The two main approaches currently used for surgical treatment of esophageal cancer are transhiatal esophagectomy (THE) and esophagectomy through a right thoracotomy. Among technical variations of THE, wide opening of the diaphragm with ample mediastinal exposure allows resection under direct view with acceptable postoperative morbidity and mortality rates. Transthoracic esophagectomy, associated with extensive mediastinal lymphadenectomy, still offers the best chance of definitive cure in intermediate stages (stages II and III), but does not influence survival in advanced cases (stage IV). In early stages, the lymph node invasion rate is negligible and may be treated by other techniques (THE or endoscopic mucosectomy). THE restores oral ingestion and avoids respiratory complications of thoracotomy, and consequently can be reserved for early cases (mucosal or submucosal lesions) or for patients with poor clinical status. To improve results of surgical treatment, protocols of associated radiochemotherapy are currently under research.

Carcinoma, Squamous Cell↗

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Surgical complications of Chagas' disease: megaesophagus, achalasia of the pylorus, and cholelithiasis.

Three surgical complications of Chagas' disease--megaesophagus, achalasia of the pylorus, and cholelithiasis--were evaluated within the framework of the experience acquired in the management of 840 cases of megaesophagus--722 in the nonadvanced stage of the disease and 118 with advanced disease (dolichomegaesophagus). In the group of the 722 patients with nonadvanced disease, achalasia of the pylorus was present in 140 (19.4%), and in the total of 840 patients, uncomplicated cholelithiasis without chagasic involvement of the gallbladder and/or papilla was observed in 58 (6.9%). The 722 subjects with nonadvanced megaesophagus were submitted to wide esophagocardiomyectomy performed at the level of the anterior esophagogastric junction, combined with an antireflux valvuloplasty procedure. We recorded no mortality, and 95% excellent and good results in long-term follow-up. On the other hand, dolichomegaesophagus required esophageal resection with reconstruction by means of an esophagogastroplasty placed in the esophageal bed. The mortality rate was 4.2% (5/118); the main postoperative complications were pleural effusion (22%) and fistulas of the esophagogastric anastomosis (8.4%). Postoperatively, the patients adapted well to their new anatomy and gained weight. Achalasia of the pylorus was confirmed by delayed gastric emptying time. This entity was managed by concomitant antropyloromyectomy without mortality. Cholelithiasis was managed by cholecystectomy and radiologic exploration of the bile ducts.

Chagas Disease↗

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Preoperative assessment in cases of adult megacolon suffering from moderate malnutrition.

Acquired megacolon is a chronic disease associated with constipation and malnutrition. Surgical treatment may be required for the alleviation of the intestinal symptoms, emphasizing the interest of nutritional assessment in this population. In a prospective study of 33 patients suffering from acquired megacolon and requiring either anterior resection or pull-through operation, standard anthropometric and biochemical measurements as well as the PNI of Buzby and Mullen were preoperatively assessed. Mean age of the population was 49 +/- 13 y, with 17 males and 16 females. The combined nutritional score indicated 63.6% of the population were malnourished (21/33) of the patients, whereas the Prognostic nutritional index (PNI) revealed 3 high-risk cases (9.1%), 9 with moderate risk (27.3%), and reduced risk for all others. Indeed, 39.4% (13/33) of the patients displayed surgical or septic problems. Chi-square analysis confirmed that both studied criteria were significantly associated with complications (p < 0.05), as morbidity was restricted predominantly to cases with unfavorable Prognostic nutritional index (PNI) results or clear signs of nutritional deficit. Both PNI and conventinoal nutritional assessment are valuable tools for the screening of these surgical candidates. Artificial alimentation was not used in this experience, but deserves consideration in selected patients. Nutritional status improved in the late postoperative period, with normalization of bowel function.

Adult↗

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Prognostic significance of intraperitoneal free cancer cells obtained by laparoscopic peritoneal lavage in patients with gastric cancer.

Laparoscopy is a safe and useful method for examining the local extent and regional spread of disease in patients with gastric cancer. Peritoneal dissemination remains a frequent type of recurrence after surgical treatment. The aim of this study was to determine the prognostic value of intraperitoneal free cancer cells (IFCCs) detected by laparoscopic peritoneal lavage. Forty-nine patients with advanced gastric cancer underwent laparoscopy with cytologic examination for staging. Peritoneal lavage was performed when ascites was not present. Aspirated fluid from the peritoneal cavity was centrifuged and subjected to cytologic examination using Giemsa and Papanicolaou staining methods. Patients were surgically treated and followed for a minimum of 5 years. IFCCs were detected in 41% of the patients. In eight cases (16.3%) laparoscopy revealed carcinomatosis and/or multiple liver metastases, so laparotomy was not performed. Patterns of recurrence after curative resection included the following: peritoneal (n = 3), local (n = 4), liver (n = 1), and other (n = 1). All patients who tested positive for IFCCs had peritoneal recurrence. The absence of IFCCs was associated with improved overall survival (21 months for a 95% confidence interval of 7.4 to 34.6 vs. 4 months for a 95% confidence interval of 2.4 to 5.6). Overall survival adjusted for type of resection also demonstrated a favorable outcome for patients who were negative for IFCCs. The following conclusions were drawn: (1) laparoscopic peritoneal lavage cytology may be useful in identifying patients at high risk for peritoneal relapses and may alter treatment, and (2) lFCCs provide additional prognostic information in patients with gastric cancer.

Female↗

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The surgical treatment of megaesophagus and megacolon.

The effect of Chagas' disease on the digestive tract is evaluated based on the experience acquired in the surgical management of 929 cases of megaesophagus: 807 in the nonadvanced state of the disease and 122 with dolichomegaesophagus. The 807 subjects with nonadvanced megaesophagus were submitted to wide esophagocardiomyectomy on the anterior esophagogastric junction combined with an antireflux valvuloplasty procedure. There was no mortality. On the other hand, dolichomegaesophagus was always resected, with an esophagogastroplasty through the esophageal bed. The index of mortality of the series was 4.1% (5/122) and the main postoperative complications were pleural effusion (22.1%) and fistula of the esophagogastric anastomosis (8.2%). Over the long term the patients adapted well to the operation and gained weight. For the treatment of the megacolon, an easier technique has been employed: resection of the dilated sigmoid colon and colorectal anastomosis just above the anorectal ring. In 30 patients, no leakages, infection or other major complications were seen. The patients, after 1 year of follow-up, had a normal bowel transit.

Adult↗

PubMedDate not supplied

Conservative management of septic parenteral nutrition catheters.

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Adult↗

PubMedDate not supplied

Squamous cell carcinoma of the esophagus and multiple primary tumors of the upper aerodigestive tract.

Squamous cell carcinoma of the esophagus is frequently associated with other, synchronous or metachronous tumors, in the upper aerodigestive tract. All 264 patients with squamous cell carcinoma of the esophagus, treated in the Gastrointestinal Surgery, Esophagus section, of the "Hospital das Clínicas" (São Paulo University Medical School, Brazil), between 1979 and 1989 were analyzed retrospectively with regards to the occurrence of multiple primary tumors in the upper aerodigestive tract. Multiple primary tumors were encountered in 10 (3.8%) patients. All patients were male and the mean age at the time of the first primary was 52.2 years. Tobacco smoke and alcohol were the principal carcinogens in these patients (n = 10). The sites of the tumors were: larynx (n = 4), tongue (n = 4), lung (n = 2), and oral cavity (n = 1). Two simultaneous, three synchronous and five metachronous multiple primary carcinomas were detected. The esophagus was the second primary tumor in nine patients. The mean overall survival after the diagnosis of the second primary was 2.8 months (SD = 0.89). Inquiry regarding other malignancies, associated with panendoscopy should be carry out prior to the treatment of the first primary to diagnose simultaneous or synchronous primary tumors, and careful follow-up should be performed after treatment of the first primary to detect new tumors in these high-risk patients.

Adult↗