Ms Sujata DesaiMs Sarita KumariMs Shiney Sam
•   Ms Sujata Desai              •   Chemotherapy•   Anatomy Physiology           •   Radiation therapy•   Definition     ...
Structure• 4 layers               Mucosa                         Submucosa                         Muscularis             ...
Functions
Blood supply
Venous Drainage
Lymphatic drainage
EpidemiologyCountry                          Incidence                    LinkUS                               6 cases/100...
Incidence                         Squamous                  AdenoNew cases per year           16980                 12450M...
Etiology• Unknown• Hereditary & Genetics• Smoking and alcohol
• Dietary factors• *N-nitroso compounds (animal carcinogens)  *Pickled vegetables and other food-products  *Toxin-producin...
ACHALASIA
Barrett’s Esophagus
Hiatus Hernia
Plummer Vinson SyndromeEsophagitisAnemiadysphagia
Tylosis
Esophageal Web
Others• Helicobacter pylori     •   h/o cancer• Injury : ingestion of   •   HPV  acids or alkalines      •   Aspirin• Coli...
Prevention and screening•   Counseling : Avoid alcohol and tobacco•   Endemic mass screening programmes•   Screening high ...
Pathophysiology
Clinical manifestation•   Dysphagia•   Odynophagia•   Hoarseness of voice•   Dysphonia•   Central chest pain
•   Wt loss•   TEF•   Chronic cough•   haemoptysis•   Malena or haematemesis•   Nausea vomiting, regurgitation•   Superior...
Signs of Metastasis• Bone pain• Malignant ascites• Malignant pleural effusion• Jaundice• Supraclavicular and cervical  lym...
Investigations• History and physical examination• Blood examinations:  – CBC,LFT, RFT, Electrolytes• Tumor marker:  Alkali...
• Imaging Tests  – Chest X ray  – CT scan  – CT guided needle biopsy  – MRI  – PET scan
• Barium Swallow
Esophagoscopy
• Endoscopy  – Upper endoscopy  – Endoscopic ultra sound  – Bronchoscopy  – Thoracoscopy and laparoscopy
• OTHERS  • Biopsy  • HER2 Testing
TNM Staging
Staging
Classificationmorphological                histological   Type I : polypoid                           Squamous carcinoma  ...
Squamous cell carcinomaa) Upper thirds of esophagus-20%b) Middle thirds of esophagus-50%c) Lower thirds of esophagus-30%
Adenocarcinoma
Spread•   Commonly spread by Lymphatic system    (1) Local spread          Trachea                 tracheoesophageal fistu...
Treatment modality•   Surgery•   Chemotherapy•   Radiation therapy•   Combination therapy•   Palliative therapy
Management protocol
Surgery•   1877- Czerny first surgeon to successfully resect a cervical esophageal    cancer•   Initially the anastomosis ...
Management of early cancers
• Photodynamic  Therapy (PDT)• Drug used: sodium  porfirmer
Laser Ablation• Neodymium-  :yttrium-aluminium-  garnet(Nd:YAG)
Endoscopic Mucosal           Resection(EMR)After resectionprotonPump inhibitorsare used
Radiofrequency AblationEndoscopicballoon ablativedevice , kills cellsby heating byelectric current
Surgery
Operable tumors    1) Tumors below the carina (tracheal  bifurcation)       Ivor Lewis operation(2 phases )         1st ph...
Tumors above the carina    Mc Keown operation (3 phases )      1st phase :laparotomy & mobilization ofstomach      2nd pha...
Transthoracic Esophagectomy
VATS
3) Tumors below the diaphragm (1                           phase)•      lt thracoabdominal  incision: the stomach  & lower...
• Other options  Transhiatal esophagectomy     Thoracotomy is avoided by mobilizing the oesophagus from the abdomen via th...
3 field lymph node dissection• Field I: abdominal field• Field II:  Paraesophageal, parabronc  hial, apical nodes, recurre...
• Endopscopic removal     through laparoscopy & thoracoscopy
Reconstructions
Colonic transposition
Chemotherapy• Neoadjuvant• Two 4-day cycles,•  3 weeks apart• Cisplatin 80 mg/m2 by infusion over 4 h•  fluorouracil 1000 ...
Radiation therapyEBRT alone 64.8Gy / 33 - 36 fractionsExternal beam radiotherapy and brachytherapy  EBRT• Dose : 60 Gy / 2...
Brachytherapy
Concomitant chemo radiation• 50Gy / 25 fractions over 5 weeks,• Cisplatin 75 mg/m2IV Day 1 of weeks  1, 5, 8, and 11,• Flu...
Targeted Therapy•   EGFR: Cetuximab•   HER-2/neu:Trastuzumab•   VEGF:Bevacizumab•   Small molecule inhibitors: Imatinib
Palliative treatment• Inoperable Tumors ( 60% of the patients)  * Local spread( e.g tracheoesophageal fistula,)  * Distant...
Intubations–    • Self expanding metal      stents    • Traction stents e.g.      Celestine stent    • Pulsion stents e.g....
Dilatation
– Radiotherapy for squamous cell ca– Dose : 3000cGy /10 fractions /2 weeks– Reduced field / boost : 2000cGy/10# / 2 weeks–...
PEG
Complications•   Anastomotic leak•   Respiratory insufficiency•   Wound infection•   Gastric outlet obstruction•   Pulmona...
Nursing Management• Preoperative management• Post operative management
Preoperative management
Psychological preparationAssess level of anxietyAnswer the questions and concernsregarding surgeryAllow time and privacy t...
Legal preparationInformed consent by surgeonNo sedation should be administeredDocumentation
Nutritional supportAims : promote wt gainInterventions–   Assess wt , nutritional assessment–   Sr Albumin , protein–   As...
Prevent pulmonary complicationsPatients are not able to clear secretionsHead elevationStent placement and dilatation
Physical and physiological              preparation•    Cleaning of surgical site•    Shaving•    Personal hygiene•    Ora...
Pain managementExplain to notify painPain medications will be prescribedNon invasive pain relieve techniques
Preoperative exercisesStop smokingChest physiotherapyIncentive spirometryFootball bladder exercisesCoughing exercisesDeep ...
Pre anesthetic work upAll investigations & corrections toCo morbiditiesECGPFTArterial blood gas2d echoMouth openingCheck l...
Post operative management
• Immediate• Intermediate• Extended
Immediate• Intensive care - 24 to 48 hrs• Care of ventilated pt : patent airway  Suctioning• Care of drains• Cardiopulmona...
Intermediate
• Neurological Status• Assess neurological status every shift.• Any neurological change should be  carefully watched and• ...
Pain Management Adequate pain control reduces the mortality and  morbidity Asess the pain Initial pain management consi...
Pain Management contd..Oral pain medications are started on the fifth or seventh postoperative day The main classes : op...
Non-pharmacological         interventionsDistraction RelaxationPositioning
Pulmonary Care Aggressive pulmonary toilet Pain control is paramount Patients are usually intubated after surgery monit...
Chest tube care Assess the drainage every shift.Serosanguinous within a few hours.Not more than 100 to 200 ml/h on the fir...
Subcutaneous emphysema Palpate the surrounding area Due to an air leak from a pleural injury Additional suction or plac...
HemodynamicsIntravenous maintenance fluid at a rate of 100 to 200 ml/h for the first12 to 16 hours. Patients may require f...
Nasogastric Tubes. Do not move, manipulate, or irrigate thenasogastric tube.Do not attempt to replace it. Monitor the tube...
Gastrointestinal CareRestricted by mouth for 5 to 7 daysOral medications, are crushed and put down the nasogastric tube on...
   At 5 to 7 days check the anastomosis for leaks   Eat 6 to 8 small frequent meals each day,   Avoid very hot or cold ...
Incision CareKeep dressings clean, dry, and intact.Change dressing 2 to 3 times a daySaliva leak out through the cervical ...
Infection RiskCompromised nutritional status,They have invasive cathetersRisk of infection at the surgical sites.Meticulou...
Prophylaxis of deep vein thrombosisHeparin s/c BDTED stockingsEarly ambulationLeg and ankle exercises
Discharge planning
• Do’s   Check surgical incision   Maintain personal hygiene   Incision site care   Resume daily activities, work and sexu...
Contd… Take stool softeners Crush all medications Observe complications: tarry stool, progressive wt loss, diarrhea Keep f...
• Don’ts   Avoid smoking (join stop smoking group)   Avoid strenuous activity for 12 wks   Avoid driving for 3 wks   Avoid...
RehabilitationPatient must sleep in a head high positionGet adapted to small frequent mealsKeep a difference of 2-3 hrs be...
Prognosis
Follow upEvery 6 monthsPlain X Ray, CBC, Biochemistry onvisitIf symptomaticCT, PET CT
Conclusion
Thank u
cancer esophagus
cancer esophagus
cancer esophagus
cancer esophagus
cancer esophagus
cancer esophagus
cancer esophagus
cancer esophagus
cancer esophagus
cancer esophagus
cancer esophagus
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cancer esophagus

  1. 1. Ms Sujata DesaiMs Sarita KumariMs Shiney Sam
  2. 2. • Ms Sujata Desai • Chemotherapy• Anatomy Physiology • Radiation therapy• Definition • Palliative management• Epidemiology and incidence • Complications• Etiology • Ms Shiney Sam• Prevention and Screening • Pre operative management• Pathophysiology • Post operative management• Clinical Manifestations • Rehabilitation• investigations • Prognosis• TNM staging • Discharge planning• Ms Sarita Kumari • Follow up• Classification• Spread• Treatment :-• Surgery
  3. 3. Structure• 4 layers Mucosa Submucosa Muscularis propria Adventitia
  4. 4. Functions
  5. 5. Blood supply
  6. 6. Venous Drainage
  7. 7. Lymphatic drainage
  8. 8. EpidemiologyCountry Incidence LinkUS 6 cases/100,000 men/year (Black>white).China (HenanProvince) 0.9% in the population Nitrosamine in the soil and older than 30 years of age contamination of foods by fungi (Geotrichum candidum) and yeast, which produce mutagensIndia, Pakistan, and Sri Lanka 9000 cases/year in 6 Chewing tobacco , smoking cancer registrySingapore Hot beverages, Chinese tobacco and wineSouth African Bantus and Zulus Nitrosamine in the soil and contamination of food by molds, especially the Fusarium speciesNormandy, Brittany Alcohol and smoking
  9. 9. Incidence Squamous AdenoNew cases per year 16980 12450Male-to-female ratio 3:1 7:1Black-to-white ratio 6:1 1:4Most common locations middle distalMajor risk factors smoking Barrett’s alcohol esophagusIn TMH 1200 pts /year2nd most common in men4th most common in femaleM0re than 180 Sx /yr
  10. 10. Etiology• Unknown• Hereditary & Genetics• Smoking and alcohol
  11. 11. • Dietary factors• *N-nitroso compounds (animal carcinogens) *Pickled vegetables and other food-products *Toxin-producing fungi *Betel nut chewing *Ingestion of very hot foods and beverages (such as tea)• Obesity• Work place exposure
  12. 12. ACHALASIA
  13. 13. Barrett’s Esophagus
  14. 14. Hiatus Hernia
  15. 15. Plummer Vinson SyndromeEsophagitisAnemiadysphagia
  16. 16. Tylosis
  17. 17. Esophageal Web
  18. 18. Others• Helicobacter pylori • h/o cancer• Injury : ingestion of • HPV acids or alkalines • Aspirin• Colic Disease • NSAIDS• Chronic peptic sore• Oral sepsis• Syphilis• Radiation Therapy
  19. 19. Prevention and screening• Counseling : Avoid alcohol and tobacco• Endemic mass screening programmes• Screening high risk factor• Surveillance Programme Barrett’s esophagus without dysplasia endoscopy 3 yearly Low grade Dysplasia: every year High Grade Dysplasia every 6months 4 quadrant biopsy 2cm apart
  20. 20. Pathophysiology
  21. 21. Clinical manifestation• Dysphagia• Odynophagia• Hoarseness of voice• Dysphonia• Central chest pain
  22. 22. • Wt loss• TEF• Chronic cough• haemoptysis• Malena or haematemesis• Nausea vomiting, regurgitation• Superior vena cava syndrome
  23. 23. Signs of Metastasis• Bone pain• Malignant ascites• Malignant pleural effusion• Jaundice• Supraclavicular and cervical lymphadenopathy• Diaphragmatic paralysis
  24. 24. Investigations• History and physical examination• Blood examinations: – CBC,LFT, RFT, Electrolytes• Tumor marker: Alkaline Phosphatase (20 to 140 IU/L) CEA (0 – 2.5ng/ml)
  25. 25. • Imaging Tests – Chest X ray – CT scan – CT guided needle biopsy – MRI – PET scan
  26. 26. • Barium Swallow
  27. 27. Esophagoscopy
  28. 28. • Endoscopy – Upper endoscopy – Endoscopic ultra sound – Bronchoscopy – Thoracoscopy and laparoscopy
  29. 29. • OTHERS • Biopsy • HER2 Testing
  30. 30. TNM Staging
  31. 31. Staging
  32. 32. Classificationmorphological histological Type I : polypoid Squamous carcinoma Type ll: ulcerated Adenocarcinoma Type lll: infiltrating ulcerated Mixed adenosquamous Type lV :diffuse undifferentiated Small cell carcinoma
  33. 33. Squamous cell carcinomaa) Upper thirds of esophagus-20%b) Middle thirds of esophagus-50%c) Lower thirds of esophagus-30%
  34. 34. Adenocarcinoma
  35. 35. Spread• Commonly spread by Lymphatic system (1) Local spread Trachea tracheoesophageal fistula Aorta Fatal hemorrhage Recurrent laryngeal nerve hoarseness of voice• (2) Lymphatic spread *Extensive submucosal lymphatic spread ( proximal line of resection should be 10cm proximal to the tumour). *Cervical ,mediastinal and coeliac LNs.• (3) Blood spread Lung, liver & brain.
  36. 36. Treatment modality• Surgery• Chemotherapy• Radiation therapy• Combination therapy• Palliative therapy
  37. 37. Management protocol
  38. 38. Surgery• 1877- Czerny first surgeon to successfully resect a cervical esophageal cancer• Initially the anastomosis was done by bringing out the ends subcutaneously with external plastic tubes, skin tubes and flaps• 1933- Ohsawa first stomach reconstruction• 1946- Ivor Lewis two staged approach (rt thoracotomy and separate laparotomy)• 1976- Mc Keown 3 stage operation• 1982 & 1994 vagus nerve preservation• 1997 – laparoscopic total esophagectomy
  39. 39. Management of early cancers
  40. 40. • Photodynamic Therapy (PDT)• Drug used: sodium porfirmer
  41. 41. Laser Ablation• Neodymium- :yttrium-aluminium- garnet(Nd:YAG)
  42. 42. Endoscopic Mucosal Resection(EMR)After resectionprotonPump inhibitorsare used
  43. 43. Radiofrequency AblationEndoscopicballoon ablativedevice , kills cellsby heating byelectric current
  44. 44. Surgery
  45. 45. Operable tumors 1) Tumors below the carina (tracheal bifurcation) Ivor Lewis operation(2 phases ) 1st phase :laparotomy & mobilization of stomach. 2nd phase Rt thoracotomy through the 5th intercostal space resection of the tumor .LNs and 10cm of the oesophagus above the tumor & GE anastomosis.
  46. 46. Tumors above the carina Mc Keown operation (3 phases ) 1st phase :laparotomy & mobilization ofstomach 2nd phase Rt thoracotomy through the5th intercostal space :esophagealmobilization 3rd phase: neck incision : theoesophagus & stomach are delivered to theneck where resection is done andanastomosis of the stomach & cervicaloesophagus is carried out.
  47. 47. Transthoracic Esophagectomy
  48. 48. VATS
  49. 49. 3) Tumors below the diaphragm (1 phase)• lt thracoabdominal incision: the stomach & lower oesophagus are removed with• Roux-en-Y esophagojujenostomy• .
  50. 50. • Other options Transhiatal esophagectomy Thoracotomy is avoided by mobilizing the oesophagus from the abdomen via the diaphragmatic hiatus and via the neck incision
  51. 51. 3 field lymph node dissection• Field I: abdominal field• Field II: Paraesophageal, parabronc hial, apical nodes, recurrent nodes, paratracheal• Field III: Cervical paraesophageal, supraclavi cular
  52. 52. • Endopscopic removal through laparoscopy & thoracoscopy
  53. 53. Reconstructions
  54. 54. Colonic transposition
  55. 55. Chemotherapy• Neoadjuvant• Two 4-day cycles,• 3 weeks apart• Cisplatin 80 mg/m2 by infusion over 4 h• fluorouracil 1000 mg/m2 daily by continuous infusion for 4 days. (MRC protocol)• Surgery performed two to four weeks after chemotherapy
  56. 56. Radiation therapyEBRT alone 64.8Gy / 33 - 36 fractionsExternal beam radiotherapy and brachytherapy EBRT• Dose : 60 Gy / 28 fractions with reducing fields. ILRT Boost : 5 - 8Gy / 2-3 fractions (HDR), one week apart or single fraction 20Gy low dose rate (LDR).
  57. 57. Brachytherapy
  58. 58. Concomitant chemo radiation• 50Gy / 25 fractions over 5 weeks,• Cisplatin 75 mg/m2IV Day 1 of weeks 1, 5, 8, and 11,• Fluorouracil, 1g/m2 per day by continuous infusion day1 – day 4 week 1, 5, 8, and 11. (RTOG regimen)
  59. 59. Targeted Therapy• EGFR: Cetuximab• HER-2/neu:Trastuzumab• VEGF:Bevacizumab• Small molecule inhibitors: Imatinib
  60. 60. Palliative treatment• Inoperable Tumors ( 60% of the patients) * Local spread( e.g tracheoesophageal fistula,) * Distant spread• * Bad general condition• Options:- – Endoscopic Laser to core a channel through the tumor
  61. 61. Intubations– • Self expanding metal stents • Traction stents e.g. Celestine stent • Pulsion stents e.g. Soutter’ tube
  62. 62. Dilatation
  63. 63. – Radiotherapy for squamous cell ca– Dose : 3000cGy /10 fractions /2 weeks– Reduced field / boost : 2000cGy/10# / 2 weeks– ILRT alone or in combination with EBRT.– 5 - 8Gy/# in 2- 3 fractions, one week apart– Chemotherapy :5 FU + Cisplatin– 5Fu 1000mg/m2/day continuous IV infusion on day1- 5Cisplatin 100mg/m2 iv on day 1– Repeat cycles on 1,5, 8, 11 wks
  64. 64. PEG
  65. 65. Complications• Anastomotic leak• Respiratory insufficiency• Wound infection• Gastric outlet obstruction• Pulmonary embolism• Radiation pneumonitis• Stricture• Fistula• haemorrhage
  66. 66. Nursing Management• Preoperative management• Post operative management
  67. 67. Preoperative management
  68. 68. Psychological preparationAssess level of anxietyAnswer the questions and concernsregarding surgeryAllow time and privacy to preparepsychologicallyProvide support and assistanceCultural aspect need to be consideredDischarge planning
  69. 69. Legal preparationInformed consent by surgeonNo sedation should be administeredDocumentation
  70. 70. Nutritional supportAims : promote wt gainInterventions– Assess wt , nutritional assessment– Sr Albumin , protein– Assessment of swallowing capacity– High calorie high protein diet in liquid and soft form– Enteral nutrition: NG feeds– Parentral nutrition– Hydration– Adjust diet according to existing problems- constipation/diarrhea
  71. 71. Prevent pulmonary complicationsPatients are not able to clear secretionsHead elevationStent placement and dilatation
  72. 72. Physical and physiological preparation• Cleaning of surgical site• Shaving• Personal hygiene• Oral care• Nutrition: liquid diet x 3 days• Monitor vital signs• Intake /output chart• Antibiotics and regular medications NPO night before No enema and laxatives can be allowed
  73. 73. Pain managementExplain to notify painPain medications will be prescribedNon invasive pain relieve techniques
  74. 74. Preoperative exercisesStop smokingChest physiotherapyIncentive spirometryFootball bladder exercisesCoughing exercisesDeep breathingSplintingGetting out of bed
  75. 75. Pre anesthetic work upAll investigations & corrections toCo morbiditiesECGPFTArterial blood gas2d echoMouth openingCheck listSend all equipments to OT
  76. 76. Post operative management
  77. 77. • Immediate• Intermediate• Extended
  78. 78. Immediate• Intensive care - 24 to 48 hrs• Care of ventilated pt : patent airway Suctioning• Care of drains• Cardiopulmonary monitoring
  79. 79. Intermediate
  80. 80. • Neurological Status• Assess neurological status every shift.• Any neurological change should be carefully watched and• Promptly reported
  81. 81. Pain Management Adequate pain control reduces the mortality and morbidity Asess the pain Initial pain management consist of morphine or bupivacaine given epidurally Patient-controlled analgesia with morphine, or a combination of both .Nothing by mouth for 5 to 7 days, intravenous or epidural pain medications are used.
  82. 82. Pain Management contd..Oral pain medications are started on the fifth or seventh postoperative day The main classes : opoids, nonsteroidal anti-inflammatory drugs, and local anesthetics.
  83. 83. Non-pharmacological interventionsDistraction RelaxationPositioning
  84. 84. Pulmonary Care Aggressive pulmonary toilet Pain control is paramount Patients are usually intubated after surgery monitor oxygenation closely (spo2) Suctioning Chest physiotherapy ,Nebulizers Coughing, deep breathing exercises, Incentive spirometer. Teach patients to splint their incision with a pillow. Early mobilization Monitor patients closely for fever
  85. 85. Chest tube care Assess the drainage every shift.Serosanguinous within a few hours.Not more than 100 to 200 ml/h on the first day.A sudden change in the color of chest tube : milky (chyleleak ) Check the chest tube site for drainage, Keep the chest tube dressing clean, dry, and intact.Keep the chest tube free of any kinks or dependentloops
  86. 86. Subcutaneous emphysema Palpate the surrounding area Due to an air leak from a pleural injury Additional suction or placement of a new chest tube New-onset may indicate a leak of the esophageal anastomosis. . Fever, tachycardia, and hypoxemia Esophageal leak can be confirmed by barium swallow Postoperative chest radiographs for pneumothorax and for placement of any chest tube. Monitor abrupt changes in oxygenation
  87. 87. HemodynamicsIntravenous maintenance fluid at a rate of 100 to 200 ml/h for the first12 to 16 hours. Patients may require fluid boluses in the immediate postoperativeperiod.Crystalloids or blood products may be usedInterstitial pulmonary edema.Malnutrition and low protein levels can complicate the situation.A delicate balance between adequate fluid replacement and fluidoverload. 30 ml/h of urine outputDetermination of body weightMeticulous skin care is necessary.
  88. 88. Nasogastric Tubes. Do not move, manipulate, or irrigate thenasogastric tube.Do not attempt to replace it. Monitor the tube for patency Assess the drainage for color andamount.
  89. 89. Gastrointestinal CareRestricted by mouth for 5 to 7 daysOral medications, are crushed and put down the nasogastric tube onthe second day ; they are never swallowed.Diligent mouth careA jejunostomy feeding tube is often placed during surgery and isused from the first post op day for feedingEarly enteral feeding helps in early healingJejunostomy site care
  90. 90.  At 5 to 7 days check the anastomosis for leaks Eat 6 to 8 small frequent meals each day, Avoid very hot or cold beverages and spicy foods. Protein supplements, high-energy foods, or a soft dysphagia diet Sit upright, chew slowly, and eat more than 3 hours before bedtime assists in reducing reflux. Drink fluids between meals rather than with meals Dumping syndrome, may arise in patients who have had their vagus nerves divided. After vagotomy is related to unregulated gastric emptying Minimizing liquids with meals Consumption of frequent, small, low-carbohydrate meals Discharged with plans for supplemental tube feeding.
  91. 91. Incision CareKeep dressings clean, dry, and intact.Change dressing 2 to 3 times a daySaliva leak out through the cervical incision. Canbe managed by simple dressingLarge volumes (>250 ml every 8 hours),application of a wound drainage bagThe leak is allowed to seal on its own,Sealing could take several weeks.
  92. 92. Infection RiskCompromised nutritional status,They have invasive cathetersRisk of infection at the surgical sites.Meticulous wound and skin care,Hand washing,Avoidance of cross-contaminationChanging of invasive cathetersAntibioticsAdequate nutrition.
  93. 93. Prophylaxis of deep vein thrombosisHeparin s/c BDTED stockingsEarly ambulationLeg and ankle exercises
  94. 94. Discharge planning
  95. 95. • Do’s Check surgical incision Maintain personal hygiene Incision site care Resume daily activities, work and sexual activities Drink fluid b/w meals Eat 3 hrs before bedtime Check wt
  96. 96. Contd… Take stool softeners Crush all medications Observe complications: tarry stool, progressive wt loss, diarrhea Keep follow up appointments
  97. 97. • Don’ts Avoid smoking (join stop smoking group) Avoid strenuous activity for 12 wks Avoid driving for 3 wks Avoid hot & cold beverages , spicy food Drink fluid in between meals
  98. 98. RehabilitationPatient must sleep in a head high positionGet adapted to small frequent mealsKeep a difference of 2-3 hrs betweenmeals and bed timeContinue spirometer for 3 monthsDonot carry weight more than 5 kgsResume daily activities
  99. 99. Prognosis
  100. 100. Follow upEvery 6 monthsPlain X Ray, CBC, Biochemistry onvisitIf symptomaticCT, PET CT
  101. 101. Conclusion
  102. 102. Thank u

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