Miotomia laparoscopica secondo Heller per acalasia esofagea. C’è bisogno di una fundoplicatio?

The last decade has witnessed radical changes in the treatment of esophageal achalasia due to the development of minimally invasive techniques. Because of the high success rate of the laparoscopic Heller myotomy, a radical shift in the treatment algorithm of these patients has occurred, and today this is the preferred treatment modality for achalasia. This remarkable change is due to the recognition by gastroenterologists and patients that a laparoscopic Heller myotomy outperforms pneumatic dilatation and intra-sphincteric injection of botulinum toxin injection. While there is agreement about the technique of the myotomy per se, some questions still linger about the need for a fundoplication after the myotomy. The following review describes the data present in the literature in order to identify the best procedure that can achieve relief of dysphagia while avoiding development of gastroesophageal reflux

Riparazione laparoscopica delle ernie paraesofagee: un approccio “evidence-based”

The approach to paraesophageal hernias has drastically changed over the last decade. The goal of this paper is to describe in detail our surgical technique of laparoscopic repair of paraesophageal hernias and to provide an evidence-based approach to the most controversial aspects of this type of repair

Primary Esophageal Motility Disorders: Beyond Achalasia

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders. The Chicago classification introduced new manometric parameters and better defined esophageal motility disorders. Motility disorders beyond achalasia with the current classification are: esophagogastric junction outflow obstruction, major disorders of peristalsis (distal esophageal spasm, hypercontractile esophagus, absent contractility) and minor disorders of peristalsis (ineffective esophageal motility, fragmented peristalsis). The aim of this study was to review the current diagnosis and management of esophageal motility disorders other than achalasia

Understanding the Chicago Classification: From Tracings to Patients

Current parameters of the Chicago classification include assessment of the esophageal body (contraction vigour and peristalsis), lower esophageal sphincter relaxation pressure, and intra-bolus pressure pattern. Esophageal disorders include achalasia, esophagogastric junction outflow obstruction, major disorders of peristalsis, and minor disorders of peristalsis. Sub-classification of achalasia in types I, II, and III seems to be useful to predict outcomes and choose the optimal treatment approach. The real clinical significance of other new parameters and disorders is still under investigation

Anatomic variations in the surgical anatomy of the thoracic esophagus and its surrounding structures

BACKGROUND: Esophagectomy is a challenging procedure due to: a) it is a complex operation; b) it is linked to very high morbidity and mortality rates; c) surgical anatomy of the esophagus is very peculiar. The anatomic variations that can be unexpectedly found during an operation may cause complications and influence the outcome. AIM: To review the anatomic basis for esophagectomy focusing on anatomic variations found in the mediastinal structures based on literature review and cadaver dissection. METHODS: Literature related to the surgical anatomy of the esophagus and mediastinal structures was reviewed. Also, a total of 20 fresh (non-embalmed, non-preserved, time of death under 12 h) human cadavers were dissected. There were 16 male and mean age was 53 ± 23 years. RESULTS: Anatomic variations for aorta, azygos system, pleura, vagus nerve, lymph nodes and thoracic duct were documented. CONCLUSIONS: The organs and structures of the mediastinum may frequently present anatomic variations. Some of these may be clinically significant during an esophagectomy. Because only a part of them may be identified before the operation with the current imaging tools, surgeons must be aware of these anatomic variations.RACIONAL: A esofagectomia é procedimento difícil, devido a: a) ser operação complexa; b) apresentar alta morbidade e mortalidade; c) a anatomia cirúrgica do esôfago é muito peculiar. As variações anatômicas que podem ser encontradas inesperadamente durante uma operação podem causar complicações e influenciar os resultados. OBJETIVO: Revisar a base anatômica para esofagectomia destacando as variações encontradas nas estruturas mediastinais através de revisão de literatura e dissecção de cadáveres. MÉTODOS: A literatura relacionada com a anatomia cirúrgica das estruturas esôfago e mediastino foi revista. Além disso, um total de 20 cadáveres humanos frescos (não embalsamados, não preservados e com tempo de morte com menos de 12 h) foram dissecados. Dezesseis eram do sexo masculino com idade média de 53±23 anos. RESULTADOS: Variações anatômicas de aorta, sistema ázigos, pleura, nervo vago, linfonodos e ducto torácico foram documentadas. CONCLUSÕES: Os órgãos e estruturas do mediastino podem, frequentemente, apresentar variações anatômicas. Algumas delas podem ser clinicamente significativas durante esofagectomia. Devido a que apenas uma parte dessas variações são identificadas antes da operação com os meios de imagens atuais, os cirurgiões devem estar cientes da possibilidade dessas variações anatômicas.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de CirurgiaUniversity of Chicago Pritzker School of Medicine Department of SurgeryUNIFESP, EPM, Depto. de CirurgiaSciEL

The Intersection of GERD, Aspiration, and Lung Transplantation

Lung transplantation is a radical but life-saving treatment option for patients with end-stage lung diseases, such as idiopathic pulmonary fibrosis (IPF) and scleroderma. In light of the proposed association and controversy linking gastroesophageal reflux disease (GERD) to IPF and lung transplant outcome, the American Gastroenterological Association convened during the DDW in Washington in May 2015 a multidisciplinary group of experts in the field of GERD and lung transplantation to make considerations about the care of these patients based on available data and subsequent expert panel discussion at this symposium. The following topics were discussed: (1) pathophysiology of GERD-induced pulmonary symptoms, (2) GERD evaluation before and after lung transplantation, (3) outcome of lung transplantation for IPF and scleroderma, and (4) role of laparoscopic fundoplication before or after lung transplantation

High-resolution Manometry Findings in Patients After Sclerotherapy for Esophageal Varices

Background/Aims Endoscopic therapy for esophageal varices may lead to esophageal dysmotility. High-resolution manometry is probably the more adequate tool to measure esophageal motility in these patients. This study aimed to evaluate esophageal motility using high resolution manometry following eradication of esophageal varices by endoscopic sclerotherapy. Methods We studied 21 patients (11 women, age 52 [45-59] years). All patients underwent eradication of esophageal varices with endoscopic sclerotherapy and subsequent high resolution manometry. Results A significant percentage of defective lower esophageal sphincter (basal pressure 14.3 [8.0-20.0] mmHg43% hypertonic) and hypocontractility (distal esophageal amplitude 50 [31-64] mmHgproximal esophageal amplitude 40 [31-61] mmHgdistal contractile integral 617 [403-920] mmHg center dot sec center dot cm48% ineffective) was noticed. Lower sphincter basal pressure and esophageal amplitude correlated inversely with the number of sessions (P < 0.001). No manometric parameter correlated with symptoms or interval between last endoscopy and manometry. Conclusions Esophageal motility after endoscopic sclerotherapy is characterized by: (1) defective lower sphincter and (2) defective and hypotensive peristalsis. Esophageal dysmotility is associated to an increased number of endoscopic sessions, but manometric parameters do not predict symptoms.Univ Fed Sao Paulo, Escola Paulista Med, Dept Surg, Sao Paulo, BrazilUniv Chicago, Dept Surg, 5841 S Maryland Ave, Chicago, IL 60637 USAUniv Fed Sao Paulo, Escola Paulista Med, Dept Surg, Sao Paulo, BrazilWeb of Scienc

Characterization of Mentorship Programs in Departments of Surgery in the United States

Importance Mentorship is considered a key element for career satisfaction and retention in academic surgery. Stakeholders of an effective mentorship program should include the mentor, the mentee, the department, and the institution. Objective The objective of this study was to characterize the status of mentorship programs in departments of surgery in the United States, including the roles of all 4 key stakeholders, because to our knowledge, this has never been done. Design, Setting, and Participants A survey was sent to 155 chairs of departments of surgery in the United States in July 2014 regarding the presence and structure of the mentorship program in their department. The analysis of the data was performed in November 2014 and December 2014. Main Outcomes and Measures Presence and structure of a mentorship program and involvement of the 4 key stakeholders. Results Seventy-six of 155 chairs responded to the survey, resulting in a 49% response rate. Forty-one of 76 of department chairs (54%) self-reported having an established mentorship program. Twenty-five of 76 departments (33%) described no formal or informal pairing of mentors with mentees. In 62 (82%) and 59 (78%) departments, no formal training existed for mentors or mentees, respectively. In 42 departments (55%), there was no formal requirement for the frequency of scheduled meetings between the mentor and mentee. In most departments, mentors and mentees were not required to fill out evaluation forms, but when they did, 28 of 31 were reviewed by the chair (90%). In 70 departments (92%), no exit strategy existed for failed mentor-mentee relationships. In more than two-thirds of departments, faculty mentoring efforts were not recognized formally by either the department or the institution, and only 2 departments (3%) received economic support for the mentoring program from the institution. Conclusions and Relevance These data show that only half of departments of surgery in the United States have established mentorship programs, and most are informal, unstructured, and do not involve all of the key stakeholders. Given the importance of mentorship to career satisfaction and retention, development of formal mentorship programs should be considered for all academic departments of surgery

A pressão do esfíncter esofagiano superior varia durante a manometria esofágica

BACKGROUND:The upper esophageal sphincter is composed of striated muscle. The stress of intubation and the need to inhibit dry swallows during an esophageal manometry test may lead to variations in basal pressure of this sphincter. Upper esophageal sphincter is usually only studied at the final part of the test. Was observed during the performance of high resolution manometry that sphincter pressure may vary significantly over the course of the test.AIM:To evaluate the variation of the resting pressure of the upper esophageal sphincter during high resolution manometry.METHODS:Was evaluated the variation of the basal pressure of the upper esophageal sphincter during high resolution manometry. Were reviewed the high resolution manometry tests of 36 healthy volunteers (mean age 31 years, 55% females). The basal pressure of the upper esophageal sphincter was measured at the beginning and at the end of a standard test.RESULTS:The mean time of the test was eight minutes. The basal pressure of the upper esophageal sphincter was 100 mmHg at the beginning of the test and 70 mmHg at the end (p<0.001). At the beginning, one patient had hypotonic upper esophageal sphincter and 14 hypertonic. At the end of the test, one patient had hypotonic upper esophageal sphincter (same patient as the beginning) and seven hypertonic upper esophageal sphincter.CONCLUSION:A significant variation of the basal pressure of the upper esophageal sphincter was observed in the course of high resolution manometry. Probably, the value obtained at the end of the test may be more clinically relevant.RACIONAL:O esfíncter esofagiano superior é constituído de musculatura estriada. O estresse da intubação e a necessidade de coibir as deglutições secas durante a manometria esofágica podem alterar a pressão basal do esfíncter esofagiano superior que geralmente é estudado somente ao final da manometria convencional. Notou-se na manometria de alta resolução significante variação no decorrer do exame.OBJETIVO:Avaliar a variação da pressão basal do esfíncter esofagiano superior durante a manometria de alta resolução.MÉTODO:Foi avaliada a variação de pressão basal do esfíncter esofagiano superior durante manometria de alta resolução. Foram estudados 36 voluntários sadios (idade média de 31 anos, 55% de mulheres). A pressão basal foi aferida no início e ao término do exame.RESULTADOS:O tempo médio dos exames foi de oito minutos. A pressão basal do esfíncter esofagiano superior foi de 100 mmHg no início do exame e de 70 mmHg ao final, em média (p<0.001). No início do teste, um paciente tinha o esfíncter esofagiano superior hipotônico e 14 hipertônicos. No final, um paciente tinha o esfíncter esofagiano superior hipotônico (o mesmo do início) e sete hipertônicos.CONCLUSÃO:Há significante variação na pressão basal do esfíncter esofagiano superior no curso manometria de alta resolução. Provavelmente, o valor obtido ao final do exame possa ser mais clinicamente relevante.Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM) Department of SurgeryUniversity of Chicago Department of SurgeryUNIFESP, EPM, Department of SurgerySciEL