Análise das complicações da esofagectomia transmediastinal no tratamento cirurgico do megaesôfago recidivado

Abstract

headings -Esophagectomy. Esophageal ahalasia.abstRact -Background -The best option for the treatment of patients with achalasia and recurrent symptoms after previous treatment, has always been very controversial. In literature review, there is no surgical technique considered the best to deal with this condition. The idea to use a more selective treatment with transmediastinal esophagectomy without thoracotomy in patients with advanced megaesophagus in relapsed cases after prior cardiomyotomy can be considered. Aim -To evaluate the results of transmediastinal esophagectomy in recurrent megaesophagus regarding local and systemic complications. Methods -Thrity two patients were treated with recurrent symptoms after previous surgery to achalasia and indication for esophagectomy with gastric transmediastinal transposition through the posterior mediastinum for grade IV megaesophagus. They were 25 men (78.1%) and seven women (21.9%), aged from 34 to 72 years. All underwent previous myotomy varying from five to 39 years to the day of transmediastinal esophagectomy. Results -Some patients had complications. Among these, eight had pulmonary infection (25.0%) resulting in good outcome to the specific clinical treatment; two died due to hemodynamic effect caused by injury to the azygos vein and the other due to trachea injury; nine (28.1% ) had cervical esophagogastric anastomotic dehiscence doing well with conservative treatment. Of the 21 patients in whom monitoring was carried out in the long term -six months to 14 years -, 17 reported good swallowing solids and pastes, four (19.0%) had gastroesophageal reflux with clinical improvement with specific medical treatment. Conclusions -Transmediastinal esophagectomy, although providing adequate swallowing in most cases, is a procedure of high morbidity. This technique should not be recommended as first treatment option for relapsed megaesophagus.Resumo -Racional -A melhor opção para o tratamento dos pacientes com megaesôfago e recidiva de sintomas após tratamento prévio sempre foi muito controversa. Em resultados de trabalhos analisados, não há seleção da técnica cirúrgica mais adequada para a doença. Assim, surge a ideia de se realizar um estudo mais seletivo com esofagectomia transmediastinal sem toracotomia em pacientes com megaesôfago avançado recidivado após cardiomiotomia prévia. Objetivo -Avaliar os resultados da esofagectomia transmediastinal no megaesôfago recidivado quanto às complicações sistêmicas e locais. Método -Trinta e dois pacientes foram atendidos todos com recidiva de sintomas após operação prévia e indicação para esofagectomia transmediastinal com transposição gástrica pelo mediastino posterior por apresentarem megaesôfago grau IV.

Non-conventional surgical approach to achalasia: mucosectomy and endomuscular pull-through

“…Other objective of this described technique is to resect the esophageal mucosa that frequently shows inflammatory findings due to long-term food stasis and brings a risk for malignization between 3% to 10% according to different series [14,15,19] . Cancer was not observed in the resected mucosa in our series but severe inflammation was noticed in all cases and leukoplakia in 15.7%.…”

“…Pleural and tracheal injury, as well as hemorrhage, may occur during mediastinal dissection due to severe periesophagitis leading to adhesions between the esophagus and mediastinal structures. It is also well known that stasis esophagitis observed in endstage disease predisposes to premalignant lesions or even carcinoma [14][15][16][17] . Based on this premises, the idea of striping the esophageal mucosa and submucosa through cervical and abdominal incisions in the absence of thoracotomy came to mind.…”

Surgical treatment analysis of idiopathic esophageal achalasia

“…However, in a more critical analysis, it has been demonstrated that this technique is not free from complications. Among them, it can be emphasized pleuromediastinal complications translated to hemomediastinum and hemothorax, which can contribute to great morbidity in the postoperative time 5 , 20 . This can happen, as the advanced megaesophagus presents periesophagitis, making this organ adhere to important structures of the mediastinum, which may predispose lesions during dissection.…”

Comparative Analysis of Late Results of Cervical Esophagogastric Anastomosis by Manual and Mechanical Suture in Patients Submitted to Esophageal Mucosectomy Through Advanced Megaesophagus

“…As it has been demonstrated by several authors for many years, the best therapy is esophagectomy without thoracotomy 13 , as it acts directly in the physiopathology of this disease, being the transmediastinal technique proposed by Pinotti the most used 5 , 8 , 22 , 23 . More recently with the advent of minimally invasive surgery, this resection can be performed by videolaparoscopy 12 , 29 .…”

“…More recently with the advent of minimally invasive surgery, this resection can be performed by videolaparoscopy 12 , 29 . In a more critical analysis; however, it has been demonstrated that transmediastinal esophageal resection is not free from complications which may contribute to greater morbidity in the postoperative 8 , 10 , 19 . This may occur, as the advanced megaesophagus presents periesophagitis leading to the adherence to mediastinal structures predisposing and complications.…”