This document discusses the diagnosis and management of caustic esophageal strictures. It begins by outlining the clinical symptoms of dysphagia that result from caustic ingestion and lead to stricture formation. Diagnosis involves esophagogram or esophagoscopy at least 6 weeks after injury to identify strictures. Treatment involves endoscopic dilatation using wire-guided dilators, with multiple sessions often needed for complex strictures. Advanced endoscopic techniques have reduced the need for esophageal replacement surgery. The document concludes that caustic esophageal strictures can be successfully managed through endoscopic dilatation.
COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...KETAN VAGHOLKAR
Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for
treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the
open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open
cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological
investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively.
Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group
A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60
years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not
develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B.
The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of
postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the
patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The
commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean
hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy
is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic
requirement, early commencement of oral feeds, and shorter duration of hospitalization
Background: Sigmoid Volvulus is the third most common cause of colonic obstruction and accounts for
2-4% of intestinal obstructions. A variety of abdominal and functional factors contribute to the development of sigmoid
volvulus. The progression of pathology is extremely rapid. Hence, understanding these factors enables early diagnosis
and prompt surgical intervention. Aims: 20 cases of surgically treated sigmoid volvulus were studied retrospectively
to identify and evaluate various factors causing morbidity and mortality in these patients. Results: The condition was
commonly seen in males, especially those who were institutionalized and were using laxatives for over 5 years. The
mean age was 65.2 years. Co-morbidities were a common accompaniment. 13 patients had diabetes, 12 patients had
hypertension, 2 patients had ischemic heart disease and 9 patients had the neurological disease (Parkinson’s disease).
6 patients had single co-morbidity, 13 patients had 2 co-morbidities and 1 patient had 3 co-morbidities. A plain X-ray
of the abdomen was diagnostic in all cases. The mean time interval from the onset of symptoms to hospital admission
was 8.1 hours, the time interval from hospital admission to confirmation of diagnosis was 2.1 hours. The mean time
interval from diagnosis to surgical intervention was 3.2 hours. The surgical options exercised were resection anastomosis
with a proximal diversion in 13 patients, Hartmann’s procedure in 6 patients, and primary resection anastomosis in
1 patient. Post-operative complications included ileus in 16 patients, stomal dysfunction in 4 patients, and surgical
infections in 10 patients. The mean duration of stay in hospital ranged from 7-13 days. Only 1 patient who had 2
co-morbidities developed complications and succumbed. Conclusion: Prompt diagnosis, optimization of haemodynamic
status including co-morbidities is essential before contemplating surgical intervention. Resection anastomosis with a
proximal diverting stoma is best suited for patients who have not developed a colonic perforation whereas Hartmann’s
procedure is indicated in patients presented with perforative peritonitis.
COMPARATIVE STUDY BETWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMY (STUDY OF 50 ...KETAN VAGHOLKAR
Background: Laparoscopic cholecystectomy is a new alternative to the traditional open approach for
treating calculous cholecystitis. It is, therefore, necessary to assess the efficacy of laparoscopic cholecystectomy over the
open cholecystectomy. Objectives: To compare the surgical outcomes of laparoscopic cholecystectomy with those of open
cholecystectomy. Materials and methods: 50 patients diagnosed as symptomatic cholelithiasis proven by radiological
investigations were distributed into two groups of 25 each. Group A patients were subjected to laparoscopic cholecystectomy, and group B patients underwent open cholecystectomy. The surgical outcomes were studied prospectively.
Intraoperative complications and postoperative care parameters were evaluated. Results: Mean age of patients in group
A was 46.68±13.6 years, and in the group, B was 42.64±14.1 years. Majority of patients were in the age group of 41 to 60
years. Patients who had diabetes in group B developed wound infections, whereas diabetic patients in group A did not
develop any infection. Significant bleeding necessitating blood transfusion occurred in one patient belonging to group B.
The duration of postoperative analgesia required was 3.16 days in group A and 5.16 days in group B. The duration of
postoperative antibiotics administered in laparoscopic and open cases was 1.48 and 4.8 days, respectively. One of the
patients in group A developed a postoperative biliary leak, whereas none in group B had any such complication. The
commencement of oral feeds and after that return of bowel movements was earlier in group A than group B. The mean
hospital stay was 4.5 days in group A as compared to 6.3 days in group B. Conclusion: Laparoscopic cholecystectomy
is superior to open cholecystectomy regarding reduced postoperative discomfort and pain, antibiotic and analgesic
requirement, early commencement of oral feeds, and shorter duration of hospitalization
Background: Sigmoid Volvulus is the third most common cause of colonic obstruction and accounts for
2-4% of intestinal obstructions. A variety of abdominal and functional factors contribute to the development of sigmoid
volvulus. The progression of pathology is extremely rapid. Hence, understanding these factors enables early diagnosis
and prompt surgical intervention. Aims: 20 cases of surgically treated sigmoid volvulus were studied retrospectively
to identify and evaluate various factors causing morbidity and mortality in these patients. Results: The condition was
commonly seen in males, especially those who were institutionalized and were using laxatives for over 5 years. The
mean age was 65.2 years. Co-morbidities were a common accompaniment. 13 patients had diabetes, 12 patients had
hypertension, 2 patients had ischemic heart disease and 9 patients had the neurological disease (Parkinson’s disease).
6 patients had single co-morbidity, 13 patients had 2 co-morbidities and 1 patient had 3 co-morbidities. A plain X-ray
of the abdomen was diagnostic in all cases. The mean time interval from the onset of symptoms to hospital admission
was 8.1 hours, the time interval from hospital admission to confirmation of diagnosis was 2.1 hours. The mean time
interval from diagnosis to surgical intervention was 3.2 hours. The surgical options exercised were resection anastomosis
with a proximal diversion in 13 patients, Hartmann’s procedure in 6 patients, and primary resection anastomosis in
1 patient. Post-operative complications included ileus in 16 patients, stomal dysfunction in 4 patients, and surgical
infections in 10 patients. The mean duration of stay in hospital ranged from 7-13 days. Only 1 patient who had 2
co-morbidities developed complications and succumbed. Conclusion: Prompt diagnosis, optimization of haemodynamic
status including co-morbidities is essential before contemplating surgical intervention. Resection anastomosis with a
proximal diverting stoma is best suited for patients who have not developed a colonic perforation whereas Hartmann’s
procedure is indicated in patients presented with perforative peritonitis.
COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAPDr Amit Dangi
THIS PRESENTATION DESCRIBES THE NOVEL SURGICAL TECHNIQUE OF TOTAL ANORECTAL RECONSTRUCTION WITH ANTROPYLORUS TRANSPOSITION AND GLUTEOPLASTY AND ITS RESULTS.
Colon cancer is one of the most common reasons for colonic obstruction. This presentation focusing on benign as well as malignant diseases with its management.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
COMPOSITE GRAFT: ANTROPYLORUS TRANSPOSITION AND GLUTEUS MAXIMUS WRAPDr Amit Dangi
THIS PRESENTATION DESCRIBES THE NOVEL SURGICAL TECHNIQUE OF TOTAL ANORECTAL RECONSTRUCTION WITH ANTROPYLORUS TRANSPOSITION AND GLUTEOPLASTY AND ITS RESULTS.
Colon cancer is one of the most common reasons for colonic obstruction. This presentation focusing on benign as well as malignant diseases with its management.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Pelvic gynecology intervention, complications and significance of teamwork co...Rustem Celami
Extensive gynecologic surgery often entails meticulous dissection near the bladder, rectum, ureters, and great vessels of the pelvis. Complications of gynecologic surgery include hemorrhage, infection, thromboembolism, and visceral damage. The risk of complications depends upon the extent and approach to surgery and patient characteristics. Understandably, the more common complications from this surgery relate to injuries to these viscera and occur during extensive resections for the treatment of cancer or when anatomy is distorted due to infection or endometriosis. Injuries to the gastrointestinal components are common during open gynecological surgery. Any delay in diagnosing a bowel perforation can lead to serious fecal peritonitis and even death. If a patient is experiencing pain, tachycardia, and fever following surgery, bowel injury should be suspected, warranting immediate consultation with a general surgeon. Gynecologists routinely operate on patients with risk factors for bowel injury; obesity, endometriosis, multiple abdominal procedures, pelvic inflammatory disease, history of malignancy, and advanced age. A general surgeon is often called, however, for bowel repairs that can be performed by a gynecologist with sufficient training and experience. There are instances, however, in which a general surgical consultation may not be readily available, another reason to master repair of bowel injuries encountered during gynecologic surgery. In conclusion, sufficient training of principles of intestinal surgery, and close collaboration with general surgeons is very important for management of these complications and a successful outcome.
An intestinal obstruction occurs when your small or large intestine is blocked. The blockage can be partial or total, and it prevents passage of fluids and digested food. If intestinal obstruction happens, food, fluids, gastric acids, and gas build up behind the site of the blockage.
Access to abdominal cavity in Laparoscopy is often associated with various injuries. Debate about Open Vs Verss needle access is still not settled. This presentation highlights the literature review, possible problems associated with abdominal wall access through Veress needle and their management.
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
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
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
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
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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
- 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
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
Caustic esophageal stricture from diagnosis untill cure
1. Caustic esophageal stricture from diagnosis untill cure
Review
Sameh Abdelhay et al 10
Sameh Abdelhaya
, Mohamed Moussaa
, Mohammed Elsherbenya,*
Abstract
Background: The diagnosis of esophageal stricture after caustic ingestion is based on clinical symptoms
of dysphagia, regurgitation and chocking that is evident initially in the acute stage. These symptoms may
ameliorate by time or proceed to evident stricture due to fibrosis. This will need either dye esophagogram
or Esophagoscopy which is better to be done not before the lapse of at least 6 weeks from injury. Esophageal
dilatation using wire-guided dilators is the cornerstone of treatment. The frequency of dilatation is based on
recurrence of dysphagia and in multiple strictures, repeated sessions with multi-level injection of steroids and
graded dilatation is needed. Failure of dilatation or occurrence of complications may necessitate esophageal
replacement and usually we prefer the transverse colon based on the left colic vessels in retrosternal position
to treat the condition. We aimed to review the management of caustic esophageal strictures based on what is
known and adding our experience in this aspect.
Methods: We reviewed the articles discussing management of caustic esophageal strictures in the last twenty
years. We added our experience of more than forty years managing an average of thirty new cases every year.
Results: Management of caustic esophageal strictures has changed in the last years. Advanced endoscopic
techniques of dilatation reduced the need for esophageal replacement.
Conclusions: Caustic esophageal strictures could be managed successfully with advanced techniques of
endoscopic dilatation.
Keywords: Caustic stricture; esophageal dilatation; esophagoscopy; esophageal replacement
*Corresponding author: Dr. Mohammed Elsherbeny
Mailing address: Department of Pediatric Surgery, Faculty of
Medicine, Ain Shams University, Lotfy Elsayed St, Abbassyyah,
Cairo, Egypt.
E-mail: mohamedsaid@med.asu.edu.eg
Received: 02 Apirl 2020 Accepted: 08 May 2020
the gastric outlet causing pyloric obstruction. Initially
all patients will have variable degrees of dysphagia that
may resolve if the injury is trivial, but it will persist if a
stricture supervenes.
Action needed for management of the resultant dyspha-
gia will be tailored depending on its degree; absolute
dysphagia better to be managed by initial gastrostomy
for maintaining the nutritional status of the patients.
Dysphagia to solids and semisolids can be managed ex-
pectantly by nutritive oral fluid intake. Further manage-
mentwilldependonthemanagementprotocolfortreat-
ingesophagealstricturebyinitialdyestudytodefinethe
characterofthestricturefollowedbyatrialofdilatation.
CLINICAL MANIFESTATIONS AND DIAG-
NOSIS
Stricture formation is manifested by variable degrees
of dysphagia, ranging from dysphagia to solids or semi-
solids to absolute dysphagia with drooling of saliva and
INTRODUCTION
Theingestionofcausticsusuallyoccursduetoaccidental
swallowing, and the effect will depend on the type of
caustic substance either acid or alkali and its concen-
tration. High concentration either acid or alkali causes
severe injury to the mouth, pharynx, and larynx with
severe affection of the esophagus up to complete necro-
sis. More diluted forms of alkali will affect mainly the
esophagus causing damage of the mucosa and mus-
cle layer with subsequent stricture depending on the
amount swallowed. Ingestion of acid will affect mainly
a
Department of Pediatric Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Creative Commons 4.0
Clin Surg Res Commun 2020; 4(2): 10-17
DOI: 10.31491/CSRC.2020.06.050
2. repeated chest infections from aspiration secondary to
spill over or tracheo-esophageal fistula (Figure. 1 and
2). Manifestations of respiratory tract affection may
present with stridor, hoarseness of voice, dyspnea or
tachypnea [1, 2]
.
After the lapse of at least 3-4 weeks, dye study should
be done carefully using water soluble non-irritant dye
for the fear of aspiration and subsequent pneumonitis
due to spill over or the presence of fistula. The study
should be done under screen and the dye is given orally
or injected slowly through a naso-esophageal tube with
suction device ready beside the patient. It will provide
a basic image before doing an intervention. The study
willdemonstratethesite,thenumber,thelengthandthe
diameterofthestrictureandwillshowassociatedgastro
esophageal reflux or pull up of the stomach by esopha-
geal fibrosis causing hiatus hernia. Once the diagnosis
of stricture is evident, the patient is scheduled for upper
endoscopy after the lapse of at least 6 weeks from the
initial injury. The data obtained from the contrast study
should be correlated with that found on endoscopy [3, 4]
.
Somestudiesrecommendeddoingendoscopyinthefirst
12-48 hours after the ingestion. Although it has the ad-
vantage of assessing the degree of affection and hence
Sameh Abdelhay et al 11
the possibility of future stricture formation, the risk of
iatrogenic esophageal perforation is high. It is better to
be done 6 weeks after the corrosive ingestion to min-
imize the risk of esophageal perforation. Endoscopic
evaluation of the esophagus will confirm the contrast
study findings and assess if the stricture if passable or
not. It also has the advantage of being therapeutic at the
same time (Figure. 3) [5, 6]
.
ENDOSCOPIC MANAGEMENT
Endoscopic dilatation is considered the cornerstone for
management of caustic esophageal stricture.
Endoscopy in the acute phase
Earlyendoscopymaybeofvalueasabout30%ofpatients
withcausticingestionmaynothaveesophagealinjuryand
can be discharged promptly. Endoscopy is usually done
within 24-48 h after ingestion. However, some centers
have recommended endoscopy as soon as possible [7, 8]
.
Initial endoscopy after 48 h of ingestion is not recom-
mended as the injured esophagus may enter the phase
of ulceration and granulation, in which the esophagus
becomes fragile and easily perforated. Early endoscopy
is beneficial to confirm the followings: existence of inju-
Figure 1. A contrast study of the esophagus showing a long caustic
esophageal stricture.
Figure 2. A contrast study of the esophagus showing a trachea-
esophageal fistula after caustic ingestion.
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Published online: 29 June 2020
3. ry, degree of injury, and area of injury which could guide
a treatment and predict a prognosis. Early endoscopy is
contraindicated in patients with a suspicion of gastro-
intestinal perforation, necrosis of oral cavity and com-
promised airway. Gentle handling and avoidance of air
over-insufflation is always recommended [9]
.
Endoscopy in the late phase
Endoscopy plays an important role in the treatment of
caustic esophageal strictures. Caustic stricture is often
complex and difficult to dilate [10]
. Early esophageal dil-
atation can be done after 3 weeks of caustic ingestion.
After 8 weeks, scar tissue is completely formed. Since
good nutritional status is strongly related to a successful
dilatation of an esophageal stricture, early feeding via
gastrostomy should start as soon as patients are clinical-
ly stable, especially in those with a significant damage in
the esophagus (Figure. 4) [11]
.
Practically, barium swallow is done at 2-4 weeks after
caustic ingestion and dilatation starts at 6 weeks after
ingestion. Barium swallow will provide crucial informa-
tion on the stricture which could determine the safety
and success of endoscopic dilatation. Esophageal dilata-
tion can be done using various types of dilators. It can
be performed under the combination of endoscopy and
fluoroscopy or endoscopy alone [12]
.
Commonly used esophageal dilatators are:
1-Bougie dilator (Maloney-Hurst dilator):
This dilator has the advantage of being easy to use but it
does not have a channel to insert a guide wire through it.
So, it is suitable for short and straight strictures.
2-Wire-guided polyvinyl dilator (Savary-Gilliard di-
lator):
This dilator has a channel through which a guide wire can
be passed under fluoroscopy followed by the appropri-
ate dilator. It is suitable for tortuous, angulated and long
strictures. Sensation of resistance during dilatation can
befeltwhileusingthisdilator,thusresultinginprotecting
against over dilatation and esophageal perforation (Fig-
ure. 5).
3-Through-the-scope balloon dilator (CRE balloon
dilator):
This instrument can be passed through the scope. It can
reach an area which cannot be accessed by other dilators.
However, resistance cannot be felt if over dilatation was
done. Dilatation achieved by balloon dilators is through a
radialforcewhileotherdilatorsmaketheiractionbyboth
radial and longitudinal forces. Although the mechanisms
by which dilatation is achieved are different, all dilators
havecomparablesuccessratesandrateofperforationbe-
tween 0.1%-0.4% (Figure. 6) [13]
.
Fluoroscopically guided esophageal balloon dilatation
(EBD) offers numerous advantages over endoscopically
guided EBD, particularly it provides superior image con-
trol and allows visualization of the esophageal stricture
(ES) in its entirety (location, severity, length, rigidity, and
shape). In the literature, the success rates for fluoroscop-
Sameh Abdelhay et al 12
Figure 3. A contrast study of the esophagus showing severe caustic
stricture.
Figure 4. An endoscopic view of a caustic esophageal stricture.
Clin Surg Res Commun 2020; 4(2): 10-17
DOI: 10.31491/CSRC.2020.06.050
4. ically guided EBD in children ranged from 64% to 100%
[14]
.
EBDcancauseexternalcompressionofthetracheaorob-
struction at the endotracheal tube tip. Thus, the surgical
team should be aware of obstruction of the airway that
may occur during maximal inflation of the balloon. The
other disadvantage of EBD is its higher cost compared to
thatoftheotherdilators.Althoughthemaincomplication
ofEBDisesophagealperforation,theriskisrelativelylow
(0%–31%).Themortalityrateinthepreviousdecadewas
close to zero; however, it must be diagnosed earlier [15]
.
Various modalities with dilatation are advocated to
improve the outcome:
Electrocision
Electro cautery could be applied to a caustic stricture. In
thistechnique,aneedleknifeispassedthroughaworking
channel of the endoscope to make multiple longitudinal
incisions until the rim of the stricture disappears. This
technique proved to be a useful adjunct in esophageal
dilatation.
Intralesional steroid injection
In this method and before esophageal dilatation, triam-
cinolone acetonide (40 mg/ml) is used. 1 mL is diluted
to 2-4 mL and injected at the stricture site in 4 quad-
rants. Combination of steroid injection and dilatation can
achieve better dilatation, improve dysphagia and reduce
dilatation sessions [16]
.
In our practice, upper endoscopy is usually done under
general anesthesia using a flexible one. The size varies
according to the age of the patients, but in the majority
number 9 F is suitable to complete the procedure. The
scopeshouldbeintroducedgentlyunderdirectvisionand
mounted by an injection needle connected to a syringe
containing 4 ml of diluted 1:1 triamcinolone acetonide.
Once the site of stricture is seen, 4 quadrant injection of
thestrictureisperformedavoidinginjectionatthelevelof
theaorticarchforfearofhemorrhage.Theneedleiswith-
drawn, and a metal guidewire is introduced to negotiate
the stricture till it can be felt over the epigastrium. Then
the scope is withdrawn and a suitable size Savary dilator
ispassedovertheintroducedguidewireandpushedwith
utmost care till felt in the stomach over the epigastrium.
Three successive sizes are used in the same session de-
pending on the response of the stricture to dilatation.
Failure of passage of the guidewire will end the proce-
dure to be repeated after 2 weeks, and in most cases the
guidewire can pass to complete the dilatation procedure.
In the presence of a multiple-level stricture, the first one
is injected and partial introduction of the dilator over the
guidewire will help to dilate the uppermost one followed
by repeated sessions to complete the dilatation of the
strictures at different levels. With around 30 new cases
of caustic esophageal stricture presented to our depart-
ment per year, studies we conducted found that, success
rateofdilatationincreasedfrom32%withdilatationonly
to 75% with steroids injection and 70% with mitomycin
Sameh Abdelhay et al 13
Figure 5. Savary-Gilliard esophageal dilators.
Figure 6. Balloon esophageal dilators.
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Published online: 29 June 2020
5. application prior to dilatation, so we don’t perform dil-
atation without either steroids injection or mitomycin
application.
Mitomycin-C injection and application
Injection or application of mitomycin-C into the stricture
site was shown to improve dysphagia score and allow
easy passage of dilators, because of mitomycin-C inhib-
ited fibroblast proliferation and scar formation without
interfering with wound healing [17]
. A randomized con-
trolled trial done in our department showed a reduction
in dilatation sessions if applying mitomycin-C during
esophageal dilatation [18]
.
Esophageal stent
Caustic esophageal strictures which are resistant to dil-
atation can be managed with insertion of esophageal
stents.Self-expandableplasticstent(SEPS),fully-covered
self-expandable metallic stent (FCSEMS) and recently,
biodegradable (BD) stent can be used. In practice, SEPS
andFCSEMScanbekeptinplacefor6weeksbutshouldbe
removed before 12 weeks. All types of esophageal stents
have comparable efficacy, but biodegradable stents have
an advantage in avoiding the need for removal. The suc-
cess rate of stent application in caustic esophageal stric-
ture was 33% with a migration rate of 40% [19]
.
Since its clinical success is about one-third and not long
lasting, efficacy is limited and the short-term radial force
applied by BD stents is inadequate to provide long term
relief in such patients. Esophageal stent is considered as
a last resource in the treatment of caustic esophageal in-
jury [20]
.
The role of endoscopy in the long term follow up:
Since caustic injury of the esophagus has been associated
with 1000-fold increased risk of esophageal carcinoma,
patients with high grades injury should undergo endo-
scopic surveillance [21]
. The incidence of caustic stricure
associated esophageal cancer ranged between 0%-30%
and bypass surgery seems to have no effect on develop-
ment of cancer. The time between occurrence of caustic
injury and malignant transformation of the esophagus
wasfoundtobeseveraldecades[22]
.Asaresult,endoscop-
ic surveillance of the injured esophagus should start at
about 15-20 years after occurrence of caustic injury and
it should be done every 2 or 3 years [23]
.
SURGICAL MANAGEMENT
It should be reserved for strictures which are resistant
to multiple sessions of endoscopic dilatation. Due to the
highsuccessratesofdilatationwiththenewmodifications
in our center, the necessity of esophageal replacement
surgery for caustic stricture decreased from around 36
cases to 6 cases per year in the last four years. More than
ten years ago, we were performing replacement surgery
Sameh Abdelhay et al 14
Figure 7. Intraoperative selection of a colonic conduit.
Clin Surg Res Commun 2020; 4(2): 10-17
DOI: 10.31491/CSRC.2020.06.050
6. if patient is still having dysphagia after three sessions of
dilatation,nowthisconcepthaschangedtoomuch.Weare
exhausting all possible ways to keep the native esopha-
gusandweonlyconsiderreplacementforcaseswithper-
sistent non-dilatable strictures or cases who required re-
peated sessions (more than 20) with no improvement in
the spacing for a long period of time (more than 2 years).
The ideal esophageal substitute should have good blood
supply, grow with the child and do not compromise the
cardiacandrespiratoryfunctions.Thesurgicaltechnique
shouldbesimple,safeandadaptabletothesmallchildren.
The most commonly done operations for esophageal
replacement are:
Colon interposition
It was first described by Kelling and Vulliet in 1911. It is
the most commonly done procedure for esophageal re-
placement. The right (ascending-transverse) or the left
(transverse-descending) colon may be used. The conduit
canbepassedfromtheabdomentobeanastomosedtothe
cervical esophagus through a subcutaneous, a retroster-
nal or a transhiatal route, with the retrosternal being the
mostcommonlyusedroute.Themostcommonpostoper-
ative complications are graft necrosis (0-14%) and cervi-
cal anastomosis leakage (6-28%) [24-26]
.
We routinely perform colon interposition as a way for
esophageal replacement, as we found it’s the best way
comparedtootherreplacementsurgeries.Throughyears,
we made some modifications in the surgical technique
which improved our outcome. We shifted from the tran-
shiataltotheretrosternalrouteasithasfewermorbidities
and mortalities with less operative time, better recovery
and less hospital stay. It is better to take the graft with
double blood supply and make it iso-peristaltic [27]
. Anti-
reflux can be made by simple suturing the colon graft to
the lesser curvature of the stomach making an angle or
by making the colo-gastric anastomosis in the posterior
wall of the stomach, these techniques improved the re-
fluxhappeningaftercoloninterposition[28,29]
.Onthelong
term follow up, no significant histopathological changes
occurred in the colonic conduit (Figure. 7) [30]
.
Gastric tube
ItwasfirstdescribedbyBurringtonandStephensin1968.
A tube is created from the greater curvature of the stom-
ach using a linear cutting gastro-intestinal anastomosis
(GIA) stapler after division of the short gastric vessels.
It can be also be passed from the abdomen to be anasto-
mosed to the cervical esophagus through a retrosternal
or a transhiatal route. The most common postoperative
complicationsareleakageintheneckanastomosis(63%)
and stricture in the tube (43%) [31, 32]
.
Gastric transposition
It was first described by Prof. Lewis Spitz in 1981. The
greater and lesser curvatures of the stomach are mobi-
lized. It will be passed from the abdomen to be anasto-
mosed to the cervical esophagus through the transhiatal
route. The incidence of postoperative cervical anastomo-
sis leakage is 12-36% and the incidence of anastomotic
stricture is 20-49% [33, 34]
.
CONCLUSION
Causticesophagealstricturescouldbemanagedsuccess-
fullywithadvancedtechniquesofendoscopicdilatation.
DECLARATIONS
Conflicts of interest
The authors declare that they have no conflict of interest.
Authors’ contributions:
Made substantial contributions to conception and design of
the study and performed data analysis and interpretation:
Sameh Abdelhay, Mohammed Elsherbeny.
Performed data acquisition, as well as provided administra-
tive,technical,andmaterialsupport:MohamedMoussa,Mo-
hammed Elsherbeny.
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