FALK SYMPOSIUM MAINZ

Transcription

1 FALK SYMPOSIUM MAINZ Paulo Sakai, MD,FASGE Hospital das Clínicas University of São Paulo Medical School São Paulo - Brazil

2 Paulo Sakai, MD, FASGE Gastrointestinal Endoscopy Unit São Paulo University Medical School ZENKER S S DIVERTICULUM ENDOSCOPIC THERAPY

3 ZENKER S S DIVERTICULUM Inferior pharyngeal constrictor muscle Cricopharyngeal muscle Pouch formed by hypopharyngeal mucosa protrusion in an area of weakness Killian s s triangle

4 ZENKER S S DIVERTICULUM Surgical Therapy Diverticulectomy with cricopharyngeal myotomy (Ellis FH et al., 1969)

5 ZD - Endoscopic Treatment Indications Older and debilitated patients Cardiopulmonary Insufficiency Hypertension / Diabetes Aspirative Bronchopneumonia High-Risk for general anesthesia and surgical treatment

6 ZD - Endoscopic Treatment Basic Principles Cutting of the ZD-bridge (cricopharyngeal muscle) Opening a way from the pouch to the esophageal lumen

7 ZD - Endoscopic Myotomy Soft Overtube Evrard S, Devière J et al., GIE 2003

8 HARMONIC SCALPEL Ultracision ELECTROCAUTERY TISSUE OXIDATION ULTRACISION PROTEIN DENATURATION (ULTRASONIC ENERGY)

9 ZD Myotomy using Harmonic Scalpel

10 Botox injection in the cricopharyngeal muscle as an alternative of myotomy in small and shallow ZD ZD - Endoscopic Therapy

11 Paulo Sakai, MD, FASGE Gastrointestinal Endoscopy Unit São Paulo University Medical School ESOPHAGEAL AND GASTRIC VARICES ENDOSCOPIC THERAPY

12 MANAGEMENT OF VARICES AND VARICEAL HEMORRHAGE International Consensus Workshops Baveno IV Consensus Workshops. AASLD/ACG Practice Guideline. J. Hepatol 2005; 43:167 Hepatology 2007; 46:922 AASLD and European Association for the study of the liver Single Topic Conference Hepatology 2008; 47:1764

13 TREATMENT OF ACUTE VARICEAL HEMORRHAGE Vaso-active active drugs (terlipressin, octreotide or somatostatin) at the admission. Antibiotic therapy Endoscopy within first 12 hours EBL / Sclerotherapy Rebleeding / Failure Endoscopic treatment HVPG > 20 mmhg TIPS

14 ENDOSCOPIC THERAPY OF GASTROESOPHAGEAL VARICES 1939 Craaford C & Frenckner P Sclerotherapy with with rigid endoscope 1973 Kapp-Buess Sclerotherapy with with flexible scope 1986 Soehendra et et al. al. Obliteration with with N-butyl-cyanoacrylate 1986 Stiegmann et et al al Band ligation 1995 Saeed et et al al Multiple band ligation 2006 SEMS ( Stent )

15 BLEEDING RECURRENCE After Band Ligation CYANOACRILATE INJECTION

16 Self-Expandable Metal Stent to Compress Esophageal Varizes Hubmann R et al. Endoscopy 2006; 38:896

17 Hubmann R et al. Endoscopy 2006; 38:896 S E M S AFTER STENT REMOVAL

18 PREVENTION OF RECURRENT VARICEAL HEMORRHAGE (SECONDARY PROPHYLAXIS) Non-selective β-blockers (NSBB) + Endoscopic band ligation (EBL) NSBB should be initiated when hemodynamically stable EBL sessions may be started weeks after bleeding episode up to complete eradication Follow-up: months after eradication and every mo.

19 ESOPHAGEAL VARICES Prevention of first variceal hemorrhage (Primary Prophylaxis) Patients with an HVPG > 10 mmhg Medium / large varices with risk of bleeding (Child B/C and red wale markings) Non-seletive β-blockers Endoscopic band ligation (EBL) EBL + non-selective β-blockers not currently recommended

20 Paulo Sakai, MD, FASGE Gastrointestinal Endoscopy Unit São Paulo University Medical School MALIGNANT ESOPHAGEAL OBSTRUCTION PALLIATIVE THERAPY

21 MALIGNANT ESOPHAGEAL OBSTRUCTION PALLIATIVE THERAPY Chemotherapy: cisplatin + epirubicin + 5-Fu5 Dysphagia relief: 59-89% Radiotherapy: dysphagia relief around 50% CHEMOTHERAPY + RADIOTHERAPY Effect in local and systemic disease as well as chemotherapeutic radiosensization. Dysphagia relief 75-90% (60% until death) Complication: fistula, striture (20-30%) Contraindication: fistula, expected survival less 3 mo.

22 MALIGNANT ESOPHAGEAL OBSTRUCTION PALLIATIVE THERAPY Endoprostheses Advantages: instant dysphagia relief, tracheoesophageal fistula and applicability in both esophageal cancer and mediastinal compression Stent placement sucess in % Functional success in % Special situations: : cervical and distal esophagus tumors Complications: : 4-20% 4 (Chest pain, migration, perforation, tumor overgrowth and aspiration)

23 Self Expandable Metal Stent with Antireflux Valve

24 SEMS w/ Antireflux Valve S type Shim,CS-Endoscopy, 2003

25 STENT IN CERVICAL ESOPHAGEAL CANCER FREQUENT COMPLICATION = FOREIGN-BODY SENSATION Shim CS et al, Endoscopy 2004;36: N. COMPLICATION DYSPHAGIA F-BODY SENS

26 Esophageal Cancer with Large Tracheal Fistula Simultaneous Esophageal/ Tracheal Stents Relief of Dysphagia and Aspiration Prevention Less Asphyxia Risk after Stent Placement

27 MALIGNANT ESOPHAGEAL OBSTRUCTION PALLIATIVE THERAPY Conclusions Chemoradiation: first line therapy for patients with larger estimated survival rate (> 6 mo) Endoprostheses (SEMS) for patients who failed to improve or presented recurrence after CT/RT, fistulas and estimated survival rate of months In patients with very short life expectancy: feeding tubes

28 Paulo Sakai, MD, FASGE Gastrointestinal Endoscopy Unit São Paulo University Medical School GASTROESOPHAGEAL REFLUX DISEASE ENDOSCOPIC THERAPY

29 GASTROESOPHAGEAL REFLUX DISEASE MEDICAL THERAPY SURGICAL THERAPY ENDOSCOPIC THERAPY To provide a minimally invasive procedure preventing the potential morbiditiy of surgical or laparoscopic fundoplication To obviate the need for long-term proton pump inhibitor (PPI)

30 GASTROESOPHAGEAL REFLUX DISEASE THERAPY Medical Therapy Endoscopic Endoscopic Plication Endocinch Bard ESD Full-thickness Plication NDO Plicator Radiofrequency application Stretta Procedure Surgical Injection Polymer (Ethilene vinyl alcohol) - Enteryx Implantation Hydrogel - Gatekeeper

31 The Endoscopic Treatment of GERD Sewing ESD, Wilson Cook DISCONTINUED 2004 EndoCinch, BARD DISCONTINUED Plicator, NDO DISCONTINUED 2008 Radiofrequency Stretta, Curon Medical DISCONTINUED 2006 Implant/Bulking Enteryx, Boston Scientific GateKeeper, Medtronic WITHDRAWN 2005 DISCONTINUED 2005

32 GASTROESOPHAGEAL REFLUX DISEASE ENDOSCOPIC THERAPY Emerging techniques Esophyx (EndoGastric Solutions Inc., Redmond, WA, USA) Hiz-Wiz MediGus SRS Syntheon ARD

33 Endoscopic Hiatal Valvuloplasty ESOPHYX Courtesy of Prof. Guy-Bernard Cadière - St Pierre Hospital, Brussels University

34 RESULTS after HIATAL VALVULOPLASTY Number of fasteners : 10 (6 13) FINAL LENGTH OF THE VALVE : 4 cm ( 3-5) Guy-Bernard Cadière

35 ENDOLUMINAL ESOPHAGEAL VALVULOPLASTY Full-Thickness Suture tissue anchors DePaula Aureo, Birkett DH, Kozarek RA, Gross SC, Swanstrom LL. Endoluminal Esophageal Valvuloplasty with tissue Anchors S.A.G.E.S poster. Dallas, Texas. USA. 2006

36 ENDOSCOPIC TREATMENT OF GERD Evidence-based medicine criteria Most of the available data are: Uncontrolled Short duration Commonly retrospective Mostly available only in abstract form Lack of sham or placebo controlled trial (only 1) Evaluation of largely incomplete and variable data Available data would be considered insufficient and validity from these studies is unknown! NOT RECOMMENDED in routine clinical practice.

37 The Expert s Corner The endoscopic anti-reflux procedures require further study. However, in the hands of a well-trained doctor, these techniques may be viable options in properly selected patients,, although long- term safety and efficacy are not yet known. Fennerty. Aliment Pharmacol Ther 2005;22:39-44

38 Endoscopic Therapy of GERD Conclusions Next generation of equipments should provide effective control of reflux for a long period Safety with Simplicity Repeatable / Reversible

39 THANK YOU FOR YOUR ATTENTION Paulo Sakai, MD,FASGE Hospital das Clínicas University of São Paulo Medical School São Paulo - Brazil

40 Endoscopic Therapies Galmiche JP, Lancet 2003 Companies develop new devices and receive approval from regulatory agencies despite a scarcity of preclinical data and physiological animal studies

41 Endoscopic Treatment of GERD Conclusions Promising anti-reflux therapy early stage of development Safe technique as PPI in the reduction of pyrosis is not yet available Next generation of equipments should provide effective control of reflux for a long period and not just the symptoms.

42 Future Directions for Endotherapies for GERD Safety & Simplicity Repeatable & Codified Durable Control the Disease and not just the symptoms

43 GASTRIC VARICES Prevalence in 10-20% of the patients with portal hypertension Bleeding intensity and mortality are higher than esophageal varices Varix obliteration with cyanoacrylate injection or TIPS No consensus on primary prophylaxis

44 MALIGNANT ESOPHAGEAL OBSTRUCTION PALLIATIVE THERAPY Unresectable tumor Poor medical condition Local recurrence Dyspagia is the most disabling symptom Median survival time: months Main goal: restoration of swallowing

45 ZD - Endoscopic Treatment Using an oblique end hood attached to the endoscope (Sakai P, 2001)

46 RESULTS after HIATAL VALVULOPLASTY Number of fasteners : 10 (6 13) FINAL LENGTH OF THE VALVE : 4 cm ( 3-5) Guy-Bernard Cadière

47

48

49

50 ZENKER S S DIVERTICULUM Pathogenesis Incoordination of the swallowing mechanism - UES fails to relax creating high pressure zone above it and leading the mucosa to the herniation. Degenerative and fibrotic changes of the cricopharyngeal muscle with reduced compliance (Lerut et al).

51

52 ZD - Endoscopic Treatment Botox injection in the cricopharyngeal muscle as an alternative of myotomy in small and shallow ZD