Stents are hollow tubes used to hold open strictured areas in various parts of the body, usually due to malignancy. There are two main types - simple plastic stents and self-expanding metal stents (SEMS). Plastic stents are used in the biliary tree and pancreas while SEMS can be placed in various areas using a guidewire. Stents are used to relieve obstructive symptoms from cancer and as a bridge to surgery. Complications include perforation, tumour overgrowth, and migration.
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Single incision laparoscopic Surgery-SILSrkmishra14
World Laparoscopy Hospital is Pioneer in SILS. Single incision laparoscopic surgery (SILS) under direction of Prof. R.K. Mishra is a new technique that has now been utilized in many centers for minimal access surgery. http://www.laparoscopyhospital.com/single_incision_laparoscopic_surgery.html
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
Single incision laparoscopic Surgery-SILSrkmishra14
World Laparoscopy Hospital is Pioneer in SILS. Single incision laparoscopic surgery (SILS) under direction of Prof. R.K. Mishra is a new technique that has now been utilized in many centers for minimal access surgery. http://www.laparoscopyhospital.com/single_incision_laparoscopic_surgery.html
OPEN RIGHT HEMICOLECTOMY- STEP BY STEP OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openrighthemicolectomy #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Open Right Hemicolectomy .
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch all my teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
OPEN RIGHT HEMICOLECTOMY- STEP BY STEP OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openrighthemicolectomy #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Open Right Hemicolectomy .
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch all my teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
Complete migration of a biliary stent into the gallbladderPremier Publishers
Biliary stents become very important tools in the hands of gastro-intestinal endoscopists. They solve a lot of problems, but they are not free of copmlications. During insertion of a biliary stent in a sixty-five-year-old female patient it broke. It broke in a place which makes its retrieval very difficult. Trial of retrieval led to pushing of the stent deep into the common bile duct. It lies just below the mouth of the cystic duct, which should have made a warning for a rare migration. Later the stent was seen in the vicinity of the gallbladder during ERCP. Cholecystectomy was done and the stent was found inside it.
An educational description of various airway stents, and a useful and practical document for general surgery and thoracic surgery residents and physicians.
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.
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
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 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.
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.
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
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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
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.
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!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
2. Hollow tubes
To hold open strictured areas in the oesophagus, the biliary tree, the
colon and the gastroduodenal region
Usually positioned in order to overcome stricturing associated with
malignancy
Bridge to surgery
Palliation of obstructive symptoms
3. Basic Principle
Initial placement of a guidewire and sometimes an overrunning
introducing catheter across the region to be stented, using endoscopic
vision /fluoroscopic guidance too
The stent is advanced over the guidewire until it traverses the area to
be stented
In the case of self-expanding stents, the restraining mechanism is then
released to deploy the stent
5. Simple plastic stents
Confined to use in the biliary tree and pancreas
Composed of one of three polymers - polyethylene, polyurethane
orTeflon
Plastic stents used in the biliary tree and pancreas
Straight with anchoring side-flaps to prevent migration
Pigtail stents - curled end of a pigtail stent is straightened over the
guidewire during positioning and the pigtail resumes its shape once the
guidewire has been removed
7. Self-expanding stents
Positioned while collapsed, using a
small calibre introducer
Easier, safer, with a reduced risk of
perforation, and much reduced need
for prior stricture dilatation
Metals - need to be biocompatible
biologically innocuous when
functioning in patients
Shape memory alloys are
‘intelligent’, possessing the ability to
recover a previously defined length
or shape when deployed in the
patient
8. Self-expanding stents
Each has its own characteristics in terms of radial forces exerted,
foreshortening on deployment, and flexibility
SEMS can be made from stainless steel
Alloys
Nitinol is an alloy of nickel and titanium used in Ultraflex stent (Boston
Scientific, Natick, MA, USA) and Alimaxx E stent (Alveolus, Charlotte,
NC, USA)
Elgiloy, a cobalt /chromium /nickel alloy, is used in Wallstent (Boston
Scientific)
9. Fluoroscopically opaque to aid positioning
Easily deployable via a small calibre introducer
Introduced in a collapsed position, being run over a guidewire
positioned through the region to be stented
Constraining mechanism is released and the stent expands, exerting
radial forces on any stricturing lesion thus increasing the lumen of the
area being stented
10. SEMS - designed to expand to a diameter of more than 20mm.
The bare metal strands of an uncovered stent may embed in the
underlying tumour and serve to anchor the stent in position
Through pressure necrosis, the struts of the stent migrate into the
mucosa and submucosa of the gut wall.
Fibrous reaction with chronic lymphocytic infiltration occurs, as the stent
becomes embedded in collagen and fibrous tissue
A chronic lymphocytic reaction occurs in the normal tissue underlying
the proximal and distal ends of the stent
MRI compatible
12. Covered metal stents
SEMS may be covered with a silicone membrane to reduce the risk of
tumour in-growth and to seal fistulas
Less likely to embed in the underlying tissues, and have an increased
risk of stent migration compared to uncovered stents
Partially covered stents have been developed with flared uncovered
segments at both ends to anchor on to the tissue
Fully covered SEMS are also increasingly used in benign oesophageal
disease, such as non-malignant strictures and anastomotic leaks
Biodegradable stents have been developed which slowly break down
over time made from the biodegradable polymer poly-dioxanon, and
poly-L-lactic acid monofilaments
13. Perforation, tumour overgrowth or ingrowth, and stent migration
Areas of development -- radioactive or drug-eluting stents for malignant
disease
15. Malignant oesophageal obstruction
Progressive dysphagia and weight loss
Inoperable tumours
Oesophageal stents - excellent option for the palliation of dysphagia
In contrast to other treatment modalities like endoscopic laser or
brachytherapy, stents are widely available and are not restricted to
specialised centres
16. Malignant oesophageal obstruction
First stents used in malignant dysphagia - rigid plastic stents
Substantial risk of perforation
SEMS were developed in the early 1990s. Their design allows them to be
preloaded onto a delivery mechanism typically measuring 5-10mm in
diameter
Oesophageal SEMS are deployed over a guidewire after delineating the
margins of the stricture endoscopically.
Diameter varies between 16 and 24 mm and their length varies between 7
and 15 cm
SEMS are usually partially or fully covered with a membrane to prevent
tumour ingrowth through the metal mesh
19. Malignant tracheo-oesophageal fistulas
Infiltration of oesophageal cancers into the respiratory tract, or cancers
of the trachea and bronchi infiltrating into the oesophagus
Difficult to treat and are associated with poor prognosis
Several case series have demonstrated that covered SEMS can lead to
fistula occlusion in 70-100% of patients
20. Oesophageal perforations and leaks
Spontaneous and iatrogenic perforations - very high mortality and morbidity
Iatrogenic perforations - more common
Endoscopy, - malignant stricture dilatation
Iatrogenic oesophageal perforation is life-threatening contamination of the
mediastinum and pleural
space with stomach contents is less problematic compared to spontaneous
perforation since
the patient is fasted
Insertion of a covered SEMS, together with thoracostomy tube drainage of the
pleural space and antibiotic administration - successful strategy in sealing off
iatrogenic perforations (Siersema et al., 2003)
Prompt stent insertion (average delay 45 minutes) after iatrogenic oesophageal
perforation leads to minimal morbidity compared to delayed treatment, and produces
results similar to surgical treatment (Fischer et al., 2006)
21. Oesophageal anastomotic leaks
Post-operative anastomotic leaks are another area where oesophageal stents
are increasingly used
Case series of anastomotic leaks following upper gastrointestinal surgery
have demonstrated high success and low complications rates, with patients
returning to eating 2 days after stent insertion
22. Bleeding oesophageal varices
Bleeding from oesophageal varices - high mortality
Advanced liver disease with portal hypertension
Endoscopic band ligation of the varices, vasopressor medication to decrease
portal
pressure.
Insertion of a Sengstaken-Blakemore tube which tamponades the varices
Balloon tamponade is a temporary measure often used as a bridge to
treatment with a transjugular intrahepatic portosystemic stent shunt (TIPSS)
24. A Sengstaken–Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in
the management of upper gastrointestinal hemorrhage due to esophageal varices (distended and fragile veins in the
esophageal wall, usually a result of cirrhosis). The use of the tube was originally described in 1950,[1] although similar
approaches to bleeding varices were described by Westphal in 1930.[2] With the advent of modern endoscopic
techniques which can rapidly and definitively control variceal bleeding, Sengstaken–Blakemore tubes are rarely used
at present.[3]
The device consists of a flexible plastic tube containing several internal channels and two inflatable balloons. Apart
from the balloons, the tube has an opening at the bottom (gastric tip) of the device. More modern models also have
an opening near the upper esophagus; such devices are properly termed Minnesota tubes.[3][4] The tube is passed
down into the oesophagus and the gastric balloon is inflated inside the stomach. A traction of 1 kg is applied to the
tube so that the gastric balloon will compress the gastroesophageal junction and reduce the blood flow to
esophageal varices. If the use of traction alone cannot stop the bleeding, the esophageal balloon is also inflated to
help stop the bleeding. The esophageal balloon should not remain inflated for more than six hours, to avoid necrosis.
The gastric lumen is used to aspirate stomach contents.
Generally, Sengstaken-Blakemore tubes are used only in emergencies where bleeding from presumed varices is
impossible to control with medication alone. The tube may be difficult to position, particularly in an unwell patient, and
may inadvertently be inserted in the trachea, hence endotracheal intubation before the procedure is strongly advised
to secure the airway. The tube is often kept in the refrigerator in the hospital's emergency department, intensive care
unit and gastroenterology ward. It is a temporary measure: ulceration and rupture of the esophagus and stomach are
recognized complications.[4][5]
A related device with a larger gastric balloon capacity (about 500 ml), the Linton–Nachlas tube, is used for bleeding
gastric varices. It does not have an esophageal balloon.
25. Gastroduodenal stents
Gastric outlet obstruction - pancreatic cancer, distal gastric cancer,
duodenal cancer, metastatic cancers
Surgical gastroenterostomy to bypass the antro-pyloroduodenal region
Gastroduodenal stent insertion offers a noninvasive means of palliating
vomiting without surgery
26. SEMS variety and are positioned under direct endoscopic vision, and with fluoroscopic
guidance
Before stent placement is attempted, a period of gastric drainage using a wide-bore
nasogastric tube is recommended
Drainage of gastric contents will improve endoscopic views and reduce the risk of vomiting
and aspiration
during the procedure. At endoscopy, the stricture’s proximal anatomy is assessed but
usually the endoscope’s diameter is too large to allow safe negotiation through the stricture.
The stricture can be outlined by fluoroscopy after the injection of a contrast agent. A
guidewire is then passed down the operating channel of a therapeutic endoscope and
advanced through the stricture. The stent assembly is then passed over the wire and
positioned so that its ends overlap the ends of the stricture. Once fluoroscopy confirms a
satisfactory position, the SEMS is deployed. An alternative method of gastroduodenal stent
insertion involves a radiologist placing the stent via the oral route using fluoroscopy alone.