic interpositions and 44 total gastric transpositions) were studied; the most frequent complication was cervical anastomosis leakage [70 (30.2%) esophagocoloplasty patients and 7 (15.9%) gastric transposition patients], which sealed spontaneously in all but 4 patients. The quality of life was considered excellent or good in approximately 90% of the studied 70 out of the 276 patients; the comparison with the esophageal elongation procedures showed that esophageal substitution procedures promoted excellent long-term results with normal deglutition function (98.2% of patients, versus 33.3%, 36.5%, and 62.5%, respectively from the elongation series, P <0.0001 for all comparisons). CONCLUSION: Esophagocoloplasty or total gastric transposition is a good alternative to treat patients with complex esophageal atresia. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: Level III.

Laparoscopic Collis-Nissen approach for shortened esophagus treatment in children.

BACKGROUND: Short esophagus is a disability to obtain a proper portion of abdominal esophagus, thus a lengthening technique is required. Collis approach is the best option. OBJECTIVE: To demonstrate effectiveness of laparoscopic Collis-Nissen approach in children. METHOD: Retrospective and descriptive case series performed in children with reflux and short esophagus, Collis esophagoplasty was carried out with stapler, together with fundoplication. Age, symptomatology, surgical background, oral nutrition beginning, hospital stay, complications and reflux control were recorded. RESULTS: Eight children, 4-15 years old were treated from 2005 to 2017. Three of them with slipped fundoplication background and two with esophageal atresia. The rest of the children had no background, two of them with stenosis. Symptoms; cough 8/8, abdominal pain 5/8, dysphagia 3/8. Without complications. Oral nutrition beginning at the 5th day. Up to 10 years follow-up, with complete remission of the symptomatology in 6 years. DISCUSSION: Since a true short esophagus diagnosis depends on transurgical findings, pediatric surgeons should notice this entity when practicing any antireflux procedure. Laparoscopic Collis-Nissen approach is safe and efficient in these patients.

ANTECEDENTES: El esófago corto es la imposibilidad de obtener una porción adecuada de esófago abdominal, por lo que se requiere alguna técnica de alargamiento. La mejor opción es el procedimiento de Collis. OBJETIVO: Demostrar la eficacia del procedimiento de Collis-Nissen por laparoscopía en niños. MÉTODO: Estudio retrospectivo, descriptivo, serie de casos, niños con reflujo y esófago corto, esofagoplastía de Collis con engrapadora y funduplicatura. Se analizaron edad, sintomatología, antecedentes quirúrgicos, tiempo quirúrgico, inicio de vía oral, tiempo de hospitalización, complicaciones y control del reflujo. RESULTADOS: De 2005 a 2017 se trataron ocho niños de 4 a 15 años. De ellos, tres con antecedente de funduplicatura deslizada y dos con antecedente de atresia esofágica. El resto sin antecedentes, dos con estenosis. Síntomas; tos 8/8, dolor abdominal 5/8, disfagia 3/8. Sin complicaciones. Inició de vía oral al quinto día. Seguimiento de hasta 10 años, con remisión total de la sintomatología en seis casos. DISCUSIÓN: Debido a que el diagnóstico de esófago corto verdadero depende de los hallazgos transoperatorios, los cirujanos pediatras deben reconocer esta condición al momento de practicar cualquier procedimiento antirreflujo. El procedimiento de Collis-Nissen laparoscópico es una opción segura y eficaz en estos pacientes.

Early and late assessment of esophagocardioplasty in the surgical treatment of advanced recurrent megaesophagus / Avaliação precoce e tardia da esofagocardioplastia no tratamento cirúrgico do megaesôfago avançado e recidivado

ABSTRACT Background Since Chagas disease has esophageal manifestations with different degrees of involvement, the best surgical option is controversial, especially for patients with advanced chagasic megaesophagus and recurrent symptoms after previous treatment. Objective To assess the early and late outcomes of esophagocardioplasty in a series of patients with advanced recurrent chagasic megaesophagus. Methods This descriptive study included 19 older patients with recurrent megaesophagus grade III/IV and positive immunofluorescence for Chagas disease. They had undergone cardiomyotomy with anterior fundoplication a mean of 16.5 years ago. Serra-Doria esophagocardioplasty was selected to treat the recurrence. The patients were followed to assess postoperative and late complications and the incidence of symptom recurrence. Results In early assessment, five (26.3%) patients presented clinical complications. One (5.2%) patient had a gastrointestinal fistula secondary to esophagogastric anastomotic leak, which responded well to conservative treatment. In the one-year follow-up, 18 (94.7%) patients could swallow normally and had no vomiting. Three years after surgery, 10 (62.5%) of 16 patients could swallow normally, and 3 (19.3%) patients complained of vomiting. Five years after surgery, only 5 (38.4%) of 13 patients could swallow normally and 7 (53.8%) had vomiting. Conclusion Serra-Doria esophagocardioplasty for the treatment of advanced recurrent megaesophagus had mild postoperative complications and good success rate in the short-term follow-up. In the long-term follow-up, it proved to be a poor surgery choice because of the high incidence of symptom recurrence, compromising quality of life. This procedure should be indicated only for patients with advanced recurrent megaesophagus without clinical conditions to undergo esophageal resection.

RESUMO Contexto A doença de Chagas, por apresentar manifestações esofágicas com diferentes graus de acometimento, faz com que haja controvérsias quanto a melhor opção cirúrgica; principalmente para pacientes com megaesôfago chagásico avançado e com recidiva de sintomas após tratamento prévio. Objetivo Avaliar o resultado precoce e tardio da esofagocardioplastia em uma série de pacientes com megaesôfago chagásico avançado e recidivado. Métodos Estudo descritivo, com 19 pacientes idosos com megaesôfago Grau III/IV recidivado e com imunoflorescência positiva para doença de Chagas. A cirurgia prévia foi a cardiomiotomia com fundoplicatura anterior, com tempo médio de realização de 16,5 anos. A cirurgia de eleição para o tratamento da recidiva foi a esofagocardioplastia de Serra-Dória. Realizou-se avaliação precoce para estudar as complicações pós-operatórias e tardias, para avaliar a incidência de recidiva de sintomas. Resultados Na avaliação precoce, 5 (26,3%) pacientes apresentaram complicações clínicas. Um (5,2%) paciente apresentou fístula digestiva consequente a deiscência da anastomose esofagogástrica, mas com boa evolução com o tratamento conservador. Na avaliação de 1 ano de pós-operatório, 18 (94,7%) pacientes apresentavam deglutição normal e sem regurgitação. Com 3 anos de pós-operatório, de 16 pacientes analisados; 10 (62,5%) pacientes apresentavam deglutição normal e 3 (19,3%) se queixavam de regurgitação. Com 5 anos de pós-operatório, de 13 pacientes analisados; somente 5 (38,4%) apresentavam deglutição normal e 7 (53.8%) com regurgitação. Conclusão A esofagocardioplastia de Serra-Dória, no tratamento cirúrgico do megaesôfago avançado recidivado, apresentou complicações pós-operatórias de baixa morbidade e com boa resolutividade, na avaliação precoce. Na avaliação de longo prazo, demonstrou não ser um procedimento cirúrgico adequado, pela alta incidência de recidiva de sintomas, com comprometimento da qualidade de vida. Deve ser indicada somente em pacientes com doença avançada recidivada, sem condições clínicas de serem submetidas à ressecção esofágica.

Reconstruction of thoracic esophagus with pediculated diaphragmatic flap in dogs

PURPOSE: To verify whether pediculated diaphragmatic flaps were suitable to correct iatrogenic wounds in dog's esophagus injuries. METHODS: Seven dogs were submitted to resection of a segment of the esophagical wall, which was then corrected by suturing a pediculated diaphragm flap. Endoscopic evaluation of the esophagical wall was done forty days after the surgical procedure. RESULTS: Three animals died, one due to implant ischemia, caused by strangulation of the phrenic artery; other due to wound infection; and the last, due to mediastinitis. Scar retraction was observed, however, there was no stenosis, allowing the passage of a 9,8 mm probe with no difficulty. The limits between the implants and the native esophagus were indistinguishable, and the implant was covered by esophageal mucosa. CONCLUSION: The diaphragmatic flaps are suitable on the restoring of continuity in dog's thoracic esophagus.

OBJETIVO: Verificar se retalhos diafragmáticos pediculados seriam adequados para correção de defeitos iatrogênicos do esôfago do cão. MÉTODOS: Sete cães foram submetidos à ressecção de um segmento da parede esofágica, o qual foi corrigido por meio da sutura de um pedículo diafragmático pediculado. Um animal morreu devido à isquemia do implante causada pelo estrangulamento da artéria frênica, outro devido à infecção da ferida cutânea e outro devido a mediastinite. Aos 40 dias após o procedimento fez-se um exame endoscópico dos animais nos cães sobreviventes. RESULTADOS: Observou-se retração cicatricial sem repercutir em estenose, permitindo a passagem de sonda de 9,8 mm, sem dificuldade. Os limites entre os implantes e o esôfago nativo se apresentaram indistinguíveis e o implante estava recoberto por mucosa esofágica. CONCLUSÃO: Os retalhos diafragmáticos são adequados na restauração da continuidade do esôfago torácico do cão.

Reconstruction of thoracic esophagus with pediculated diaphragmatic flap in dogs / Reconstrução do esôfago torácico com retalho pediculado do diafragma em cães

PURPOSE: To verify whether pediculated diaphragmatic flaps were suitable to correct iatrogenic wounds in dog's esophagus injuries. METHODS: Seven dogs were submitted to resection of a segment of the esophagical wall, which was then corrected by suturing a pediculated diaphragm flap. Endoscopic evaluation of the esophagical wall was done forty days after the surgical procedure. RESULTS: Three animals died, one due to implant ischemia, caused by strangulation of the phrenic artery; other due to wound infection; and the last, due to mediastinitis. Scar retraction was observed, however, there was no stenosis, allowing the passage of a 9,8 mm probe with no difficulty. The limits between the implants and the native esophagus were indistinguishable, and the implant was covered by esophageal mucosa. CONCLUSION: The diaphragmatic flaps are suitable on the restoring of continuity in dog's thoracic esophagus.(AU)

OBJETIVO: Verificar se retalhos diafragmáticos pediculados seriam adequados para correção de defeitos iatrogênicos do esôfago do cão. MÉTODOS: Sete cães foram submetidos à ressecção de um segmento da parede esofágica, o qual foi corrigido por meio da sutura de um pedículo diafragmático pediculado. Um animal morreu devido à isquemia do implante causada pelo estrangulamento da artéria frênica, outro devido à infecção da ferida cutânea e outro devido a mediastinite. Aos 40 dias após o procedimento fez-se um exame endoscópico dos animais nos cães sobreviventes. RESULTADOS: Observou-se retração cicatricial sem repercutir em estenose, permitindo a passagem de sonda de 9,8 mm, sem dificuldade. Os limites entre os implantes e o esôfago nativo se apresentaram indistinguíveis e o implante estava recoberto por mucosa esofágica. CONCLUSÃO: Os retalhos diafragmáticos são adequados na restauração da continuidade do esôfago torácico do cão.(AU)

Reconstrução faringoesofágica com retalho microcirúrgico de jejuno após esofagectomia cervical / Faringoesophageal reconstruction with jejunum micro surgical flap after cervical esophagectomy: case report

A reconstrução faringoesofágica após a ressecção de carcinomas da laringe e faringe localmente avançados representa desafio ao cirurgião reconstrutor. Historicamente, a reconstrução faringoesofágica vem sendo realizada com retalhos locais ou à distância, necessitando de múltiplos procedimentos e hospitalizações prolongadas, além de resultados cirúrgicos pobres. O advento das técnicas reconstrutivas microcirúrgicas possibilitou aumento na qualidade de vida desses pacientes por meio de procedimento em tempo único e com baixas taxas de complicações. Neste artigo, os autores apresentam relato de caso de paciente submetido à reconstrução tardia de esôfago com retalho microcirúrgico de jejuno, após laringectomia total, faringectomia parcial e esofagectomia cervical e discutindo-se a técnica, fazendo-se uma breve revisão da literatura.

Reconstruction of the pharyngoesophagus after resection of locally advanced carcinoma of larynx and pharynx can be a difficult problem for the reconstructive surgeon. Historically, pharyngoesophagus reconstruction has been made with local or distant flaps, with multiple stages and long hospitalization, frequently with poor results. The approach with microsurgical techniques has enabled an increase in quality of life of these patients by means of a single stage procedure with low complication rates. In this article, the authors present a case report of a patient submitted to esophageal delayed reconstruction with jejunum microsurgical flap, after a total laringectomy, partial faringectomy and cervival esophagectomy, and discuss its technique and a brief literature review.

Esofagoplastia torácica com retalho de pericárdio em gatos

The efficiency of autogenous pericardial flap was evaluated as an alternative surgical procedure for repairing lesion in the thoracic esophagus in the feline. Twelve adult cats were studied. Six animals were observed at the 15th day and other animals at the 30th day. All animals were submitted to esophageal resection and subsequently repair with autogenous pericardial graft. The animals were clinically evaluated after surgery. At the determined period of observation the animals were sacrificed. Gross and microscopic evaluation were done from the surgical site at the esopahagus. An esophageal mucous membrane proliferation was identified on most of the grafts.

Com o objetivo de testar a eficiência do retalho de pericárdio autógeno pediculado como alternativa para reparar defeitos esofágicos torácicos em felinos, foram estudados doze animais adultos, sendo seis avaliados até 15 dias e os outros seis até 30 dias de pós-operatório. Todos os animais foram submetidos à ressecção esofágica e posterior reparo com pericárdio pediculado. As análises constaram de exames clínicos diários e, ao final do período estabelecido, os animais foram submetidos à eutanásia e necropsiados para avaliação macroscópica e microscópica dos esôfagos. Observou-se proliferação da mucosa esofágica sobre o pericárdio pediculado.

Esofagoplastia torácica com retalho de pericárdio em gatos

The efficiency of autogenous pericardial flap was evaluated as an alternative surgical procedure for repairing lesion in the thoracic esophagus in the feline. Twelve adult cats were studied. Six animals were observed at the 15th day and other animals at the 30th day. All animals were submitted to esophageal resection and subsequently repair with autogenous pericardial graft. The animals were clinically evaluated after surgery. At the determined period of observation the animals were sacrificed. Gross and microscopic evaluation were done from the surgical site at the esopahagus. An esophageal mucous membrane proliferation was identified on most of the grafts.

Com o objetivo de testar a eficiência do retalho de pericárdio autógeno pediculado como alternativa para reparar defeitos esofágicos torácicos em felinos, foram estudados doze animais adultos, sendo seis avaliados até 15 dias e os outros seis até 30 dias de pós-operatório. Todos os animais foram submetidos à ressecção esofágica e posterior reparo com pericárdio pediculado. As análises constaram de exames clínicos diários e, ao final do período estabelecido, os animais foram submetidos à eutanásia e necropsiados para avaliação macroscópica e microscópica dos esôfagos. Observou-se proliferação da mucosa esofágica sobre o pericárdio pediculado.

Tratamento cirúrgico das complicações da anastomose esôfago-visceral cervical / Surgical treatment of the complications of the cervical esophago visceral anastomosis

A anastomose esôfago-visceral cervical apresenta como complicações a fístula e a estenose, que podem necessitar de reintervenção cirúrgica para sua correção. Com o objetivo de avaliar as táticas para abordagem operatória dessas complicações e seus resultados, os autores estudaram retrospectivamente nove pacientes, que demandaram esta conduta, num período de 17 anos. Foram operadas duas fístulas e sete estenoses da anastomose esôfago-visceral cervical, sendo a via de acesso inicial a cervicotomia em todos ospacientes. Em quatro casos, houve necessidade de ampliação para esternotomia mediana total, que facilitousignificativamente a reconstrução, porém com mortalidade de 75%. As táticas adotadas foram a reanastomoseem cinco casos, a sutura do orifício da fístula em um caso e a plastia em três casos. A ressutura teve mau resultado. As plastias evoluíram satisfatoriamente, e os doentes submetidos a reanastomose sem ésternotomiatambém evoluíram satisfatoriamente. A plastia da anastomose demonstrou ser uma boa tática para o tratamento da estenose cervical, enquanto a reanastomose parece ter a melhor indicação nas fístulas, devendo-se evitar a esternotomia total mediana.

The esophago-visceral cervical anastomosis presents complications such as fistula and stenosis that mayneed surgical reintervention for it’s correction. The authors, with the objective of evaluating proceduresfor surgical approach and the results of these complications, have studied retrospectively 9 patients whom demanded this conduct in a 17-year period. Two fistulas and seven esophago-visceral cervical anastomosisstenosis were performed, being cervicotomy the initial access in all patients. In four cases there was a needto enlarge the access, achieved with a total median sternotomy, which made the reconstruction significantly easier, therefore there was 75% mortality. The tactics adopted were reanastomosis in 5 cases, suture of the fistula’s orifice in one case, and plasty in three. Ressuturing obtained bad results. The patients subbmited to plasties evoluted satisfactorily and patients submitted to reanastomosis without total median sternotomy also evoluted satisfactorily. Anastomosis plasty proved to be a good tactic for the treatment of cervicalstenosis, while reanastomosis seems to be a better indication for treatment of fistulas, being that total median sternotomy is avoided.