RESUMO

INTRODUCTION: esophageal replacement in children is indicated when it is impossible to maintain the native esophagus, which in the pediatric population includes patients with esophageal atresia and esophageal caustic stenosis. The objective of this communication is to report the experience of a university service with two techniques of esophageal replacement. METHODS: this is a retrospective study based on the revision of hospital files. The study population consisted of patients who underwent esophageal replacement from 1995 to 2022, at the Hospital de Clínicas of the State University of Campinas. The analyzed data were age, sex, underlying disease, technical aspects, complications, and long-term results. RESULTS: during the study period, 30 patients underwent esophageal replacement. The most common underlying diseases were esophageal atresia (73.33%) and caustic stenosis (26.67%). Twenty-one patients underwent gastric transposition (70%), and nine underwent esophagocoloplasty (30%). The most frequent postoperative complication was fistula of the proximal anastomosis, which occurred in 14 patients. Most of the patients with fistulas had a spontaneous recovery. There were three deaths. Of the 27 survivors, 24 can feed exclusively by mouth. CONCLUSION: esophageal replacement in children is a procedure with high morbidity and mortality. Esophagocoloplasty and gastric transposition have similar results and complications, with the exception of proximal anastomotic fistulas, which are generally self-resolving and are more common in esophagocoloplasty. The choice of the best surgical technique must be individualized according to the patients characteristics and the surgeons experience, as both techniques offer the ability to feed orally in the short or medium term.

Assuntos

RESUMO

BACKGROUND: Caustic ingestion is still a health problem of utmost importance in the West. In developing countries, this incident remains at increase and it is associated with unfavorable factors like social, economic, and educational handicaps, besides a lack of prevention. Esophagocele is a rare consequence of caustic ingestion. AIM: We aimed to describe a patient with multiple caustic ingestions who presented an esophagocele resected by videothoracoscopy. METHODS: A woman ingested caustic soda when she was only 17 years old in a suicidal attempt during a depressive crisis. Initially, she was submitted to a retrosternal esophagocoloplasty with the maintenance of her damaged esophagus. After 1 year of this first surgery, she ingested caustic soda again in a new suicidal attempt. Her transposed large bowel in the first surgery became narrow, being replaced in a second surgery by a retrosternal esophagogastroplasty. Still, at the second surgery, her damaged esophagus remained in its original position in the posterior mediastinum. However, after 5 years, she developed an esophagocele. RESULTS: The esophagocele was resected through videothoracoscopy in a prone position, employing four trocars. The postoperative was uneventful. CONCLUSION: Esophageal exclusion must always be recorded because esophagocele presents unspecific symptoms. The videothoracoscopy in a prone position is an excellent technical option to resect esophagoceles.

Assuntos

RESUMO

Introduction: Chemical substances are important causes of gastrointestinal tract injuries and usually affect two groups of patients: children under 5 years of age and adults who attempt suicide. Its effects can range from necrosis to perforation of the digestive tract, which can affect the mouth, pharynx, esophagus and stomach. The main complication of accidental caustic ingestion is esophageal stricture. The frequency with which esophageal strictures appear ranges from 15% to 35% and is related to the degree of injury induced by the ingested agent. They may become symptomatic by the second or third week after a latent repair phase or, in other cases, months or years after ingestion. Different forms of treatment have been applied to treat caustic esophageal strictures, and endoscopic dilation is the first line, with successful results in 60% to 80% of patients. If these are not effective, surgical treatment for esophageal replacement is indicated. Clinical Case: A clinical case of a 48-year-old male patient with no chronic degenerative history is presented, who began suffering after accidental ingestion of caustic substance 4 months ago with dysphagia to liquids and solids, for which he is protocolized in our unit for definitive surgical resolution by gastric pull-up. Conclusions: Although associated with high rates of anastomotic stricture, transhiatal esophagectomy and gastric pull-up with cervical anastomosis are safe procedures for the treatment of caustic esophageal strictures.

Introducción: las sustancias químicas son causas importantes de lesiones del tracto gastrointestinal y suelen afectar a dos grupos de pacientes: los niños menores de 5 años y los adultos que intentan el suicidio. Sus efectos pueden variar, desde la necrosis hasta la perforación del tubo digestivo, que puede afectar la boca, faringe, esófago y estómago. La principal complicación de la ingesta accidental de cáusticos es la estenosis esofágica. La frecuencia con la que aparecen las estenosis esofágicas oscila entre el 15 y el 35% y se relaciona con el grado de lesión inducida por el agente ingerido. Pueden hacerse sintomáticas hacia la segunda o tercera semanas después de una fase latente de reparación o, en otros casos, meses o años después de la ingesta. Diferentes formas de tratamiento se han aplicado para tratar las estenosis esofágicas por cáusticos, y en primera línea está la dilatación endoscópica, con resultados exitosos en el 60 a 80% de los pacientes. Si estas no son efectivas se indica el tratamiento quirúrgico de reemplazo esofágico. Caso clínico: se presenta el caso clínico de un paciente masculino de 48 años de edad sin antecedentes crónico-degenerativos, el cual inicia padecimiento tras la ingesta accidental de sustancia cáustica hacía 4 meses, con disfagia a líquidos y sólidos, por lo que es protocolizado en nuestra unidad para resolución quirúrgica definitiva mediante ascenso gástrico. Conclusiones: aunque se asocia con tasas altas de estenosis anastomótica, la esofagectomía transhiatal y el ascenso gástrico con anastomosis cervical son procedimientos seguros para el tratamiento de estenosis esofágicas por sustancias cáusticas.

Assuntos

RESUMO

Esophageal stenosis is a morphofunctional alteration that causes inflammatory lesion in the submucosal and muscular layers of the esophagus, inducing them to fibrosis and altering the esophageal diameter. The present report addresses the use of a balloon dilator as an auxiliary way to correct esophageal stenosis in a canine, female, Pug patient, with a history of recurrent vomiting as the main complaint. Through endoscopy, it was observed that the thoracic esophagus was inflamed, with thickened and fibrotic mucosa, in addition to whitish colored fibrous rings, which hindered the passage of the probe, enabling the determination of the diagnosis of esophageal stenosis. In this report, we opted for the use of a dilator balloon, with three procedures being performed one week apart, to improve the symptomatic condition. After the dilator procedure, the favorable development of the clinical condition presented by the patient was possible.

A estenose esofágica é uma alteração morfofuncional que ocasiona em lesão inflamatória das camadas submucosa e muscular do esôfago, induzindo-as a fibrose e que altera o diâmetro esofágico. O presente relato aborda a utilização de balão dilatador, como forma auxiliar de correção de estenose esofágica em paciente canino, fêmea, da raça Pug, apresentando histórico de vômitos recorrentes como queixa principal. Por meio da endoscopia, observou-se que o esôfago torácico estava inflamado, com a mucosa espessada e fibrótica, além de anéis fibrosos de coloração esbranquiçada, o que dificultava a passagem da sonda, possibilitando a determinação do diagnóstico de estenose esofágica. Nesse relato, optou-se pelo uso do balão dilatador, sendo feitos três procedimentos intervalados de uma semana entre eles, para a melhora da condição sintomática. Após o procedimento dilatador, foi possível o desenvolvimento favorável do quadro clínico apresentado pela paciente.

La estenosis esofágica es una alteración morfofuncional que provoca una lesión inflamatoria en las capas submucosas y musculares del esófago, induciéndolas a la fibrosis y alterando el diámetro esofágico. El presente informe aborda el uso de un dilatador de balón como vía auxiliar para corregir la estenosis esofágica en un paciente canino, hembra, Pug, con antecedentes de vómitos recurrentes como principal síntoma. Mediante endoscopia se observó que el esófago torácico estaba inflamado, con mucosa engrosada y fibrótica, además de anillos fibrosos de color blanquecino, lo que dificultaba el paso de la sonda, lo que permitía determinar el diagnóstico de estenosis esofágica. En este informe se optó por el uso de balón dilatador, realizándose tres procedimientos con una semana de diferencia, para mejorar la condición sintomática. Tras el procedimiento dilatador, fue posible el desarrollo favorable del cuadro clínico presentado por el paciente.

Assuntos

RESUMO

An 83-year-old female patient presented to the Emergency Department with shortness of breath, difficulty swallowing and left-sided chest pain following a vomiting attempt. A rupture in the left lower third of the esophagus, with hydropneumothorax, pneumomediastinum, and subcutaneous emphysema was revealed by chest X-ray, thoracic computed tomography scan, and contrast esophagography. The patient was successfully treated conservatively with closed thoracostomy, intravenous fluids, parenteral nutrition, and broad-spectrum antibiotics coverage. Following the successful conservative treatment, the patient developed a distal esophageal stenosis which was treated with an intra-esophageal self-expanding stent.

Una paciente de 83 años acudió al Servicio de Urgencias con disnea, dificultad para tragar y dolor en el lado izquierdo del pecho tras un intento de vómito. Una rotura en el tercio inferior izquierdo del esófago, con hidroneumotórax, neumomediastino y enfisema subcutáneo fue revelada por radiografía de tórax, tomografía computarizada de tórax y esofagografía con contraste. El paciente fue tratado con éxito de manera conservadora con toracostomía cerrada, líquidos intravenosos, nutrición parenteral y cobertura de antibióticos de amplio espectro. Tras el exitoso tratamiento conservador, el paciente desarrolló una estenosis esofágica distal que fue tratada con un stent autoexpandible intraesofágico.

Assuntos

RESUMO

Congenital esophageal stenosis (CES) is a very rare clinical condition found in 1 per 25,000 to 50,000 live births. There are three histological types of CES described: tracheobronchial remnants, fibromuscular stenosis (FMS), and membranous stenosis. The first-line treatment in most cases is the conservative treatment (dilatation with a Savary bougie or balloon), but in some CES types, dilatation may be ineffective or result in esophageal perforation with serious complications or lethal outcome. Resection of the stenotic segment and end-to-end esophageal anastomosis was formerly presented as the most common surgical treatment option for CES. However, esophagoplasty is a safe and feasible alternative for surgical treatment of esophageal stenosis in children. Our aim is to report two cases of FMS submitted to thoracoscopic esophagoplasty. Both cases started with dysphagia and refusal after transition to solid diet, at 6 months old, and the radiological examination showed stricture of the distal esophagus. Esophagoplasty was performed with the patients in prone position. The stenotic esophageal wall was incised longitudinally and transverse synthesis was performed. After surgery, the patients had prompt recovery, without recurrent stenosis, remaining asymptomatic, with good diet acceptance.

Assuntos

RESUMO

INTRODUCTION: Congenital esophageal stenosis (CES) is an extremely rare pathology in children, with an incidence of 1/25,000-50,000 live births. According to its histopathological classification, there are three types of CES: fibromuscular hyperplasia, membranous diaphragm, and tracheobronchial remnants. CLINICAL CASE: We present the clinical case of a 39-month-old male patient diagnosed with CES secondary to tracheobronchial remnants, with multiple vomit and reflux episodes since he was 4 months old. He was admitted at the emergency department with respiratory distress. An upper GI endoscopy and an esophagogram were initially carried out. Stenosis resection and thoracoscopic esophageal anastomosis were performed. CONCLUSIONS: Tracheobronchial remnants are the second most common presentation of congenital esophageal stenosis. They can be managed through dilatations or surgery according to etiology.

INTRODUCCION: La estenosis congénita de esófago es una patología extremadamente rara en niños, con una incidencia de 1/25.000-50.000 nacimientos. Según la clasificación histopatológica se encuentran tres tipos: hiperplasia fibromuscular, diafragma membranoso y remanentes traqueobronquiales. CASO CLINICO: Se presenta un caso clínico de un paciente masculino de 39 meses con diagnóstico de estenosis congénita del esófago secundario a remanentes traqueobronquiales, que presentó múltiples episodios de vómito y reflujo desde los 4 meses del nacimiento. Ingresó en el Servicio de Urgencias por presentar signos de dificultad respiratoria, realizándosele estudios iniciales de endoscopia de vías digestivas altas y esofagograma. Se practicó resección de estenosis y anastomosis esofágica toracoscópica. CONCLUSIONES: Los remanentes traqueobronquiales son la segunda causa de presentación de la estenosis esofágica congénita. El manejo de esta patología puede ser de dos formas, ya sea por medio de dilataciones o quirúrgico, y la elección de una u otra va a depender de su etiología.

Assuntos

RESUMO

A 26-year-old female patient, from La Paz-Bolivia. She came with a disease period of 15 months characterized by progressive dysphagia. One month before the onset of the symptomatology she ingested bleach with autolytic intentions. In the study of diagnostic upper gastrointestinal endoscopy at 25 centimeters of the dental arch was evidenced a stenosis of about 3 mm in diameter, central and with adjacent esophageal epithelium of a preserved appearance. In the x-ray of contrasted esophagus at the level of the middle third of the esophagus was evidenced a stenosis, short tubular, with a smooth border, of approximately 2 cm in length. Treatment was initiated using axial mechanical dilatations with Savary Guilliard bougies with an interval between sessions of 2 to 3 weeks and with 8 sessions in total. In the last session the largest bougie used was 12.8 mm. It is then that taking into account the diagnostic criteria of Kochman, the diagnosis of refractory caustic esophageal stenosis was made. During the period of realization of the dilations with bougies the patient became pregnant, which made difficult the accomplishment of the procedures for the routine use of fluoroscopic control. At 14 weeks of pregnancy, a SX-ELLA uncovered biodegradable esophageal stent of 10 cm length was implanted. We present the case as an alternative and novel management for this type of pathology.

Assuntos

RESUMO

Paciente mujer de 26 años de edad, natural y procedente de La Paz-Bolivia. Acudió con un tiempo de enfermedad de 15 meses caracterizado por disfagia progresiva. Un mes antes del comienzo de la sintomatología ingirió lejía con intenciones autolíticas. En el estudio de endoscopia digestiva alta diagnóstica se evidenció a los 25 centímetros de la arcada dentaria una estenosis, de unos 3 mm de diámetro, central y con el epitelio esofágico adyacente de aspecto conservado. En la radiografía de esófago contrastada se evidenció a nivel de tercio medio de esófago una estenosis tubular corta, de bordes lisos, de aproximadamente 2 cm de longitud. Se inició tratamiento mediante dilataciones mecánicas axiales con bujías Savary Guilliard con un intervalo entre sesiones de 2 a 3 semanas y con 8 sesiones en total. En la última sesión la bujía de mayor calibre usada fue 12,8 mm. Es entonces que tomando en consideración los criterios diagnósticos de Kochman, se hizo el diagnóstico de estenosis esofágica cáustica refractaria. Durante el periodo de realización de las dilataciones con bujías la paciente quedo embarazada, lo que dificultaba la realización de los procedimientos por el rutinario uso de control fluoroscópico. Con 14 semanas de gestación se implantó un Stent esofágico biodegradable no cubierto SX-ELLA de 10 cm de longitud. Presentamos el caso por ser un manejo alternativo y novedoso para este tipo de patología.

A 26-year-old female patient, from La Paz-Bolivia. She came with a disease period of 15 months characterized by progressive dysphagia. One month before the onset of the symptomatology she ingested bleach with autolytic intentions. In the study of diagnostic upper gastrointestinal endoscopy at 25 centimeters of the dental arch was evidenced a stenosis of about 3 mm in diameter, central and with adjacent esophageal epithelium of a preserved appearance. In the x-ray of contrasted esophagus at the level of the middle third of the esophagus was evidenced a stenosis, short tubular, with a smooth border, of approximately 2 cm in length. Treatment was initiated using axial mechanical dilatations with Savary Guilliard bougies with an interval between sessions of 2 to 3 weeks and with 8 sessions in total. In the last session the largest bougie used was 12.8 mm. It is then that taking into account the diagnostic criteria of Kochman, the diagnosis of refractory caustic esophageal stenosis was made. During the period of realization of the dilations with bougies the patient became pregnant, which made difficult the accomplishment of the procedures for the routine use of fluoroscopic control. At 14 weeks of pregnancy, a SX-ELLA uncovered biodegradable esophageal stent of 10 cm length was implanted. We present the case as an alternative and novel management for this type of pathology.

Assuntos

RESUMO

BACKGROUND: Pneumatic balloon and bougie dilation are widely used methods for pediatric esophageal dilation. There are no studies directly comparing the safety of these techniques in pediatric patients. This study compared adverse events (AEs) of balloon and bougie dilation in children at a single institution. METHODS: AEs were identified by means of a prospective clinical registry of all procedure related AEs from 2012 to 2015 at a single institution. Identified AEs underwent retrospective review of procedural and clinical details. The category of each AE was recorded and severity was assigned using a 5-point scoring system. AEs were compared between balloon and bougie dilation for different severities. RESULTS: There were 105 patients who underwent 246 dilation sessions. Balloon dilation was performed more commonly (n = 190, 77%) as compared to Maloney dilators (n = 56, 23%). Patients with balloon dilation were younger (3.0 vs 14.5 years, P = 0.0001) and more likely to have strictures from caustic ingestion (42% vs 2%, P < 0.0001) or surgical anastomoses (34% vs 5% P < 0.0001). Bougie dilation was used more commonly in patients with eosinophilic esophagitis (77% vs 7%, P < 0.0001)). In multivariate analysis, each year of increasing age was associated with a 12% increase in any AEs (P = 0.015), but no difference in clinically significant AEs (grade 2 or higher) was identified between dilation methods. CONCLUSIONS: Bougie and balloon dilation did not have significant differences in AE rates, but the patient populations differed between the 2 methods. The dilation method should depend on stricture characteristics and endoscopist expertise with each method.

Assuntos