421 USE OF BIOABSORBABLE MESH TO REINFORCE HIATAL CLOSURE—EARLY RESULTS

The hiatoplasty is one of the keypoints of hiatal hernia surgery. Reherniation is known to be a frequent reason for recurrence and reoperation. Biodegradable materials for reinforcement have been. shown in some series to reduce these outcomes with very low risks of mesh-related complications. Long term reports, however, have shown conflicting results. This may be because meshes have been used in complicated cases, in which other variables can be involved in unfavourable outcomes. Methods Based on the safe profile of absorbable meshes, we have used meshes to reinforce the hiatoplasty in patients with theoretical higher risks of hernia recurrence. Twenty four patients were operated using bioabsorbable mesh (Gore Bio A®), implanted as an onlay inverted C over a completely closed hiatus. Two surgeons were responsible for all the surgeries. There were 16 (66,6%) women and 8 (33,3%) men. The main reasons for using a mesh were: primary large hiatal hernias (4 cm or more)—14 cases; redo hiatal hernias—8 cases; increased abdominal pressure—2 cases. Results All surgeries were performed between April 2018 and January 2020. Meshes were fixed to the diaphragm using absorbable sutures, fibrin sealant or cyanoacrylate. In all cases, a Nissen fundoplication was performed. There were no conversions. Two (8,3%) patients complained of troublesome dysphagia requiring intervention. One had to be operated within the first 48 hours after surgery: 2 stitches of the hiatus were removed and the fundoplication was converted into a Toupet. The other patient was submitted to endoscopic dilatation and still referes mild dysphagia. In a short follow up period (1–19 months), 23 patients (95,8%) are asymptomatic. Conclusion The use of bioabsorbable mesh in the hiatus is safe and have shown good symptomatic outcomes in the short follow up period. Objective results and longer follow up are needed to see if additional reinforcement of hiatoplasty contributes to reduce recurrence and reoperation rates.

Surgical Treatment of Diffuse Idiopathic Skeletal Hyperostosis (DISH) Involving the Cervical Spine: Technical Nuances and Outcome of a Multicenter Experience

Study Design: Retrospective multicenter. Objectives: diffuse idiopathic skeletal hyperostosis (DISH) involving the cervical spine is a rare condition determining disabling aero-digestive symptoms. We analyzed impact of preoperative settings and intraoperative techniques on outcome of patients undergoing surgery for DISH. Methods: Patients with DISH needing for anterior cervical osteophytectomy were collected. Swallow studies and endoscopy supported imaging in targeting bone decompression. Patients characteristics, clinico-radiological presentation, outcome and surgical strategies were recorded. Impact on clinical outcome of duration and time to surgery and different surgical techniques was evaluated through ANOVA. Results: 24 patients underwent surgery. No correlation was noted between specific spinal levels affected by DISH and severity of pre-operative dysphagia. A trend toward a full clinical improvement was noted preferring the chisel ( P = 0.12) to the burr ( P = 0.65), and whenever C2-C3 was decompressed, whether hyperostosis included that level ( P = 0.15). Use of curved chisel reduced the surgical times ( P = 0.02) and, together with the nasogastric tube, the risk of complications, while bone removal involving 3 levels or more ( P = 0.04) and shorter waiting times for surgery ( P < 0.001) positively influenced a complete swallowing recovery. Early decompressions were preferred, resulting in 66.6% of patients reporting disappearance of symptoms within 7 days. One and two recurrences respectively at clinical and radiological follow-up were registered 18-30 months after surgery. Conclusion: The “age of DISH” counts more than patients’ age with timeliness of decompression being crucial in determining clinical outcome even with a preoperative mild dysphagia. Targeted bone resections could be reasonable in elderly patients, while in younger ones more extended decompressions should be preferred.

Lingual Thyroid with Subclinical Hypothyroidism in a Young Female

Thyroid tissue presenting as a nodule in the base of the tongue due to the embryonic failure to descend to the anterior neck is a rare clinical entity, called lingual thyroid. Clinical presentation varies depending upon the degree of obstruction caused by an enlarged nodule or features related to thyroid function. We report a case of a 27-year-old female who presented with a foreign body sensation in the throat with mild dysphagia for 3 weeks. The patient was diagnosed as lingual thyroid with subclinical hypothyroidism based on clinical findings, imaging, and fine-needle aspiration cytology. Conservative management with hormone suppression can result in size reduction of ectopic thyroid tissue improving symptoms without surgery. Lingual thyroid with mild symptoms and subclinical hypothyroidism can be managed conservatively.

ORAL AND PHARYNGEAL TRANSIT IN FUNCTIONAL HEARTBURN

ABSTRACT BACKGROUND: Gastroesophageal reflux disease is associated with slower transit of the bolus through the pharynx and upper esophageal sphincter. Functional heartburn has similar symptoms to gastroesophageal reflux disease, however, the symptoms are not caused by reflux. OBJECTIVE: The aim of this investigation was to evaluate oral and pharyngeal transit in patients with functional heartburn, with the hypothesis that, similar to patients with gastroesophageal reflux disease, they have changes in pharyngeal and upper esophageal sphincter transit time. METHODS: Oral and pharyngeal transit was evaluated by videofluoroscopy in eight women with functional heartburn, five with mild dysphagia for solid foods, and 12 female controls. Controls and patients swallowed in duplicate 5 mL and 10 mL of liquid and paste boluses. RESULTS: No difference in the oral or pharyngeal transit time was found between patients and controls. No aspiration of bolus into the airways was detected in any individual. Pharyngeal residues were detected in the same proportion of swallows, in patients (12.5%) and controls (15.0%), after swallows of 10 mL paste bolus. CONCLUSION: Oral, pharyngeal and upper esophageal sphincter transit time are similar in patients with functional heartburn to healthy controls.

OROPHARYNGEAL DYSPHAGIA: AN ASSOCIATION BETWEEN DYSPHAGIA LEVEL, SYMPTOMS AND COMORBIDITY

Objective: Associate levels of dysphagia according to the patient health condition. Methods: Retrospective study analyzing 149 medical records of patients who underwent Fiberoptic endoscopic evaluation of swallowing (FEES) in a tertiary hospital from 2016 to 2018. Data was collected on symptoms, comorbidities, FESS findings and oropharynx dysphagia classification. Statistical analysis was performed through descriptive and bivariate analysis using the Chi-square and Fisher's exact tests with a 5% significance level. Results: Most patients are elderly, female and with the main complaint of gagging for liquids and solids (30.9%), and gagging only for liquids was associated with the presence of mild dysphagia. The most prevalent degree of oropharynx dysphagia (OD) was mild (45%). In relation to patients' diseases, associations were identified between amyotrophic lateral sclerosis and mild dysphagia, Parkinson's disease and moderate dysphagia, and past pneumonia and / or head and neck cancer with severe dysphagia. Conclusions: The main complaint of patients with dysphagia and their pathological history should guide the treatment, without dispensing with complementary exams such as FESS, highlighting Parkinson's disease with moderate oropharynx dysphagia and past pneumonia and / or head and neck cancer as severe dysphagia.

DYSPHAGIC COMPLAINT EVALUATION ON PATIENTS ON OTORRINOLARYNGOLOGY AMBULATORY AT ONOFRE LOPES UNIVERSITY HOSPITAL

Purpose: The present study aims to to evaluate, diagnose, treat and refer patients with swallowing disorders, in different age groups, referred to the otorhinolaryngology outpatient clinic of Onofre Lopes University Hospital. Methods: The consultations took place on a frequency of once a week for a period of 12 months. They consisted of speech therapy evaluation, nutritional risk and otorhinolaryngology evaluation, in addition to the Fiberoptic endoscopic evaluation of swallowing. Results: The average age of the patients seen was 62.5 years, and the main comorbidities presented were neurological. Most patients were classified as having mild dysphagia and indicated oral diet with multiple consistencies, but with the need for special preparation or compensation. Approximately 25% of patients with dysphagic complaints had a risk of malnutrition, a risk that was statistically more significant in those with severe dysphagia (37.5%) related to those with mild/moderate dysphagia. Among the parameters observed in the fiberoptic endoscopic evaluation of swallowing, the presence of salivary stasis, aspiration and penetration were those that showed a statistical association with nutritional risk. Conclusion: The work concludes that nutritional assessment should play a prominent role in the routine of outpatient clinics specialized in dysphagia, reducing the risk of adverse events and improving the general health and quality of life of patients with these complaints.

Laparoscopic treatment of giant circumferential leiomyoma of the distal esophagus

Introduction: Leiomyomas are rare esophagus tumors, with 0.4-1% incidence of all esophagus tumors. Only 5% grow to the point of being called giant tumors, measuring more than 10cm. Symptoms usually begin on tumors bigger than 5cm. Objective: Reporting a new therapeutic course of action to giant leiomyomas of distal esophagus. Case Report: VCA, female, 38 years old, presented retrosternal oppression for 4 months. Having realized a computed tomography on another service which demonstrated a mass suggestive of leiomyoma. On the endoscopy exam, performed for heartburn complaint and mild dysphagia, was determined a hiatal hernia of 2cm and mild gastritis. Patient submitted to complete excision of tumor without mucosal lesion and reconstruction of the external muscular wall, by the video laparoscopic method. Hiatoplasty and partial esophagogastrofundoplication were associated. The anatomic pathological examination confirmed leiomyoma, with 10x5x2cm. Patient evolved clinically without the appearance of the heartburn or dysphagia. With contrast examination of the esophagus after 6 months and endoscopy and tomography the following 4 years, all normal. The classic treatment of giant leiomyomas, includes thoracotomy with esophagectomy. Considering that in 80% of the cases it is found in the middle and lower thirds of the esophagus, the videolaparoscopic approach by transhiatal route becomes possible. The reconstruction of the external muscular layer is important to prevent a possible prolapse of the mucosa. Also, the realization of the fundoplication in addition to avoiding the gastroesophageal reflux, allows the suture area of the esophageal muscular wall to be covered, increasing the safety in the treatment. In services with experience in the surgical treatment of diseases of the gastric esophagus transition through the videolaparoscopic method, it is possible to perform with adequate safety the surgical treatment of the tumor lesions of the distal esophagus. The method provides greater postoperative comfort and prompt clinical surgical recovery.

Laparoscopic treatment of giant circumferential leiomyoma of the distal esophagus

Introduction: Leiomyomas are rare esophagus tumors, with 0.4-1% incidence of all esophagus tumors, being more frequent in medium and distal portions1. Only 5% grow to the point of being called giant tumors, measuring more than 10cm2. Symptoms usually begin on tumors equal to or bigger than 5cm. Objectives: The following case objectifies reporting a new therapeutic course of action to giant leiomyomas of distal esophagus. Case Report: VCA, female, 38 years old, presented retrosternal oppression for 4 months. Having realized a computed tomography (CT) on another service 5 days ago which demonstrated a tumor injury on the distal esophagus and suggestive of leiomyoma. Patient was submitted through endoscopy exam 4 months ago, for complaint of heartburn and mild dysphagia. It was determined a hiatal hernia of 2cm and mild gastritis. Patient was submitted to complete excision of tumor without mucosal lesion and reconstruction of the external muscular wall, by the video laparoscopic method. Hiatoplasty and partial esophagogastrogemorplication were associated. The anatomic pathological examination confirmed the leiomyoma, with 10x5x2cm. Patient evolved clinically in the long term without the appearance of the heartburn or dysphagia. The patient underwent contrast examination of the esophagus after 6 months and endoscopy and tomography for the following 4 years, all normal. The classic treatment of giant leiomyomas larger than 10cm, includes thoracotomy with esophagectomy. Considering that in 80% of the cases it is found in the middle and lower thirds of the esophagus, the videolaparoscopic approach by transhiatal route becomes possible3. The reconstruction of the external muscular layer is important to prevent a possible prolapse of the mucosa1. Also, the realization of the fundoplication in addition to avoiding the gastroesophageal reflux, allows the suture area of the esophageal muscular wall to be covered, increasing the safety in the treatment4. In services with experience in the surgical treatment of diseases of the gastric esophagus transition through the videolaparoscopic method, it is possible to perform with adequate safety the surgical treatment of the tumor lesions of the distal esophagus. The method provides the patient with greater postoperative comfort and prompt clinical surgical recovery.

Substernocleidomastoid Muscle Neck Lipoma: An Isolated Case Report

Introduction. We report this large neck mass, located behind the sternocleidomastoid (SCM) within the posterior cervical space and anterior to the prevertebral fascia. The mass is displacing the carotid sheath and its neurovascular contents medially. It extends almost the whole length of the SCM muscle all the way down to the lung apex. Case Presentation. A 30-year-old female patient presented to our clinic with a left anterior neck mass for a few months with dysphagia. The lipoma was excised completely along with level II to IV lymphadenectomy. A very small volume chyle leak was noted intraoperatively. The drain was removed 2 weeks later only to recur in one month. A new drain was placed by interventional radiology, and the drainage resolved completely. Discussion. The patient with mild dysphagia had a lipoma large enough to push vital structures away from their normal anatomical position. Due to the difficult location and the size of the lipoma, a meticulous formal lateral neck dissection was required. A 3D imaging like CT or MRI would be helpful to preoperatively plan the dissection. Substernocleidomastoid neck lipoma in our case is a rare benign tumor that was challenging to excise.