This document provides an overview of carcinoma of the esophagus. It discusses the epidemiology, etiology, pathological classification, clinical features, staging, diagnosis and management of esophageal cancer. Esophageal cancer is the 8th most common cancer worldwide and has a poor 5-year survival rate of less than 18%. Risk factors and types of esophageal cancer vary globally. The document outlines the various diagnostic tests and staging systems used to evaluate esophageal cancer as well as endoscopic, surgical and non-surgical treatment options.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
In Depth review of the Surgical management of esophageal carcinoma including management overview, endoscopic management, Type of surgeries, Open, and minimally invasive, Extent of lymphadenectomy. Literature review of evidence for type of surgery and complications
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- 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
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
1. Carcinoma oesophagus
Presenter: Dr. Anjali (2nd yrPG)
Guide :Dr. Y.prabhakara rao M.s,M.ch.,
professor , General surgery Department
NRI general hospital ,chinakakani
Dr.M. Prasanna kumar M.S
Dr.sai prasuna (final year postgraduate)
3. Introduction
• Oesophagus cancer is the eighth most common cancer worldwide.
• sixth most common cause of death from cancer.
• Most commonly present in 6th -7th decade of life.
• M : F (7:1)
• 1% of all malignancies , 7% of all GI malignancies.
• Esophageal cancer remains one of the deadliest cancers with an overall 5-year survival rate
estimated to be less than 18%
4. Epidemiology
The highest-risk area, referred to as the esophageal cancer belt -
>100cases/1,00,000 annually.
M/c benign tumor of esophagus : leiomyoma
M/c esophageal cancer in India : squamous cell carcinoma
M/C esophageal carcinoma in western countries : adenocarcinoma
M/C esophageal cancer in the world : squamous cell carcinoma
5. ETIOLOGY
FACTOR SQUMOUS CELL CARCINOMA ADENOCARCINOMA
SMOKING ++++ +
ALCOHOL ++++ --
HOT BEVERAGES + --
HISTORY OF AERODIGESTIVE
MALIGNANCIES
+++ --
CHEWING BETEL NUT + --
ACHALASIA + --
PLUMMER VINSON SYNDROME + --
LOW SOCIO ECONOMIC GROUP + --
LYE CORROSIVE STRICTURE + --
H/O RADIATION TO MEDIASTINUM + +
DEFICIENCY OF VITAMIN A ,B AND E + --
OBESITY -- ++
GERD -- +++
BARRETS ESOPHAGUS -- ++++
6. ETIOLOGY
• Genetic predisposition
TYLOSIS (hovels – evans syndrome)
• Human papilloma virus (16,18)
• Geotrichum candidum fungi, mycotoxins.
• NSAIDS and H. pylori infection – protective role.
7. Anatomical distribution of ca.esophagus
M/C esophageal carcinoma in
upper 1/3rd : SCC
M/C esophageal carcinoma in
middle 1/3rd : SCC
M/C esophageal carcinoma in
lower 1/3rd : adenocarcinoma
m/c site of esophageal cancer :
middle 1/3rd
8. Oesophageal tumours – 1% of all tumours. 7% of all GI tumours.
Benign tumours (rare)
leiomyomas(<1%)
Granulosa cell tumours
Fibrovascular polyps
Squmous papillomas
Lipoma
Hemangioma
Neural tumours
Malignant tumours
Squmous cell carcinoma
Adenocarcinoma
Small cell carcinoma
Primary melanoma of the
oesophagus
GIST and leiomyosarcoma
lymphoma
12. Clinical features
Early lesions are usually
asymptomatic are
incidental findings on
endoscopy for barrett’s
oesophagus .
Advanced cases :
Dysphagia (74%)
progressive (solids
>semisolids>liquids)
weight loss (57%)
Odynophagia(17%) H/o reflux symptoms Hoarseness Anemia
Aspiration pneumonia
Malignant tracheo
oesophageal fistula
Hepatomegaly ,pleural
effusion , cervical
lymphadenopathy.
13. Spread
Direct
Lack of serosal layer
Upper 1/3rd -- left main bronchus ,trachea, left recurrent laryngeal nerve,
aorta or its branches.
Lymphatic
Hematogenous spread
14.
15. STAGING
• squamous cell carcinoma :epithelial tumour with squamous cell differentiation
containing keratinocyte like cells microscopically with keratinisation or
intercellular bridges.
Adenocarcinoma :epithelial tumour with glandular differentiation.
T stage indicates tumour infiltration from mucosa to adventitia &beyond
esophagus.
N stage – regional lymphnodes
M stage –distant metastases.
23. Identification of location of tumour
During endoscopy, the location
of the tumor relative to the
incisors and GEJ should be
noted. as well as the length of
the tumor and degree of
obstruction.
24.
25. Diagnosis
• Standard initial investigation in patient c/o
dysphagia and wt.loss
• Endoscopy should be performed in any patient
with dysphagia, even if the barium
oesophagogram is suggestive of a motility
disorder.
• Upper GI endoscopy and Biopsy :
Findings: ulceration or nodularity (early lesions)
friable ulcerated mass (advanced lesions)
To obtain length of lesion
distance of lesion from incisors and GEJ
%of circumferential involvement and most
proximal extent as for barrets – PRAGUE criteria
26.
27. Barium studies
• The diagnostic accuracy of the double-contrast barium esophagogram is
70%. Before endoscopy and as a road map (not a routine).
• This radiological technique is capable of documenting stricture length,
diameter, location, and contour, axis of the esophagus and prescence of
other pathology (hernia & diverticulum).
• Findings :
Irregular narrowing
Mucosal irregularity
Shouldered margins
Rat tail appearance
Apple core constrictions
28.
29. CT Imaging
• It is performed as the first radiologic test in the staging evaluation of an
endoscopically diagnosed esophageal cancer.
• >5mm thickness is abnormal.
• T1 -2 :5-10 mm thickness , T3 - >15mm thickness
• Advantages:
To identify the lesion
Surrounding structures
Regional organ invasion
Lymph nodal status
distant metastasis,
Area of contact b/w oesophagus & aorta extends beyond the 90 degrees of
circumference then 80% accuracy of infiltration is reported.
30. Axial and coronal CECT Thorax images showing
concentric esophageal wall thickening, hold up of
contrast (HC) and dilatation of proximal
esophagus (PD), involving the middle thoracic
esophagus with a periesophageal lymph node
(PLN).
Metastases to lung and liver are also shown on
Pulmonary window and axial CECT image of
upper abdomen respectively
31. Disadvantages
• Sensitivity and specificity is less.
• Lymph nodal detection is suboptimal with CT as normal sized LN may be
metastatic & sometimes abnormal enlargement maybe due to reactive or
inflammatory lesions.
• It is inferior to laparoscopy in detecting peritoneal metastasis.
32. PET –CT SCAN
Advantages:
• It can detect primary tumour & provide functional assessment of lymphnodes &metastatic
sites.
• Distinguish b/w inflammatory and malignant lymphnodes.
Disadvantages :
• Histologically, SCCs were found to highly accumulate FDG at the primary tumor site in contrast
to adenocarcinomas, which demonstrate more limited FDG accumulation.
• PET does not provide enough definition of the esophageal wall and thus has no value in T
staging.
• Overall sensitivity ranges from 78-95% with high false negative rates with T1 & small T2
tumors.
33. PET/CT improves the detection of metastatic
disease and, thus, can often result in a change of the
management strategy
34. Endoscopic ultra sound
ADVANTAGES
• Only modality able to distinguish 5 layers of oesophageal wall.
• Oesophagus seen as alternate hypo and hyperechoic layers.
• Helpful in detecting lymph nodal staging and also helps to take FNAC from
suspicious nodes.
• It is best for detecting paraesophageal nodes
• EUS OF LN :HYPOECHOIC , SMOOTH & ROUNDED SIZE >5—10 mm
• Best for detecting paraesophageal nodes.
DISADVANTAGES
• Accuracy is operator dependent
• False –ve results will come if peritumoral oedema present.
36. BRONCHOSCOPY (Tracheo bronchial ultrasound)
• Tracheo bronchial tree is involved in advanced cases of proximal 1/3rd of
esophageal lesions.
• Findings on bronchoscopy
Widening of carina
Extrinsic compression Particularly posterior wall
of trachea.
Tumour infiltration fistulisation (unresectable)
Laryngoscopy – in case of hoarseness
37.
38. Laparoscopy
• For visual inspection of liver surfaces & peritoneal cavity
• Collection of peritoneal fluid for biopsy
• Celiac lymphnodal biopsy.
• DISADVANTAGE: requires GA
39. Thoracoscopy
• Thoracoscopic staging usually involves a right-sided approach, with opening of
the mediastinal pleura from below the subclavian vessels to the inferior
pulmonary vein with lymph node sampling.
• Disadvantage : requires GA , ONE lung ventilation & hospital stay
• Only to improve preoperative staging are done if +ve conformation of metastatic
disease is not otherwise obtainable & is essential for treatment planning.
40. Predictors ofprognosis.
Staging of disease at diagnosis
Weight loss of more than 10 percent of body mass
Dysphagia
Large tumors
Advanced age
lymphatic micrometastases (identified by immunohistochemical
analysis)
At the time of diagnosis around 2/3 of all patient with Oesophageal
cancer will already have incurable disease.
42. Treatment of Squamous cell carcinoma
Early carcinoma Management
ENDOSCOPIC SUBMUCOSAL RESECTION
ENDOSCOPIC SUBMUCOSAL DISSECTION
T1a-MM or T1b-SM1 (200 μm deep from the
muscularis mucosa) but without evidence of
nodal spread in pretreatment staging
investigation. EMR AND ESD
There is a moderate chances of nodal involvement
Hence treated as advanced carcinoma.
43. Locally advanced carcinoma(T1b N1 +T2 –T4a)
• Surgical resection is first line.
• Low risk lesions esophagectomy
• High risk lesions
<5cm from cricopharyngeal muscle
PLAN : CHEMORADIOTHERAPY
F/B SURGERY
Cervical oesophagus
NON CERVICAL OESOPHAGUS
PREOPERATIVE CHEMORADIOTHERAPY
F/B SURGERY
F/B CONCURRENT POSTOP CHEMORADIOTHERAPY
44. ADENOCARCINOMA
• EARLY CARCINOMA
ENDOSCOPIC MUCOSAL RESECTION (OR)ENDOSCOPIC SUBMUCOSAL DISSECTION
OR
RADIOFREQUENCY ABLATION (OR ) PHOTO DYNAMIC ABLATION
BEST TRT : EMR f/b RFA
45. ADVANCED CARCINOMA
• Low risk --- oesophagectomy
• High risk
Thoracic oesophagus preop CRT + SURGERY +postop CRT
Tumours at GEJ
46. Endoscopic treatment
Types
1)Endoscopic mucosal resection
2)Endoscopic submucosal dissection
Indications
Well differentiated superficial lesions (T1a , T1b).
No nodal involvement
Nodular barrett oesophagus (high grade dysplasia)
Lesions which are <2cm in maximum dimension.
47. • Limitations :
lesions >2cm are removed
by piecemeal resection and
increases the chances of
recurrence.
48. Endoscopic submucosal dissection
•Procedure
Mark lesion by electrocautery
Submucosal injection of solution
Precut the mucosal edges along the
marking
Submucosal dissection
Secure hemostatsis.
LIMITATIONS :
higher bleeding and perforation rates
Technical difficulties
49. • ESD Vs EMR
ENDOSCOPIC
MUCOSAL
RESECTION
ENDOSCOPIC
SUBMUCOSAL
DISSECTION
LESS CHANCE OF +VE MARGINS
MORE ENBLOCK RESECTION
LOW RECURRENCE RATES
50. COMPLICATIONS OF ENDOSCOPIC THERAPY
Bleeding (2%)
PERFORATION (0.2%)
STRICTURE FORMATION (IF >50% CIRCUMFERENCE OF
TIISUE REMOVED)
51. Endoscopic cryoablation
Endoscopic cryotherapy is a relatively new thermal ablative modality used for the
treatment of neoplastic lesions of the esophagus. It relies on cycles of rapid cooling and thawing
to induce tissue destruction with a cryogen (liquid nitrogen or carbon dioxide) leading to intra and
extra-cellular damage and thrombi formation in the blood vessels inducing apoptosis and
ischemia.
Cryoballoon focal ablation using liquid nitrogen is a novel mode of cryogen delivery which has
been used for the treatment of BE with dysplasia and squamous cell carcinoma.
The truFreeze system delivers liquid nitrogen through a low-pressure, non-contact, 213 cm long,
7F spray catheter and results in flash freezing the mucosa to -196 °C
Complications
No specimen for HPE
c/o chest pain
Stricture formation
Requires repeated sessions &intense surveillance for recurrence.
52. • Mechanisam: thermal energy to promote coagulative
necrosis. Implies destruction and ultimately removal of
tissue.
• A balloon catheter covered with electromagnetic coils is
inserted into the esophagus and inflated at the place where
the abnormal cells are found. Radio wave energy passing
through the coils then burns away the affected tissue,
leaving normal tissue undamaged.
• After treatment, participants were followed for a year with
biopsies.
Radiofrequency
ablation
54. Choice of surgery approach
• Lesions involving cervical oesophagus
pharyngo laryngo oesophagectomy f/b pharyngo gastric anastomosis.
• Pharyngolaryngoesophagectomy (PLE), with or without adjuvant radiotherapy, has been the
gold standard of treatment since first reported by Ong and Lee in 1960.75 The procedure
involves cervical and abdominal incisions and a thoracotomy.
• Tumors located at the hypopharyngeal and cervical esophageal regions were resected
together with the whole length of the esophagus, and the gastric tube was pulled up to the
neck via the posterior mediastinum for pharyngogastric anastomosis.
• A permanent end tracheostomy was created. Modern technique replaces the thoracotomy
part with a transhiatal or minimally invasive approach.
55. • Other alternative reconstructive procedures :
free jejunal inter positional graft.
PMMC flap
anterolateral thigh flap
free post tibial flap
• With the possibility of laryngeal preservation when treated by chemoradiation
therapy, however, surgery is often not the preferred first choice of treatment.
Therefore, the current role of surgery for cervical esophageal cancer is mainly for
salvage after incomplete response or recurrent disease after chemoradiotherapy.
56. surgery for Intrathoracic and abdominal oesophageal lesions
Upper 1/3rd
- McKeown -3-phase oesophagectomy
Middle 1/3rd
-Ivor Lewis or lewis tanner-2-phase oesophagectomy
Lower 1/3rd
-Orringer transhiatal oesophagectomy with anastomosis in neck.
Extent of resection: To achieve R0 resection ,resection should be 10cm proximal
and 5cm distal to the tumour and also the adventitial margins for primary
tumour+ radical clearance of lymphatic system.
57. Mckeown -3-phase oesophagectomy
• Includes
Right thoracotomy (To mobilise oesophagus)
Laparotomy(conduit preparation)
right side cervical incision
Ivor lewis -2-phase or lewis tanner operation
• Includes – laparotomy + rt . thoracotomy = anastomosis in mediastinum
Orringer transhiatal oesophagectomy
Includes laparotomy + left sided neck dissection = anastomosis on left side of
the neck .
58.
59.
60.
61.
62.
63. • Siewert type 1 tumours
Trans hiatal oesophagectomy + mediastinal lymphadenectomy
• Siewert type 2 &3 tumours
Distal gastrectomy with roux –en-Y jejunal loop reconstruction + celiac nodal
dissection.
64. Extent of lymphadenectomy
• Lymph node invasion is more with squamous cell carcinoma than adeno
• Extent of lymphadenectomy differs based on tumour location and its histology .
• Performed along three fields
Single field
Abdominal Ln
around celiac
axis for siewert
type 2 and 3
tumours
Three field
Abdomen +
mediastinal + b/l
cervical LN’S
dissection done for
intrathoracic SCC in
japan
65. Two field lymphadenectomy
•
• Infracarinal +b/l bronchial bifurcation +celiac trifurcation
• +superior mediastinal nodes along with
• right paratracheal +right recurrent
laryngeal nodes
+ left paratracheal + left recurrent
laryngeal nodes
Standard
extended standard
Total extended
66. Reconstruction after oesophagectomy
• Choice of oesophageal substitute : The most commonly used conduit is the gastric tube, and
of the many configurations, an isoperistaltic tube based on the greater curvature with
preservation of the right gastric and right gastroepiploic vessels is most reliable.
• The simplicity of preparation, adequate length, and robust blood supply make it the first
choice as the esophageal substitute. Based on right.gastric and right.gastro epiploic arteries.
Disadvantages
postprandial discomfort
early satiety
acid reflux with possible ulceration
esophagitis
inadequate gastric anastomosis
67. Colon as substitute
Conduit of choice in benign disorders of stomach
Left (left colic artery ) > rt.colon (middle colic artery)
Advantages
Good longterm swallowing function
active peristalsis.
avoids acid reflux
If distal stomach retained ,colo gastric
anastomosis provides additional
reservoir function.
Disadvantages
• Need more complex mobilisation
• Less reliable blood supply- increases
conduit necrosis
• Requirement of 3 anastomosis
• Longer operation time ,more blood
loss
• High chances of anastomotic leak
• Colon ischemia
68.
69. Jejunum as substitute
• The jejunum is used most frequently after distal esophagectomy and total
gastrectomy for cancer of the lower esophagus and gastric cardia.
• A Roux-en-Y configuration seems best, as it prevents bile reflux to the esophagus.
DISADVANTAGES
Tedious preparation
less reliable vasculature
microvascular anastomosis to
cervical vessels may be required.
70. Route of reconstruction of esophagus
1) orthotopic- preferred route
Advantage :better nutritional status
Disadvantage :chances of recurrence.
2) Retrosternal:
Advantage : less recurrence , best route if post op RT is planned.
Disadvantage : postoperative cardiopulmonary morbidity and mortality
3)Sub cutaneous : cosmetically unsighty.
71. Complications of oesophagectomy
• Anastomotic leak (MC) – higher with cervical anastomosis than intrathoracic.
• Anastomotic stricture
• Pulmonary complications – MC after THE
• RLN palsy
• Chylothorax
72. • Chemotherapy
neoadjuvant
Adjuvant
Both associated with significant results
in both SCC and EAC
Doublet regimens (5fu+cisplatin)
most preferred.
Triplet regimen (5fu+cisplatin+anthracyclin)
Preferred in medically fit with good physical
status.
Oxaliplatin >cisplatin.
74. Palliative therapy
• The aim of Palliative treatment is to overcome debilitating or distressing
symptoms while maintaining the best quality of life possible for the
patient ( i.e restore swallowing).
• Nodes >5 involvement
• Invasive, poorly differentiated grade
• Length of involvement >8 cm
• Abnormal oesophageal axis in barium study
• Horner's syndrome
• Loss of weight >20%
• Metastatic disease
To palliate
Pain
Dysphagia
Prevent bleeding
Prevent aspiration
75. • Endoscopic palliative treatments for more advanced tumors include
oesophageal dilatation
self expanding metal stents(SEMS)
Endoscopic laser
Photodynamic therapy
Chemotherapy
Radiotherapy
Cryoablation
Orringer Trans hiatal blind oesophagectomy
The aim of Palliative treatment is to
overcome debilitating or distressing
symptoms while maintaining the best
quality of life possible for the patient (
i.e restore swallowing)
76. SEMS
Indication : malignant severe dysphagia.
These are passed through endoscope under C-arm guidance. It is the ideal method of palliation.
Stent is collapsed during insertion and released once it is placed in proper position. There is no
need to dilate oesophagus more than 8 mm to pass this expanding stent and so chances of
perforation is minimal.
Uncovered SEMS-here tissues project through the mesh to have a better grip with less chances
of migration. But stent occlusion is more.
• Plastic covered SEMS-it shows less stent occlusion and friction. Stent migration is more.
• Problems of stents are-aspiration, displacement, erosion, bleeding, tumour growth across or
beyond mesh, food bolus obstruction, retrosternal pain, need for reinsertion (40%). Mortality
is 1- 2%.
77.
78. Endoscopic laser
It is used to core a channel through the tumour to improve dysphagia and to control
bleeding (Nd YAG laser; Diode laser). It causes thermal destruction of tumour.
It improves dysphagia but needs repeated laser ablation. It may be used more effectively
to remove tumour block in previously placed stents.
• Exophytic tumour less than 6 cm is suitable for laser. Noncontact high power Nd:YAG 50-100
W laser from distal to proximal end facilitates visualisation of lumen and also reduces the
chances of perforation.
• Contact low power Nd:YAG 10-20 W laser is used for fully occluded tumour with less smoke
formation and less perforation chance.
• Success rate of palliation is 85%.
• Problems are- fever, chest pain, 3% mortality, perforation(2%) and fistula formation 5%,
costly, takes one week to relieve dysphagia
79.
80. Endoscopic dilatation
• 1)savary bougie dilators
Both radial and longitudinal force
better for more focal anastomotic or post fundoplication stricture.
2)Baloon dilatation
only radial force better for long stricture like malignant.
Complications :
fever
pain
chance of perforation (pneumo mediastinum, pneumothorax)
81.
82. Intubation
Intubation was described by Symmonds in 1887. It is commonly used method. Guidewire is passed across the
growth under X-ray screening or C-arm guidance; flexible introducer and prosthetic tube is pushed across the
tumour along the guidewire. It carries 90% success rate.
Complications :
• Tube intolerance
• poor drainage,
• airway compression,
• reflux, aspiration, displacement, food blockage,
• Tumour overgrowth beyond the prosthesis causing its failure.
Intubation is used for trachea-oesophageal fistula or external compression. Prosthesis with a sponge-filled
balloon is used for fistula closure. Standard tube wrapped with multilayered polyvinyl sponge is other option.
It is less expensive, single time, rapid acting . They can be traction or pulsion tubes. Perforation chance is
10%.
83.
84. REFERENCES
• MAINGOT’S ABDOMINAL OPERATION 13TH EDITION
• SHACKELFORD’S SURGERY OF THE ALIMENTARY TRACT 8TH EDITION
• SABISTON TEXT BOOK OF SURGERY 20TH EDITION
• SRB ‘S MANUAL OF SURGERY 6TH EDITION