Esophagus 1

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י" ז/ חשון/ תשע" ד1

description

Esophagus 1

Transcript of Esophagus 1

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ESOPHAGUS

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Esophagomanometry Barium swallow

Symptoms of

Gastroesophageal Reflux Disease

GERD

Gastro-esophageal

reflux disease

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GERD

Gastro-esophageal

reflux disease

GERD

Gastro-esophageal

reflux disease

GERD Sliding Esophageal Hernia

Type I

GERD Sliding Esophageal Hernia

Type I

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GERD Barrett’s Esophagus

GERD Barrett’s Esophagus

GERD Barrett’s Esophagus

GERD Sliding Esophageal Hernia

Type I

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s GERD

Esophageal stricture Management Stages for

Gastroesophageal Reflux Disease

Management Stages for

Gastroesophageal Reflux Disease

Management Stages for

Gastroesophageal Reflux Disease

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Nissen fundoplication for

Gastroesophageal Reflux Disease Rolling Esophageal Hernia

Type II

Zenker’s diverticula Zenker’s diverticula

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Zenker’s diverticula Zenker’s diverticula

בליעת באריום עם דגש על מנגנון בליעה•

אנדוסקופיה מסוכנת•

Zenker’s diverticula Zenker’s diverticula

A 68 year-old man was referred because of progressive dysphagia

and regurgitation that had reached a stage at which he could no

longer eat or drink without coughing and sputtering. He was

hypothyroid and was receiving eltroxin replacement therapy.

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מאפיינים

, 30נדיר מתחת , 50הרוב מעל •

יותר בגברים

: פתולוגיות נלוות•

50%-הרניה סרעפתית ורפלוקס בכ–

.מהחולים

Zenker’s diverticula התייצגות קלינית

בשלב מוקדם•

.רגורגיטציות, הליטוזיס, רעשים בצוואר, הפרעה בבליעה–

בשלב מאוחר•

, (Esophageal lung)אסטמה , דלקות ריאה חוזרות -

.חנק, צרידות, ירידת משקל

Zenker’s diverticula Zenker’s diverticula

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תוצאות הניתוח

טוב 10%, מצוין 85%•

-סיבוכים•

רקרנט לארינגיאל 2.5%–

דליפה 2.5%–

היצרות 1%–

טיפול אנדוסקופי

Endoscopic esophago-

diverticulostomy

טיפול אנדוסקופי

Endoscopic esophago-diverticulostomy

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Achalasia

!בעיקר קרים!! הפרעה בבליעה של נוזלים •

בהמשך הפרעה בבליעת מוצקים•

(vigorous-פרט ל)לרוב ללא כאבים•

מחלה ריאתית -אספירציות , רגורגיטציות •

ירידה במשקל•

Achalasia

גישה אבחנתית

בליעת באריום•

מנומטריה •

אנדוסקופיה לשלול •

גידול

(pseudoachlasia)

Achalasia

bird beak -מקור ציפור

Achalasia

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טיפול

תרופתי•

הזרקות +הרחבות -אנדוסקופי•

בוטוליזם

מיוטומיה אורכית -ניתוחי•

Achalasia

תוצאות

: הזרקות +הרחבות אנדוסקופיות •

שיפור 70-80%–

20%<הישנות –

נזקקים לניתוח 25%-15% -כ –

בהמשך

.פרפורציות 1.5%–

Achalasia

תוצאות-טיפול ניתוחי

90-95% -שיפור ניכר•

שיעור סיבוכים ותמותה נמוכים•

2%> שיעור הישנות •

Achalasia

גישה ניתוחית

•Heller השכיח ביותר אך יש מודיפיקציות

גישה פתוחה , רבות בגישה דרך החזה והבטן

VAS -ו

: עקרונות•

.סמ וכחצי סמ בקרדיה 8<מיוטומיה –

Achalasia

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Heller’s myotomy Heller’s myotomy

Heller’s myotomy Esophageal Cancer

• Eighth most common cancer worldwide

• 1.5 - 2.0% of all cancers

• 3 times more common in blacks than in whites

• 12,500 new cases of esophageal cancer per year in

North America

• 316,000 new cases per year worldwide

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Geographic variation

epidemic proportions parts of China 500/100,000 high-risk 13/100,000 southern African men eastern Africa South America southern Asia

low-risk 5/100,000 Western Europe

USA

Increased Risk Factors for squamous cell carcinoma

•Smoking

•Alcohol abuse

•older age

•male gender

•African-American

Carcinoma of mid-esophagus

Esophageal

carcinoma

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Increased Risk Factors for adenocarcinoma

Barrett’s esophagus- found in 50%

Barrett’s esophagus

•Change of normal squamous epithelium to columnar epithelium

•risk of cancer is increased 50-100x normal

•there is a spectrum of histologic changes with dysplasia

preceding malignant transformation

•low grade dysplasia can remain stable or even regress

•high grade dysplasia is equivalent to carcinoma in situ and can

predict imminent or existing cancer in 50%

Esophageal

adenocarcinoma Esophageal Carcinoma

• At diagnosis 75% have lymph node metastases

• 45% present with distant metastases

• Over 60% of patients are either poor surgical

candidates or have unresectable carcinomas at

the time of presentation

• Only 10% of patients presenting with carcinoma

of the esophagus will actually be cured of their

tumor

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Indications for curative esophageal surgery

Stage 0 and I cancers

confined to the esophageal mucosa

• all bypass procedures have high morbidity and in-hospital mortality

• Choose only those patients with an expected survival that is meaningful and select the least morbid approach

Surgical considerations

T2N1

Endoscopic ultrasound - EUS

T3

Esophagectomy

Surgical approaches

Lt transthoracic Ivor Lewis

Three hole Transhiatal

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Factors to consider

• The experience of the surgeon

• The expected survival of the patient

• The general condition of the patient

Surgical considerations Palliation of

Inoperable Carcinoma

of the Esophagus

Dysphagia:The most frequent symptom

Aspiration:life-threatening

Thoracic pain: caused by invasion of

an unresectable tumor

- cannot be relieved surgically

symptoms requiring palliation The aim of palliation

• to improve the quality of the

limited life remaining for the patient

• To improve the ability to swallow

saliva and to eat as normally as

possible

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Gastric tubes

Whole

stomach

using the

retrosternal

route

The

esophagus

has been

excluded

proximally

and distally

Palliative Bypass Surgery Palliative Bypass Surgery

Disadvantages

• Mortality 20-40%

• Morbidity 25%

• High incidence of anastomotic leak

• Gastric emptying procedure

recommended

• Roux-en-Y drainage of esophageal

remnant is recommended

• Relieves severe dysphagia

• Reduces aspiration from

tracheoesophageal fistula.

• Median survival after tube

insertion is only 3 months with

few patients surviving beyond

1 year

Esophageal intubation

Plastic tubes are rapidly

becoming obsolete

Expandable metal stents

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Expandable metal stents

• Interlocking network or coil of metal wire

• Contained in a deployment system that

is placed over a guide wire under

fluoroscopic guidance.

• Tumor dilatation is usually not

necessary

• Self expanding metal stents have

revolutionized the treatment of these

patients

• virtually replaced plastic esophageal

tubes as the prosthesis of choice

• have made indications for bypass

surgery and palliative resection even

more rare

Expandable Stents

Expandable metal stents

• Used for the management of

esophageal obstruction at the cervical-

esophageal junction, esophagogastric

junction

• Tracheoesophageal fistula

Expandable metal stents

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Nonsurgical Methods of Palliation of Dysphagia

• External beam radiotherapy • Chemotherapy • Brachytherapy • IV hyperalimentation • Gastrostomy tube feedings

• Valuable option once swallowing is

restored by other methods

• If used alone there is a high incidence

of radiation stricture formation

External beam radiation

Nonsurgical Methods of Palliation of Dysphagia

Chemotherapy • No additional palliative benefit whether

used alone or in combination with radiotherapy

• 44% severe side effects

• 20% life-threatening side effects

• Only 58% reported improved swallowing

Nonsurgical Methods of Palliation of Dysphagia

• No benefit until dysphagia has been relieved

• Reasonable fistula control

• Overall survival 7.9 months

• Dysphagia –free survival 7.1 months

• Local complications of chronic painful esophageal ulcers

Brachytherapy

Nonsurgical Methods of Palliation of Dysphagia

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Inadequate Methods of Palliation of Dysphagia

IV hyperalimentation Gastrostomy/jejunostomy tube feedings

• Can be used as an adjunct to other palliative techniques: RTx or CTx

• maintain nutrition but do not address the issue of dysphagia

• Eventually these patients are unable to swallow saliva

• High incidence of aspiration

Inadequate Methods of Palliation of Dysphagia

dilatation of the malignant stricture

• Only temporary benefit • High risk of perforation