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PURPOSE: Approximately 4% to 10% of patients diagnosed with Chagas-induced megaesophagus disease develop esophageal carcinoma. However, the natural history and clinical pattern of this entity are not well described. METHODS: Herein, we retrospectively analyzed 593 patients with esophageal carcinoma treated at a single Brazilian institution. We identified 32 patients with Chagas disease, of whom 11 had megaesophagus. The epidemiologic profile and oncological treatment outcomes were evaluated. RESULTS: Although baseline characteristics were similar among the three groups, patients with Chagas megaesophagus-associated carcinoma (CMAC) presented with a lower rate of smoking. This factor reinforced the concept that achalasia is the predominant risk factor for cancer development. The CMAC group had a higher rate of tumor in situ (two of 11 patients) compared with the other groups. These patients were treated with endoscopic resection, and no recurrence was detected. Eight of 11 patients with CMAC were diagnosed with locally advanced disease. Patients with locally advanced CMAC presented with a median progression-free survival of 7.8 months and a median overall survival of 9.1 months. CONCLUSION: If CMAC is not promptly detected, it has a dismal prognosis, indicating that a high index of suspicion of esophageal carcinoma is required for patients with Chagasic megaesophagus. Additional studies are needed to improve the surveillance and treatment approaches for this neglected disease.
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Enfermedad de Chagas/complicaciones , Neoplasias Esofágicas/virología , Estudios de Casos y Controles , Neoplasias Esofágicas/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available. PURPOSE OF THE STUDY: The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition. METHODS: An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015). RESULTS: One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council. CONCLUSIONS: The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.
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Esophageal cancer (EC) is among the 10 most common and fatal malignacies in the world, presenting a marked geographic variation in incidence rates between and within different countries. The TP53 tumor suppressor gene is highly mutated in esophageal tumors and its mutation pattern can offer clues to the etiopathology of the tumor. As Brazil presents one of the highest incidence areas in the West, a deeper knowledge of the molecular mechanisms related to EC development in the Brazilian population is needed. We analyzed the mutation profile of 110 esophageal squamous cell carcinomas (ESCC) of patients from Southeastern Brazil (Rio de Janeiro and São Paulo) and collected data regarding alcohol intake and tobacco smoking. We detected 41 mutations in tumor samples from 38 patients. There was no association between mutation frequency and tobacco smoking or alcohol drinking. The most frequently mutated codons were 179, 214, 220 and 248. Codons 179, 220 and 248 are hot-spots for ESCC, but codon 214 presents only 0.7% of the mutations registered in the IARC database. The mutation profile revealed a high percentage of mutations at A:T base pairs (34.1%) followed by deletions (17.1%). We concluded that the mutation profile detected in this study is different from that of patients from Southern Brazil but very similar to that previously seen in French patients, being characterized by a high frequency of mutations at A:T base pairs, which may be associated with acetaldehyde, the metabolic product of ethanol.
Asunto(s)
Carcinoma de Células Escamosas/genética , Genes p53 , Mutación , Adulto , Anciano , Anciano de 80 o más Años , Consumo de Bebidas Alcohólicas , Brasil/epidemiología , Neoplasias Esofágicas/genética , Femenino , Humanos , Masculino , Persona de Mediana Edad , FumarRESUMEN
UNLABELLED: Tracheoesophageal voice (TEV) with voice prosthesis (VP) is an efficient and reproducible method used in vocal rehabilitation after total laryngectomy (TL), prevented by spasms in the pharyngoesophageal segment (PES). Computerized Manometry (CM) is a new, direct and objective method used to assess the PES. AIM: to carry out an objective analysis of the PES, with CM, before and after the injection of botulinum toxin (BT). STUDY DESIGN: Clinical-prospective. MATERIALS AND METHODS: Analysis of eight patients consecutively submitted to TL with TEV and VP, without vocal emission, with PES spasms seen through videofluoroscopy, considered the gold standard for spasm detection. All had their spasms treated with the injection of 100 units of BT in the PES. The assessment was based on PES videofluoroscopy and CM, before and after BT injection. RESULTS: There was a PES pressure reduction according to the CM after BT injection in all patients. The average pressure in the PES seen through the CM in eight patients before BT injection was 25.36 mmHg, and afterwards it dropped to 14.31 mmHg (p=0.004). There was vocal emission without stress and PES spasm improvement seen through the videolaryngoscopy after BT injection. CONCLUSION: We observed a reduction in PES pressure after BT injection, seen through CM in all the patients, with spasms improvement seen through videofluoroscopy.
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Toxinas Botulínicas Tipo A/uso terapéutico , Fármacos Neuromusculares/uso terapéutico , Músculos Faríngeos , Procesamiento de Señales Asistido por Computador/instrumentación , Espasmo/tratamiento farmacológico , Voz Esofágica , Trastornos de Deglución/diagnóstico por imagen , Trastornos de Deglución/fisiopatología , Fluoroscopía/métodos , Humanos , Laringectomía , Laringe Artificial , Manometría/métodos , Músculos Faríngeos/diagnóstico por imagen , Músculos Faríngeos/fisiopatología , Presión , Estudios Prospectivos , Espasmo/diagnóstico por imagen , Acústica del LenguajeRESUMEN
It has been suggested that the blood clotting initiator protein, tissue factor (TF), participates in tumor growth, metastasis and angiogenesis. In addition, a family of G protein-coupled-receptors known as protease-activated receptors (PARs) has also been implicated in tumor biology. These receptors might be activated by blood coagulation proteases thus eliciting a number of pro-tumoral responses, including the expression of interleukin-8 (IL-8). Therefore, in this study we analyzed the expression of TF, PAR-1, PAR-2 and IL-8 genes in patients with esophageal cancer, one of the most aggressive neoplastic diseases. Total RNA was extracted from tissue samples (tumor and the corresponding normal mucosa) obtained from patients submitted to esophagectomy or endoscopy and further analyzed by semi-quantitative reverse transcriptase-polymerase (RT-PCR) and/or real-time quantitative PCR (qPCR). Expression of full-length transmembrane TF was significantly higher in tumor samples whereas no differences were observed in alternatively spliced TF transcripts. Tumor tissue showed increased mRNA levels for PAR-1 but not PAR-2. Remarkably, IL-8 expression was not detected in most normal tissues but showed very high expression in tumor samples. As expected, qPCR revealed greater differences in the expression pattern of all transcripts analyzed but the general profile was very similar to that observed by RT-PCR. Altogether our data suggest a possible role for blood clotting proteins in the biology of human esophageal cancer.
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Biomarcadores de Tumor/genética , Neoplasias Esofágicas/genética , Regulación Neoplásica de la Expresión Génica , Receptor PAR-1/genética , Tromboplastina/genética , Adulto , Anciano , Anciano de 80 o más Años , Brasil , Neoplasias Esofágicas/cirugía , Esofagectomía , Esofagoscopía , Femenino , Humanos , Interleucina-8/genética , Masculino , Persona de Mediana Edad , ARN Mensajero/análisis , Receptor PAR-2/genética , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Regulación hacia ArribaRESUMEN
Voz traqueoesofágica (VTE) com prótese fonatória (PF) é método eficaz e reproduzível na reabilitação vocal após laringectomia total (LT), impedida pelo espasmo do segmento faringoesofágico (SFE). A manometria computadorizada (MC) é novo método objetivo e direto de avaliação do SFE. OBJETIVO: Análise objetiva do espasmo do SFE, com MC, antes e após aplicação de toxina botulínica (TB). DESENHO DO ESTUDO: Prospectivo clínico. MATERIAL E MÉTODOS: Análise de oito pacientes consecutivos submetidos à LT com VTE e PF, sem emissão vocal, com espasmo do SFE à videofluoroscopia, considerado padrão ouro para detecção de espasmo. Todos trataram o espasmo com injeção de 100 unidades de TB no SFE. Avaliação constituiu-se de videofluoroscopia e MC do SFE, antes e após aplicação de TB. RESULTADOS: Houve diminuição na pressão do SFE à MC, após injeção de TB em todos. A média de pressão do SFE à MC, nos oito pacientes, antes da aplicação de TB foi de 25.36 mmHg e após foi de 14.31 mmHg (p=0,004). Houve emissão vocal sem esforço e melhora do espasmo do SFE à videofluoroscopia após o uso da TB. CONCLUSÃO: Foi observada diminuição na pressão do SFE após injeção da TB à MC em todos os pacientes, com melhora do espasmo à videofluoroscopia.
Tracheoesophageal voice (TEV) with voice prosthesis (VP) is an efficient and reproducible method used in vocal rehabilitation after total laryngectomy (TL), prevented by spasms in the pharyngoesophageal segment (PES). Computerized Manometry (CM) is a new, direct and objective method used to assess the PES. AIM: to carry out an objective analysis of the PES, with CM, before and after the injection of botulinum toxin (BT). STUDY DESIGN: clinical-prospective. MATERIALS AND METHODS: analysis of eight patients consecutively submitted to TL with TEV and VP, without vocal emission, with PES spasms seen through videofluoroscopy, considered the gold standard for spasm detection. All had their spasms treated with the injection of 100 units of BT in the PES. The assessment was based on PES videofluoroscopy and CM, before and after BT injection. RESULTS: There was a PES pressure reduction according to the CM after BT injection in all patients. The average pressure in the PES seen through the CM in eight patients before BT injection was 25.36 mmHg, and afterwards it dropped to 14.31 mmHg (p=0.004). There was vocal emission without stress and PES spasm improvement seen through the videolaryngoscopy after BT injection. CONCLUSION: We observed a reduction in PES pressure after BT injection, seen through CM in all the patients, with spasms improvement seen through videofluoroscopy.
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Humanos , Toxinas Botulínicas Tipo A/uso terapéutico , Fármacos Neuromusculares/uso terapéutico , Músculos Faríngeos , Voz Esofágica , Procesamiento de Señales Asistido por Computador/instrumentación , Espasmo/tratamiento farmacológico , Trastornos de Deglución/fisiopatología , Trastornos de Deglución , Fluoroscopía/métodos , Laringectomía , Laringe Artificial , Manometría/métodos , Presión , Estudios Prospectivos , Músculos Faríngeos/fisiopatología , Músculos Faríngeos , Acústica del Lenguaje , EspasmoRESUMEN
Most reports of autoimmune response during infection with the parasite Trypanosoma cruzi have dealt with the cardiomyopathic form of Chagas' disease, but little is known about the mechanisms of tissue damage involved in the gastrointestinal form, which was studied here. Chronically infected patients with a severe gastrointestinal form of Chagas' disease present increased antibody production and proliferative responses to peripheral myelin components, such as myelin basic protein (MBP), which is homologous to the P1 protein fraction of peripheral myelin. T lymphocytes preferentially recognize a region on the MBP molecule (1-30), which suggests that the MBP is a potential target on the peripheral nerve for autoimmune reactions in patients with gastrointestinal lesions resulting from Chagas' disease.
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Enfermedad de Chagas/inmunología , Sistema Nervioso Entérico/inmunología , Enfermedades Gastrointestinales/inmunología , Vaina de Mielina/inmunología , Adulto , Animales , Autoanticuerpos/inmunología , Autoantígenos/inmunología , Autoinmunidad/inmunología , Encéfalo/inmunología , Encéfalo/patología , Encéfalo/fisiopatología , Enfermedad de Chagas/fisiopatología , Sistema Nervioso Entérico/patología , Sistema Nervioso Entérico/fisiopatología , Femenino , Enfermedades Gastrointestinales/microbiología , Enfermedades Gastrointestinales/fisiopatología , Tracto Gastrointestinal/inmunología , Tracto Gastrointestinal/inervación , Tracto Gastrointestinal/fisiopatología , Humanos , Activación de Linfocitos/inmunología , Masculino , Persona de Mediana Edad , Proteína Básica de Mielina/inmunología , Proteínas de la Mielina/inmunología , Vaina de Mielina/patología , Neuronas/inmunología , Neuronas/patología , Nervios Periféricos/inmunología , Nervios Periféricos/patología , Nervios Periféricos/fisiopatología , Polirradiculoneuropatía/inmunología , Polirradiculoneuropatía/microbiología , Polirradiculoneuropatía/fisiopatología , Linfocitos T/inmunología , Trypanosoma cruzi/fisiologíaRESUMEN
OBJECTIVE: To evaluate the utility of computerized manometry (CM) to identify pharyngoesophageal segment (PES) spasm during tracheoesophageal speech. STUDY DESIGN: Prospective clinical, controlled study. SUBJECTS AND METHODS: Intraluminal pressures of the PES were collected in 12 tracheoesophageal speakers without spasm and 8 tracheoesophageal speakers with PES spasm before and after localized injection of botulinum toxin to the PES. All subjects underwent voice analysis and videofluoroscopy in addition to CM before and after treatment. RESULTS: All tracheoesophageal speakers with PES spasm presented with mean intraluminal pressures greater than 16 mmHg (mean, 25.36 mmHg). In contrast, mean intraluminal pressures of subjects without spasm was 11.76 mmHg (P<0.05). The negative predictive value associated with the use of 16 mmHg as a threshold value for spasm was 100%. CONCLUSION: CM is a clinically useful tool to aid in speech rehabilitation for tracheoesophageal speakers. Intraluminal pressures of greater than 16 mmHg was highly predictive for PES spasm.
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Espasmo Esofágico Difuso/diagnóstico , Manometría/métodos , Voz Esofágica , Toxinas Botulínicas Tipo A/uso terapéutico , Espasmo Esofágico Difuso/tratamiento farmacológico , Espasmo Esofágico Difuso/fisiopatología , Humanos , Fármacos Neuromusculares/uso terapéutico , Presión , Sensibilidad y EspecificidadRESUMEN
UNLABELLED: In tracheo esophageal puncture (TEP), we carry out a myotomy of the pharynx constrictor muscle; however, about 9 to 79% of patients need such procedure. The consequence of such procedure is an increase in salivary fistula rates in the postoperative. Botulin toxin is used in an outpatient basis. AIM: analyzing the efficacy of botulin toxin (BT) use in the rehabilitation of totally laryngectomized patients with tracheo-esophageal voice (TEV) with spasms (S) of the pharyngo-esophageal segment (PES) without myotomy. MATERIALS AND METHODS: We analyzed eight patients submitted to total laryngectomy (TL), rehabilitated with TEV, with speech prosthesis (SP) and struggle to utter voice because of PES spasms. They were all submitted to treatment of such motor alteration with the injection of 100 units of BT in the PES. The evaluation was based on perceptive voice analysis, video fluoroscopy (VF) of the PES, acoustic voice analysis and computerized manometry (CM) of the PES, all before and after BT injection. STUDY DESIGN: prospective. RESULTS: There was a reduction in PES CM pressure after BT injection. Acoustic analysis showed an improvement in harmonics quality after treatment. There was smoother voice utterance and spasm improvement after BT. CONCLUSION: all patients with PES spasms presented vocal improvement after BT injection in the PES.
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Toxinas Botulínicas/uso terapéutico , Espasmo Esofágico Difuso/tratamiento farmacológico , Laringectomía/rehabilitación , Laringe Artificial , Voz Esofágica , Antidiscinéticos/administración & dosificación , Espasmo Esofágico Difuso/fisiopatología , Esófago/efectos de los fármacos , Esófago/fisiopatología , Esófago/cirugía , Humanos , Faringe/efectos de los fármacos , Faringe/fisiopatología , Faringe/cirugía , Fonación/fisiología , Estudios Prospectivos , Voz/fisiologíaRESUMEN
Na punção tráqueo-esofágica(PTE) é realizada miotomia do músculo constritor da faringe, mas sua necessidade é entre 9 por cento a 79 por cento dos pacientes. Sua realização pode aumentar as taxas de fístula salivar no pós-operatório. A aplicação da TB é ambulatorial. OBJETIVO: Análise da eficácia da aplicação de toxina botulínica (TB), na reabilitação do laringectomizado total com voz tráqueo-esofágica(VTE) com espasmo(E) do segmento faringo-esofágico (SFE) sem miotomia. MATERIAL E MÉTODOS: Análise de oito pacientes submetidos à laringectomia total (LT), reabilitados com VTE com prótese fonatória (PF), esforço para emissão de voz devido à E do SFE. Todos submetidos a tratamento dessa alteração motora com injeção de 100 unidades de TB no SFE. A avaliação constituiu-se de análise perceptiva de voz, videofluoroscopia (VF) do SFE, análise acústica de voz e manometria computadorizada (MC) do SFE, todos antes e após aplicação de TB. DESENHO DE ESTUDO: Estudo prospectivo. RESULTADOS: Houve diminuição na pressão à MC do SFE, após a injeção de TB. Análise acústica demonstrou melhora na qualidade de harmônicos após o tratamento. Houve emissão de voz sem esforço e melhora do E após o uso da TB. CONCLUSÃO: Todos os pacientes com E do SFE apresentaram melhora vocal após aplicação da TB neste SFE.
In tracheo esophageal puncture (TEP), we carry out a myotomy of the pharynx constrictor muscle; however, about 9 to 79 percent of patients need such procedure. The consequence of such procedure is an increase in salivary fistula rates in the postoperative. Botulin toxin is used in an outpatient basis. AIM: analyzing the efficacy of botulin toxin (BT) use in the rehabilitation of totally laryngectomized patients with tracheo-esophageal voice (TEV) with spasms (S) of the pharyngo-esophageal segment (PES) without myotomy. MATERIALS AND METHODS: We analyzed eight patients submitted to total laryngectomy (TL), rehabilitated with TEV, with speech prosthesis (SP) and struggle to utter voice because of PES spasms. They were all submitted to treatment of such motor alteration with the injection of 100 units of BT in the PES. The evaluation was based on perceptive voice analysis, video fluoroscopy (VF) of the PES, acoustic voice analysis and computerized manometry (CM) of the PES, all before and after BT injection. STUDY DESIGN: prospective. Results: There was a reduction in PES CM pressure after BT injection. Acoustic analysis showed an improvement in harmonics quality after treatment. There was smoother voice utterance and spasm improvement after BT. CONCLUSION: all patients with PES spasms presented vocal improvement after BT injection in the PES.