Файловый архив студентов. Файловый архив студентов.
1327 вузов, 5482 предметов.
/ Регистрация
FAQ Обратная связь Вопросы и предложения
Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Ростовский Государственный Медицинский Университет
Предмет:
Медицина общая
Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1050_Библиотеки_им_академика_М_И_Перельмана

.pdf
Скачиваний:
0
Добавлен:
31.08.2026
Размер:
23 Мб
Скачать
☆
■Carefulpositioningandendoscopicvisualizationof
thecatheterandperformingthefirstablationpass
■Cleaningofdeviceexternallywhileperforming
debridementoftissueusingtheendoscopeandcap
■Performingthesecondablationpass
Focalablation ■Endoscopicidentificationoflandmarks
■Attachmentofdevicetoendoscopesuchthatitisin
12o’clockendoscopicview
■Optimaloppositiontotargetedmucosaandenergy
deliveredusing“dualtechnique”withcontinued ablationofallareas
■Debridementoftissue,cleaningofdevice,and
secondpassofablationforallareas
Follow-up ■Immediatepostprocedureinstructionsaregiven
regardingfoodintake,painmanagement,and antirefluxmedications.
■Follow-upafter2monthsforrepeatendoscopy,
furtherablation,orbiopsies.
POSTOPERATIVECARE
■ AfterRFAtreatment,patientsmayexperiencechestpainanddysphagiafor3to 4daysthereafter.
■ Postoperativecareincludesapainmanagementwithviscouslidocaineorliquid acetaminophenwithnarcotic.Aliquiddietisadvisedfor24hoursafter treatmentandthentoslowlyreturntonormaldiet.
■ Amaintenancedoseofprotonpumpinhibitor(PPI)suchasesomeprazole40mg twiceadayduringtheentiretreatmentperiodforadequateacidsuppressionis requiredtopromotehealing.Inaddition,sucralfate1gfourtimesadayfor2 weeksisprescribed.
■ Patientsareusuallydischargedhomeonthesamedayastheprocedure.On occasion,severechestpainmayrequireadmissionforobservationand optimizingpainmanagement.
■ Theyareinstructedtobefollowedupfor2monthsaftertheinitialablationwhen theyarereassessedforfurthertreatmentorbiopsiesifneo-squamous epitheliumisseen.Approximately3.5treatmentsessionsmaybenecessaryto clearalldysplasticBEandthiswilldependonthelengthofsegment.
OUTCOMES
■ RFAiseffectivefortreatmentofHGDandLGD.
3
■ Inarandomizedsham-controlledtrial,completeeradicationforHGDwasnoted in81.0%comparedto19.0%incontrols.Similarly,diseaseprogressionwas lowerintheablationgroup(3.6%vs.16.3%).10PatientswithLGDachieved eradicationin90.5%oftheablationgroupascomparedto22.7%ofcontrol groupattheendof12months.DurabilityofRFAdemonstratederadicationof dysplasiain98%and91%ofmetaplasiaattheendof3yearssinceablation therapy.
11
COMPLICATIONS
■ RFAhasalowcomplicationratewithlowadverseevents.Chestpainand dysphagiaarecommonlyassociatedsymptomslastingforaperiodof3to4 daysposttreatmentandresolvesspontaneouslytobaseline.
12,13
■ Stricturescanoccuronfollow-upandtheratevariesbetween0%and8%,with longersegmentsandprecedingEMRtobehigherriskfactorsfordeveloping them.Theycan,however,bemanagedbyendoscopicdilatation.
■
Bleedingisrare(<1%)andencounteredespeciallyinpatientsonantiplateletor anticoagulationtherapy.
■ NoperforationsorRFA-relateddeathshavebeenreportedafterRFA.Feveris alsoararecomplicationandcanbemanagedusingantipyretics.
■ Buriedintestinalmetaplasiaorglandshasbeenofconcernpostablationandmay notbevisibleendoscopically.ItislessfrequentlyreportedafterRFA(0.9%) andhighlightstheneedfordeependoscopicbiopsies,whichneedtobe carefullyreviewedbythepathologist.
14
REFERENCES
1.ShaheenNJ,CrosbyMA,BozymskiEM,etal.Istherepublicationbiasinthereportingofcancer
riskinBarrett’sesophagus?Gastroenterology.2000;119:333–338.
2.Hvid-JensenF,PedersenL,DrewesAM,etal.Incidenceofadenocarcinomaamongpatientswith
Barrett’sesophagus.NEnglJMed.2011;365:1375–1383.
3.AmericanGastroenterologicalAssociation,SpechlerSJ,SharmaP,etal.American GastroenterologicalAssociationmedicalpositionstatementonthemanagementofBarrett’sesophagus. Gastroenterology.2011;140:1084–1091.
4.NelsenEM,HawesRH,IyerPG.DiagnosisandmanagementofBarrett’sesophagus.SurgClin NorthAm.2012;92:1135–1154.
5.ChakA,Ochs-BalcomH,FalkG,etal.FamilialityinBarrett’sesophagus,adenocarcinomaof theesophagus,andadenocarcinomaofthegastroesophagealjunction.CancerEpidemiolBiomarkers Prev.2006;15:1668–1673.
6.ASGEStandardsofPracticeCommittee,EvansJA,EarlyDS,etal.Theroleofendoscopyin Barrett’sesophagusandotherpremalignantconditionsoftheesophagus.GastrointestEndosc. 2012;76:1087–1094.
7.SharmaP,DentJ,ArmstrongD,etal.Thedevelopmentandvalidationofanendoscopicgrading systemforBarrett’sesophagus:thePragueC&Mcriteria.Gastroenterology.2006;131:1392–1399.
8.EndoscopicClassificationReviewGroup.Updateontheparisclassificationofsuperficial neoplasticlesionsinthedigestivetract.Endoscopy.2005;37:570–578.
9.LevineDS,HaggittRC,BlountPL,etal.Anendoscopicbiopsyprotocolcandifferentiatehigh­gradedysplasiafromearlyadenocarcinomainBarrett’sesophagus.Gastroenterology.1993;105:40–50.
10.ShaheenNJ,SharmaP,OverholtBF,etal.RadiofrequencyablationinBarrett’sesophaguswith
dysplasia.NEnglJMed.2009;360:2277–2288.
11.ShaheenNJ,OverholtBF,SamplinerRE,etal.Durabilityofradiofrequencyablationin
Barrett’sesophaguswithdysplasia.Gastroenterology.2011;141:460–468.
12.SharmaVK.AblationofBarrett’sesophagususingtheHALOradiofrequencyablationsystem.
TechniquesGastrointestEndosc.2010;12:26–34.
13.vanVilsterenFG,BergmanJJ.Endoscopictherapyusingradiofrequencyablationfor
esophagealdysplasiaandcarcinomainBarrett’sesophagus.GastrointestEndoscClinNAm.
2010;20:55–74,vi.
14.GrayNA,OdzeRD,SpechlerSJ.BuriedmetaplasiaafterendoscopicablationofBarrett’s
esophagus:asystematicreview.AmJGastroenterol.2011;106:1899–1908;quiz1909.
15.FrantzDJ,DellonES,ShaheenNJ.RadiofrequencyablationofBarrett’sesophagus.Techniques
GastrointestEndosc.2010;12:100–107.
Chapter11
EndoscopicMucosal ResectionforBarrett Neoplasia
ShajanPeterC.MelWilcox KlausMönkemüller
DEFINITION
■ Barrettesophagus(BE)isastrongriskfactorforesophagealadenocarcinoma.
1
■ TheannualriskofBEprogressiontoadenocarcinomarangesfrom01.12%to
0.61%.
1,2
■ Thetraditionaltreatmentofchoicefor“resectable”esophagealadenocarcinoma isesophagectomy.
■ However,surgicalresectionisstillassociatedwithsignificantmortalityand morbidity,eveninhigh-volumecentersandespeciallyinelderlyorpoor surgicalcandidates.
3
■ Thus,duringthelasttwodecades,patientswithearlycancerorthosewithhigh- gradedysplasiahavebeensuccessfullytreatedwithendoscopicresection methods.
4,5
■ Themostcommonmethodusedisendoscopicmucosalresection(EMR)or “mucosectomy.”
4,5
DIFFERENTIALDIAGNOSIS
■ Thedifferentialdiagnosisofmucosalneoplasiaofthedistalesophagusis narrow.Themostcommonmalignantneoplasiaofthedistalesophagusis adenocarcinoma,followedbysquamouscellcancer.
4,5
■ Proximalstomachcancersuchascardiacorfundicadenocarcinomaextending intotheesophagusmaybedifficulttodifferentiatefromdistalesophageal adenocarcinoma.
■ Submucosaltumorssuchasgastrointestinal(GI)tumors,spindlecelltumors, lipoma,andleiomyomaareeasilydifferentiatedfrommucosallesionsasthese tumorsgenerallyhaveanormaloverlyingmucosa.
PATIENTHISTORYANDPHYSICALFINDINGS
■ MostpatientswithBarrett’sneoplasiadonothaveanyspecificsymptomsand BEisdiscoveredincidentallyduringanupperGIendoscopyperformedfor theevaluationofgastroesophagealrefluxsymptoms,dyspepsia,orabdominal pain.
6
■ However,Barrett’sneoplasiaismorecommoninpatientswiththefollowing characteristics:male,centralobesity,Caucasian,ageolderthan50years, tobaccouse,andchronicgastroesophagealrefluxdisease(GERD).
6
■ AlthoughrefluxofacidisacommonoccurrenceinBE,ahighproportionofBE patientsdenyahistoryofrefluxsymptoms.
7
■ Therefore,anypatientundergoingupperendoscopyshouldbecarefully investigatedforcolumnar-linedepitheliumandintestinalmetaplasiaofthe distalesophagus,withspecialattentiontopatientswiththeriskfactors mentionedearlier.
IMAGINGANDOTHERDIAGNOSTICSTUDIES
■ RadiologicstudiesdonotplayaroleintheevaluationofBEunlessthereisa stricturepresent(benignormalignant).Inthisinstance,abarium esophagogramcanbehelpfultodeterminethelengthandcharacteristicsof thestenosis.
■ Althoughcomputedaxialtomographyisusefultoevaluateforlungmetastasis andmediastinalandperigastriclymphnodeinvolvementinesophageal adenocarcinoma,itsroleinpatientswithearlyBarrettneoplasiaisnegligible, asmostofthesepatientshavelocaldisease,whichdoesnotextendbeyondthe submucosaoftheesophagus.
■ PatientswithBarrett’scancerinvadingthesubmucosa(sm1)haveaverylow riskoflymphnodemetastasisandthusareidealcandidatesforEMR.
4–6
■ Inthepast,endoscopicultrasound(EUS)wasusedtodeterminethedepthofGI layersinvolvementinearlyBarrettneoplasia.
8
■ However,thesensitivityandspecificityofEUSforearlyBarrettneoplasiaare lowandtheresultscanbemisleading.
8
■ ThemainstayofdiagnosisofBEiswithlightendoscopy,ideallyusinghigh­definitionendoscopesandequipment.
9
■ Itisveryimportanttomeasuretheproximaldistanceofextensionofcylindrical- typeepitheliumintotheesophagus.TheextentofBEsegmentshouldbe definedusingthePragueC&Mclassificationincludingthelengthofthe circumferentialsegment(C)andthemaximalextentoftheBEsegment(M).
10
■ Theuseofvariousstainingagentsanddyes(chromoendoscopy)suchas methyleneblue(FIG1)andindigocarmineoragentssuchasaceticacid (FIG2)enhancesthemucosalpitpatternanalysis(seethefollowingtext)and
thusfacilitatesthedetectionhigh-gradedysplasiaandcarcinoma.
9
■ OtherimagingmodalitiesthatmighthelpindelineatingBEarenarrowband imaging(NBI)(FIG3),autofluorescenceimaging,andconfocallaser endoscopy.
■ Magnificationendoscopyisalsoimportanttocharacterizethemucosalsurface andpitpattern(FIG4).
■ ThemostwidespreadclassificationusedtocategorizethepitpatterninBEisthe Endoclassification(adaptedfromS.E.Kudo).
11
■ Thisclassificationcategorizestheopeningofthepitsintoround(I),stellaror asteroid(II)(seeFIG2),tubularelongated(IIIL),tubularshortorround (IIIS)(seeFIG1),gyrusorsulcusbranched(IV)(seeFIG4),andirregularor amorphous(V)(FIG5).
■ TypesI,II,andIIIpitpatternsare“benign,”whereaspitpatterntypesIVandV aremorecommonlypresentinadvancedneoplasiaorcarcinoma.
■ Chromoendoscopyisperformedtoaidinobtainingdirected(i.e.,targeted) biopsiespriortomucosectomytodefinethepreciseextentofneoplastic involvement.
■ Targetedbiopsiesareobtainedfromvisibleabnormalities,followedbyfour­quadrantbiopsiesofevery1to2cmoftheBEsegment(Seattleprotocol;see
Chapter10)andtheseshouldbereviewedbyadedicatedGIpathologist.
ENDOSCOPICMANAGEMENT
■ ThetwomostimportantindicationsforEMRofBarrett’sneoplasiaare diagnosticandtherapeutic.
5,6,12
■ EMRcanbegenerallyattemptedifthelesionsaresmallerthan20mmin diameter.
■ Endoscopicsubmucosaldissection(ESD)shouldbereservedforlargerlesions.
■ However,ESDisatechniquethathasbeenmainlyusedforearlysquamouscell canceroftheesophagus.TheresultsofESDforBarrettneoplasiaarestill
Соседние файлы в папке Библиотека им академика М.И. Перельмана
Помощь Обратная связь Вопросы и предложения Пользовательское соглашение Политика конфиденциальности