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ما هي المعالجة الأكثر فعالية لعلاج اللارتخائية (الأكاليزيا)؟


ما هي المعالجة الأكثر فعالية لعلاج اللارتخائية (الأكاليزيا)؟

المعلومة

ما هي المعالجة الأكثر فعالية لعلاج اللارتخائية (الاكاليزيا) ؟
1- الأدوية المضادة للتشنج
2- توسيع المعصرة المريئية السفلية
3- خزع عضلية المري
4- استئصال الوصل المريئي المعدي

المرجع

schwartz's principles of surgery

by


اذا من ناحية الفعالية بتوقع الجواب هو اربعة رغم انو اكيد ما نو الاختيار الاول للمعالجة
يعني بنبلش بالتوسيع بعد المرخيات و اذا ما مشي الحال منعمل خزع بس نظريا استئصال الوصل هو الاكتر فعالية و ان كان الاقل او الاندر استخداما

whatever's picture
whatever
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طيب whatever هل الالية الامراضية بالاكليزيا محصورة بالوصل المريئي المعدي حتى نستفاد من الاستئصال ..
الالية الامراضية ليست بالمعصرة والوصل !

qusei


هلأ بصراحة انا مو مارء معي قصة استئصال الوصل ضمن معالجة الاكاليزيا لهيك قلتلك نظريا الجواب اربعة كون الالية الامراضية للأكاليزيا بتعتمد على زوال التعصيب و انحلال الخلايا العقديةالعصبية و انا اعتبرت انو الاستئصال يكون جذري
و افترضتها و برجع بقلك انو وقت قريت الاكاليزيا ما مرء معي هيك معالجة على اساس استئصال كامل

كمان و بشكل اكيد انو الجواب الرابع هو الجواب الصحيح بحالة ال PSEUDOACHALASIA

whatever's picture
whatever
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There is a problem here . There is somthing called reference bias. i,e if you get a question from a surgical book then they will emphasize the surgical option more than anything else.
But if you analyze the available data and read it from a medical point of view then you will read that: Balloon dilation is as effective as Hiller myotomy in achieving symptomatic treatment in achalasia patients. However the durability of results are longer in the surgical arm . On the other hand endoscopy and balloon dilation can be repeated as much as needed with much less procedure morbidity and mortality with definately less cost .

So for the most part endocscopy and ballon dialtion is THE preferred method of treatment .

By the way this is not accurate

Quote:
- استئصال الوصل المريئي المعدي

It is not resection , rather it is a procedure called hiller myotomy where the surgen cuts muscular layer of the esophagus leaving only smaller segment of the wall (which decreases the muscular tension in the lower esophagus)

ABIM's picture
ABIM


مر معي فكرة بالفيزيولوجيا أنو ممكن بالعلاج حقن الذيفان الوشيقي لمعالجة الأكاليزيا .. حدا عنده فكرة ممكن يفيدني فيها Rolling Eyes

Dr.TH's picture
Dr.TH


اي مكن نستخدم الذيفان الوشيقي عند المرضى عالية الخطورة للعمل و التدخل الجراحي وبينعاد الحقن كل ست أشهر و نسبة نجاح هالعلاج تقريباَ 65% من المرضى

whatever's picture
whatever
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بعد التمحيص وجدت ما يلي:
المعالجة المقترحة هي الثلاثي الآتي:
1- توسيع المعصرة المريئية السفلية بالبالون.
2- المعالجة للGERD الحاصل دوائياً + إجراء عملية Balsey Mark IV
3- خزع عضلية المري السفلي+المعصرة المريئية السفلية

ملاحظة: عملية Balsey marker IV:
an operation for gastroesophageal reflux performed through a thoracic incision; the fundus is wrapped 270 degrees around the circumference of the esophagus, leaving its posterior wall free

ملاحظة2: استغربت أول الأمر من استخدام العلاج ضد ال GERD مع أن المعصرة مستمسكة بشدة و لكن اتضح لي أن هذا العلاج هو لما بعد الإجراءات التي تجرى و تعمل على توسيع دائم في LES

Stranger4ever's picture
Stranger4ever
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اعتراض صغير: كما قرأنا في محاضراتنا... توسيع المعصرة بالبالون عملية ناكسة بشدةShocked Shocked

Stranger4ever's picture
Stranger4ever
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مضادات التشنج بتلعب دور كبير .. صحيح؟ طيب بتذكر في نترات الكالسيوم بالموضوع .؟!

DR-MAK

Quote:
مضادات التشنج بتلعب دور كبير .. صحيح؟

Nop . Ca channel blockers and Nitrates are just a waste of time. Only 40 % response and many side effects. This option is taken only when you can't do anything else.

ABIM's picture
ABIM


معناها شو أول مقاربة منعملها ؟

DR-MAK


هون في عنّا خيارين: توسيع المصرّة بالبالون عن طريق التنظير العلوي، أو إجراء خزع لعضلة المري myotomy.

حسب الـ uptodate، الخيار يعود للمريض هنا بعد أن يخبره الطبيب بمحاسن واختلاطات كل عمل.

DILATION OF THE LOWER ESOPHAGEAL SPHINCTER — Bougienage, a technique that is highly effective in the treatment of peptic esophageal strictures, usually provides only temporary and incomplete relief for patients with achalasia [5] . Definitive dilation therapy for this disorder requires more forceful stretching of the sphincter muscle than can be achieved with bougienage.

For many years, pneumatic balloon dilation of the LES has been a popular form of treatment for achalasia [6-8] . This therapy is designed to weaken the LES by tearing its muscle fibers. A number of different balloon dilators have been used over the years (eg, Mosher bag, Sippy dilators, Brown-McHardy dilator, Rider-Moeller dilator), but most of these are no longer being manufactured. At present, the most popular pneumatic dilator in the United States is the Rigiflex balloon (similar in design to the Gruntzig angioplasty catheter) which is passed over a guidewire and positioned fluoroscopically in the LES.

There is no clear consensus on the optimal method for performing pneumatic dilation, and reported protocols have varied widely with regard to the types of dilators used, the maximum diameter of the balloon (reported range 2.4 to 5.0 cm), the pressure to which the balloon is inflated (reported range 105 to >1000 mmHg), the rate of balloon inflation (rapid versus gradual), the duration of balloon inflation (reported range several seconds to 5 minutes), and the number of balloon inflations per dilating session (reported range 1 to 5) [8] .

As noted below, esophageal perforation is a potential serious complication of pneumatic dilation. Early recognition of perforation is essential; thus, following dilation, patients should routinely undergo an esophagram with water-soluble contrast or dilute barium. Without evidence of a leak, the patient can gradually resume eating after a six hour period.

Outcome — Despite the many variations in technique, most studies describe good to excellent short-term results in 60 to 85 percent of patients with achalasia who are treated with a single session of pneumatic dilation [6-8] . The duration of follow-up in most of these retrospective reports is relatively brief, and few data are available on the long-term outcome of pneumatic dilation. The efficacy of pneumatic dilation is discussed in greater detail separately. (See "Pneumatic dilation and botulinum toxin injection for achalasia").

Approximately 50 percent of patients with achalasia who are treated initially with a single pneumatic dilation will require further therapy within five years, and subsequent pneumatic dilations are progressively less likely to result in a sustained remission [9-12] . Other forms of therapy should be considered for patients who have had two or three unsuccessful pneumatic dilations.

Complications — Esophageal perforation is the most common serious complication of pneumatic dilation, occurring in most large series by experienced endoscopists in 2 to 6 percent of cases [8,13] . (See "Pneumatic dilation and botulinum toxin injection for achalasia"). Perforation most commonly occurs in the distal left side of the esophagus. Mortality from pneumatic dilation is rare, and has been estimated at approximately 0.2 percent [8] . Approximately 2 percent of patients treated with pneumatic dilation develop reflux esophagitis due to the resulting LES hypotension [8] . (See "Pathophysiology of reflux esophagitis").

SURGICAL MYOTOMY — Surgical myotomy, in which the surgeon weakens the LES by cutting its muscle fibers, has been viewed as the primary alternative to pneumatic dilation for achalasia. Modern surgeons use a modification of the myotomy technique first performed by Ernst Heller in 1913 [8] . The standard "open" myotomy can be performed using either an abdominal or, more commonly, a thoracic approach [14,15] . More recently, laparoscopic and thoracoscopic techniques have been used to perform the myotomy [16-20] .

Modified Heller approach — Surgical myotomy via the modified Heller approach results in good to excellent relief of symptoms in 70 to 90 percent of patients with few serious complications [8,21] . The mortality rate (approximately 0.3 percent) is similar to that reported for pneumatic dilation [8] . Reflux esophagitis (that may be complicated by esophageal ulceration, stricture, and Barrett's esophagus) develops in approximately 10 percent of patients treated by surgical myotomy [8] , and surgeons continue to debate the need for the addition of an antireflux (fundoplication) procedure. I usually discourage fundoplication but many excellent surgeons continue to recommend it.

The few long-term studies available suggest that surgical myotomy results in sustained remission rates of approximately 70 to 85 percent at 10 years, and 65 percent at 20 years [22-26] . There is only one published prospective, randomized trial of myotomy versus pneumatic dilation in 79 patients with achalasia [27] . The likelihood of an excellent result after a median follow-up period of approximately five years was higher in the surgical group (95 versus 65 percent with pneumatic dilation). This study has been criticized for using a pneumatic dilation protocol that may have been suboptimal. A follow-up report of this study included 67 patients who had undergone myotomy (with a modified fundoplication) and were followed for up to 30 years [25] . Three patients developed squamous cell esophageal carcinoma, 5, 7, and 15 years after surgery. Nine patients developed Barrett's esophagus. Clinical results were considered to be good to excellent in 73 percent of patients, while 22 percent were considered to have failed mainly do to the development reflux esophagitis.

It appears that surgery generally is superior to pneumatic dilation for both the short-term and long-term relief of dysphagia. Furthermore, the rate of serious complications, such as esophageal perforation, appears to be less in surgically-treated patients, and the mortality rates for the two procedures are approximately equal. In addition, an observational study suggested that surgical myotomy performed subsequent to endoscopic therapy (including pneumatic dilation and botulinum toxin injection) was associated with an increase in post-operative complications and an increased likelihood of persistent or recurrent symptoms [28] .

The major disadvantages of surgery are the high initial cost, the protracted recovery period, and the frequent development of gastroesophageal reflux disease (GERD) postoperatively. At present, the decision between pneumatic dilation and myotomy as initial therapy for achalasia should be based upon consideration of the patient's preferences and on the availability of personnel experienced in the two techniques.

Laparoscopic myotomy — There is increasing experience with Heller myotomy performed by a minimally invasive technique (laparoscopic or thoracoscopic) [16-19] . These approaches shorten hospital stays and recovery times [17,18,29] . Long-term follow-up is not yet available, but short- and medium-term outcomes are sufficiently promising that minimally invasive surgery is becoming the procedure of choice by many experienced surgeons for uncomplicated cases [16-19,30] . A retrospective study that included a total of 106 patients found that the success of Heller myotomy (88 percent done laparoscopically) was comparable to pneumatic dilation (44 versus 57 percent) after six years of follow-up when success was defined as dysphagia/regurgitation less than three times/week or freedom from alternative treatment [31] .

KMG's picture
KMG
طبيب مقيم


متوقع مني أقرأ كل هالمقال؟ Evil Evil

نحن هربانين من المحاضرات لحكيم مشان أستمتع باللي عم بقرأه !

DR-MAK


فيك تقراه وفيك ما تقراه.. بس لازم حط دليل الكلام يلي قلته Rolling Eyes

KMG's picture
KMG
طبيب مقيم


Summery

It appears that surgery generally is superior to pneumatic dilation for both the short-term and long-term relief of dysphagia. Furthermore, the rate of serious complications, such as esophageal perforation, appears to be less in surgically-treated patients, and the mortality rates for the two procedures are approximately equal.

The major disadvantages of surgery are the high initial cost, the protracted recovery period, and the frequent development of gastroesophageal reflux disease (GERD) postoperatively. At present, the decision between pneumatic dilation and myotomy as initial therapy for achalasia should be based upon consideration of the patient's preferences and on the availability of personnel experienced in the two techniques.

So for a surgeon
!_ Surgery is the best

for an endoscopist
Dilation is the best

and for patients : it is variable but most patient prefer to start with endscopy and if not improved then do surgery and it is not unreasonable to go to surgery directly in healthy wealthy young patients

ABIM's picture
ABIM


شكراً جزيلاً ABIM

DR-MAK


بس لهلأ ما عرفنا شو هي المقاربة الافضل

whatever's picture
whatever
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السلام عليكم
بتوقع وحسب ما بتذكر انو المعالجة الافضل والنهائية هي خزع عضلية المري

Tayba's picture
Tayba
السنة السادسة


عملية هيلر (نيسن المعدلة) ؟؟

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nice monamoor
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ابق على تواصل مع حكيم!
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