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Esophageal stents are devices used to maintain or restore the lumen of the esophagus. There are several types of esophageal stents including self-expanding plastic stents (SEPS), self-expanding metal stents (SEMS), and biodegradable stents. SEMS are the most commonly used and come in uncovered, partially covered, and fully covered varieties. Stents are used to treat conditions causing dysphagia such as esophageal cancer, benign strictures, leaks, and fistulas. Complications include pain, bleeding, reflux, perforation, migration, and tissue growth through the stent mesh. Placement of stents near the upper esophagus or gastroesophageal junction
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.
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
This document provides information on gastrointestinal stents. It discusses the history of stents, the types of stents including metal, plastic and biodegradable stents. It outlines the indications for stenting in the esophagus, stomach and colon. It details the procedure for stent placement and possible complications. It provides specifics on esophageal, gastric and colonic stents.
This document discusses surgical approaches for esophageal cancer. It covers:
- Esophageal anatomy, blood supply, lymph drainage
- Staging of esophageal cancer and criteria for resection
- Preoperative evaluation including imaging, biopsy, and laparoscopy
- Surgical procedures for cervical, thoracic, and esophagogastric junction cancers including transhiatal esophagectomy, Ivor-Lewis procedure, and tri-incisional esophagectomy
- Oncologic principles for lymphadenectomy and margins during resection
This document discusses esophageal resection and reconstruction techniques. It covers indications for resection such as carcinoma or injury. Common reconstruction conduits are the stomach, colon, jejunum or combinations. Reconstruction routes include posterior mediastinal, substernal or subcutaneous. Complications can include fistula, stricture or dysfunction. The goal is a viable patient with functional gastrointestinal continuity. Successful reconstruction lasts long, provides nutrition and is done safely with flexibility and a team approach.
Laparoscopic Roux En-Y-Gastric Bypass: One Surgeon's TechniqueGeorge S. Ferzli
31 slides•4.7K views
The document describes the technique for performing a laparoscopic Roux-en-Y gastric bypass surgery. It details the steps of the procedure including identifying the ligament of Treitz, measuring and dividing the jejunum to create the Roux limb and biliopancreatic limb, performing a jejunojejunostomy, creating the gastric pouch, and completing an antecolic antegastric gastrojejunostomy. The summary emphasizes key points such as proper identification of anatomical landmarks, appropriate measurement of limb lengths, use of hand sewing for anastomoses, and performing a leak test.
Dr. Yajnadatta Sarangi discusses hyperthermic intraperitoneal chemotherapy (HIPEC), which involves delivering chemotherapy intraperitoneally at high temperatures to treat peritoneal metastasis. HIPEC is usually performed along with cytoreductive surgery to remove all visible tumor deposits. It aims to treat microscopic residual disease remaining after surgery. The document discusses the rationale for HIPEC, techniques, indications, contraindications and complications. It presents evidence that HIPEC combined with cytoreductive surgery improves survival outcomes for several cancer types compared to palliative chemotherapy alone.
Presentation describing surgical technique and principles of anastomosis, factors for good healing in the post operative phase, risk factors for leak and the role of staplers in modern day surgical practice, advantages over hand sewn anastomosis.
The document discusses different procedures for inguinal lymph node dissection, including standard, modified, and radical dissection. It describes key aspects of modified inguinal lymphadenectomy such as a shorter skin incision and preservation of structures like the saphenous vein. Complications of inguinal node dissection are also outlined, ranging from minor issues like lymphocele and wound infection to major complications including debilitating lymphedema, flap necrosis, and blood clots. The document provides details on surgical techniques, postoperative care, and risks associated with dissection of lymph nodes in the groin area.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
18 slides•1.7K views
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
1) Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that uses an endoscope passed through natural openings like the mouth, vagina, or anus to perform internal surgery without external incisions.
2) NOTES was first described in animal models in the early 2000s and the first human transgastric cholecystectomy was reported in 2007.
3) While offering advantages over laparoscopy by avoiding external incisions, NOTES faces challenges of developing improved flexible instruments, closing access sites without leaks, and standardizing safe techniques.
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
Liver resection indications & methodsDr Harsh Shah
103 slides•11.6K views
This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
The document discusses properties that surgeons should consider when choosing a mesh for hernia repair. Ideal meshes are lightweight, with large pores to reduce foreign body reaction and chronic pain. Monofilament meshes have the lowest risk of infection. For intraperitoneal placement, composite meshes may reduce adhesions by providing an absorbable surface. Overall, lightweight polypropylene or polyester meshes are generally suitable in most contexts by balancing strength, flexibility and biocompatibility.
This document discusses the management of colorectal liver metastases. It addresses topics such as:
- The role of PET-CT scans in assessing resectability and the limited impact they have on surgical management.
- Strategies to improve resectability for patients with multiple or bilobar tumors, including portal vein embolization, portal vein ligation, and ALPPS.
- The importance of volumetric assessment of the future liver remnant using CT or MRI to ensure sufficient functional liver remains post-resection.
- Approaches for synchronous and metachronous colorectal liver metastases, including primary-first, liver-first, and simultaneous resections.
- The role
Bile duct injuries are a complex complication seen more frequently with laparoscopic cholecystectomies due to aberrant anatomy and increased procedures. They can involve the cystic duct, gallbladder bed, or major bile ducts. Various classification systems exist to describe the level and extent of injury. Injuries may be detected intraoperatively by cholangiogram abnormalities, bile drainage from unusual locations, or anomalous anatomy. Prevention strategies include proper case selection, opening retroperitoneal folds, dissecting close to the gallbladder, achieving the critical view of safety, and using intraoperative cholangiography.
The Whipple procedure, also known as pancreaticoduodenectomy, involves removal of the pancreatic head, duodenum, gallbladder and bile duct. It is one of the most complex surgical procedures performed and is used to treat various conditions of the pancreas and surrounding organs. The key steps of the procedure include mobilization of the pancreas and attached organs, resection of these structures, and reconstruction by anastomosing the pancreas and bile duct to the small intestine. Post-operative management focuses on pain control, early feeding and mobilization using evidence-based protocols to optimize recovery.
This document discusses the role of stents in surgery. It provides a history of stents, describes the different types of stents including self-expanding metal stents (SEMS), self-expanding plastic stents (SEPS), and biodegradable stents. It outlines the indications for stents and the procedures for placement. Complications of stenting are also mentioned.
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCEDr Amit Dangi
This document discusses esophagectomy, the surgical approaches for esophageal cancer resection. It covers the relevant anatomy, blood supply, lymph drainage, and histology of esophageal cancer. It then discusses pre-treatment evaluation including staging assessments and criteria for resection. The key surgical procedures for cervical, thoracic, and esophagogastric junction cancers are described including the transhiatal, Ivor-Lewis, and tri-incisional approaches. Post-operative outcomes from recent studies comparing these approaches are summarized.
EUS has revolutionized both the diagnostic and therapeutic aspects of gastroenterology. It combines an endoscope with an ultrasound probe to examine the GI tract walls and nearby structures. EUS is very useful for staging cancers of the esophagus, pancreas, and biliary tract, and is the most sensitive method for distinguishing between benign and malignant pancreatic tumors. EUS also has several important therapeutic roles, including draining pancreatic fluid collections, accessing the biliary tree non-surgically, celiac plexus neurolysis for pancreatic cancer pain relief, and delivering targeted cancer treatments. Recent advances have further increased the diagnostic and therapeutic capabilities of EUS.
Natural Orifice Transluminal Endoscopic Surgery, NOTES.
"scarless" abdominal surgery with an endoscope passed through a natural orifice (MOUTH, URETHRA, ANUS, VAGINA) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.
This document discusses the management of pancreatic fistulas. It defines pancreatic fistulas as leakage of pancreatic fluid resulting from pancreatic duct obstruction, which can be iatrogenic such as from surgery or ERCP, or non-iatrogenic due to conditions like pancreatitis. Initial management involves controlling pancreatic secretions with drain placement or TPN, correcting electrolyte imbalances, and evaluating the pancreatic duct with imaging. Most fistulas close spontaneously with drainage alone. For persistent fistulas, octreotide can help while ERCP with stenting has closure rates over 80%. Surgery is reserved for failures of other methods and involves duct decompression or resection. Risk factors for postoperative fistulas include duct size, texture, jaundice, and
This document discusses surgical considerations for rectal cancer, including:
1. The total mesorectal excision (TME) technique aims to remove the mesorectum containing all lymph nodes, leading to low local recurrence rates of 3-4% after 5-10 years.
2. Pre-operative chemoradiotherapy can downstage tumours and improve survival, especially for T3/T4 tumours.
3. A modified TME removing the mesorectum at least 5cm below the tumour is acceptable for high and mid rectal cancers, as distal spread beyond this is rare.
4. Good surgical outcomes depend on meticulous technique, surgeon experience operating in the pelvis, and multidis
Carcinoma rectum the complete aproach to how to investigate and treat a case ...nikhilameerchetty
this is a complete guide to the understanding of the anatomy clinical features and the latest investigation to the most modern methods of treating the case of carcinoma rectum , all the latest journal published and the ongoing trials hav been searched and incorporated
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
Types of intestinal stomas and management Ankita Singh
The document discusses types of intestinal stomas including classifications based on duration, anatomical location, and reconstruction. It covers indications for stoma creation, principles of stoma formation including challenges, common complications, and dietary advice for ostomates. Stoma appliances and management of various stoma-related complications are also described.
The document discusses different procedures for inguinal lymph node dissection, including standard, modified, and radical dissection. It describes key aspects of modified inguinal lymphadenectomy such as a shorter skin incision and preservation of structures like the saphenous vein. Complications of inguinal node dissection are also outlined, ranging from minor issues like lymphocele and wound infection to major complications including debilitating lymphedema, flap necrosis, and blood clots. The document provides details on surgical techniques, postoperative care, and risks associated with dissection of lymph nodes in the groin area.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
18 slides•1.7K views
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
1) Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that uses an endoscope passed through natural openings like the mouth, vagina, or anus to perform internal surgery without external incisions.
2) NOTES was first described in animal models in the early 2000s and the first human transgastric cholecystectomy was reported in 2007.
3) While offering advantages over laparoscopy by avoiding external incisions, NOTES faces challenges of developing improved flexible instruments, closing access sites without leaks, and standardizing safe techniques.
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
Liver resection indications & methodsDr Harsh Shah
103 slides•11.6K views
This document provides information on liver resection techniques and methods. It discusses the history and indications for liver resection, preoperative assessment including future liver remnant assessment, portal vein embolization to augment the liver volume, and surgical techniques for vascular control and parenchymal transection including the Pringle maneuver, water jet dissection, CUSA, and radiofrequency devices. The key steps in liver resection are preoperative planning, intraoperative assessment, inflow and outflow control, low central venous pressure, and parenchymal transection using various techniques and instruments.
The document discusses properties that surgeons should consider when choosing a mesh for hernia repair. Ideal meshes are lightweight, with large pores to reduce foreign body reaction and chronic pain. Monofilament meshes have the lowest risk of infection. For intraperitoneal placement, composite meshes may reduce adhesions by providing an absorbable surface. Overall, lightweight polypropylene or polyester meshes are generally suitable in most contexts by balancing strength, flexibility and biocompatibility.
Types of intestinal stomas and management Ankita Singh
64 slides•6.5K views
The document discusses types of intestinal stomas including classifications based on duration, anatomical location, and reconstruction. It covers indications for stoma creation, principles of stoma formation including challenges, common complications, and dietary advice for ostomates. Stoma appliances and management of various stoma-related complications are also described.
This document discusses ureteral stents and percutaneous nephrostomy (PCN) tubes. It covers the history of stents, ideal stent properties, common biomaterials used, coatings to reduce complications, and newer stent designs. Common indications for stents include intrinsic and extrinsic urinary obstruction. Complications include urinary symptoms, infection, encrustation, and migration. The ideal length depends on patient height or anatomy. Stent removal is important to prevent long-term issues like encrustation.
Vaginal approach for Stress Urinary Incontinence surgeryRohan Sharma
94 slides•340 views
This document discusses various surgical approaches for stress urinary incontinence (SUI), including pubovaginal slings and midurethral slings. It provides details on the operative technique for pubovaginal sling surgery, including patient positioning, incisions, dissection, sling placement, and postoperative care. Complications like erosion, extrusion, and voiding dysfunction are also reviewed. The document also discusses the anatomical basis for midurethral slings and how they work to treat SUI.
This document provides guidelines on the role of endoscopy in the evaluation and management of dysphagia. It discusses the various causes of dysphagia including structural and motility disorders. Endoscopy is an effective tool for diagnosing and treating dysphagia through procedures like dilation. Different types of dilators and techniques are described for dilating various types of esophageal strictures. The risks, outcomes, and alternatives for refractory cases are also covered.
Resection & anastomosis of boweL its complications PRANAYA PPTPRANAYA PANIGRAHI
104 slides•12.1K views
This document discusses intestinal resection and anastomosis. It defines anastomosis as establishing communication between two portions of intestine after removal of diseased bowel. Factors that influence healing, techniques for performing anastomoses (hand sewn vs. stapling), and common complications are described. Maintaining adequate blood supply, tension-free closure, and paying attention to technical details are emphasized for achieving successful anastomotic healing.
This document outlines Netflix's culture of freedom and responsibility. Some key points:
- Netflix focuses on attracting and retaining "stunning colleagues" through a high-performance culture rather than perks. Managers use a "Keeper Test" to determine which employees they would fight to keep.
- The culture emphasizes values over rules. Netflix aims to minimize complexity as it grows by increasing talent density rather than imposing processes. This allows the company to maintain flexibility.
- Employees are given significant responsibility and freedom in their roles, such as having no vacation tracking or expense policies beyond acting in the company's best interests. The goal is to avoid chaos through self-discipline rather than controls.
- Providing
Three business basics to always remember! People don't care about your brand. They care about what you can do for them. Back to basics... Give people what they want, do it consistently and do it better than your competition.
This document outlines Seth Familian's presentation on working with big data. It discusses key concepts like what constitutes big data, popular tools for working with big data like Splunk and Segment, and techniques for building dashboards and inferring customer segments from large datasets. Specific examples are provided of automated data flows that extract, load, transform and analyze big data from various sources to generate insights and populate customized dashboards.
Did you know that our brains are naturally biased? Let's explore the functions of unconscious bias together and navigate their impact on our decision-making processes. We will examine our own background and identities so we can interact more authentically with colleagues, consumers, and the community at large.
- The document discusses a web-based application that helps streamline the process of obtaining patient consent for sharing medical records between doctors.
- It aims to reduce the time required from over a week currently to just a few days by facilitating electronic consent forms and record transfers.
- The target customers are small medical practices, smaller EHR vendors, and insurance companies who want to cut costs from delays in medical care due to lengthy consent processes.
This Brainmates presentation seeks to answer the question "What is product management?"
This presentation investigates this important strategic role and illustrates its responsibilities and functional applications.
A useful reference for people working in product management or who are interested in a career in this field.
** About Brainmates:
Brainmates is an Australian based business that has is championing the important role that Product Managers perform in delivering a product's that are loved by their customers and deliver a return on investment to the businesses that provide them.
Brainmates trains coaches and supported Product Management Professionals in all kinds of industries and business sizes. Contact the team on +61 1800 272 466 to see if we can help your products and business.
** Connect with Brainmates online:
Visit the Brainmates WEBSITE: http://bit.ly/1lQ51mE
Like Brainmates on FACEBOOK: http://bit.ly/2c0RVaO
Follow Brainmates on TWITTER: http://bit.ly/2bNhKft
Brainmates - Product Management Training and Expertise
How to Craft Your Company's Storytelling Voice by Ann Handley of MarketingProfsMarketingProfs
You know your company's story, but what's the right voice to use in telling it? Find out how to craft your company's storytelling voice. Ann Handley, chief content officer of MarketingProfs and author of "Content Rules" shares tips and ideas for crafting your brand's storytelling voice.
Presentation on Innovation Games ™ - What are Innovation Games and for what you can use them... Questions over questions... ;-)
Here you get the answers!
The abdominal aorta continues from the descending thoracic aorta and supplies blood to the abdominal organs and lower limbs. It lies slightly left of the spine and divides into the common iliac arteries. Abdominal aortic aneurysms are focal dilations that are 1.5 times larger than normal diameter and can be saccular or fusiform in shape. Ultrasound is used to diagnose and measure aneurysms longitudinally, transversely, and with color Doppler to identify flow patterns. Measurements of greater than 5.5 cm indicate risk of rupture.
Transarterial chemoembolization (TACE) involves delivering chemotherapy drugs and embolic agents directly into liver cancers via catheters in the hepatic artery. TACE is generally used to treat hepatocellular carcinoma that cannot be surgically removed. During the procedure, a catheter is placed into the hepatic artery supplying the tumor and chemotherapy mixed with iodinated oil is injected, followed by embolization of the artery with gelatin sponges. TACE can reduce tumor size and symptoms but common side effects include abdominal pain and nausea. Response to treatment is evaluated after 3-4 weeks using imaging to assess the extent of tumor coverage by the oil and residual enhancement.
Retrograde pyelography is an x-ray imaging technique used to visualize the kidneys and ureters. A catheter is inserted into the ureter and contrast dye is injected under fluoroscopy. Images are taken of the renal pelvis, ureters and bladder. It is used to evaluate abnormalities seen on intravenous urograms or investigate causes of hematuria when the ureters were not fully visualized. The procedure has some risks but is less risky than intravenous urography. It can demonstrate various conditions like ureteral strictures, filling defects, diverticula or stenosis. Care is taken during injection to avoid overdistension and complications.
This document discusses various imaging modalities used to evaluate renal masses, including plain radiography, intravenous urography, ultrasound, computed tomography, magnetic resonance imaging, and renal arteriography. For each modality, it describes their utility in detecting and characterizing renal masses and differentiating renal cell carcinoma from other lesions. It also provides examples of imaging findings for various renal pathologies such as abscesses, cysts, angiomyolipomas, and others.
This document provides an overview of renal isotope studies used to assess renal function and anatomy. It describes the radiopharmaceuticals, patient preparation, indications, and findings for renal scans, renograms, and nuclear cystograms. Key points include that renal scans evaluate renal blood flow, structure, and drainage using agents retained in tubules, filtered by glomeruli, or secreted by tubules. Renograms generate time-activity curves to assess obstruction, transplantation, renovascular hypertension, and hydronephrosis. Nuclear cystograms evaluate vesicoureteral reflux.
Multiplanar reformatted images in CT scans of the chest allow radiologists to view the scans in different planes and orientations beyond just axial sections. This helps identify patterns of diffuse lung disease, distributions of lesions, and other findings more quickly. Techniques like longitudinal reformation, minimum intensity projection (mIP), maximum intensity projection (MIP), multiplanar virtual reality (VR) averaging, and three-dimensional VR and volume intensity projection (VIP) generate reformatted images that provide additional clinical information about characteristics and locations of abnormalities in a more efficient manner compared to just reviewing numerous axial images.
This document discusses obstructive jaundice and the role of various imaging modalities in evaluating it. It begins by defining jaundice and describing its types and causes. Imaging methods for investigating obstructive jaundice are then outlined, including ultrasound, CT cholangiography, MRCP, ERCP, PTC and intraoperative cholangiography. The anatomy of the biliary tree is reviewed along with normal findings and examples of obstructions on different exams. The principal role of imaging is identified as identifying and assessing major bile duct obstruction to determine if it is present, its level, cause, and whether any obstruction appears malignant.
HIDA scan evaluates hepatobiliary function and anatomy. It involves injecting a radiotracer that is taken up by the liver and excreted in bile. Images track the radiotracer's flow from liver to gallbladder and small intestine. Findings are used to diagnose conditions like acute cholecystitis, bile duct obstruction, and leaks. A normal scan shows sequential activity in the liver, bile ducts, gallbladder, and small bowel within an hour, confirming a patent system.
"I’m Excited About Writing a Computer Policy” — Said Nobody Ever.pdfTechSoup
32 slides•53 views
In technology, we tend to spend most of our time and efforts working on the actual technology — purchasing and setting up new computers, adding users to software systems, troubleshooting the printer (again), and trying to get that report out to the funders on time — and very little time analyzing our organization’s data risk. Risk management is an overwhelming topic, and, in this webinar with Heather Newlin of TechImpact, we will be focusing on a fundamental aspect of having an up-to-date and comprehensive computer use policy.
3. History
• Invented in 1856 by the English dentist
Charles Stent .
• The first (self expanding) "stents" used in
medical practice in 1986 by Ulrich Sigwart in
Lausanne were initially called "Wallstents".
• Julio Palmaz et al. created a balloon
expandable stent that is currently used.
4. • Sir Charters Symonds was the first to successfully
place an oesophageal prosthesis across a
malignant stricture.
• There were many modifications of rigid
oesophageal stents in which various materials
(wood, metal, plastic, latex) and designs were
used.
• The rigid prosthesis (plastic and latex) was
extensively used from the 1970s to the 1990s,
but the complication rates and mortality
associated with insertion-related perforations
remained significant.
5. • In the early 1990s, self-expandable metal
stents (SEMS) were developed for
oesophageal use.
6. Types of Esophageal Stents
1. SEPS (self-expanding plastic stents)
2. SEMS (self-expanding metal stents)
3. Biodegradable stents
7. SEPS
• SEPS (Polyflex; Boston Scientific, Natick, Mass)
has been developed for esophageal strictures.
• This stent has a woven polyester skeleton and
is completely covered with a silicone
membrane.
8. • The silicone prevents tissue in growth through
the mesh.
• Polyester braids on the external surface
anchor the stent to the mucosa to limit
migration.
9. SEMS
• There are three varieties of metal stents:
uncovered, partially covered, and fully
covered.
• The advantage of covered stents is that they
resist tumour ingrowth, but they have a higher
migration rate, especially when fully covered
but have advantage of potentially being
removable.
10. • Partially covered stents are uncovered at their
ends, which allows the stent to embed in the
tissue and helps to prevent migration.
• Uncovered stents are less likely to migrate, but
are subject to tumour ingrowth and resultant
obstruction.
• SEMS consist of woven, knitted, or laser-cut
metal mesh cylinders that exert self-expansive
forces until they reach their maximum fixed
diameter.
11. • SEMS are composed of stainless steel, alloys
such as elgiloy and nitinol, or a combination of
nitinol and silicone.
• Elgiloy, an alloy composed primarily of cobalt,
nickel, and chromium, is corrosion resistant
and capable of generating high radial forces.
• Nitinol, an alloy of nickel and titanium, yields
increased flexibility that is helpful for stenting
sharply angulated regions at the cost of lesser
radial force.
12. • To prevent tumour ingrowth, the interstices
between the metal mesh of oesophageal
SEMSs may be wholly or partially covered by a
plastic membrane or silicone.
• For tumours located near the GE junction
(Oesophageal Z-stent with Dual Anti-reflux
valve; Wilson-Cook Medical, Winston-Salem,
NC) uses an extended polyurethane
membrane 8 cm beyond the metal portion of
the stent to prevent gastroesophageal reflux.
13. Biodegradable stents
• Oesophageal Degradable BD (Ella-CS, Czech
Republic) is made from woven surgical suture
material, polydioxanone.
• It is uncovered and does not have an anti-
reflux valve.
• The stent fully degrades in approximately
three months
14. Photograph shows
Atkinson (A) and
Celestin (B) plastic
stents and
Wilson-Cook (C)
Ultraflex nitinol (D),
Wallstent (E),
Gianturco Z (F), and
Esophacoil (G) metal
stents.
16. From left to right,
Boston Scientific’s
Polyflex
Esophageal Stent,
Ultraflex
Esophageal NG
Stent System,
WallFlex Fully
Covered
Esophageal Stent,
and WallFlex
Partially Covered
Esophageal Stent.
21. Technique
• Assessment of the length of the stricture and
degree of obstruction is the first step.
• If the stricture is too tight to advance a
standard gastroscope, an ultrathin endoscope
may be used.
• To guide accurate stent deployment, the
proximal and distal ends of the stricture need
to be marked appropriately.
22. • During stent selection, it is important to
choose a stent length that is 4 cm longer than
the stricture being stented.
• This allows for 2 cm of stent on either end of
the stricture to decrease the risk of migration.
• Foreshortening is the property of the stent by
which, on fluoroscopy, the stent constrained
in its catheter will appear longer than the
unconstrained deployed stent length.
23. • Stenting a stricture in the cervical oesophagus
ensure at least a 2-cm distance between the
proximal end of the stent and the upper
oesophageal sphincter.
24. Barium swallow shows a short
stricture in the mid oesophagus.
Biopsy showed squamous cell
carcinoma.
25. A guide wire and catheter
combination has been passed
down through the stricture and a
small amount of contrast injected
at the proximal and distal margins
of the tumour.
Paper clips have been taped to the
patient’s skin to indicate the
stricture length.
26. The stent deployment system has
been passed across the stricture.
Note in this example the markers
on the proximal and distal ends of
the stent and also in the centre of
the stent. The stent should be
placed so that the proximal and
distal ends are 2 cm beyond the
stricture.
27. The stent has been
released.
Note the immediate
expansion of the proximal
and distal ends, while the
central area is still
constrained by the tumor.
28. The delivery system has been
removed. The stent expanded
fully over the next 48 hours
without further dilatation.
33. Complications
Complications associated with oesophageal
stents are generally classified as either early or
delayed.
Early complications- 2-4 weeks
• Chest pain, fever, bleeding, gastroesophageal
reflux disease, globus sensation, perforation,
and stent migration
34. Delayed complications- after 4 weeks
• Tumour ingrowth, stent migration, stent
occlusion, development of oesophageal
fistulae, and recurrence of strictures.
35. Perforation. Barium
esophagogram shows a
Celestin tube placed across
the oesophagogastric
junction. There is
extravasation of barium into
the left pleural space and
mediastinum due to
perforation.
38. Challenges in Oesophageal Stent
Placement
High-Grade Strictures
• If a stricture is very tight or difficult to traverse
with a standard endoscope.
• One option is to use a dilator(Mercury or
tungsten-weighted bougies, Polyvinyl dilators
& Through-the-scope (TTS) balloon dilators).
• Another method involves using a stent with a
smaller diameter.
39. Upper Oesophageal and Cervical Oesophageal
Strictures
• Traditionally, strictures close to the upper
oesophageal sphincter (UES) have been
considered more difficult to manage.
• However, studies have recently demonstrated the
effectiveness and safety of newer stents for the
palliation of dysphagia and sealing of fistulae in
patients with strictures close to the UES.
40. Distal Oesophageal Strictures,
Gastroesophageal Cancers, and Cardia Cancers
• Distal oesophageal strictures still present a
significant challenge because stent placement
across the gastroesophageal junction can lead
to gastroesophageal reflux disease and
aspiration.
• In an attempt to remedy these problems,
stents with antireflux mechanisms have been
developed (Esophageal Z-Stent with Dua Anti-
Reflux Valve)
41. Management of Benign Oesophageal
Conditions
• The use of self-expandable oesophageal stents
for the management of benign conditions has
grown immensely over the past decade.
• Temporary placement of self-expandable stents is
now used in a variety of benign conditions,
including postoperative anastomotic leaks,
refractory strictures due to peptic ulcers or
radiation, and tracheoesophageal fistulae.
42. • SEPS are increasingly being used for the
treatment of benign oesophageal conditions.
• These stents are thought to have several
advantages over standard SEMS—including
low cost, ease of placement and retrieval, and
limited local tissue reaction—and still provide
symptomatic relief of dysphagia
43. Management of Malignant
Oesophageal Diseases
• Despite advances in the diagnosis, staging,
neoadjuvant care, and perioperative care of
patients with oesophageal cancer, the 5-year
survival rate of these patients remains less than
15%, and chemotherapy has shown limited
survival benefit.
• Therefore, patients with incurable oesophageal
and other nonluminal malignancies of the head
and neck often require palliation for dysphagia
and/or tracheoesophageal fistulae.
44. • Currently, SEMS, along with SEPS, have
become the mainstay of treatment for
malignant oesophageal strictures and fistulae.
• Covered stents are commonly used as they
resist tumour ingrowth because they do not
have an uncovered region that embeds into
tissue they also offer the advantage of being
completely removable.
45. • Use of SEMS for treating cancer closer to the
UES is controversial because of the perceived
increased risk of complications such as
perforation, migration, pain, and patient
intolerance.