Salvage Esophagectomy in Advanced Esophageal Cancer

Even through the esophageal cancer has innumerable treatment options, its prognosis is still unsettled. Because esophagectomy is rarely curative, others therapies, such as chemoradiation emerging in advanced disease followed or not surgery. The salvage esophagectomy is an alternative for those patients with recurrent disease. Thus in this chapter the intend is show the results of the salvage esophagectomy in patients with esophageal cancer who had previously undergone chemoradiation and discussion about the morbidity of this surgical tecnic. Too, its show the our experience in 72 patients with unresectabeled esophageal carcinoma were treated with chemorradiation followed by salvage esophagectomy by trans-toracic approach. Patients was evaluated with regard pos-operative complications and disease free survival. The major complications was deiscence at the level of the of the anastomosis esophagogastric cervical, presents in 16 patients (22,2%) and pulmonar infection in 23 patients (31,9%). In 53 patients that were available for a five years follow-up, was a rate of 43,3% (23 patients) of disease free survival. Thus with the results its conclude that the salvage esophagectomy seems to be valuable in cases without any other therapeutic options

Surgical Treatment of Esophageal Advanced Achalasia

Of the several procedures that has to treat esophageal achalasia, the esophagectomy is to be the most indicated in advanced disease, which prompted Pinotti the disseminate the transmediastinal esophagectomy technique in the 1970s, with the advantage of avoiding thoracotomy. Nevertheless, several series demonstrated that this technique was not exempt from complications one of which could lead to massive hemopneumothorax due to injury to the trachea- bronchial tree and vessels due the periesophagitis that may be present with consequent adherence of the esophagus to these noble organs. Thus, Aquino in 1996 introduced the esophageal mucosectomy technique with preservation of the esophageal muscle tunic at the level of mediastinum as well as the transposition of the stomach to the cervical region inside in this tunic for the reconstruction of digestive tract. The advantage of this procedure is to avoid transgression of the mediastinum. This author describes in details this procedure, and shows early results and late evaluation using the ECKARDT score in a series of patients showing the advantages of the esophageal mucosectomy due the low incidence of immediate postoperative complications and good resolution in long term due the absence of symptoms in most patients

Pneumomediastino espontâneo (síndrome de Hamman) relato de dois casos

Objective: Describe two cases of spontaneous pneumomediastinum in the same service unit in young patients of different sex and that showed good progress with conservative treatment. Methods: The first case is a male patient, 18, with neck pain on the right side complaints and dysphonia for 2 days. Denied injuries or ingestion of strange bodies, heavy physical exertion, coughing and vomiting or drug use. CT of the chest and neck revealed the presence of bilateral anterior cervical subcutaneous emphysema, pneumomediastinum presence and absence of pneumothorax. The second case to be analyzed it is a female patient, 16 years old, complaining of sudden dyspnea and standard voice change (nasal). It was identified to fine crackling suggestive cervical palpation of subcutaneous emphysema. He denied any probable cause of secondary pneumomedistino. CT of the chest and neck revealed sharp pneumomediastinum extending to the deep neck spaces. Result: Both cases share of signs and symptoms previously described in the literature and had their diagnoses obtained by computed tomography. Symptomatic treatment associated with home was effective in both situations. Conclusions: Spontaneous pneumomediastinum may be underdiagnosed because of its nonspecific signs and symptoms, contributing to their unique character. It is important to establish the differential diagnoses and events to which patients were exposed. Accompanied a detailed history of radiological devices allow precise diagnosis and correct treatment.Objetivo: Descrever dois casos de pneumomediastino espontâneo na mesma unidade de serviço, em pacientes jovens de sexo diferentes e que apresentaram boa evolução com tratamento conservador. Métodos: O primeiro caso é de um paciente do sexo masculino, 18 anos, com queixa de cervicalgia à direita e disfonia há 2 dias. Negou traumatismos ou ingesta de corpos estranhos, esforços físicos intensos, acessos de tosse e vômitos ou uso de drogas. TC de tórax e pescoço revelou presença de enfisema subcutâneo cervical anterior bilateral, presença de pneumomediastino e ausência de pneumotórax. O segundo caso a ser analisado trata-se de uma paciente do sexo feminino, 16 anos, com queixa de dispneia súbita e mudança do padrão de voz (nasalada). Identificou-se crepitação fina à palpação cervical sugestiva de enfisema subcutâneo. Negou qualquer causa provável de pneumomedisatino secundário. TC de tórax e pescoço revelou pneumomediastino acentuado com extensão para os espaços cervicais profundos. Resultado: Ambos os casos partilham de sinais e sintomas previamente descritos na literatura e tiveram seus diagnósticos obtidos por meio de tomografia computadorizada de tórax. O tratamento sintomático associado a repouso foi eficaz em ambas situações. Conclusões: Pneumomediastino espontâneo pode ser subdiagnosticado devido aos seus sinais e sintomas inespecíficos, contribuindo para seu caráter raro. É importante estabelecer-se os diagnósticos diferenciais e eventos a que os pacientes estiveram expostos. Uma anamnese detalhada acompanhada de aparatos radiológicos permitem o diagnóstico preciso e tratamento correto

TARGET, PRESCRIPTION AND INFUSION OF ENTERAL NUTRITIONAL THERAPY OF CRITICAL PATIENTS IN INTENSIVE CARE UNIT

ABSTRACT BACKGROUND: Enteral nutritional therapy (ENT) is the best route for the nutrition of critically ill patients with improved impact on the clinical treatment of such patients. OBJECTIVE: To investigate the energy and protein supply of ENT in critically ill in-patients of an Intensive Care Unit (ICU). METHODS: Prospective longitudinal study conducted with 82 critically ill in-patients of an ICU, receiving ENT. Anthropometric variables, laboratory tests (albumin, CRP, CRP/albumin ratio), NUTRIC-score and Nutritional Risk Screening (NRS-2002), energy and protein goals, and the inadequacies and complications of ENT were assessed. Statistical analysis was performed using the Chi-square or Fischer tests and the Wilcoxon test. RESULTS: A total of 48.78% patients were at high nutritional risk based on NUTRIC score. In the CRP/albumin ratio, 85.37% patients presented with a high risk of complications. There was a statistically significant difference (P<0.0001) for all comparisons made between the target, prescription and ENT infusion, and 72% of the quantities prescribed for both calories and proteins was infused. It was observed that the difference between the prescription and the infusion was 14.63% (±10.81) for calories and 14.21% (±10.5) for proteins, with statistically significant difference (P<0.0001). In the relationship between prescription and infusion of calories and proteins, the only significant association was that of patients at high risk of CRP/albumin ratio, of which almost 94% received less than 80% of the energy and protein volume prescribed (P=0.0111). CONCLUSION: The administration of ENT in severely ill patients does not meet their actual energy and protein needs. The high occurrence of infusion inadequacies, compared to prescription and to the goals set can generate a negative nutritional balance

Is total lymphocyte count related to nutritional markers in hospitalized older adults?

ABSTRACT BACKGROUND Older patients are commonly malnourished during hospital stay, and a high prevalence of malnutrition is found in hospitalized patients aged more than 65 years. OBJECTIVE To investigate whether total lymphocyte count is related to other nutritional markers in hospitalized older adults. METHODS Hospitalized older adults (N=131) were recruited for a cross-sectional study. Their nutritional status was assessed by the Nutritional Risk Screening (NRS), anthropometry, and total lymphocyte count. The statistical analyses included the chi-square test, Fisher's exact test, and Mann-Whitney test. Spearman's linear correlation coefficient determined whether total lymphocyte count was correlated with the nutritional markers. Multiple linear regression determined the parameters associated with lymphocyte count. The significance level was set at 5%. RESULTS According to the NRS, 41.2% of the patients were at nutritional risk, and 36% had mild or moderate depletion according to total lymphocyte count. Total lymphocyte count was weakly correlated with mid-upper arm circumference (r=0.20507); triceps skinfold thickness (r=0.29036), and length of hospital stay (r= -0.21518). Total lymphocyte count in different NRS categories differed significantly: older adults who were not at nutritional risk had higher mean and median total lymphocyte count ( P =0.0245). Multiple regression analysis showed that higher lymphocyte counts were associated with higher triceps skinfold thicknesses and no nutritional risk according to the NRS. CONCLUSION Total lymphocyte count was correlated with mid-upper arm circumference, triceps skinfold thickness, and nutritional risk according to the NRS. In multiple regression the combined factors that remained associated with lymphocyte count were NRS and triceps skinfold thickness. Therefore, total lymphocyte count may be considered a nutritional marker. Other studies should confirm these findings