This document discusses endoscopic therapies for the management of variceal hemorrhage, specifically endoscopic sclerotherapy (EST) and endoscopic variceal ligation (EVL). It provides background on variceal bleeding and survival rates over time. It then describes the modalities and techniques of EST and EVL, including injection methods, sclerosing agents used, risks, and indications. Randomized controlled trials comparing EST and EVL are summarized, showing higher eradication rates with EVL. In conclusion, endoscopic therapies like EST and EVL are effective for controlling acute variceal bleeding and reducing recurrence when used for primary or secondary prophylaxis.
The document discusses surgical management of chronic pancreatitis. It describes various surgical procedures for treating chronic pancreatitis including resection procedures like Whipple procedure, drainage procedures like Puestow's procedure, and hybrid procedures like Frey procedure. Studies have shown that duodenum-preserving pancreatic head resection procedures and longitudinal pancreaticojejunostomy provide better postoperative outcomes and pain control compared to resection procedures while preserving exocrine and endocrine function. The document concludes that surgery is effective for relieving pain in chronic pancreatitis and duodenum-preserving pancreatic head resection procedures have advantages over other surgical options.
Approximately 10% of patients with mesenteric cysts present with an acute abdominal emergency, the most common picture is small-bowel obstruction, which may be associated with intestinal volvulus or infarction.
This document provides an overview of splenic injuries, including epidemiology, anatomy, evaluation, management, and guidelines. Key points include:
- The spleen is the most commonly injured organ in blunt abdominal trauma. Evaluation involves clinical exam, hematology tests, ultrasound, and CT scan to grade injuries.
- Management depends on hemodynamic stability and injury grade. Options include non-operative management with observation or angioembolization, or splenectomy/splenorrhaphy during surgery.
- Complications of splenic injuries and splenectomy include hemorrhage, infection, and post-splenectomy sepsis. Guidelines recommend attempting non-operative management for stable patients
Surgical management of Carcinoma EsophagusLoveleen Garg
A detailed dicussion on surgical procedures & steps to be followed during surgery for Carcinoma esophagus.
Source- Schwartz's Principles of Surgery, 9th Edition
This document discusses benign gastric and duodenal ulcers. It defines peptic ulcers as lesions in the stomach or duodenum mucosa. Gastric ulcers are caused by an imbalance of protective and damaging factors in the gastric mucosa. Duodenal ulcers are often caused by Helicobacter pylori infection or NSAID use. Medical management includes treating H. pylori infection, providing pain relief, and protecting the mucosa. Surgical procedures are indicated for complications like perforation or hemorrhage. Common procedures include vagotomy, drainage procedures like pyloroplasty, and resections like antrectomy or subtotal gastrectomy.
This document discusses achalasia, including its etiology, clinical presentation, diagnosis, and management. It provides a historical overview and describes the current understanding of achalasia as aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter due to degeneration of inhibitory neurons. For diagnosis, it recommends high resolution manometry, barium swallow, and endoscopy. The standard treatment is described as laparoscopic Heller myotomy with partial fundoplication to prevent reflux, with options for medical management, pneumatic dilation, or injection of botulinum toxin as alternatives. Complications and approaches for managing treatment failure are also outlined.
The document summarizes the anatomy of the anal canal. It describes the anal canal as having both a surgical and anatomic component. The surgical anal canal extends from the anorectal junction to the anal verge, while the anatomic canal extends from the dentate line to the anal verge. Key structures discussed include the anorectal ring, internal and external anal sphincters, longitudinal muscle, blood supply, and innervation. The document emphasizes that the anorectal area involves complex anatomical and physiological interactions important for continence and defecation.
The document discusses surgical management of chronic pancreatitis. It describes various surgical procedures for treating chronic pancreatitis including resection procedures like Whipple procedure, drainage procedures like Puestow's procedure, and hybrid procedures like Frey procedure. Studies have shown that duodenum-preserving pancreatic head resection procedures and longitudinal pancreaticojejunostomy provide better postoperative outcomes and pain control compared to resection procedures while preserving exocrine and endocrine function. The document concludes that surgery is effective for relieving pain in chronic pancreatitis and duodenum-preserving pancreatic head resection procedures have advantages over other surgical options.
Approximately 10% of patients with mesenteric cysts present with an acute abdominal emergency, the most common picture is small-bowel obstruction, which may be associated with intestinal volvulus or infarction.
This document provides an overview of splenic injuries, including epidemiology, anatomy, evaluation, management, and guidelines. Key points include:
- The spleen is the most commonly injured organ in blunt abdominal trauma. Evaluation involves clinical exam, hematology tests, ultrasound, and CT scan to grade injuries.
- Management depends on hemodynamic stability and injury grade. Options include non-operative management with observation or angioembolization, or splenectomy/splenorrhaphy during surgery.
- Complications of splenic injuries and splenectomy include hemorrhage, infection, and post-splenectomy sepsis. Guidelines recommend attempting non-operative management for stable patients
Surgical management of Carcinoma EsophagusLoveleen Garg
A detailed dicussion on surgical procedures & steps to be followed during surgery for Carcinoma esophagus.
Source- Schwartz's Principles of Surgery, 9th Edition
This document discusses benign gastric and duodenal ulcers. It defines peptic ulcers as lesions in the stomach or duodenum mucosa. Gastric ulcers are caused by an imbalance of protective and damaging factors in the gastric mucosa. Duodenal ulcers are often caused by Helicobacter pylori infection or NSAID use. Medical management includes treating H. pylori infection, providing pain relief, and protecting the mucosa. Surgical procedures are indicated for complications like perforation or hemorrhage. Common procedures include vagotomy, drainage procedures like pyloroplasty, and resections like antrectomy or subtotal gastrectomy.
This document discusses achalasia, including its etiology, clinical presentation, diagnosis, and management. It provides a historical overview and describes the current understanding of achalasia as aperistalsis of the esophageal body and incomplete relaxation of the lower esophageal sphincter due to degeneration of inhibitory neurons. For diagnosis, it recommends high resolution manometry, barium swallow, and endoscopy. The standard treatment is described as laparoscopic Heller myotomy with partial fundoplication to prevent reflux, with options for medical management, pneumatic dilation, or injection of botulinum toxin as alternatives. Complications and approaches for managing treatment failure are also outlined.
The document summarizes the anatomy of the anal canal. It describes the anal canal as having both a surgical and anatomic component. The surgical anal canal extends from the anorectal junction to the anal verge, while the anatomic canal extends from the dentate line to the anal verge. Key structures discussed include the anorectal ring, internal and external anal sphincters, longitudinal muscle, blood supply, and innervation. The document emphasizes that the anorectal area involves complex anatomical and physiological interactions important for continence and defecation.
The document discusses the anatomy of the esophageal hiatus and types of hiatal hernia. It describes four types of hiatal hernia, with type I being the most common sliding hernia associated with GERD. Surgical options for repair include laparoscopic and open approaches, with the goals being to relieve symptoms and prevent complications by reducing reflux and returning the GE junction below the diaphragm. Post-operative care involves a progressive diet and activity plan, with most patients finding symptom relief but recurrence rates remaining between 20-40% even at large centers.
This document discusses recurrent pyogenic cholangitis (RPC), a condition characterized by recurrent bacterial cholangitis, intrahepatic pigmented stones, and biliary strictures. It is seen predominantly in Southeast Asia. Parasitic infections and bacterial infections both contribute to the formation of stones within the bile ducts. Patients typically present with recurrent episodes of cholangitis. Imaging studies can identify stones and bile duct abnormalities. Treatment involves stone removal, antibiotics, and sometimes surgical interventions like duct clearance or liver resection to prevent long-term complications like cirrhosis or cancer. Recurrence rates remain high even after treatment.
This document discusses obstructive jaundice and neonatal hyperbilirubinemia. Neonates are more susceptible to hyperbilirubinemia due to physiological factors such as higher red blood cell count and liver immaturity. Biliary atresia is described as the atresia of the extrahepatic bile ducts in newborns caused by an unknown destructive inflammatory process. It is diagnosed using imaging and liver function tests and treated with surgery like Kasai portoenterostomy, though long term outcomes are generally poor without liver transplant.
This document discusses the management of caustic ingestion injuries. It notes that the severity of injuries depends on factors like amount, concentration and contact time of the ingested substance. Gastrointestinal endoscopy within 24 hours is recommended to assess injury grade unless contraindicated. Long term complications include esophageal strictures and cancer, so endoscopic cancer screening is advised 15-20 years later. Surgery is indicated if perforation signs appear.
Colorectal anastomosis leaks are most difficult to manage for a surgeon carrying morbidity and mortality. Discussion on risk factors as well as management of anastomotic leak.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Bile is produced by the liver and stored and concentrated in the gallbladder before being released to aid digestion. The biliary tree consists of intrahepatic and extrahepatic ducts that drain bile from the liver to the gallbladder and duodenum. Developmental variations in branching patterns can occur and need to be recognized to avoid complications during surgery or imaging studies. Biliary disorders in children may be developmental, such as biliary atresia or choledochal cysts, or acquired, like inspissated bile plug syndrome. Gallbladder diseases include cholecystitis, porcelain gallbladder, and adenomyomatosis.
This document provides an overview of acute gastrointestinal bleeding. It defines upper gastrointestinal bleeding and discusses its causes, including variceal and non-variceal sources. Signs and symptoms are outlined. The approach involves taking a thorough history and physical exam. Key lab tests include CBC, LFTs, coagulation panels and endoscopy. Treatment depends on the bleeding source, and may include endoscopic methods, radiological embolization, surgery, or medications like PPIs and vasoactive drugs. Complications are also reviewed.
Presented during Surgical Grand Round in Clonmel Hospital in 2011. The purpose of this presentation is to educate junior doctors on appendicitis.
This presentation was presented in 2011. So the content may be outdated. So please keep yourself updated.
WanYusof Wan Jeffery
zenslides.com [Eng]
presentasipukau.com [Malay]
This document describes a case of rectal prolapse in a 15-year-old male patient who reported a mass coming out of his anus for the past 4 years. On examination, the doctor observed a pinkish mass coming out of the anus during straining that was soft and reducible. Rectal prolapse was included in the differential diagnosis along with large rectal polyp and hemorrhoids. The document proceeds to provide details on the types, causes, symptoms, evaluation, and management of rectal prolapse, including non-surgical and surgical treatment options such as perineal and abdominal procedures. Complications of treatment are also discussed.
POSTERIOR URETHRAL VALVES- Pediatric Surgery
• Dear viewers,
• Greetings from “ Surgical Educator”
• Today I have uploaded one more video in Pediatric Surgery/Pediatric Urology- “ Posterior Urethral Valves”
• Posterior Urethral Valves is the congenital cause for Bladder Outlet Obstruction, resulting in abnormal development of the kidneys as well as the bladder.
• In this video, I talked about the learning outcomes, introduction, etiopathogenesis, clinical features, investigations, differential diagnosis, treatment, follow-up and prognosis of “ Posterior Urethral Valves”
• I hope you will enjoy the video for its educational value.
• You can watch all my teaching videos in the following links
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
1. Choledochal cysts are abnormal dilations of the bile ducts that are more common in Asia and women.
2. They are classified into 5 types based on location and extent of dilation.
3. Presentation varies from jaundice and abdominal mass in children to pain and cholangitis in older patients.
4. Investigation involves ultrasound, CT, MRCP and cholangiography to determine type and rule out complications.
5. Treatment is complete excision of the cysts and biliary tree with Roux-en-Y hepaticojejunostomy, except for type III which can be managed endoscopically.
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
The document provides guidance on evaluating a patient presenting with an abdominal lump. It outlines taking a thorough history including demographics, present complaints, associated symptoms, past medical history, and family history. A comprehensive physical exam of the abdomen and other systems is described. Differential diagnoses are provided for lumps in various abdominal regions, including the right hypochondrium, epigastrium, lumbar regions, umbilical region, right and left lower quadrants. Recommended investigations are ultrasound and other imaging and labs guided by history and exam to determine the cause.
This document discusses urinary tract obstruction, specifically ureteropelvic junction obstruction (UPJO). It covers the causes, evaluation, and surgical treatment options for UPJO, with a focus on laparoscopic pyeloplasty. Key points include that UPJO can be congenital or acquired, and indications for intervention include symptoms, impaired renal function, stones or infection. Laparoscopic pyeloplasty is a less invasive alternative to open surgery that provides comparable success rates while reducing morbidity. The procedure involves mobilizing the colon, dissecting the ureter, and performing a dismembered pyeloplasty reconstruction.
This document discusses the management of common bile duct (CBD) stones. It begins by describing the causes, symptoms, signs, and diagnosis of CBD stones. CBD stones can be primary (formed in the duct) or secondary (passed from the gallbladder). Diagnosis involves blood tests, ultrasound, MRCP, and ERCP. Treatment depends on whether stones are detected before, during, or after cholecystectomy. Options include ERCP sphincterotomy and stone extraction, laparoscopic CBD exploration, open CBD exploration, and surgery like choledochoduodenostomy. For retained stones, additional options are extracting through a T-tube or dissolving chemically. The goal is to remove stones using the least
This document discusses a case of a 60-year-old male diagnosed with rectal cancer. It provides details on his medical history, including a sigmoidoscopy that revealed adenocarcinoma of the rectum. He received neoadjuvant chemoradiation therapy. The document discusses the clinical anatomy of the rectum, risk factors for rectal cancer, staging systems, diagnostic workup, and treatment options like surgery. The main treatment is surgery, with the goal of total mesorectal excision to reduce local recurrence rates.
The spleen is an organ located in the upper left abdomen. It filters blood and fights infections. A splenectomy is the surgical removal of the spleen. It is usually performed laparoscopically to avoid complications of open surgery. During the procedure, the surgeon uses cameras and surgical tools inserted through small incisions to carefully dissect and divide attachments of the spleen. This allows the spleen to be removed while preserving surrounding structures like the pancreas and stomach. A splenectomy may be recommended for conditions like immune thrombocytopenia or certain blood disorders.
This document provides an overview of cholangiocarcinoma, a cancer originating from the bile duct epithelium. It discusses the risk factors, clinical presentation, diagnostic evaluation, staging, and treatment approaches for intrahepatic and extrahepatic cholangiocarcinoma. For resectable disease, the standard treatment is surgical resection with negative margins, while unresectable disease is treated with chemotherapy, radiation, palliative procedures, or best supportive care. Liver transplantation may be an option for highly selected patients with unresectable hilar cholangiocarcinoma.
esophageal cancer surgery types and complicationsved sah
Background-Anatomy & Staging
Surgical Candicate
Contraindication of sx
Assessment of patients for surgery
Approaches of esophagectomies
Esophageal reconstruction
Complications of esophagectomy
1) The document summarizes a conference on the Kono-S anastomosis technique for preventing anastomotic recurrence in Crohn's disease.
2) The technique involves creating a supporting column at the anastomosis site to avoid stenosis, while preserving blood flow and the nervous system, which are important for ulcer healing.
3) The Kono-S technique was developed to address issues like selective loss of vasodilators in Crohn's disease and reduced blood flow along the mesenteric margin, where ulcers tend to occur.
This document discusses intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) for head and neck cancers. It provides details on contouring targets and organs at risk for treatment planning. It summarizes evidence from trials on reducing xerostomia with IMRT. It also discusses the benefits of daily imaging with IGRT for accurate treatment delivery and potentially reducing planning target volume margins. Adaptive planning is mentioned as an area that continues to be explored to account for anatomical changes over the course of radiation treatment.
The document discusses the anatomy of the esophageal hiatus and types of hiatal hernia. It describes four types of hiatal hernia, with type I being the most common sliding hernia associated with GERD. Surgical options for repair include laparoscopic and open approaches, with the goals being to relieve symptoms and prevent complications by reducing reflux and returning the GE junction below the diaphragm. Post-operative care involves a progressive diet and activity plan, with most patients finding symptom relief but recurrence rates remaining between 20-40% even at large centers.
This document discusses recurrent pyogenic cholangitis (RPC), a condition characterized by recurrent bacterial cholangitis, intrahepatic pigmented stones, and biliary strictures. It is seen predominantly in Southeast Asia. Parasitic infections and bacterial infections both contribute to the formation of stones within the bile ducts. Patients typically present with recurrent episodes of cholangitis. Imaging studies can identify stones and bile duct abnormalities. Treatment involves stone removal, antibiotics, and sometimes surgical interventions like duct clearance or liver resection to prevent long-term complications like cirrhosis or cancer. Recurrence rates remain high even after treatment.
This document discusses obstructive jaundice and neonatal hyperbilirubinemia. Neonates are more susceptible to hyperbilirubinemia due to physiological factors such as higher red blood cell count and liver immaturity. Biliary atresia is described as the atresia of the extrahepatic bile ducts in newborns caused by an unknown destructive inflammatory process. It is diagnosed using imaging and liver function tests and treated with surgery like Kasai portoenterostomy, though long term outcomes are generally poor without liver transplant.
This document discusses the management of caustic ingestion injuries. It notes that the severity of injuries depends on factors like amount, concentration and contact time of the ingested substance. Gastrointestinal endoscopy within 24 hours is recommended to assess injury grade unless contraindicated. Long term complications include esophageal strictures and cancer, so endoscopic cancer screening is advised 15-20 years later. Surgery is indicated if perforation signs appear.
Colorectal anastomosis leaks are most difficult to manage for a surgeon carrying morbidity and mortality. Discussion on risk factors as well as management of anastomotic leak.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Bile is produced by the liver and stored and concentrated in the gallbladder before being released to aid digestion. The biliary tree consists of intrahepatic and extrahepatic ducts that drain bile from the liver to the gallbladder and duodenum. Developmental variations in branching patterns can occur and need to be recognized to avoid complications during surgery or imaging studies. Biliary disorders in children may be developmental, such as biliary atresia or choledochal cysts, or acquired, like inspissated bile plug syndrome. Gallbladder diseases include cholecystitis, porcelain gallbladder, and adenomyomatosis.
This document provides an overview of acute gastrointestinal bleeding. It defines upper gastrointestinal bleeding and discusses its causes, including variceal and non-variceal sources. Signs and symptoms are outlined. The approach involves taking a thorough history and physical exam. Key lab tests include CBC, LFTs, coagulation panels and endoscopy. Treatment depends on the bleeding source, and may include endoscopic methods, radiological embolization, surgery, or medications like PPIs and vasoactive drugs. Complications are also reviewed.
Presented during Surgical Grand Round in Clonmel Hospital in 2011. The purpose of this presentation is to educate junior doctors on appendicitis.
This presentation was presented in 2011. So the content may be outdated. So please keep yourself updated.
WanYusof Wan Jeffery
zenslides.com [Eng]
presentasipukau.com [Malay]
This document describes a case of rectal prolapse in a 15-year-old male patient who reported a mass coming out of his anus for the past 4 years. On examination, the doctor observed a pinkish mass coming out of the anus during straining that was soft and reducible. Rectal prolapse was included in the differential diagnosis along with large rectal polyp and hemorrhoids. The document proceeds to provide details on the types, causes, symptoms, evaluation, and management of rectal prolapse, including non-surgical and surgical treatment options such as perineal and abdominal procedures. Complications of treatment are also discussed.
POSTERIOR URETHRAL VALVES- Pediatric Surgery
• Dear viewers,
• Greetings from “ Surgical Educator”
• Today I have uploaded one more video in Pediatric Surgery/Pediatric Urology- “ Posterior Urethral Valves”
• Posterior Urethral Valves is the congenital cause for Bladder Outlet Obstruction, resulting in abnormal development of the kidneys as well as the bladder.
• In this video, I talked about the learning outcomes, introduction, etiopathogenesis, clinical features, investigations, differential diagnosis, treatment, follow-up and prognosis of “ Posterior Urethral Valves”
• I hope you will enjoy the video for its educational value.
• You can watch all my teaching videos in the following links
• surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
• Thank you for watching the video.
1. Choledochal cysts are abnormal dilations of the bile ducts that are more common in Asia and women.
2. They are classified into 5 types based on location and extent of dilation.
3. Presentation varies from jaundice and abdominal mass in children to pain and cholangitis in older patients.
4. Investigation involves ultrasound, CT, MRCP and cholangiography to determine type and rule out complications.
5. Treatment is complete excision of the cysts and biliary tree with Roux-en-Y hepaticojejunostomy, except for type III which can be managed endoscopically.
Role and types of surgery in chronic pancreatitisShambhavi Sharma
This document discusses the role and types of surgery in chronic pancreatitis. It begins with an introduction and overview of chronic pancreatitis and its causes. It then discusses the various symptoms and complications that can arise. The document outlines the surgical and non-surgical management options, including drainage procedures like Puestow's procedure and resection procedures like pancreaticoduodenectomy. It provides details on the indications, advantages, and disadvantages of different surgical procedures. The key message is that surgery aims to relieve pain and complications while preserving pancreatic function as much as possible.
The document provides guidance on evaluating a patient presenting with an abdominal lump. It outlines taking a thorough history including demographics, present complaints, associated symptoms, past medical history, and family history. A comprehensive physical exam of the abdomen and other systems is described. Differential diagnoses are provided for lumps in various abdominal regions, including the right hypochondrium, epigastrium, lumbar regions, umbilical region, right and left lower quadrants. Recommended investigations are ultrasound and other imaging and labs guided by history and exam to determine the cause.
This document discusses urinary tract obstruction, specifically ureteropelvic junction obstruction (UPJO). It covers the causes, evaluation, and surgical treatment options for UPJO, with a focus on laparoscopic pyeloplasty. Key points include that UPJO can be congenital or acquired, and indications for intervention include symptoms, impaired renal function, stones or infection. Laparoscopic pyeloplasty is a less invasive alternative to open surgery that provides comparable success rates while reducing morbidity. The procedure involves mobilizing the colon, dissecting the ureter, and performing a dismembered pyeloplasty reconstruction.
This document discusses the management of common bile duct (CBD) stones. It begins by describing the causes, symptoms, signs, and diagnosis of CBD stones. CBD stones can be primary (formed in the duct) or secondary (passed from the gallbladder). Diagnosis involves blood tests, ultrasound, MRCP, and ERCP. Treatment depends on whether stones are detected before, during, or after cholecystectomy. Options include ERCP sphincterotomy and stone extraction, laparoscopic CBD exploration, open CBD exploration, and surgery like choledochoduodenostomy. For retained stones, additional options are extracting through a T-tube or dissolving chemically. The goal is to remove stones using the least
This document discusses a case of a 60-year-old male diagnosed with rectal cancer. It provides details on his medical history, including a sigmoidoscopy that revealed adenocarcinoma of the rectum. He received neoadjuvant chemoradiation therapy. The document discusses the clinical anatomy of the rectum, risk factors for rectal cancer, staging systems, diagnostic workup, and treatment options like surgery. The main treatment is surgery, with the goal of total mesorectal excision to reduce local recurrence rates.
The spleen is an organ located in the upper left abdomen. It filters blood and fights infections. A splenectomy is the surgical removal of the spleen. It is usually performed laparoscopically to avoid complications of open surgery. During the procedure, the surgeon uses cameras and surgical tools inserted through small incisions to carefully dissect and divide attachments of the spleen. This allows the spleen to be removed while preserving surrounding structures like the pancreas and stomach. A splenectomy may be recommended for conditions like immune thrombocytopenia or certain blood disorders.
This document provides an overview of cholangiocarcinoma, a cancer originating from the bile duct epithelium. It discusses the risk factors, clinical presentation, diagnostic evaluation, staging, and treatment approaches for intrahepatic and extrahepatic cholangiocarcinoma. For resectable disease, the standard treatment is surgical resection with negative margins, while unresectable disease is treated with chemotherapy, radiation, palliative procedures, or best supportive care. Liver transplantation may be an option for highly selected patients with unresectable hilar cholangiocarcinoma.
esophageal cancer surgery types and complicationsved sah
Background-Anatomy & Staging
Surgical Candicate
Contraindication of sx
Assessment of patients for surgery
Approaches of esophagectomies
Esophageal reconstruction
Complications of esophagectomy
1) The document summarizes a conference on the Kono-S anastomosis technique for preventing anastomotic recurrence in Crohn's disease.
2) The technique involves creating a supporting column at the anastomosis site to avoid stenosis, while preserving blood flow and the nervous system, which are important for ulcer healing.
3) The Kono-S technique was developed to address issues like selective loss of vasodilators in Crohn's disease and reduced blood flow along the mesenteric margin, where ulcers tend to occur.
This document discusses intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) for head and neck cancers. It provides details on contouring targets and organs at risk for treatment planning. It summarizes evidence from trials on reducing xerostomia with IMRT. It also discusses the benefits of daily imaging with IGRT for accurate treatment delivery and potentially reducing planning target volume margins. Adaptive planning is mentioned as an area that continues to be explored to account for anatomical changes over the course of radiation treatment.
Congress presentation in S.PAULO 2010
DOES ANEURYSM SAC STABILIZATION DURING EVAR REDUCE THE INCIDENCE OF ENDOLEAKS?
Presentazione al congresso di S.Paulo 2010
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
Treatment of failed roux en-y hepaticojejunostomy after post cholecystectomy ...Ferstman Duran
This study evaluated the outcomes of a multidisciplinary approach to treating failed Roux-en-Y hepaticojejunostomy (RYHJ) after post-cholecystectomy bile duct injuries. 44 patients with recurrent cholangitis or jaundice after a failed initial RYHJ underwent either revisionary surgery including repeat RYHJ or hepatectomy, or a percutaneous approach including biliary interventions or portal vein embolization. Immediate treatment with revisionary surgery or a percutaneous approach achieved a clinical success rate of 89%, with no postoperative mortality and generally mild morbidity. Delayed revisionary surgery after attempting to dilate the bile ducts through percutaneous means failed in all patients. An immediate multidis
This document discusses antiviral therapy peri-liver transplantation. It provides data on primary liver disease in adult transplant recipients, with chronic hepatitis C being the most common at 20.7-40%. It also shows survival rates after transplantation by diagnosis. Therapeutic strategies for patients with HBV, HDV, and HCV undergoing liver transplantation aim to prevent recurrent infection of the graft. Recurrence of HBV infection is related to liver disease and HBV replicative status pre-transplant. Combination therapy with hepatitis B immune globulin and antiviral drugs like lamivudine is most effective for preventing HBV recurrence post-transplant according to various studies cited. Guidelines are provided for HBV prophylaxis and treatment of recurrence after
Surgeon Performed Ultrasound In Proctological Practiceu.surgery
This document discusses the use of surgeon-performed ultrasound in proctological practice. It provides an overview of how endoluminal ultrasonography can be used to evaluate perirectal sepsis, faecal incontinence, and rectal and anal cancers. It describes the principles, techniques, and applications of endoanal, endorectal, 3D, and transperineal ultrasound. Dynamic transperineal ultrasound is presented as a non-invasive alternative to defaecography for assessing pelvic floor disorders and functional conditions.
DETAILS OF EVIDENCE TAVI FROM ITS EXISTENCE IN INTERVENTIONAL CARDIOLOGY TO THE SURTAVI REGISTRY ..AS AN OPTION FROM HIGH RISK UNOPERABLE PATIENTS TO INTERMEDIATE AND LOW RISK PATIENTS
The document discusses various techniques for treating superficial venous insufficiency in the 21st century, with a focus on preserving the great saphenous vein (GSV) when possible. It notes that while no technique is perfect, conservative techniques that do not destroy veins have shown lower recurrence rates than ablative techniques. Ultrasound is important for evaluating reflux qualitatively and quantitatively by measuring parameters like reflux time and total reflux volume. The document concludes that destructive treatment of the GSV for varicose veins may jeopardize its future use for life-saving bypass procedures.
1) IMRT and IGRT techniques aim to improve outcomes for head and neck cancer patients by better targeting tumors and reducing toxicity to organs at risk.
2) Early phase trials show dose escalated IMRT is feasible and improves local control for larynx and hypopharynx cancers compared to conventional radiotherapy.
3) Ongoing randomized trials are investigating whether parotid gland-sparing IMRT reduces xerostomia compared to conventional radiotherapy for oropharynx cancers.
4) Novel applications of IMRT include its use for unknown primary cancers to potentially improve local control without high toxicity. Integration of imaging techniques with IMRT may further optimize treatment.
recommandations ESC 2012 sur les pathologies valvulaires cardiaquessiham h.
This document summarizes the results of the ACCESS-EUROPE study on the MitraClip procedure for treating mitral regurgitation. The study found that at 1 year follow up:
- Mitral regurgitation was reduced to ≤2+ in 79% of patients and NYHA functional class was I/II in 72% of patients.
- Quality of life scores improved significantly and 6-minute walk distance increased by an average of 59.5 meters.
- Adverse events rates were consistent with the high risk nature of the study patients, with death occurring in 17.3% of patients at 1 year.
This document provides an overview of acute renal failure (ARF), including definitions, epidemiology, diagnostic workup, specific syndromes, treatment, and prevention strategies. It discusses the etiology of ARF, including pre-renal, intra-renal, and post-renal causes. Pre-renal ARF can be caused by factors like volume depletion, NSAIDs, and ACE inhibitors. Intra-renal ARF includes vascular occlusion, glomerular diseases, tubular disorders like crystal nephropathy, and interstitial nephritis. Effective prevention strategies for ischemic acute tubular necrosis (ATN) include maintaining euvolemia through fluid hydration.
Acute renal failure is a common condition in hospitalized patients with a high mortality rate. While many patients recover from ARF, a significant number do not survive. The document discusses the definitions, epidemiology, etiologies, diagnostic workup, treatment and prevention of ARF. It emphasizes that the most effective preventive strategy is to maintain proper fluid volume status in at-risk patients. Biomarkers are being investigated to aid early diagnosis but hydration remains the key prevention method.
Dental diagnosticians are responsible for detecting salivary gland disorders using applicable imaging techniques. Salivary gland disorders can be inflammatory, non-inflammatory, or space-occupying masses. Clinical signs may include swelling, pain, altered salivary flow, and a review of medical history. Diagnostic imaging is used to differentiate inflammatory from neoplastic processes, identify sialoliths, and determine tumor location and characteristics. Common imaging modalities discussed include plain radiography, sialography, CT, MRI, scintigraphy, and ultrasonography.
DELINEATION OF NODAL VOLUMES AND OARS A PROBLEM BASED APPROACHKanhu Charan
This document discusses various problems and considerations for delineating nodal volumes and organs at risk (OARs) in head and neck radiotherapy planning. It addresses 30 specific problems or questions regarding delineation of nodal volumes, lymph node levels, high/low risk nodal areas, OARs like parotid glands and dysphagia structures, and other challenges like extracapsular extension and unknown primary tumors. The document provides detailed guidelines and proposed solutions for each delineation problem.
Measurement of Aortic area in Echocardiography and DopplerNizam Uddin
This study compared aortic valve area (AVA) measurements from Doppler echocardiography (AVAEcho) and multidetector computed tomography (MDCT) (AVACT) in 269 patients with aortic stenosis. The study aimed to determine if AVACT was superior to AVAEcho in assessing hemodynamic correlations, predicting survival outcomes, and resolving discordant assessments of aortic stenosis severity. The study found that while AVACT measurements of the left ventricular outflow tract were larger than AVAEcho, leading to slightly higher calculated AVA values, AVACT did not improve correlations with transvalvular gradients, concordance between gradient and AVA, or prediction of mortality compared to AVAEcho. Both AVAEcho and AV
1) The document discusses genetic colon cancer syndromes familial adenomatous polyposis (FAP) and Lynch syndrome (LS), providing definitions, terminology, guidelines, and case examples.
2) For FAP, it recommends monitoring for iron/B12 deficiencies annually in patients and considers chemoprevention with fish oil. For retained rectum in FAP, surveillance is every 6 months.
3) For LS, it states the emerging standard is universal microsatellite instability testing on all or most colon cancers to identify cases, rather than relying on clinical criteria alone.
This document discusses ultrasound evaluation of the carotid arteries. It begins by describing carotid artery anatomy and variations in bifurcation geometry. It then covers Doppler ultrasound techniques for assessing carotid stenoses, including spectral Doppler parameters. Measurement of intima-media thickness and characterization of carotid plaques is also addressed. The prevalence of carotid plaques and stenoses increases with age. Contrast-enhanced ultrasound can identify neovascularization within unstable plaques. Grading scales are presented for estimating the severity of carotid stenoses based on ultrasound measurements. Management algorithms for carotid stenosis are also reviewed.
Consecutive Aneurysms Treated by Endovascular ApproachDr Vipul Gupta
Endovascular coiling is now the primary treatment approach for ruptured intracranial aneurysms based on evidence from trials like ISAT showing improved outcomes compared to clipping. The presenter's experience with 33 patients with 35 consecutive aneurysms showed high rates of aneurysm occlusion (95%) and good clinical outcomes (87.6% had mRS 0-2) when treated using a protocol-based endovascular approach with neurosurgical and critical care support. Complications were low when meticulous techniques were used along with protocols for management of issues like vasospasm.
1) The document outlines the consensus approach to managing non-variceal upper GI bleeding, including risk stratification, endoscopic treatment, and the role of PPIs.
2) Early endoscopy within 24 hours allows for safe discharge of low risk patients and improves outcomes for high risk patients through endoscopic hemostasis.
3) Combination endoscopic therapy with injection followed by thermal treatment is the most effective approach for achieving hemostasis.
4) High dose intravenous PPIs reduce recurrent bleeding rates and improve mortality when used in conjunction with endoscopic hemostasis in patients with high risk stigmata.
1) The surgical treatment of portal hypertension has evolved significantly in Egypt over the last century, driven by changes in liver pathology and the development of new techniques.
2) Initially, procedures like splenectomy were used but caused only temporary effects. Total portosystemic shunts were then introduced but were later abandoned due to high mortality and morbidity rates.
3) More selective surgeries and techniques were developed like Hassab's operation and mesocaval shunts but still had issues. The distal splenorenal shunt became more widely used as a selective shunt.
This document discusses chemotherapy options for biliary tree carcinoma. It begins by outlining the increasing mortality rates and poor prognosis of the disease. It then provides detailed information on the anatomical classification, histological classification, definition, risk factors, and problems associated with diagnosis and treatment. The document discusses surgery as the only potentially curative option but notes that most patients present with advanced, unresectable disease. It reviews several palliative chemotherapy regimens and their response rates and survival benefits, with various gemcitabine-based combinations showing the most promise. The challenges of treating this rare cancer are also summarized.
This document discusses the multimodal treatment of hepatocellular carcinoma. It begins by noting that 70% of HCC occurs in patients with cirrhosis. Available treatment methods include surgical resection, liver transplantation, transarterial embolization, chemotherapy, and various ablation techniques. Surgical resection has improved and offers the best chance of cure for non-cirrhotic patients, though recurrence rates are high. Liver transplantation offers the best disease-free survival for selected cirrhotic patients meeting criteria such as tumor size and number, but organ shortage is a major limitation. Other treatments such as arterial embolization and chemotherapy have limited or debated efficacy.
This document summarizes a study comparing outcomes of surgical treatment for intrahepatic cholangiocarcinoma (ICC) and hilar cholangiocarcinoma (Klatskin tumor). 59 patients who underwent liver resection for these tumors were analyzed. Klatskin tumors required more extensive resections and had higher postoperative morbidity. 5-year survival was similar for both tumor types at around 35%. Expression of the p27 protein was associated with lower recurrence rates and better survival outcomes. Surgical resection remains the primary treatment when possible but molecular markers may help guide future adjuvant therapies.
The document discusses the proximal splenorenal shunt procedure for patients with liver cirrhosis and portal hypertension combined with hypersplenism. The procedure involves creating a shunt from the splenic vein to the left renal vein to decompress the portal system. It is indicated for select patients as an alternative to other procedures to prevent variceal bleeding while removing the spleen. However, it carries risks of hepatic encephalopathy, worsening liver function, and is not suitable for future transplantation. The authors' experience with 17 patients who underwent this procedure is presented, along with postoperative outcomes.
The document discusses various treatment options for portal hypertension and its complications. It covers surgical procedures like devascularization operations, portosystemic shunts and splenorenal shunts that are aimed at preventing bleeding, stopping active bleeding, and preventing recurrent variceal bleeding. The choice of surgical treatment depends on factors like the severity of bleeding, liver dysfunction, and type of portal hypertension.
The document discusses different surgical treatments for portal hypertension between 1877-2003. It lists various types of shunt procedures that were developed over time to reduce portal pressure, including Eck-Pavlov-Vidal shunt in 1967, Warren shunt in 1967, and Starzl auxiliary liver transplantation in 1973. The document also discusses surgical treatments for Budd-Chiari syndrome and ascites, such as portocaval shunts, mesenterico-caval shunts, and LeVeen shunts. It concludes by providing data on the types of shunt procedures performed between 1997-2003 for portal hypertension treatment and their results.
TIPSS is a procedure that creates a permanent connection between the portal and hepatic veins to reduce portal hypertension. It has several indications including uncontrolled variceal bleeding and refractory ascites. The procedure involves catheterization of the jugular vein and placement of a stent. Complications can include thrombosis, hemorrhage, and encephalopathy. Success rates are over 80% for variceal bleeding and 50% for ascites, but secondary dysfunction occurs in 40% after 1 year often requiring revision. TIPSS provides immediate reduction in portal pressure and is less invasive than surgical shunting.
The document discusses pathogenesis and management of portal hypertension. It covers hemodynamic assessment of portal hypertension, causes of non-cirrhotic portal hypertension including nodular regenerative hyperplasia. Animal models of portal hypertension are described. The role of nitric oxide and endothelin in regulating vascular tone is discussed. Clinical consequences of cirrhotic portal hypertension include variceal bleeding. Management of acute variceal bleeding involves vasoactive drugs and endoscopic therapy. Secondary prophylaxis to prevent rebleeding involves non-selective beta-blockers or band ligation.
The document discusses guidelines for evaluating and treating hepatic metastases from colorectal cancer. It recommends investigations like CT, MRI, and ultrasound to evaluate metastases. Metastases are considered immediately resectable if the surgery is technically possible and leaves at least 40% of liver volume. Resection may be possible but risky if it requires complex procedures. Factors like number, size and location of metastases impact prognosis but are not absolute contraindications to resection. Repeat resection of recurrent metastases can provide long-term survival.
This document summarizes various radiation therapy modalities for treating hepatic malignant tumors. It discusses external beam radiotherapy techniques like conventional radiotherapy, 3D conformal radiotherapy, stereotactic radiotherapy, and proton radiotherapy. It also covers internal radiotherapy techniques like selective internal radiotherapy using yttrium microspheres, metabolic radiotherapy with iodine-131 lipiodol, and brachytherapy. The document provides details on each technique's dosimetry, efficacy, and safety considerations.
1. The document discusses the history and mechanisms of radiofrequency ablation (RFA) for treating hepatic tumors. RFA uses alternating current within 200-1200 MHz to generate heat and coagulate tissue.
2. RFA can be performed percutaneously, laparoscopically, or during open surgery. Different ablation schemes and needle types are used depending on tumor size and location.
3. Complications of RFA include wound infection, bleeding, and abscesses. Studies show high rates of initial tumor necrosis but frequent recurrence within a year.
This document discusses the management of cholangiocarcinoma based on the author's experience at the Mansoura University Gastroenterology Surgical Center in Egypt. Some key points include:
- Cholangiocarcinoma is the second most common malignant liver tumor after hepatocellular carcinoma.
- Surgical resection remains the main treatment when possible but many cases are unresectable due to advanced stage at presentation.
- Of 385 patients treated between 1995-2002, 216 had central cholangiocarcinoma and most (79%) of these were unresectable.
- For unresectable cases, various palliative treatments were used with a mean survival of 5.8
The document discusses classification and surgical treatment options for extrahepatic bile duct cancer. It examines preoperative biliary drainage and portal embolization. Surgical techniques discussed include laparoscopy, posterior approach, tumor resection, hepatectomy, and caudate lobe resection. Operative procedures and mortality are analyzed according to tumor location, TNM classification, and staging. Long-term survival outcomes are presented for different patient groups and surgical approaches.
1) This document discusses liver surgery for hepatocellular carcinoma (HCC), with a focus on techniques and outcomes in Japan.
2) The use of intraoperative ultrasound during liver surgery has enabled more limited and precise resections, such as subsegmentectomies, while preserving important vascular structures.
3) Hepatic resection for HCC has become much safer over time, with mortality rates decreasing to less than 1% at specialized centers due to techniques like intermittent inflow occlusion and precise limited resections guided by intraoperative ultrasound.
This document discusses liver transplantation for hepatitis C virus (HCV) disease. It outlines that HCV reinfection is common after transplantation, occurring in 87-97% of cases. There are different patterns of HCV recurrence post-transplant, including minimal liver injury, chronic HCV, and cholestatic HCV. Factors associated with increased rates of fibrosis post-transplant include older recipient age, bolus steroid use for rejection, induction with mycophenolic acid, and short duration of prednisone use. High pre-transplant HCV RNA levels are also associated with worse patient and graft survival outcomes.
- Liver resection (LR) and liver transplantation (LTx) are two treatment options for hepatocellular carcinoma (HCC). This study compares outcomes of 282 patients receiving LR and 187 receiving LTx.
- Patients who received LTx had a higher perioperative mortality rate compared to LR patients (18.1% vs 4.5%), mainly due to sepsis, multiple organ failure, and vascular complications. Late mortality was higher in LR patients and mainly due to tumor recurrence.
- Recurrence rates were significantly higher after LR (47.4% vs 9%), and survival after recurrence was also lower with LR. Factors associated with recurrence and survival included tumor characteristics such as α-fetoprotein levels,
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
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Top 10 Best Ayurvedic Kidney Stone Syrups in India
29
1. I A S G - ROMANIAN C HAPTER
BUC HARES T 1 1 s t April 2 0 0 3
ENDOSCOPIC THERAPYIN THE MANAGEMENTOF
VARICEAL HEMORRHAGE
Cristian Gheorghe
Center of Gastroenterology & Hepatology
Fundeni Clinical Institute
Bucharest Romania
2. BACKGROUND
s Variceal bleeding is a common and
serious complication of portal
hypertension (PHT)
s The optimal management of patients
with variceal bleeding today requires
a multidisciplinary approach by a
team that includes
gastroenterologist-endoscopist,
interventional radiologist, and
surgeon.
3. SURVIVAL CURVES AFTER ACUTE VARICEAL BLEEDING
Comparison during the last 6 decades
100
90
80 Raztnoff
70 (1941)
Nachalas
60 (1955)
Graham
50
(1981)
40 Pinto
(1989)
30 Current
20 (2001)
10
0
0 2 6 12 18 24 36
mo. mo. mo. mo. mo. mo. mo.
4. MODALITIES OF ENDOSCOPIC TREATMENTFOR VARICEAL
BLEEDING
s Endoscopic sclerotherapy (EST)
« Crafoord & Frenckner first introduced EST 1939
« rediscovered late ~‘70
« first choice for acute variceal bleeding control over the two past decades
(‘80-’90)
s Endoscopic variceal ligation
« Stiegmann 1986
« Saeed 1995 “sixshooter” band ligator
C ha la s a ni N, e t a l Am J Ga s tro e nte ro l 2 0 0 3
5. ENDOSCOPIC SCLEROTHERAPY
s successful in controling active
bleeding in 90%
s useful in reduction of frequency and
severity of recurrent variceal
bleeding (secondary prophylaxis)
s not indicated for the primary
prevention
Paq ue t KJ, He p ato lo gy 1 9 8 5
Ro b e rts LR, M ayo C lin Pro c 1 9 9 6
AS GE Guid e line s , Gas tro inte s t End o s c 2 0 0 2
6. ENDOSCOPIC SCLEROTHERAPY
s ESTmay be performed by injecting
the sclerosant
« directly into the varix(intravariceal)
to produce thrombosis
« adjacent to the varix(paravariceal)
to induce submucosal fibrosisand
obliteration of deeper perforating
vessels
« combining the two techniques during
the same session
7. ENDOSCOPIC SCLEROTHERAPY
s Injection of the sclerosant agent
intravariceal produces thrombosis
and paravariceal determines
submucosal fibrosis and obliteration
of deeper perforating vessels
s In practice, the combination of both
techniques may be used during the
same session
8. ENDOSCOPIC SCLEROTHERAPY
Ag e nt Conc e ntra tion Ulc e rs (%) Oblite ra tion
(%) (%)
Alc ohol 95 80 60
S odium 1 .0 -3 % 40 90
te tra de c yl
s ulfa te
S odium 5% 30 80
m orua te
P olidoc a nol 0 .5 % 51 82
E tha nola m ine 5% 7% 33%
ole a te
Ad ap te d fro m Je ns e n DM, End o s c o p y 1 9 8 6
9. ENDOSCOPIC SCLEROTHERAPY
q
Gastric varices
ª esogastric varices type I (GOV 1)
ª esogastric varices type II (GOV 2)
ª isolate gastric varices type I (IGV 1)
ª isolate gastric varices type I (IGV 2)
q Esogastric varices type I and II may be
treated with ESTbelowthe esogastric
junction
S arin S K, In: De Franc his R. Po rtal Hyp e rte ns io n (Bave no III),
2001
AS GE Guid e line s 2 0 0 2
10. ENDOSCOPIC CYANOACRYLATE INJECTION
s Histoacryl is a watery substance that polymerises and hardens within
seconds of its contact with blood; it permanently ocludes the vessel
lumen
s The technique of injection is that of intravariceal sclerotherapy
s Risks and drawbacks: embolization and damage of the endoscope
s Useful particularly for gastric varices type IGV
11. « 130 patients underwent sclerotherapy with alcohol - for acute
variceal bleeding
« follow up period - 4 years
La rge oe s opha ge a l va ric e s 80 %
Va ric e a l ble e ding his tory 7 6 .9 %
He m ora gic e me rge nc ie s 23 %
Im m edia te m orta lity 0 .7 6 %
21%
36%
64%
79%
R - b le e ding
e C nse cutive m o rb idity
o
Yes No Y es No
G h e o rg h e C ., G h e o rg h e L. - 1 s t UEG W , A th e n s ; He lle n ic J
G a s tro e n te ro l (S u p p l) 1 9 9 2
12. ENDOSCOPIC VARICEAL LIGATION (EVL)
s indicated for controling active
bleeding
s useful in reduction of frequency
and severity of recurrent variceal
bleeding (secondary prophylaxis)
s indicated for the primary
prevention
13. ENDOSCOPIC VARICEAL LIGATION (EVL)
s A transparent cylinder is
attached to the end of the
forward viewing endoscope
s Prestressed rubber bands are
already positioned at the distal
end of the cylinder
s A drawstring that extends from
the cylinder is backloaded
through the working channel and
connected to the handle
mechanism positioned at the
proximal part of the channel
14. ENDOSCOPIC VARICEAL LIGATION (EVL)
s EVL is begun at the most distal point
of the variceal column
s Having targeting the varix, the tip of
the endoscope is angulated toward
the varixand suction is applied
continuously until the varixis
sucked completely into the cylinder
s The band is release over the
entrapped varixby pulling the trip
wire
15. « 132 patients with acute variceal bleeding were treated with EVL
until variceal eradication
« mean followup period - 12 months
I pe nde nt pre dicto rs o f re b le e ding
nde
OR Pvalue
P G (+)
Ho 5.63 0.003
E (+)
H 9.98 0.005
32%
68%
Yes No
R -b le e ding
e
Ghe o rghe C - Gut 2 0 0 2 ; 5 1 S up p l 3 , A1 8 4
16. RANDOMIZED COMPARATIVE TRIALS OF EST& EVL
Am e ta-ana lysis o f pub lishe d a rticle s 1 9 9 2 - 2 0 0 1
RATE OF ERADICATION
88
Masci (1999) 82
Hou (1999) 88
86
Sarin (1997) 96
92
Avgerinos (1997) 93
97
Baroncini (1997) 93
92
Hou (1995) 87
EVL
79
Lo (1995) 74 EST
63
Laine (1993) 59
69
82
Gimson (1993)
71
55
Stiegmann (1992) 56
0 20 40 60 80 100
17. Sample Chi2 P value Effect size
size (r)
S tie g m a n n 129 1.13 0.28 0.09
(1 9 9 2 )
G im s o n (1 9 9 3 ) 103 1.45 0.22 0.11
La in e (1 9 9 3 ) 77 1.06 0.30 0.11
Lo (1 9 9 5 ) 120 1.69 0.19 0.11
Ho u (1 9 9 5 ) 134 1.31 0.25 0.09
Ho u (1 9 9 9 ) 168 0.20 0.64 0.03
B a ro n c in i 111 0.18 0.66 0.04
(1 9 9 7 )
A v g e rin o s 77 1.22 0.26 0.12
(1 9 9 7 )
S a rin (1 9 9 7 ) 95 0.66 0.41 0.08
M a s c i (1 9 9 9 ) 100 0.7 0.4 0.08
18. RATE OF VARICEAL ERADICATION AFTER EST/ EVL
To tal N = 1105 N b e r o f S
um tudie s: k = 1 0
• Po pula tio n e ffe ct size
90 78 82.5
r = 0 .0 3
80 • 9 5 % co nfide nce inte rva l o f po p. e ffe ct
size : fro m
70
60 0 .0 1 3 to 0 .0 6 3
• E ine d va ria nce
xpla
50
r-sq ua re = 0 .0 0 1
40 • C rre spo nding Z N rm al
o in o
30 22 17.5
D istrib utio n = 1 .2 7
20 •S ignifica nce
10 p = 0 .1 - NS
0 • Fail S fe Nfo r critical r o f .0 5 = 2
a
EST EVL • Fail S fe Nfo r critical r o f .1 0 = 6
a
Eradication ( +) Eradication ( - )
Pe rce nta ge o f o b se rve d va riance a cco unte d fo r b y sam pling e rro r
= 1 0 0 .0 0 % → ho m o ge ne o us
Te st o f ho m o ge ne ity C hi-sq ua re = 1 .9 8 → ho m o ge ne o us
Significa nce p = 0 .9 9 1 7
19. RANDOMIZED COMPARATIVE TRIALS OF EST& EVL
Am e ta-ana lysis o f pub lishe d a rticle s 1 9 9 2 - 2 0 0 1
RATE OF COMPLICATION
18
* Masci (1999) 38
0
* Sarin (1997) 10
35
* Avgerinos (1997) 60
11
* Baroncini (1997) 31
Lo (1997) 5
* 29
5
EVL
* Hou (1995) 22
* Lo (1995) 3
EST
19
* Laine (1993) 24
56
56
Gimson (1993)
57
* 2
Stiegmann (1992) 22
0 20 40 60 80
* p < 0.05
20. Sample Chi2 P value Effect size
size (r)
S tie g m a n n 129 10.06 0.001 0.269
(1 9 9 2 )
G im s o n (1 9 9 3 ) 103 0.99 0.31 0.09
La in e (1 9 9 3 ) 77 8.57 0.03 0.31
Lo (1 9 9 5 ) 120 7.3 0.006 0.239
Ho u (1 9 9 5 ) 134 9.2 0.002 0.253
Lo (1 9 9 7 ) 71 7.2 0.007 0.3
B a ro n c in i 111 7.4 0.006 0.25
(1 9 9 7 )
A v g e rin o s 77 4.7 0.02 0.2398
(1 9 9 7 )
S a rin (1 9 9 7 ) 95 5.16 0.02 0.227
M a s c i (1 9 9 9 ) 100 4.9 0.025 0.216
21. RATE OF VARICEAL COMPLICATION AFTER EST& EVL
To tal N = 1017 N b e r o f S
um tudie s: k = 1 0
85.8 • Po pulatio n e ffe ct size
90
r = 0 .2 1 1 3 2
80 68 • 9 5 % co nfide nce inte rva l o f po p.
70 e ffe ct size : fro m
60 0 .1 7 to 0 .2 5
50 • E ine d va riance
xpla
40 32 r-sq uare = 0 .0 4 4 6 5
• C rre spo nding Z N rm a l
o in o
30
14.2 D istrib utio n = 6 .8 0 7 7 3
20 • Significa nce
10 p→ 0
0 • Fa il Safe Nfo r critica l r o f .0 5 =
EST EVL 32
• Fa il Safe Nfo r critica l r o f .1 0 =
Complications ( + ) Complications ( - ) 11
Pe rce nta ge o f o b se rve d va ria nce acco unte d fo r b y sam pling e rro r
= 1 0 0 .0 0 % → ho m o ge ne o us
Te st o f ho m o ge ne ity C hi-sq ua re = 4 .3 6 2 7 6 → ho m o ge ne o us
Significa nce p = 0 .8 8 5 9 5 8
22. RANDOMIZED COMPARATIVE TRIALS OF EST& EVL
Am e ta-ana lysis o f pub lishe d article s 1 9 9 2 - 2 0 0 1
RECURRENCE OF VARICES
32
Masci (1999)
27
* Sarin (1997) 29
8
30
* Baroncini (1997) 13 EVL
48 EST
* Hou (1995)
30 * p < 0.05
33
Stiegmann (1992)
50
0 10 20 30 40 50 60
23. Sample Chi2 P value Effect size
size (r)
S tie g m a n n 129 3.59 0.058 0.16
(1 9 9 2 )
Ho u (1 9 9 5 ) 134 4.5 0.03 0.18
B a ro n c in i 111 4.65 0.03 0.20
(1 9 9 7 )
S a rin (1 9 9 7 ) 95 6.03 0.01 0.25
M a s c i (1 9 9 9 ) 100 0.43 0.5 0.06
0.98 1.99 4.32
Stiegmann 0.21 0.47
0.98
Hou
Sarin 0.05 0.24 0.87
Masci 0.29 0.75 1.94
0.12 0.35 0.83
Baroncini
0.47 0.69 0.92
META
OR 0 1 2
24. RATE OF VARICEAL RECURRENCE AFTER EST& EVL
To tal N = 569 N b e r o f S
um tudie s: k = 5
• Po pulatio n e ffe ct size
80 73.3 r = 0 .1 4 3
65.3 • 9 5 % co nfide nce inte rva l o f po p.
70
e ffe ct size : fro m
60 0 .0 7 4 to 0 .2 1
50 • E ine d va riance
xpla
34.7
40 26.7 r-sq uare = 0 .0 2
30 • C rre spo nding Z N rm a l
o in o
D istrib utio n = 3 .4 3
20
• Significa nce
10 p = 0 .0 0 0 2 9
0 • Fa il Safe Nfo r critica l r o f .0 5 = 9
EST EVL
• Fa il Safe Nfo r critica l r o f .1 0 = 2
Varices recurrence ( + ) Varices recurrence ( - )
Pe rce ntage o f o b se rve d va ria nce a cco unte d fo r b y sam pling e rro r
= 1 0 0 .0 0 % → ho m o ge ne o us
Te st o f ho m o ge ne ity C hi-sq ua re = 3 .2 4 → ho m o ge ne o us
Significa nce p = 0 .5 1
25. RANDOMIZED COMPARATIVE TRIALS OF EST& EVL
Am e ta-ana lysis o f pub lishe d article s 1 9 9 2 - 2 0 0 1
RATE OF REBLEEDING
Masci (1999) 14
8
24
Hou (1999) 38
*
6
* Sarin (1997) 21
Avgerinos (1997) 27
47
Baroncini (1997) 16
19
Lo (1997) 17
33 EVL
* Hou (1995) 18
33 EST
* Lo (1995) 33
51
Laine (1993) 26
44
30
* Gimson (1993) 53
36
Stiegmann (1992) 48
0 10 20 30 40 50 60
* p < 0.05
26. Sample Chi2 P value Effect size
size (r)
S tie g m a n n (1 9 9 2 ) 129 1.83 0.17 0.11
G im s o n (1 9 9 3 ) 103 5.84 0.01 0.23
La in e (1 9 9 3 ) 77 2.52 0.11 0.18
Lo (1 9 9 5 ) 120 4.02 0.044 0.18
Ho u (1 9 9 5 ) 134 3.94 0.047 0.17
Lo (1 9 9 7 ) 71 2.5 0.11 0.18
B a ro n c in i (1 9 9 7 ) 111 0.14 0.7 0.03
A v g e rin o s (1 9 9 7 ) 77 3.43 0.063 0.21
S a rin (1 9 9 7 ) 95 4.19 0.04 0.21
Ho u (1 9 9 9 ) 168 4.01 0.045 0.15
M a s c i (1 9 9 9 ) 100 0.91 0.33 0.09
27. 0.76 1.63 3.5
S gm a nn
tie
1.1 2.58 6.65
G so n
im
0.75 2.16 6.34
Laine
1.02 2.12 4.76
L (1 9 9 5 )
o
1.05 2.24 5.43
H u (1 9 9 5 )
o 0.41 1.21 3.63
B ncini
aro 0.85 2.44 7.12
A rino s
vge 0.89 3.86
23.09
Sarin 1.08 1.97 4.06
H u (1 9 9 9 )
o
0.11 0.53 2.29
Masci
0.70 2.47 8.93
L (1 9 9 7 )
o
1.53 1.59 2.07
META
OR 0 1 2 3 7
28. RATE OF REBLEEDING AFTER EST& EVL
To tal N = 1185 N b e r o f S
um tudie s: k = 1 1
80 75.9 • Po pulatio n e ffe ct size
66
70 r = 0 .1 2
• 9 5 % co nfide nce inte rva l o f po p.
60 e ffe ct size : fro m
50 0 .0 8 to 0 .1 6
34
40 • E ine d va riance
xpla
24.1
30 r-sq uare = 0 .0 1
20 • C rre spo nding Z N rm a l
o in o
10 D istrib utio n = 4 .3 2
• Significa nce
0
EST EVL p = 0 .0 0 0 0 1
• Fa il Safe Nfo r critica l r o f .0 5 =
Varices re-bleeding ( + ) Varices re-bleeding ( - ) 16
Pe rce nta ge o f o b se rve d va ria nce acco unte d fo r b y sam pling e rro r • Fa il Safe Nfo r critica l r o f .1 0 = 2
= 1 0 0 .0 0 % → ho m o ge ne o us
Te st o f ho m o ge ne ity C hi-sq ua re = 6 .2 5 → ho m o ge ne o us
Significa nce p = 0 .7 9
29. PROPOSED ALGORITHM FOR THE Variceal bleeding
MANAGEMENTOF VARICEAL
BLEEDING Endoscopy available ?
YES NO
UGI Endoscopy Glypressin
Somatostatin
Octreotide
Oesophageal variceal Gastric variceal
bleed bleed
Band ligation / Gastroesophageal Isolated gastric
Sclerotherapy varices varices
Uncontrolled Controlled Treat as oesophageal TIPPS /
varices Butylcyanoacrylate
Baloon tamponade Banding eradication
programme
UK Guid e line s , Gut 2 0 0 0
TIPS / surgery