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Laparoscopic gastrostomy in a patient with esophageal squamous cell carcinoma
Percutaneous endoscopic gastrostomy (PEG) and self-expanding endoscopic prosthesis are considered to be the "gold standard" for patients with neurological or oncologic diseases, which do not allow feeding per os. When they fail, surgical gastrostomy is considered. Recent data suggest that the laparoscopic approach may be better regarding early complications as compared to PEG.
We present the case of an 81-year-old male patient diagnosed with squamous cell carcinoma of the esophagus. The patient presented with total dysphagia. The attempt of placing a self-expanding endoscopic prosthesis was unsuccessful. The patient was then proposed for the placement of a feeding laparoscopic gastrostomy. The postoperative period was uneventful and the patient was discharged on day two.
Surgical gastrostomy is associated with frequent complications, such as erythema, chronic suppuration, migration and complications associated with surgical access. Laparoscopic access and technical details of the procedure allowed to reduce such complications and to perform the main steps under direct visual control, making it very safe and easily reproducible.
A Gomes, D Luis, T Carneiro, C Veiga
Surgical intervention
4 years ago
2040 views
58 likes
0 comments
06:40
Laparoscopic gastrostomy in a patient with esophageal squamous cell carcinoma
Percutaneous endoscopic gastrostomy (PEG) and self-expanding endoscopic prosthesis are considered to be the "gold standard" for patients with neurological or oncologic diseases, which do not allow feeding per os. When they fail, surgical gastrostomy is considered. Recent data suggest that the laparoscopic approach may be better regarding early complications as compared to PEG.
We present the case of an 81-year-old male patient diagnosed with squamous cell carcinoma of the esophagus. The patient presented with total dysphagia. The attempt of placing a self-expanding endoscopic prosthesis was unsuccessful. The patient was then proposed for the placement of a feeding laparoscopic gastrostomy. The postoperative period was uneventful and the patient was discharged on day two.
Surgical gastrostomy is associated with frequent complications, such as erythema, chronic suppuration, migration and complications associated with surgical access. Laparoscopic access and technical details of the procedure allowed to reduce such complications and to perform the main steps under direct visual control, making it very safe and easily reproducible.
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres, NS Gómez Peña-Alfaro
Surgical intervention
4 months ago
6848 views
25 likes
4 comments
12:40
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
Respective indications of EMR and ESD
Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion
N Fukami
Lecture
3 years ago
439 views
21 likes
0 comments
29:26
Respective indications of EMR and ESD
Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion
LIVE INTERACTIVE SURGERY: Esophagogastroduodenoscopy (EGD), chromoendoscopy, and BARRX treatment of remaining Barrett's mucosa
Chromoendoscopy is a procedure where dyes are instilled in the gastrointestinal tract at the time of visualization with endoscopy. It enhances the characterization of the tissues. The most common applications are as follows:
- Identification of squamous cell carcinoma or dysplasia;
- Identification of Barrett’s esophagus;
- Detection of early gastric cancer;
- Characterization of colonic polyps;
- Screening.
BARRX™ is a radiofrequency ablation of the metaplastic esophageal mucosa. The concept is to resect the epithelium and the muscularis mucosa without damaging the submucosa. It reduces the risk of developing carcinoma.
E Coron, G Rahmi
Surgical intervention
3 years ago
444 views
20 likes
0 comments
09:12
LIVE INTERACTIVE SURGERY: Esophagogastroduodenoscopy (EGD), chromoendoscopy, and BARRX treatment of remaining Barrett's mucosa
Chromoendoscopy is a procedure where dyes are instilled in the gastrointestinal tract at the time of visualization with endoscopy. It enhances the characterization of the tissues. The most common applications are as follows:
- Identification of squamous cell carcinoma or dysplasia;
- Identification of Barrett’s esophagus;
- Detection of early gastric cancer;
- Characterization of colonic polyps;
- Screening.
BARRX™ is a radiofrequency ablation of the metaplastic esophageal mucosa. The concept is to resect the epithelium and the muscularis mucosa without damaging the submucosa. It reduces the risk of developing carcinoma.