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Chagas Disease Surgery

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Chagas Disease Surgery Mem Inst Oswaldo Cruz, Rio de Janeiro, Vol. 94, Suppl.I: 343-347, 1999 343 Chagas Disease Surgery Alcino Lázaro da Silva Departamento de Cirurgia Digestiva, Universidade Federal de Minas Gerais, Caixa Postal 340, 30130-100 Belo Horizonte, MG, Brasil Key words: Chagas disease - surgery Chagas disease has a cronic course in various Classification regions of the body, creating functional incompe- Classification is based on the stage (grade) of tence and dilatations known as mega formations. the disease - grade I: dilatation of up to 3 cm; grade For the general surgeon, the digestive forms of II: dilatation of 3 cm to 7 cm; grade III: dilatation Chagas disease are the dilatations thar occur of more than 7 cm; grade IV: dilatation of more throughout the digestive tract jeopardizing the nor- than 7 cm with deviation of the longitudinal axis mal transit or even impeding it completely. of the esophagus (Rezende 1973). NOMENCLATURE Symptoms The dilatations of the digestive tract are named The most prevalent symptoms are: dysphagia megaesophagus, megastomach (achalasia of the (100%), retrosternal pain, regurgitation and loss of pylorus), megaduodenum, megacolon, megasig- weight. moid and megarectum. Diagnosis is based on the symptoms, by swal- Dilated forms have not been described in the lowing of barium examination , manometric criteria, jejunum and in the ileum. This may be due to the mecolil test, endoscopy, biopsy and radiography fact that these two segments of the digestive tract, of the chest. Serological tests may confirm the re- because of their essential functions,are very resis- sults of these exams. tant to infection. Surgical operations CLASSIFICATION Operations to correct megaesophagus are di- vided as follows (Ferreira Santos 1965): operations The dilatations that occur in the body are clas- on the esophagus (6); operations on the intrinsic sified according to different systems: (1) biliary: obstacle (31); intra lumen (oral route) operations mega-gallbladder, mega-common bile duct; (2) car- (3); operations on the extrinsic obstacle (4); opera- diovascular: cardiomegaly; (3) urinary: megapelvis, tions on the nerves of the esophagus (4); opera- megaureter, megabladder; (4) respiratory: bron- tions on the esophagus and the cardiac opening chiectasis, megabronchus; (5) megapharynx (?); (6) (5): (a) partial esophagectomy followed by sub aor- megaesophagus; (7) megastomach; (8) achalasia tic esophagogastrostomy; (b) ressection of the of the pylorus or hypertrophic pyloric stenosis; (9) esophagogas-tric junction followed by interposi- megaduodenum; (10) megaintestine (mega-small tion of a jejunal segment; (c) subtotal bowel); (11) megappendix; (12) megacolon; (13) esophagectomy followed by cervical megasigmoid; (14) megarectum; (15) hypertrophy transmediastinal anterior esophagogas-troplasty; of the salivary glands (parotid). (d) same as (c) followed by transmediastinal poste- MEGAESOPHAGUS rior esophagogastroplasty; (e) esophagojejunal This is the most common form of mega in anastomosis with mobilization of the stomach to Chagas disease. the neck for a cervical gastrostomy. At this level, As for megacolon, all therapeutic attempts have during a second operation, an anastomosis be- some restrictions for this reason most surgeons tween the stomach and the esophagus is carried tend to adopt more than one procedure. out. History Prefered operations (Ferreira Santos 1965, Chaib 1969). Esophagocardiamyotomy (Heller operation) - The main steps for this operation are: upper para- median internal pararectus laparotomy; partial mo- bilization, from the left side, of the esophagogastric Fax: +55-31-222.0998. E-mail: [email protected] junction preserving the vagus nerves and their Received 9 June 1999 main branches; exposure of the anterior aspect of Accepted 9 August 1999 the esophagus; and an 8 cm extra mucosal myo- 344 Chagas Disease Surgery Alcino Lázaro da Silva tomy of all muscular layers (longitudinal, oblique ment (approximately 20 cm) always presents distal and transverse) of the esophagus, cardiac region peristalsis, acting as an excellent sphincter and 3 cm on the stomach is completed. (Rezende 1973, Lázaro et al. 1987, Lázaro 1991). This operation benefits swallowing but allows MEGASTOMACH free gastroesophageal reflux and may generate esophagitis and stenosis. Isolated gastric dilatation is rare. It occurs more Esophagocardiamyotomy plus lateral-lateral frequently in association with dilatations of the esophagogastric fundic wrap (Heller operation as- esophagus and the free part of the duodenum, al- sociated with the Toupet-Lind procedure) - After though they are also rare. completing the previous procedure, the fundus and Significant gastric stasis may occur due to the the cranial part of the greater curvature of the stom- dilated stomach and the dyskinesia of the gas- ach are mobilized. Nonabsorbable sutures are troduodenal segment, similarly to pyloric stenosis. placed between the elements cited and the walls of Two alternatives are available to overcome the ob- the esophagus, for an extension of approximately struction. 10 cm. The first one is a gastrojejunostomy which cre- The association of both techniques will pro- ates a large passage, but has the inconvenience of vide a better antireflux mechanism which will pre- a marginal ulcer or the late recurrence of the steno- vent esophagitis. sis (narrowing of the gastrojejunostomy due to the The success of this operation may be jeopar- decrease of the gastric dilatation). dized by a folded, sigmoid type esophagus. Dys- The second alternative is the distal ressection phagia is rare, but simple dilatation may occur in of the stomach and a funnel shaped reconstruction. the postoperative period, even if esophagitis with The upper part of this funnel is located at the level esophageal shortening is present. of the major gastric curvature favoring gravitational Longitudinal esophagocardiotomy plus drainage to the duodenum through the gas- esophagogastric fundic wrap (Girard operation troduodenal anastomosis. associated with the Toupet-Lind procedure) - An MEGADUODENUM 8cm incision is made on the distal esophagus, car- Isolated megaduodenum is the most infrequent diac region, and extending to the stomach. The form of mega; but more frequent is its association opening is sutured transversely in order to enlarge with megaesophagus and megastomach. the diameter of the esophagus. Due to the possibil- The duodenum becomes elongated, widened, ity of free gastroesophageal reflux, an antireflux and has evident symptomatic stasis. mechanism is created as previously described. The Little is known about the causes of possible complications are as previously cited. megaduodenum: if the problem is incoordination Cardiaectomy plus interposition of a jejunal along the duodenum or at the level of the duodenal segment (Merendino procedure) (Merendino & jejunal junction, like in achalasia of the lower esoph- Dillard 1955) - The esophagogastric junction is ageal sphincter (Lázaro 1969). mobilized. Both vagus nerves are transected. The Supposing the latter is true, we may ressect the cardiac region of the stomach is ressected along duodenal jejunal junction and then construct an with 3 cm of the stomach. On the esophagus, end to end anastomosis recreating the transit, with ressection varies with the alongation of the organ, satisfactory results. This is a more delicate opera- in order to make the esophagus straight. Transit is tion than the simple side to side duodenal jejunos- reconstructed by placing a 20 cm segment of the tomy, but provides material for histopathological jejunum between the divided ends of the esopha- and motility studies which will allow further research gus and the stomach. in this subject (Lázaro & Pereira 1977). For megaesophagus grade III or higher this op- eration provides a definitive solution for the dys- MEGA-SMALL BOWEL phagia and safely prevents reflux. Lack of success This phenomenum, if it really exists, it is ex- may occur due to a high incidence of immediate tremely rare. If a patient presents this abnormality postoperative complications which may happen in all the extension of the small bowel, a surgical when one is not familiarized with the technique; in solution would be probably impossible because this very advanced forms of megaesophagus, specially segment of the digestive tract is vital. From a phys- those sigmoid types (folded esophagus) an experi- iopathological point of view, one may suggest the enced surgeon should do the small bowel interpo- displaying of the bowel loops in an organized way sition. by means of a partial thickning of the tract, sutur- In this operation, the gastroesophageal reflux ing one another, in order to better orient the bowel does not occur because the interposed jejunal seg- stasis. Mem Inst Oswaldo Cruz, Rio de Janeiro, Vol. 94, 1999 345 MEGAPPENDIX Prefered choice This form is rare and not very significant be- Duhamel-Grob procedure (transanal rectal pull- cause it is usually associated with dilatation of the through of the colon): (a) lower left paramedian in- colon. The choosen procedure is ressection, and it ternal pararectus laparotomy; (b) exposure of the can be associated or not with portions of the co- descending colon, sigmoid and the cranial portion lon. of the rectum by opening the mesentery anteriorly and laterally; (c) ligation and division of the sig- MEGACOLON moid and superior rectal vessels, preserving the This form may appear alone or with dilatation vascular arcade parallel to the islolated segment; of
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