Gastric Cancer
Barrett's Esophagus adenocarcinoma

Video Endoscopic Sequence 1 of 26.

Barrett's Esophagus and adenocarcinoma of the Gastroesophageal Junction.

Palliation of Dysphagia of Esophageal Cancer by
Endoscopic Lumen Restoration.

This is the case of a 81 year old male with long standing GERD, obesity, his weight of 260 pounds, one month previously presented with dysphagia.

Adenocarcinoma that arising from Barrett esophagus is seen.

The recanalization of the lumen was achieved with the combination of ablative therapy using Argon Plasma Coagulation (APC) and dilation with hydrostatic balloon.

 

Barrett's Adenocarcinoma

Video Endoscopic Sequence 2 of 26.

Barrett's Adenocarcinoma.

The video clip shows tongues of Barrett Esophagus.

The video clip shows magnification endoscopy of this
Barrett´s tongue.

 

<vacíBarrett's Adenocarcinomao>

Video Endoscopic Sequence 3 of 26.

Chromoendoscopy with lugol´s stain

This endoscopy was taken 15 days after the first the
images show the tongue has been thickened, compare
imagenes from sequence 1 of 26 and 2 of 26.

New developments in the endoscopic detection of early
neoplastic lesions include chromoendoscopy and
magnification endoscopy, narrow band imaging, optical
coherence tomography, fluorescence spectroscopy, and
brush cytology.


Video Endoscopic Sequence 4 of 26.

The video clip shows magnification endoscopy of this Barrett´s tongue.

The alarming rise in the incidence of esophageal
adenocarcinomas in the Western world has focused interest
on so-called Barrett's esophagus. Barrett's esophagus is
characterized by specialized intestinal epithelium replacing
the normal squamous epithelium in the distal esophagus
and is considered a consequence of long-lasting and severe
gastroesophageal reflux disease.
A metaplasia-dysplasia-carcinoma sequence links Barrett's
esophagus with adenocarcinoma of the distal esophagus
(Barrett's cancer). Despite intensive research, many
questions concerning the pathogenesis, diagnosis, and
treatment of Barrett's esophagus and associated
adenocarcinoma are still unanswered.



Barrett Adenocarcinoma

Video Endoscopic Sequence 5 of 26.

Barrett Adenocarcinoma of gastroesophageal junction.

Barrett's metaplasia develops in 6% to 14% of individuals with gastroesophageal reflux. Barrett's adenocarcinomas are increasing in epidemic proportions for, as yet unknown, reasons; approximately 0.5% to 1% of patients with Barrett's metaplasia develop adenocarcinoma. Heartburn duration and frequency (but not severity), male gender, and white race are major risk factors for developing cancer. Obesity and smoking are weak risk factors. Survival is determined by depth of tumor invasion (stage). Once invasion of the muscularis propria occurs, most patients have developed widespread metastasis, even when clinical staging studies are negative. No currently available therapy results in prolonged survival once metastases develop. Thus, the more widespread use of effective surveillance strategies is the only currently available means for reducing the morbidity and mortality associated with Barrett's adenocarcinoma.

Gastroenterol Clin North Am. 1999 Dec;28(4):917-45.


Video Endoscopic Sequence 6 of 26.

Iinitiated Recanalization of the lumen.

In this video clip shows dilation of the stricture cause by the tumor at the gastroesophageal junction with a hydrostatic balloon.

Is Adenocarcinoma of the Esophagogastric Junction or Cardias Different From Barrett Adenocarcinoma?.

Over time the relative distribution of cancers of the proximal digestive tract has changed. Squamous cell carcinomas of the esophagus have become less common, while numbers of adenocarcinomas have greatly increased. This shift most likely reflects an increase in the incidence of gastroesophageal reflux. Moreover, there is a decline in the incidence of distal gastric cancer, which in turn may be related to Heliobacter pylori eradication. Simultaneously, there is a time trend toward a more proximal localization of gastric cancer. If the above-mentioned etiopathologic links are correct, this could indicate that the so-called cardia adenocarcinomas are not related to H pylori infection and that they may instead be related to gastroesophageal reflux and eventually may not be considered to be "gastric" cancers.

(Arch Pathol Lab Med. 2005;128:183-185).



Video Endoscopic Sequence 7 of 26.

The rapidly growing quantity of literature on this subject is,
however, confounding. A major source of discordance
would seem to be a Babylonian confusion of tongues
concerning the terms cardia and cardiac carcinomas.
Unfortunately, this confusion is also apparent in the
classification systems available for staging of cancer, thus
closing the "vicious" circle.

(Arch Pathol Lab Med. 2005;128:183-185).



Video Endoscopic Sequence 8 of 26.

Ablative therapy with argon plasma coagulator.

Transendoscopic ablation of obstructing intraluminal
cancer by aggressive setting of argon plasma coagulation.


Video Endoscopic Sequence 9 of 26.

The most significant complication is the development of adenocarcinoma in the esophagus. Recent data suggest that the risk of dysplasia is strongly associated with increasing age of the patient and the segment length of Barrett's esophagus.

Although Barrett's esophagus is the only known precursor to esophageal adenocarcinoma, most patients with Barrett's esophagus do not develop cancer. Barrett's esophagus has a 2-25% risk of mild-severe dysplasia and a 2-5% risk of developing adenocarcinoma. 40-50% of those patients with Barrett's esophagus and severe dysplasia go on to develop esophageal adenocarcinoma within 5 years.




Video Endoscopic Sequence 10 of 26.

The necrotic tissues are being removed.

Based on current data, the malignant progression of
Barrett's esophagus cannot be substantially prevented by
medical or surgical therapy for reflux. Although no firm
data are available to show that surveillance strategies can
reduce overall mortality from Barrett's cancer, early
detection and cure are possible. Management of Barrett's
esophagus and carcinoma is reviewed with reference to the
sequence of disease from metaplasia to carcinoma.


Video Endoscopic Sequence 11 of 26.

Transendoscopic APC ablation of obstructing Barrett adenocarcinoma using high-power APC.



Video Endoscopic Sequence 12 of 26.

Lumen restoration techniques performed with the aid of
endoscopy.


Video Endoscopic Sequence 13 of 26.

Again the necrotic tissues are being removed.

 

 

Video Endoscopic Sequence 14 of 26.

The patient presented with paraesophageal hernia and hiatal hernia also.



Video Endoscopic Sequence 15 of 26.

Lumen restoration to relieve dysphagia and provide the
opportunity for sustaining reasonable peroral nutrition is
an essential element in the overall management.
Nonsurgical lumen restoration procedures have much to
offer for dysphagia palliation.







Video Endoscopic Sequence 16 of 26.

Recanalization of the lumen was achieved.

The Hiatus Hernia is observed with a nodule of the neoplasia.

Successful ablation usually provides a wider lumen
diameter than a stent and allows intake of a more solid
consistency diet temporarily. Approximately one third of
patients can take a modified regular diet initially, and
another 50% are able to take some solids or semi-solids.

 

Video Endoscopic Sequence 17 of 26.

The plan was to place an esophageal stent but the patient did not return to the appointment, the neoplasia overgrown again.

 

Video Endoscopic Sequence 18 of 26.

Again the recanalization of the lumen was performed with the combination of Argon Plasma and balloon dilation.


Video Endoscopic Sequence 19 of 26.

Four hours later the necrotic tissues were removed.


Video Endoscopic Sequence 20 of 26.

A small fistula tract is displayed.

After the therapy with the argon plasma coagulator,
the muscular layer of the esophagus has been exposed.



Video Endoscopic Sequence 21 of 26.

The video clip shows the esophagus- hernia fistula using a
5.9 mm. endoscope (pediatrics), the endoscope is advanced
which is passed through the fistula to the hernia.


Video Endoscopic Sequence 22 of 26.

More images and video clips of this esophagus-hernia fistula.

 

 

Video Endoscopic Sequence 23 of 26.

Fluroscopy video clip.

Shows the fistula tract.

 

Video Endoscopic Sequence 24 of 26.

The video clip shows the esophagus- hernia fistula, the
endoscope is advanced which is passed through the fistula
to the hernia.



Video Endoscopic Sequence 25 of 26.

The 5.9 endoscope which is observed with the 10.5 mm endoscope.

Two endoscopes have been introduced by mouth, one through the cardias and the other through the
esophago-hernia fistula.



Video Endoscopic Sequence 26 of 26.

Two endoscopes are observed in retroflexed image.

Recanalization of the lumen was achieved.

Most patients with esophageal cancer will require
palliation for the multiple problems that develop during
their limited life span. The responsibility of the palliation
therapist is to provide the patient with safe and
cost-effective treatments that provide the best possible
dysphagia relief.



Video Endoscopic Sequence 1 of 6.

Endoscopy of Gastrointestinal bleeding due to an Advanced Gastric Carcinoma

This 48 year-old male with advanced gastric
adenocarcinoma with jaundice and abdominal mass as well
as hepatic. Has been presented with 15 days history of
intermittent black, tarry stools and multiple blood
transfusions, he was referred to our endoscopic unit for
hemostatic therapy.


Video Endoscopic Sequence 2 of 6.

Ablative therapy with argon plasma is performed

 

 

Video Endoscopic Sequence 3 of 6.

Appears the vessel responsible for the activity bleeding


Video Endoscopic Sequence 4 of 6.

It is observed abundant sanguineous residues


Video Endoscopic Sequence 5 of 6.

Enormous irregular ulcer due to this neoplasia is observed

 

Video Endoscopic Sequence 6 of 6.

Besides argon plasma we used hemostatic reinforcement with absolute alcohol injections.

 

Video Endoscopic Sequence 1 of 14.

This 84 year-old, female underwent an upper endoscopy due to a epigastric pain, finding dark red blood, stigmata of bleeding.

Gastrointestinal bleeding affects a substantial number of
elderly people and is a frequent indication for
hospitalization. Bleeding can originate from either the
upper or lower gastrointestinal tract, and patients with
gastrointestinal bleeding present with a range of symptoms.
In the elderly, the nature, severity, and outcome of
bleeding are influenced by the presence of medical
comorbidities.



Video Endoscopic Sequence 2 of 14.

A large ulcer was found at the posterior wall of the gastric
fundus, the biopsies showed to be an adenocarcinoma.

In elderly patients who have gastrointestinal bleeding,
immediate attention should focus on hemodynamic
stabilization, followed by diagnostic evaluation to identify
the bleeding source.

 


Video Endoscopic Sequence 3 of 14.

Gastrointestinal bleeding in such elderly people can
originate from lesions common to all age-groups or from
lesions associated specifically with aging. In elderly people,
morbidity and mortality from gastrointestinal bleeding is
determined by both the nature of the bleeding lesion and
the presence of comorbid medical conditions. The incidence
and outcome of gastrointestinal bleeding in elderly people
can also be influenced by the use of aspirin and other
antiplatelet and anticoagulant agents.



Video Endoscopic Sequence 3 of 14.

Gastrointestinal bleeding in such elderly people can
originate from lesions common to all age-groups or from
lesions associated specifically with aging. In elderly people,
morbidity and mortality from gastrointestinal bleeding is
determined by both the nature of the bleeding lesion and
the presence of comorbid medical conditions. The incidence
and outcome of gastrointestinal bleeding in elderly people
can also be influenced by the use of aspirin and other
antiplatelet and anticoagulant agents.

 

Video Endoscopic Sequence 5 of 14.

As the ulcer burrows deeper into the gastroduodenal mucosa, the process causes weakening and necrosis of the arterial wall, leading to the development of a pseudoaneurysm. The weakened wall ruptures, producing hemorrhage. The flow through the vessel varies with the fourth power of the radius; thus, small increases in vessel size can mean much larger amounts of blood flow and bleeding. Visible vessels usually range from 0.3-1.8 mm.

 

Video Endoscopic Sequence 6 of 14.

Gastric cancer is an uncommon cause of hemorrhage in the United States, but it remains a major problem in non-Western countries; worldwide, it is the leading cause of digestive cancer deaths.



Video Endoscopic Sequence 7 of 14.

3 days after the first episode of bleeding, patient began a life- threatening hemorrhage that was successful managed with sclerotherapy with absolute alcohol.



Video Endoscopic Sequence 8 of 14.

Rebleeding or continued bleeding is associated with
increased mortality; therefore, differentiating the patient
with a low probability of rebleeding and little comorbidity
from the patient at high risk for rebleeding with serious
comorbidities is imperative.



Video Endoscopic Sequence 9 of 14.

Identify stigmata that connote a risk of recurrent or
continued hemorrhage, and permit endoscopic therapy to
reduce the risk of rebleeding.



Video Endoscopic Sequence 10 of 14.

Video Endoscopic Sequence 11 of 14.

Injections of absolute alcohol was carry out


Video Endoscopic Sequence 12 of 14.

Endoscopic injection treatment stops active bleeding and
prevents further haemorrhage in most of these patients.
The mechanism of action may include tamponade,
vasoconstriction, sclerosis, tissue dehydration and
thrombogenesis; substances injected include adrenaline,
sclerosants, alcohol, thrombin, or a combination of agents.
Although trials often define the need for surgery as an
injection treatment failure, an alternative view is that
endoscopic control may facilitate safe, early, elective
surgery. A successful outcome may require a combination
of endoscopic and operative approaches.



Video Endoscopic Sequence 13 of 14.

Endoscopic injection is widely used for the arrest of active ulcer bleeding and for prevention of re-bleeding from ulcers with visible vessels.


Video Endoscopic Sequence 14 of 14.

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