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ד"תשע/חשון/ז"י
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Esophagomanometry Barium swallow
Symptoms of
Gastroesophageal Reflux Disease
GERD
Gastro-esophageal
reflux disease
ד"תשע/חשון/ז"י
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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
ד"תשע/חשון/ז"י
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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
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