Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a ...careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end‐stage, esophagectomy is the last option to manage recurrent achalasia.
Achalasia: from diagnosis to management Vaezi, Michael F.; Felix, Valter N.; Penagini, Roberto ...
Annals of the New York Academy of Sciences,
October 2016, Letnik:
1381, Številka:
1
Journal Article
Recenzirano
Achalasia is an esophageal motility disorder associated with abnormalities in peristalsis and lower esophageal sphincter (LES) relaxation. The etiology of the disease remains elusive. It is often ...misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia to solids and liquids but may focus on regurgitation as the primary symptom, leading to the early misdiagnosis. Chest pain, weight loss, and occasional vomiting may be additional symptoms encountered in those with achalasia. The disease may be suspected on the basis of clinical presentation, but diagnosis depends on classic findings using high‐resolution manometry, showing either failed or simultaneous contractions with associated normal or high LES pressures with no or incomplete relaxation with swallows. There are no cures for achalasia, and, in most patients, treatments have to be repeated over time. Definitive treatment options in achalasia include pneumatic dilation, surgical myotomy, and the new technique of per‐oral endoscopic myotomy. Botulinum toxin (Botox) or other medical therapies are often reserved for those who cannot have definitive therapies owing to comorbid conditions.
In the cancer of the esophagus, with recent technologic advances, self-expanding metal stents (SEMS) are at the forefront of the armamentarium for re-establishing luminal patency. Weighed against the ...numerous advantages of stents are the import conditions and the cost. In light of this, we tested new low cost prostheses having the basic needs and characteristics to aim a significant benefit to poor people having advanced esophageal cancer, in a Brazilian regional public hospital.
This initial experience included fifteen patients (eleven men and four women, 55 ± 6.17 years old), presenting esophageal cancer, located at the medium third of the thoracic esophagus, extending for 5.5-8 cm long, not suitable for surgical procedure because they had been staged on fourth grade of the disease, two of them having fistula communicating esophagus to respiratory tree. The stents were placed under endoscopic and fluoroscopic guidance, after attempting an esophageal dilatation. An appropriate covered stent was then deployed, twelve of 10 cm and three of 13 cm in length. A chest X-ray was done 2 h after the procedure and a barium swallow was performed within 12 hours. Seven days and monthly until complete a six month follow-up after the procedure the patients were questioned about presence of pain, regurgitation, heartburn, cough, and their alimentary behavior.
There were no severe complications and transient mild chest pain resolved until the seventh day after the stent deployment. Chest X-ray demonstrated expansion of the stent in all patients. In 2 cases of fistula, a barium swallow showed its complete sealing. The completion of the proposed follow-up was not achieved in three cases, limited by the patient's death until the third month, due to cancer progression. Recurrent dysphagia to paste food accounted for by tumor overgrowth proximal or distal to the stent and stent migration were not observed in the series.
The new low cost endoprostheses is effective and forthcoming increased experience and prospective trials including questionnaires to analyze quality of life will allow for more informed decisions tailoring to a particular patient situation or to unexpected complications.
There is a large consensus to preserve the distance of 5 cm above the proximal border of the lower esophageal sphincter (PBLES) as appropriate to the location of the electrode of the pH-metry. The ...main objective of this study is to determine whether placement of the electrode below the recommended location achieves a significant difference in the calculation of the DeMeester score.
The study was made up of 60 GERD patients and 20 control subjects. They were submitted to esophageal manometry and to pH-metric examination with two pH-metric catheters contained antimony electrodes - the distal was positioned 3 cm above the PBLES, leaving the other 5 cm away from it.
LES pressure (LESP) in the GERD group was significantly lower than in the control group (P = 0.005). Normal mean DeMeester score was observed simultaneously in the control group, by both the electrodes, but abnormal DeMeester score was much more expressive when observed by the distal electrode in the GERD group. There were significant differences as for DeMeester score, of patients with GERD from that of the control group and of distal from the proximal electrode in the GERD group.
Acid reflux is directly related to lower levels of LESP. Lower location of the catheter may strongly affect the results of prolonged esophageal pH monitoring in GERD patients.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The indeterminate form of Chagas' disease is characterized by positive serology for the disease in the absence of clinical findings and in the presence of both normal esophagogram and ...electrocardiogram. When more sensitive methods were used, abnormalities have been described either in the esophagus or in the heart. The authors have studied simultaneously the esophagus and the heart in the same subjects. In thirteen adults with diagnosis of indeterminate form and nine adult controls, the esophageal manometry both in basal conditions and after stimulus (bethanecol) and vectorcardiogram were performed. In the control group none of the subjects presented concomitant esophageal and cardiac alterations while in the chagasic group 92,3% of the patients presented results simultaneously altered. It is concluded that the studied patients showed indications of parasympathetic denervation manifested by simultaneously esophageal and heart alterations.
A forma indeterminada da Doença de Chagas é caracterizada por sorologia positiva com ausência de manifestações clínicas, na presença de resultados normais aos exames radiológico do tubo digestivo e eletrocardiográfico. No presente trabalho, os autores estudam simultaneamente o esôfago e o coração, nos mesmos indivíduos. Treze adultos com diagnóstico de forma indeterminada da Doença de Chagas e nove adultos controles foram submetidos ao exame vetorcardiográfico e à manometria esofágica em condições basais e sob estímulo com cloridrato de betanecol (0,08 mg/kg p.c). No grupo controle nenhum dos indivíduos apresentou concomitância de alterações esofágicas e cardíacas, enquanto no grupo chagásico 92,3% dos pacientes apresentaram exames concomitantemente alterados. Concluem que os pacientes estudados apresentam evidências de desnervação parassimpática manifestada por alterações simultâneas esofágicas e cardíacas.
Surgical treatments for esophageal cancers Allum, William H.; Bonavina, Luigi; Cassivi, Stephen D. ...
Annals of the New York Academy of Sciences,
September 2014, Letnik:
1325, Številka:
1
Conference Proceeding, Journal Article
Recenzirano
Odprti dostop
The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients ...who develop high‐grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long‐term quality of life in patients following esophagectomy.
Cancer heterogeneity at the proteome level may explain differences in therapy response and prognosis beyond the currently established genomic and transcriptomic-based diagnostics. The relevance of ...proteomics for disease classifications remains to be established in clinically heterogeneous cancer entities such as chronic lymphocytic leukemia (CLL). Here, we characterize the proteome and transcriptome alongside genetic and ex-vivo drug response profiling in a clinically annotated CLL discovery cohort (n = 68). Unsupervised clustering of the proteome data reveals six subgroups. Five of these proteomic groups are associated with genetic features, while one group is only detectable at the proteome level. This new group is characterized by accelerated disease progression, high spliceosomal protein abundances associated with aberrant splicing, and low B cell receptor signaling protein abundances (ASB-CLL). Classifiers developed to identify ASB-CLL based on its characteristic proteome or splicing signature in two independent cohorts (n = 165, n = 169) confirm that ASB-CLL comprises about 20% of CLL patients. The inferior overall survival in ASB-CLL is also independent of both TP53- and IGHV mutation status. Our multi-omics analysis refines the classification of CLL and highlights the potential of proteomics to improve cancer patient stratification beyond genetic and transcriptomic profiling.
This paper presents commentaries on neoadjuvant treatment esophagectomy; the prognostic and predictive effects of single nucleotide polymorphisms (SNP) in the multimodality therapy of esophageal ...cancer; optimal preoperative treatment prior to surgery for esophageal cancer; a possible role for trastuzumab in treating esophageal adenocarcinoma or any esophageal dysplasia/intra‐epithelial neoplasia; surgery after chemoradiation in resectable esophageal cancer; whether para‐aortic lymph node dissection should be performed in esophagogastric junction (EGJ) tumors; and transhiatal esophagectomy in treatment of the esophageal cancer
Despite the progressive development of technology and better knowledge of physiopathology, GERD diagnosis remains a medical problem. The aim of the study is to verify whether the measurement of bile ...reflux can increase the diagnostic accuracy of GERD.
6 healthy volunteers adhered to a standard protocol, 11 Barrett's patients and 15 GERD patients (endoscopic erosive esophagitis) were fasted for 6 h before any examinations and the patients ceased acid suppression medications 72 h earlier. Manometric study was performed to localize the LES. Then The Bilitec 2000 fiberoptic probe (Synectics, Medtronics) and an antimony pH probe attached to a Digitrapper Mark III pH recorder (Synectics, Medtronics), together, were inserted through the nostril and positioned 5cm above the LES. They received an uncolored diet and after around 24 h, both Bilitec and pH data were downloaded simultaneously to a personal computer for analysis, using the Synectics software. Absorbance threshold was set at 0.14 absorbance units and acceptable esophageal pH at 4, to verify fraction of time of bile reflux (absorbance > 0.14) and DeMeester score.
Except controls, in whom DeMeester and Johnson scoring and fraction time of absorbance were always normal, all patterns of combined results were observed in GERD and Barrett's patients, showing possibilities of "normal" pHmetry in patients with detectable bile reflux, normal fraction time of absorbance with pathologic pH recording and both normal in GERD (40%) and Barrett's patients (only 18%).
This study showed that Bilitec measurements combined with 24-hour monitoring of intraluminal pH can offer other diagnostic and screening contributions in GERD and Barrett's patients, but cases of normal pHmetry and spectrophotometry demonstrate that none is definitive in characterization of reflux.
The purpose of this survey was to describe the occurrence of bovine mastitis caused by Prototheca zopfii in Goiás State, Brazil. Samples of milk, environment and udder were taken from a herd of 120 ...Holstein cows. Sabourauds dextrose agar plates were incubated under aerobic conditions at 37 degrees C/96 h, for microbiological analysis. Somatic cell count and milk composition were also determined. Histological sections from two udders were stained with HE and PAS. Prototheca zopfii was identified in six cows whose milk had a watery appearance. They also showed a pronounced decrease in milk yield, fat and lactose. Pronounced infiltration of mononuclear cells, atrophy of alveoli and fibrosis were observed. The presence of this agent in other herds in the State is highly likely.
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