1) Cancers of the gastroesophageal junction are either adenocarcinomas or squamous cell carcinomas. Adenocarcinomas arise from Barrett's esophagus, an abnormal change in the esophageal lining, while squamous cell carcinomas are preceded by dysplasia.
2) Endoscopic ultrasound and diagnostic laparoscopy are used to accurately stage gastroesophageal junction cancers before deciding if the cancer can be surgically removed.
3) The type of surgery performed depends on the location and stage of the cancer, with tumors closer to the stomach treated more like gastric cancers and those higher up treated like esophageal cancers. The goal is to remove the cancer and nearby lymph nodes.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Whipple's procedure - Indications, Steps, ComplicationsVikas V
Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Whipple's procedure - Indications, Steps, ComplicationsVikas V
Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps
This presentation demonstrates the current paradigm in the treatment of desmoid tumors. As the management is shifting from surgical approach to medical management.
This presentation demonstrates the current paradigm in the treatment of desmoid tumors. As the management is shifting from surgical approach to medical management.
This Presentation gives summarized overview of Gall Bladder Carcinoma especially the management as per latest National Comprehensive Cancer Network(NCCN) Guidelines version 2.2013
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
Comprehensive review of Isolated Axillary lymph nodal metastasis of unknown origin- Clinically unknown primary axilla which includes detailed approach and management of inguinal lymph nodal metastasis also
Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinomaDr.Bhavin Vadodariya
Comprehensive review of evidence in Neoadjuvant Chemoradiation in Borderline resectable pancreatic adenocarcinoma which includes classification of pancreatic 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
Detailed Information regarding MSKCC,IMDC score with evidence .
SSIGN Score, Fuhrman's grading described .
Prognostic significance of risk score explained
The Trial Assigning IndividuaLized Options for Treatment (Rx) -TAILORx,TAILORx clinical trial showed that most women with hormone receptor (HR)–positive, HER2-negative, axillary node–negative early-stage breast cancer and a mid-range score on a 21-tumor gene expression assay (Oncotype DX® Breast Recurrence Score) do not need chemotherapy after surgery
Brief Review of Surgical management of Early laryngeal cancer e.g glottic and supraglottic cancer.
This presentation describes latest literature evidence of conservative laryngeal surgery as well as radiotherapy in early glottic cancer
Ca ovary staging(AJCC 8th Edition& FIGO 2014) and classificationDr.Bhavin Vadodariya
Pathological classification of ovary in details.
Principles of Staging in Ca Ovary.
Staging according to AJCC 8th edition & Figo 2014.
Summary of changes in 8th Edition AJCC
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 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.
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.
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.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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.
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.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Title: Sense of Taste
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 structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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
2. Biology
• The vast majority of esophageal cancers are of two subtypes:
esophageal squamous cell cancer (ESCC) and esophageal
adenocarcinoma (EAC). ESCC is preceded by squamous dysplasia.
• EAC is preceded by a Barrett esophagus (BE) or an incomplete
intestinal metaplasia of the normal squamous epithelium of the
esophagus .
• A BE undergoes transition from low-grade and high-grade
dysplasia before progressing into EAC.
3. ESCC and EAC have
common and divergent
genetic features as
manifest by alterations in
canonical oncogenes and
tumor suppressor genes
in somatic cells of tumors
4. • Most adenocarcinomas of the esophagus occur in the area of
the cardia and originate in islands of gastrointestinal mucosa,
less often in the submucosal glands, and from the histological
point of view are usually similar to gastric adenocarcinoma
and its various histological patterns. Most tumors are well-
differentiated
• Adenocarcinomas extensively infiltrate the esophageal wall
and often show perineural invasion, lymphatic and vascular
invasion, and direct extension through the esophageal wall.
5. • The prognosis of the esogastric junction carcinoma is
worsened by the potential two-way route of spread in case of
lymph node metastasis: mediastinum and abdomen.
6.
7.
8.
9. • Who Should Be Screened?
• Evidence-based guidelines recommend against
routine screening for Barrett esophagus.
Patients with GERD who have alarm signs
should undergo endoscopy. Screening may be
considered in patients with multiple risk
factors for Barrett esophagus.
15. Endoscopic ultrasound examination
(EUS)
• Endoscopic ultrasound (EUS) is helpful to determine the
proximal and distal extent of the tumour and to assess
tumour depth and lymph node status, although it is less
useful in antral tumours.
• For clinical T1/T2 disease,EUS is recommended to clarify
clinical T stage and to ascertain if preoperative
chemotherapy is indicated.
16. EUS
• Only imaging that can
distinguish the layers of
the esophageal wall
• T staging 85% accurate
• N staging 75% accurate
▫ Up to 2cm from esophagus
• 1/3 non-traversable stricture
• Less accurate post-therapy
17.
18. Diagnostic laparoscopy
• Laparoscopy may be useful in select patients in detecting
radiographically occult metastatic disease, especially in
patients with Siewert II and III tumors.
• Positive peritoneal cytology (performed in the absence of
visible peritoneal implants) is associated with poor prognosis
and is defned as M1 disease.
• In patients with advanced tumors, clinical T3 or N+ disease
should be considered for laparoscopic staging with peritoneal
washings.
19. Imaging
• MRI for T staging and invasion of adjacent structures.
• PET/CT scan can be considered for patients undergoing
multimodality curative treatment.
• PET may not be helpful in some patients with mucinous or T1
tumours.
• False negative rates for PET are high in gastric cancer, due to
the absence of the GLUT-1 transporter in mucinous and signet
ring histologies.
20. PET
• Detects mets not seen on CT
• No value in T staging
• Better for detecting higher nodes
(cervical>thoracic>abdominal)
• Assess response to chemoradiation
downstatesurgery.org
29. Resectable EGJ cancer
• T1a tumors, defined as tumors involving the mucosa but not invading the
submucosa, may be considered for EMR + ablation or esophagectomy in
experienced centers.
• Tumors in the submucosa (T1b) or deeper may be treated with
esophagectomy.
• T1-T3 tumors are resectable even with regional nodal metastases (N+),
although bulky; multi-station lymphatic involvement is a relative
contraindication to surgery, to be considered in conjunction with age and
performance status.
• T4a tumors with involvement of pericardium, pleura, or diaphragm are
resectable.
30. Unresectable esophageal cancer:
• cT4b tumors with involvement of the heart, great vessels, trachea, or
adjacent organs including liver, pancreas, lung, and spleen are
unresectable.
• Most patients with multi-station, bulky lymphadenopathy should be
considered unresectable, although lymph node involvement should be
considered in conjunction with other factors, including age and
performance status and response to therapy.
• Patients with EGJ and supraclavicular lymph node involvement should be
considered unresectable.
• Patients with distant (including nonregional lymph nodes) metastases
(stage IV) are unresectable.
31. • The type of esophageal resection is dictated by the location of
the tumor, the available choices for conduit, as well as by the
surgeon's experience and preference and the patient's
preference.
• In patients who are unable to swallow well enough to
maintain nutrition during induction therapy, esophageal
dilatation or a feeding jejunostomy tube are preferred to a
gastrostomy (which may compromise the integrity of gastric
conduit for reconstruction).
32. • The surgical approach for Siewert Type I and II EGJ tumors are
similar to esophageal cancer.
• Type III tumors are considered as gastric cancers and the
surgical approach for these tumors is similar Gastric Cancer.
• In some cases, additional esophageal resection may be
necessary to obtain adequate surgical margins.
33.
34. • Transhiatal esophagectomy was associated with lower morbidity than
transthoracic esophagectomy with extended en bloc lymphadenectomy.
Although median overall, disease-free, and qualityadjusted survival did
not differ statistically between the groups, there was a trend toward
improved long term survival at five years with the extended transthoracic
approach.
35. •The IEBLDs were similar between Siewert type II and III AEGs at all
stations except for lower perigastric lymph nodes.
•Total gastrectomy should be selected as a standard treatment for
Siewert type III AEG, whereas in Siewert type II AEG, preservation of
the distal part of the stomach may be an acceptable procedure.
36. • The 8M, 8L, 16, 17, and G3 should be excised for Siewert type II AEG.
Considering the lymphadenectomy, the Ivor-Lewis procedure is the
optimal choice for patients with Siewert type II AEG.
37. Surgical Approach - PreOp
• Consider age – typically not done if >80 y/o
• Cardiopulmonary reserve
▫ FEV-1 : >2L is ideal; >1.25 for thoracotomy
▫ Clinical eval, EKG, echo
• Nutritional status
▫ Most predictive of postop complications (wt loss >20lb, albumin
<3.5)
• Clinical staging
▫ Paralysis of diaphragm
▫ Bronchiotracheal involvement
▫ Malignant pleural effusion
Schwartz 2010
38. Treatment approach for GEJ
cancer
• Type 1: Treat as esophageal cancer
- Esophagectomy
• Type 2: controversial
- Total gastrectomy + distal
esophagectomy
- Esophagectomy + proximal gastrectomy
• Type 3: Treat as gastric cancer
- Gastrectomy
40. Absolute indications for endoscopic
resection
• Macroscopically intramucosal (cT1a) differentiated
carcinomas measuring less than 2 cm in diameter
• Macroscopic type does not matter but no ulceration scar
(UL[–])
49. Reconstruction
• Tubularized or whole stomach
▫ Preferred b/c blood supply
▫ Proximity
▫ Single anastomosis
• Colon
▫ Stomach can’t be used
Prior Sx, PUD scarring, tumor involvement
▫ L colon preferred b/c
Diameter closer to that of esophagus, more length, less variation of blood
supply
▫ Problems w/ L. colon
most affected by diverticular Dz, IMA most affected by atherosclerosis
• Jejunum
▫ Cannot replace entire esophagus
▫ Free graft, pedicled graft, or Roux-en-Y
downstatesurgery.org
51. Surgical Approach –
Which way do I go?
• Transhiatal esophagectomy (THE) is may be safer
• One major incision instead of 2
• Shorter OR time
• Transthoracic esophagectomy (TTE) may be a better
oncological procedure
• Extended lymph node dissection in the posterior
mediastinum
• Better for tumors close to tracheobronchial tree & after
neoadjuvant Tx especially mid & upper esophagus
downstatesurgery.org
52. Transthoracic
The transthoracic approach provides direct visualization and exposure of
the intrathoracic esophagus, facilitating a wider dissection to achieve a
more adequate radial margin around the primary tumor and more
thorough lymph node dissection, which theoretically results in a more
sound cancer operation.
In patients with signifcant comorbid conditions, the combined effects of
an abdominal and thoracic incision may compromise cardiorespiratory
function.
53. Transthroacic
An intrathoracic anastomotic leak can lead to mediastinitis, sepsis, and
death.
In addition, esophagitis in the nonresected thoracic esophagus may occur
secondary to bile reflux.
The threeincision (cervical, thoracic, and abdominal) modifcation of the
procedure effectively eliminates the potential for complications
associated with an intrathoracic esophagogastric anastomosis
54. Transhiatal
Limitations and disadvantages of transhiatal esophagectomy,
increased anastomotic leak rate with subsequent stricture
formation, the possibility of chylothorax, and the possibility
of recurrent laryngeal nerve injury.
55. Outcomes after Transhiatal &
Transthoracic Esophagectomy
Chang AC et al. Ann Thorac Surg2008
downstatesurgery.org
56. • Lower operative mortality (30 days)
▫ 6.7% vs 13.1%, p = 0.009
• Trend towards higher 5-yr survival
▫ No statistically significant difference
• More likely to require endoscopic dilatation w/in 6months
▫ 43.1% vs 34.5%, p = 0.02
Outcomes after Transhiatal &
Transthoracic Esophagectomy
Pts s/p THE had:
Chang AC et al. Ann Thorac Surg2008
downstatesurgery.org
57. Extended TTE vs Limited THE for
AdenoCa of the mid/distal Esophagus
• 1994-2000; randomly assigned 220 pts w/ THE (n=95) or TTE
(n=110); 15 pts excluded b/c unresectable
• 5-yr survival THE 34% vs TTE 36%, p = 0.71
• Survival benefit 14% in Type I tumor w/ TTE (51% vs 37%, p =
0.33)
▫ Not seen in pts w/ Type II tumor, no positive nodes, or >8 + nodes
• TTE higher perioperative morbidity but no difference in
mortality
Omloo et al. Ann Surg 2007.
downstatesurgery.org
58. LN along the lesser curvature, right and left paracardial LN, and LN along
the left gastric artery should be dissected in patients with Siewert
type Ⅱ or Ⅲ adenoca rcinoma of the esophagogastric junction.
.
60. Current recommendation for Type
2
• For tumor with esophageal invasion
<2cm
• Extended gastrectomy
• For tumor with esophageal invasion
>2cm
• Esophagectomy
61. A positive CRM was more common with gastrectomy in patients with
a type II GEJ adenocarcinoma.
Esophagectomy provides for a more complete paraesophageal lymphadenectomy.
Furthermore, the high prevalence of mediastinal nodal involvement indicates that
a full lymphadenectomy of these stations should be considered in type II tumors
62.
63. Assessment of Treatment Response
• Residual primary tumor in the resection specimen following
neoadjuvant therapy is associated with shorter overall
survival for both adenocarcinoma and squamous cell
carcinoma of the esophagus.
• Sizable pools of acellular mucin may be present after
chemoradiation but should not be interpreted as representing
residual tumor.
65. Role of PET Scans in the Assessment
of Treatment Response
• The NCCN guidelines recommend consideration of PET/CT or PET
only for the assessment of response to preoperative or definitive
chemoradiation therapy before surgery or initiation of
postoperative treatment (category 2B).
• However, the guidelines emphasize that PET scans should not be
used for the selection of patients to surgery following preoperative
chemoradiation.
67. Summary
• Tumors of the esophagogastric junction seem to be a distinct
pathophysiologic entity, separate from esophageal and gastric carcinomas
yet with some oncologic features of each.
• Accurate preoperative staging is crucial in the management of these
tumors