NEOADJUVANT CHEMORADIOTHERAPY FOLLOWED BY TRANSHITAL ESOPHAGECTOMY IN LOCALLY ADVANCED ESOPHAGEAL SQUAMOUS CELL CARCINOMA: IMPACT OF PATHOLOGICAL COMPLETE RESPONSE

BACKGROUND

Multimodal therapy with neoadjuvant chemoradiotherapy, followed by esophagectomy has offered better survival results, compared to isolated esophagectomy, in advanced esophageal cancer. In addition, patients who have a complete pathological response to neoadjuvant treatment presented greater overall survival and longer disease-free survival compared to those with incomplete response.

AIM

To compare the results of overall survival and disease-free survival among patients with complete and incomplete response, submitted to neoadjuvant chemoradiotherapy, with two therapeutic regimens, followed by transhiatal esophagectomy.

METHODS

Retrospective study, approved by the Research Ethics Committee, analyzing the medical records of 56 patients with squamous cell carcinoma of the esophagus, divided into two groups, submitted to radiotherapy (5040 cGY) and chemotherapy (5-Fluorouracil + Cisplatin versus Paclitaxel + Carboplatin) neoadjuvants and subsequently to surgical treatment, in the period from 2005 to 2012, patients.

RESULTS

The groups did not differ significantly in terms of gender, race, age, postoperative complications, disease-free survival and overall survival. The 5-year survival rate of patients with incomplete and complete response was 18.92% and 42.10%, respectively (p> 0.05). However, patients who received Paclitaxel + Carboplatin, had better complete pathological responses to neoadjuvant, compared to 5-Fluorouracil + Cisplatin (47.37% versus 21.62% - p = 0.0473, p <0.05).

CONCLUSIONS

There was no statistical difference in overall survival and disease-free survival for patients who had a complete pathological response to neoadjuvant. Patients submitted to the therapeutic regimen with Paclitaxel and Carboplastin, showed a significant difference with better complete pathological response and disease progression. New parameters are indicated to clarify the real value in survival, from the complete pathological response to neoadjuvant, in esophageal cancer.

Surgical treatment of relapsed megaesophagus

OBJECTIVE

to analyze the surgical treatment of patients with recurrent megaesophagus followed at the esophageal-stomach-duodenal outpatient clinic of the Hospital de Clínicas - UNICAMP.

METHODS

a retrospective study, from 2011 to 2017, with 26 patients with Chagas or idiopathic megaesophagus, surgically treated, and who recurred with dysphagia. Clinical, endoscopic and radiographic aspects were assessed and correlated with the performed surgical procedures.

RESULTS

50% had dysphagia for liquids, 69% regurgitation, 65.3% heartburn, 69.2% weight loss and 69.2% had Chagas disease. In addition, 38.4% had megaesophagus stage 1 and 2 and 61.5% stage 3 and 4. Regarding the reoperations, 53% of them underwent Heller-Pinotti surgery by laparoscopy, Serra-Dória in 30.7% and esophageal mucosectomy in 7.9%. In 72% of the reoperations there were no postoperative complications, and 80% of the patients had a good outcome, with reduction or elimination of dysphagia. Among the reoperated patients undergoing the laparoscopic Heller-Pinotti technique, three reported little improvement of dysphagia in the postoperative period and among those who underwent Serra-Dória surgery, 100% had no dysphagia. It was observed that, when the time between the first procedure and the reoperation was longer, the better the surgical result was, with statistical significant decreased dysphagia (p=0.0013, p<0.05).

CONCLUSIONS

there was a preference to perform laparoscopic re-miotomy and, as a second option, Serra-Dória surgery, for patients with recurrent megaesophagus. Esophagectomy or esophageal mucosectomy were reserved for more severe patients.

Total esophagogastrectomy in the neoplasms of the esophagus and esofagogastric junction: when must be indicated?

OBJECTIVE

to analyse the indications and results of the total esophagogastrectomy in cancers of the distal esophagus and esophagogastric junction.

METHODS

twenty patients with adenocarcinomas were operated with a mean age of 55 ± 9.9 years (31-70 years), and 14 cases were male (60%). Indications were 18 tumors of the distal esophagus and esophagogastric junction (90%) and two with invasion of gastric fundus (10%) in patients with previous gastrectomy. Preoperative colonoscopy to exclude colonic diseases was performed in ten cases.

RESULTS

the surgical technique consisted of median laparotomy and left cervicotomy, followed by transhiatal esophagectomy associated with D2 lymphadenectomy. The reconstructions were performed with eight esophagocoloduodenoplasty and the others were Roux-en-Y esophagocolojejunoplasty to prevent the alkaline reflux. Three cases were stage I / II, while 15 cases (85%) were stages III / IV, reflecting late diagnosis of these tumors. The operative mortality was 5 patients (25%): a mediastinitis secondary to necrosis of the transposed colon, abdominal cellulitis secondary to wound infection, severe pneumonia, an irreversible shock and sepsis associated with colojejunal fistula. Four patients died in the first year after surgery: 3 (15%) were due to tumor recurrence and 1 (5%) secondary to bronchopneumonia. The 5-year survival was 15%.

CONCLUSION

the total esophagogastrectomy associated with esophagocoloplasty has high morbidity and mortality, requiring precise indication, and properly selected patients benefit from the surgery, with the risk-benefit acceptable, contributing to increased survival and improved quality of life.

Obstructive Gastric Pseudotumor Caused by Cytomegalovirus in an AIDS Patient: A Case Report and Review of Surgical Treatment

BACKGROUND

Cytomegalovirus (CMV) is a common opportunistic pathogen in patients with HIV. It is also a major cause of gastrointestinal ulcers in patients with acquired immunodeficiency syndrome (AIDS). CMV pseudotumor in the stomach is a rare cause of digestive tract obstruction.

CASE REPORT

In this study we report a male patient infected with HIV in 2002. In 2014 he evolved C3 stage AIDS with pre-pyloric gastric ulcer which provoked deformity and pseudotumoral aspect of the gastric outlet. Endoscopic biopsy confirmed CMV infection. He underwent Roux-en-Y gastroenteroanastomosis with good recovery.

CONCLUSIONS

CMV infection should be considered as an agent in gastric lesions in HIV-infected patients. Roux-en-Y gastroenteroanastomosis is a surgical option for this group of patients, allowing improvements in quality of life and decreasing risks of perioperative complications.

Surgical gastrostomy: current indications and complications in a university hospital

OBJECTIVE

To analyze the surgical gastrostomies performed at a public University Hospital, their indications and complications.

METHODS

We conducted a retrospective, nonrandomized review of medical records of patients who underwent surgical gastrostomy from 2007 to 2011;

RESULTS

, In the period of studied, 86 patients underwent surgical gastrostomies for enteral nutrition. The Stamm technique was employed in all cases. Men constituted 76 (88%) of the cases and the mean age was 58.4 years, the maximum age being 87 years and the minimum 19. We observed 16 (18.60%) minor complications, 17 (19.76%) serious complications and 8 (9.3%) perioperative deaths.

CONCLUSION

Surgical gastrostomy, while considered a smaller procedure, is not without complications and mortality. The Stamm technique, despite the complications reported, is easy to perform and to handle, as well as safe.

Local effectiveness and complications of neoadjuvant therapy in esophageal squamous cell carcinoma: radiotherapy versus chemoradiotherapy

OBJECTIVE

To evaluate tumor responses to neoadjuvant therapy, according to the histopathological findings of surgical specimens of patients operated and treated for squamous cell carcinoma of the middle third and distal esophagus.

METHODS

We conducted a retrospective nonrandomized study including 97 patients distributed as follows: Group I - 81 (83.5%) underwent neoadjuvant radiation therapy, and group II - 16 (16.5%) underwent neoadjuvant radiotherapy and chemotherapy. A third group of 26 patients undergoing esophagectomy alone was used for comparison of postoperative complications. The characteristics of each patient (age, gender and race), tumor site, staging, and histological evaluation of treatment modalities were reviewed and analyzed. Tumor response to neoadjuvant therapy was evaluated by histopathology of the specimen.

RESULTS

There was no statistically significant differences regarding race, gender, age, staging and postoperative complications in patients in the three groups. Patients undergoing radiotherapy and neoadjuvant chemotherapy showed more satisfactory tumor reduction, with improved local efficacy when compared to the group only submitted to neoadjuvant radiotherapy.

CONCLUSION

The study suggests that radiotherapy combined with chemotherapy was more efficient in reducing tumor site when compared to the group treated with radiotherapy. In addition, neoadjuvant therapy did not increase the postoperative complications when compared to patients undergoing surgery alone.