What is Surgery – Gist tumor
STOMAL TUMORS OF THE GASTROINTESTINAL SYSTEM
Interstitial cells of Cajal, pacemaker cells linked with Auerbach's plexus that coordinate peristalsis, may be the source of gastrointestinal mesenchymal tumours. Exhibit a range of malignant potential, from very minimal risk to downright dangerous.
Mutations in KIT (75–80%, CD117) or PDGFR- (platelet derived growth factor receptor alpha, 5–10%) cause constitutively active receptor tyrosine kinase signalling pathways and cellular proliferation.
Carney's triad , neurofibromatosis type I, and familial GIST syndrome are risk factors.
Annual incidence ranges between 11 and 15 per million, with a frequency of 129 per million. Males and females have a wide age range, however 75 percent are above 50 years old (median 58 years).
Endoscopy/imaging/laparotomy may reveal an asymptomatic/incidental finding. Gl bleeding (70 percent), abdominal pain/bloating (57 percent), bowel blockage (30 percent), satiety/weight loss (22 percent), palpable mass (13 percent), and, more infrequently, rupture are some of the other symptoms.
Findings are dependent on the location, size, and difficulties. The stomach (50 percent), small bowel (25 percent), colon/rectum (10 percent), mesentery, omentum, and retroperitoneum (10 percent), and oesophagus (10 percent) are the most common sites
Endoscopy: Biopsies are frequently negative unless 'inkwell' biopsies are conducted, which may reveal a submucosal tumour. Endoscopic ultrasound reveals a hypoechoic mass adjacent to the muscularis mucosa or propria, which is usually hypoechoic. Because of the risk of tumour rupture and dissemination, perioperative or percutaneous biopsy is not often indicated.
CT abdomen and 18FDG PET scans are used for imaging. To pinpoint the tumor's location.
Immunohistochemistry: KIT (95%) and CD34 positive (60-70 percent ).
For non-metastatic GISTs, surgical resection is the treatment of choice. Complete excision has a high possibility of being successful and should be undertaken if at all possible.
Lymphadenectomy is not suggested on a regular basis. For small-to-intermediate tumours, laparoscopic excision can be utilised.
Neoadjuvant and adjuvant imatinib clinical trials are currently underway. Advanced disease : Imatinib inhibits the receptor tyrosine kinases KIT, PDGFRA, and BCR-ABL by binding competitively to the ATP binding site. It is used to treat advanced/metastatic GISTs. Disease control was achieved in up to 85% of patients, with a median survival time of more than 36 months. With the course of the disease, dose escalation or surgical resection or radio frequency ablation of liver metastases may be considered.
Sunitinib is used to treat advanced instances that have failed to respond to imatinib treatment.
During surgery, extreme caution should be exercised to avoid tumour rupture and seeding. Local and haematogenous spread modes exist. Metastases to the liver or transperitoneum are common, as are lung/bone metastases in advanced instances; lymph node metastases are uncommon.
Almost all GISTs have the potential to become cancerous. Site, with gastric cancer having a better prognosis than small bowel cancer, size (>5–10 cm, greater malignant potential), mitotic activity (>5 mitoses per 5O HPFs), and resection completeness are also prognostic markers.
What is Surgery – gastrointestinal perforation / perforations in stomach
Perforation of the gastrointestinal tract wall, resulting in bowel contents spilling out.
Perforated duodenal or gastric ulcer are the most prevalent gastroduodenal conditions, followed by gastric cancer (1–2%) in gastroduodenal.
Diverticulitis and colorectal cancer (80 percent) are the most prevalent conditions in the large bowel, and a perforated appendix is a common consequence of appendicitis. Other causes include volvulus, ulcerative colitis (toxic megacolon), trauma, radiation enteritis, post-operative anastomotic leaks, and colonoscopy complications.
Trauma, infection (typhoid, tuberculosis), Crohn's disease, cancer, vasculitis, and radiation enteritis (rarely lead to perforation in small bowel).
Boerhaave's syndrome may cause the oesophagus perforation while iatrogenic perforation occurs less frequently during OGD and more frequently after stricture dilatation.
The rate of occurrence is determined by the cause. However, presenting with abdominal pain as a result of intestinal perforation is a rather common and possibly life-threatening emergency.
It all depends on the situation. Abdominal discomfort that is sometimes rapid in onset and is accompanied by nausea and vomiting may be one of the presenting symptoms.
The patient is sick, with indications of localised or generalised peritonitis, including abdominal stiffness and guarding, as well as diminished or missing bowel sounds. Overlying gas causes a loss of liver dullness. Shock, pyrexia, pallor, and dehydration are all signs of dehydration.
FBC, U&Es, LFT, amylase (levels may be elevated in perforation), ABGs, and clotting are all blood tests. Gas under the diaphragm may be visible on an erect CXR (70 percent of perforated peptic ulcer cases).
AXR: Abnormal gas shadows in tissues can be seen. Gas on each side of the intestinal wall is referred to as Rigler's sign; alternatively, intraperitoneal gas can be seen on a lateral decubitus film.
CT scan: Can identify underlying pathology and is very sensitive for free intraperitoneal gas.
Chest X Ray : Gas under the diaphragm on an erect chest radiograph, indicating bowel perforation.
Resuscitation: Intravenous rehydration and electrolyte imbalances correction, broad spectrum IV antibiotics, analgesics, urinary catheter and central line placement if needed.
Conservative: For people with little symptoms, little contamination, or a high anaesthetic risk. Bowel rest, high-dose PPIs, IV fluids and antibiotics, NG tube, and monitoring are all used to treat gastroduodenal perforations.
Surgical: The perforation is closed and an omental patch is inserted.
Gastroduodenal: Laparoscopy or laparotomy and peritoneal lavage: The perforation is closed and an omental patch is placed. Biopsies of gastric ulcers should be performed to check for malignancy. Closure is more difficult than with duodenal ulcers, however a Billroth I partial gastrectomy with gastroduodenal anastomosis is possible. If Helicobacter pylori is found after surgery, it must be eradicated.
Large intestine: Peritoneal lavage and identification of the perforation location via laparoscopy or laparotomy. Resection of the affected colon, commonly as part of a Hartmann's procedure, followed by the development of an end colostomy and closure of the distal stump or exteriorization as a mucous fistula. Resection and primary anastomosis with a defunct ileostomy are other options. The right colon may be perforated, allowing surgical resection and a main anastomosis. In ulcerative colitis toxic megacolon, a subtotal colectomy is performed with a terminal ileostomy with the rectal stump preserved (allows future reconstruction of ileoanal pouch).
Sepsis, peritonitis, fistula formation, and death are all possible outcomes.
Perforated stomach ulcers have a higher morbidity and mortality rate than duodenal ulcers, and perforated gastric carcinomas have a very dismal prognosis. With little or local contamination in the large bowel, the prognosis is better. Faecal peritonitis is linked to a mortality rate of more than 50%.
What is Surgery – Appendicitis Pain Location
The vermiform appendix becomes inflamed and infected.
A faecolith (inspissated faeces), lymphoid hyperplasia, or oedema might cause luminal blockage. Helminths and caecal cancer are two less common causes of luminal blockage.
Any age, with a high incidence in the second and third decades, one of the most common emergency surgical diagnoses in the United Kingdom, with a 7% lifetime risk.
50 percent of the time, the classic presentation is as follows: Abdominal pain, first widespread, periumbilical, and colicky (typically 72 hours) (visceral pain lasting a few hours). The pain becomes acute and localised to the RIF (somatic pain due to the involvement of the parietal peritoneum).
The most prevalent symptoms are anorexia (the most persistent) and nausea. It's possible that you'll vomit. Pain in the right flank (retrocaecal appendix), right upper quadrant (long appendix), or lower abdomen are other possible symptoms (pelvic appendix). Because the inflamed appendix irritates the bladder or intestine, it may cause urine frequency or loose stools.
Mild pyrexia, flushing of the face, and tachycardia. McBurney's point (2/3 of the way from the umbilicus to the anterior superior iliac spine) is sometimes associated with rebound soreness (visible on percussion) and guarding. Pain in the right iliac fossa evoked by pressure over the left iliac fossa is known as Rovsing's sign.
Proliferation of intestinal flora and inflammation that extends transmurally occur as a result of luminal blockage. Swelling causes end artery occlusion and thrombosis, and the appendix becomes gangrenous and necrotic. If left untreated, the inflammation may become localised by the omentum or bowel loops, resulting in an appendix mass or abscess, or perforation with peritonitis. On histology, a carcinoid tumour is occasionally discovered; if it is larger than 1–2cm, a right hemicolectomy is recommended.
Appendicitis is frequently diagnosed clinically. WCC and CRP, LFTs, amylase (to look for biliary pathology, pancreatitis), U&Es are all tests that are done on the blood. In women of childbearing age, urine is used for microscopy, culture, and sensitivity, as well as a pregnancy test. Ultrasound (sometimes difficult to visualise appendix, but useful in competent hands for detecting other pathology, such as ovarian cysts) CT offers a sensitivity of 94% and a specificity of 95%, making it particularly beneficial when other pathology, such as diverticulitis, is concerned, but it exposes the patient to a lot of radiation. Laparoscopy for diagnostic purposes: Allows for precise diagnosis and therapy.
General: If there are substantial signs of sepsis, IV fluids and broad-spectrum antibiotics are given before and after surgery. If symptoms or indicators are ambiguous, keep an eye on them and re-examine them frequently. An appendicectomy, either open or laparoscopic, is performed (see Procedures). Antibiotics may be continued after surgery, especially if the appendix is gangrenous or perforated.
Appendiceal abscess: Drainage is done either percutaneously, using ultrasound or CT guidance, or intraoperatively (with appendicectomy if safe). Antibiotics, parenteral fluids, and periodic reassessment may be used to manage an appendiceal mass, with surgery being considered if clinical deterioration occurs.
Interval appendicectomy (Ochsner–Sherren method) is sometimes performed weeks afterwards. If this is not done in adults, a barium enema or colonoscopy should be done to rule out a right colon cancer.
Inflammatory mass, appendix abscess, perforation and peritonitis, and portal pyaemia are all possible complications. Wound infection, abscess, ileus, and a faecal fistula from the appendix stump are all possible complications after surgery.
Appendicectomy is a curative procedure. It can be life-threatening if left untreated. In the extremely young, the elderly, and pregnant women, diagnosis might be difficult; morbidity and mortality are higher in these groups.
What is Surgery – ATLS Courses
Advanced trauma life support (ATLS) INDICATIONS
Early management of trauma with emphasis on treating the greatest threat to life first.
Pre-hospital phase: Rapid assessment of the trauma patient. Treatment of hypoxaemia,shock and prompt evacuation to an appropriate hospital.
Hospital phase: Primary survey is carried out by a trauma team comprising of a team leader, and usually at least a general surgeon, an orthopaedic surgeon, an anaesthetist and nursing support. The team leader should ensure a systematic approach to the primary and secondary surveys and each member of the team should have a pre-specified function.
Airway management with c-spine control: Suction and check mouth for foreign body. Check for capacity to maintain own airway (conscious/unconscious patient). Chin lift/jaw push, oral or nasopharyngeal (not in head injuries) airway as necessary, intubation or cricothyroidotomy as required.
Breathing: Give oxygen, 100 percent via non-rebreather mask. Check for tracheal deviation and symmetrical chest expansion, bilateral breath sounds and respiratory rate. Pulse oximetry. If tension pneumothorax, needle decompression on side of pneumothorax. Check for subcutaneous emphysema. Open sucking pneumothorax requires dressing with closure on three sides and chest drain. Look for flail chest.
Circulation: Assess pulse, blood pressure, pulse pressure, capillary return, combined with intravenous access (two large-bore peripheral cannulae) and blood collection for FBC, U&E, G&S ± crossmatch blood. Assessment of shock/haemodynamic instability, treatment of external haemorrhage, assessment for internal bleeding: evaluate main body cavities, abdomen, pelvis for evidence of pelvic fractures, chest for haemothorax. Fluid resuscitation (crystalloid/colloid/blood); however, if intracavity bleeding is not yet controlled, ‘permissive hypotension’ of systolic BP may be appropriate (not in severe head injury where cerebral perfusion pressure should be adjusted).
FAST (focused abdominal sonogram for trauma) scan or CT if stable.
Disability: Assessment of neurologic damage grossly utilising an AVPU (Alert, Voice elicits response, Pain elicits response, Unresponsive) score or the Glasgow Coma Score (GCS) (GCS). Check blood glucose.
Exposure: Check for other injuries, totally strip patient, prevent hypothermia, logroll patient, checking for posterior or spinal injuries.
Avoid and treat hypothermia: warming blankets, warm IV fluids, etc. Frequent reassessment is crucial. Any worsening needs quick reevaluation of the ABC. When a team is completing the assessment and resuscitation, most of the ABC may be carried out in simultaneously.
Secondary survey: Does not begin until the primary survey is completed and resuscitation is started. Head-to-toe evaluation. AMPLE history (Allergies, Medications, Past illness/ Pregnancy, Last meal, Events linked to the injury).
Frequent reassessment vital! Full neurological examination. Radiology, and other indicated tests, e.g. FAST scan, ABG, radiographic imaging of any fractures. Urinary catheter/gastric tube. Further definitive management is dependent on injuries.
Transfer to tertiary trauma or neurosurgical centre is sometimes essential.
INVESTIGATIONS Blood: FBC, U&E, LFTs, clotting, blood group and crossmatch as appropriate. Urinalysis: Urine dipstick for haematuria, β-HCG if danger of pregnancy.
Imaging: Cervical spine, chest and pelvic radiographs as part of primary survey. Penetrating abdominal injuries may be evaluated using erect chest X-ray.
FAST scanning: Taking over as a non invasive quick assessment for haemoperitoneum in trauma.
CT scanning: As appropriate in the stable patient. Suspicion of intra-abdominal bleed (e.g. hypotension, enlarged abdomen) demands rapid laparotomy. Radiographs: If shattered bone is suspected.
MORTALITY Trimodal distribution of death. Early (within minutes) caused by large-vessel/brain/spinal cord damage. Second peak (within hours) owing to haemorrhage, the golden hour refers to the period in which there is the highest possibility that prompt medical treatment may avoid mortality. Third peak (within days to weeks) owing to sepsis.
What is Surgery – What causes abscess?
An abscess is a mass of necrotic tissue, including dead and living neutrophils suspended in tissue breakdown products (pus), surrounded by a coating of inflammatory exudate.
The rupture of a tissue barrier by a penetrating injury, local infection, or the migration of normal flora to sterile areas of the body gets walled off in an attempt to inhibit further spread of the infection. Common bacteria include Staphylococcus, streptococci, enteric organisms (e.g. Escherichia coli), other coliforms and anaerobes (e.g. Bacteroides spp). (e.g. Bacteroides spp.). TB classically creates ‘cold’ abscesses.
ASSOCIATIONS/RISK FACTORS Local: Tissue necrosis, an underperfused area or foreign substance that provides a focus for infection, e.g. a tooth or root fragment, splinters, mesh of hernia repair or embedded hair. Systemic: Diabetes, immunosuppression (but may interfere with pus formation).
Common in all ages.
The patient may complain of local consequences of pain, swelling, heat, redness and impaired function of the area where the abscess is present (dolor, tumour, calor, rubor and functio laesa, the Celsian symptoms of acute inflammation) and/or systemic effects such as fever and feeling poorly.
The foregoing symptoms of acute inflammation are present at the site of the abscess. If present within an organ (e.g. liver or lung, or bodily cavity), localising indications may be missing, the only indicator being a swinging pyrexia (produced by periodic release of microbes or inflammatory mediators into the systemic circulation), which should initiate a search for an infected collection. One ancient proverb is that if pus is somewhere and pus is nowhere, then pus is under the diaphragm (subphrenic abscess).
Bacteria instigate a severe acute inflammatory response with the development of pus, a collection of cellular debris and bacteria. An abscess occurs as it becomes surrounded by a fibrinous exudate and granulation tissue (macrophages and fibroblasts), with subsequent collagen deposition and walling off. Cold abscesses are collections of caseating necrosis containing mycobacterium — ‘cold’ because there is no concomitant acute inflammatory reaction.
Bloods: FBC (↑ neutrophils). Imaging: Ultrasound, CT or MRI scanning or even 67Ga white cell scanning may be employed in the search for the site of a collection or abscess. Aspiration: Pus is low in glucose and acidic. Culture of pus for microbes and sensitivity to antibiotics.
Prevention: Prophylactic antibiotics (e.g. during procedures), if given early during an infection. Often not effective after an abscess has formed. General: Principles involved include drainage of pus, removal of necrotic and foreign material, antimicrobial cover and repair of the underlying factor. Surgery: Drainage of pus is carried done by incision and drainage, with debridement of the cavity and subsequent free drainage by packing of the cavity (if superficial) or by drains (if deep) (if deep). Interventional radiology: Ultrasound or CT guidance can be used to localise and aspirate the contents of an abscess.
Spread may occur in cellulitis (in skin) or bacteraemia with systemic sepsis. If the focus of infection is not removed, a persistent abscess or draining sinus or fistula may occur. Occasionally, antibiotics may penetrate and result in the formation of a sterile collection or antibioma. If limited by strong facial planes, slow expansion might cause pressure necrosis of adjacent tissues. Abscesses may induce destruction of properly functioning tissue (e.g. liver or nephric abscess).
Good if fully drained and predisposing factor removed. If left untreated, abscesses tend to ‘point’ to the nearest epithelial surface and may spontaneously discharge their contents. Deep abscesses may become chronic, undergoing dystrophic calcification.
What is Surgery – Pulmonary Embolism causes
The most prevalent cause of pulmonary vessel occlusion is a thrombus that has travelled to the circulatory system from another location.
Thrombus (>95 percent originating from DVT of the lower limbs, with the right atrium in patients with atrial fibrillation being the uncommon exception). Amniotic fluid, air, fat, tumours, and mycotic emboli from right-sided endocarditis are among the other factors that can embolize pulmonary vessels. Surgical patients, as well as those with immobility, obesity, OCP, heart failure, and cancer, are at danger.
Relatively prevalent, especially in hospitalised patients; 10–20% of those with a proven proximal DVT develop this condition.
HISTORY It is determined by the size and location of the pulmonary embolus. Small: It's possible that it's asymptomatic. Sudden onset dyspnoea, cough, haemoptysis, and pleuritic chest discomfort are moderate cases of emboli. All of the above plus severe central pleuritic chest pain, shock, collapse, acute right heart failure, or sudden death for large or proximal. Symptoms of pulmonary hypertension include several minor recurring headaches.
EXAMINATION Clinical probability evaluation: Various scores can be used to forecast probability, which can help with future inquiry and management. Follow the rules in your area. The severity of a pulmonary embolism can be determined by the following signs: Small: There are frequently no clinical indications. Tachycardia or tachypnoea is the first symptom. Moderate: tachycardia, pleural rub, and low oxygen saturation (despite oxygen supplementation). Shock, cyanosis, and symptoms of right heart strain (JVP, left parasternal heave, exaggerated S2 heart sound) are all present in a massive PE. Signs of pulmonary hypertension and right heart failure in multiple recurrent PE.
Use the D-dimer blood test (cross-linked fibrin degradation products, sensitive but poor specificity) if you have a low chance. High probability: Imaging is required. Additional preliminary investigations include: ABG and thrombophilia screening should be considered. ECG: May be normal or exhibit tachycardia, right axis deviation, or RBBB, among other things. It's rare to see a classic SI, QIII, or TIII pattern. CXR: Usually normal, but used to rule out alternative possibilities. Spiral CT pulmonary angiography is the preferred first-line investigation. Small emboli have low sensitivity, but medium to large emboli have high sensitivity. Administration of IV 99mTc macro-aggregated albumin and inhalation of krypton-81 gas during a ventilation-perfusion (VQ) scan. Any locations of ventilation and perfusion mismatch are identified. Because of the difficulty in interpreting an abnormal CXR or concurrent lung disease, it is not recommended. Pulmonary angiography is the gold standard, but it is also the most invasive. It's only used on rare occasions. To check for venous thrombosis, a Doppler USS of the lower limb is used. Right heart strain may be visible on an echocardiogram.
Primary prevention: For those at risk, graduated pressure stockings (TEDs) and heparin prophylaxis are recommended (e.g. undergoing surgery). Following surgery, early mobilisation and appropriate hydration are essential. If haemodynamically stable, O2, heparin or LMW heparin anticoagulation, then oral warfarin therapy (INR 2–3) for a minimum of 3 months. Analgesics are pain relievers. If you have a severe case of haemodynamic instability (massive PE), you should: If cardiac arrest is imminent, resuscitation, oxygen, IV fluid resuscitation, and thrombolysis with tPA (tissue plasminogen activator) can all be considered on clinical grounds alone. Surgical or radiological intervention: Embolectomy when thrombolysis is contraindicated. For recurrent pulmonary emboli despite appropriate anticoagulation or when anticoagulation is contraindicated, IVC filters (e.g. Greenfield filter) may be placed.
COMPLICATIONS Death, pulmonary embolism, pulmonary hypertension, and right heart failure are all possible outcomes.
PROGNOSIS Untreated mortality was 33%, while treated mortality was 8% (due to recurrent emboli or underlying disease). Patients are at risk of developing thrombo-embolic illness in the future.
What is Surgery – SCLC cancer
DEFINITION OF LUNG CANCER Lung cancer is a primary malignant neoplasm of the lung. WHO classification of primary malignant neoplasm( bronchocarcinoma) are Small cell (20%) and non-small cell (80%) such as squamous cell carcinoma, adenocarcinoma, large-cell carcinoma, and adenosquamous carcinoma.
AETIOLOGY Primary lung tumor : Smoking (both active and passive) and asbestos exposure are believed to trigger genetic alterations that lead to neoplastic transformation. Tumors most commonly occur in the main or lobar bronchi , while adenocarcinomas are more common in the periphery. Secondary tumours: Lung metastasis is a regular occurrence.
Tobacco use, occupational exposures (polycyclic hydrocarbons, asbestos, nickel, chromium, cadmium, radon), and pollution in the environment.
The most prevalent deadly malignancy in the West (18% of cancer mortality worldwide), with 35,000 fatalities per year (UK), and three times more common in men (but not in women).
With a radiographic anomaly, it may be asymptomatic (5 percent ). Symptoms of primary malignancy ( such as small cell lung carcinoma (sclc): Recurrent pneumonia, cough, haemoptysis, chest discomfort Brachial plexus (Pancoast's tumour) causing pain in the shoulder or arm, left recurrent laryngeal nerve causing hoarseness and bovine cough, oesophagus (dysphagia), palpitations (arrhythmias). Weight loss, weariness, bone discomfort or fractures, and fits are all symptoms of metastatic illness or paraneoplastic conditions.
There could be no warning indications. Wheeze is monophonic and fixed. Signs of pleural effusion or lobar collapse.
Symptoms of metastasis (e.g. supraclavicular lymphadenopathy or hepatomegaly). Horner's syndrome is a condition that affects people.
CXR, sputum cytology, bronchoscopy with brushings or biopsy, CT or ultrasound-guided percutaneous biopsy, lymph node biopsy are all used to determine the diagnosis.
TNM staging: CT chest, CT or MRI head and abdomen, bone scan, and PET scan are used to determine tumour size, nodal involvement, and metastatic metastasis.
Mediastinoscopy or video-assisted thoracoscopy are two invasive procedures that may be used.
FBC, U&Es, Ca2+ (hypercalcaemia is prevalent), AlkPhos (bone metastases), LFT. Blood: FBC, U&Es, Ca2+ (hypercalcaemia is common), AlkPhos (bone metastases), LFT.
ABG, pulmonary function tests (FEV1 >80% anticipated to tolerate a pneumonectomy; lung resection is contraindicated if FEV1 30% projected), V/Qscan, ECG, echocardiography, and general anaesthesia assessment are all done prior to surgery.
A multidisciplinary discussion about tumour stage and the best treatment option is held. Resectibility of the tumour (stage I and II disease, selectively IIIa) and operability are important concerns (surgery is not recommended for small-cell carcinoma) (whether a patient is fit enough to undergo surgery). It's critical to have an open and honest conversation with the patient regarding the risks and benefits of the procedure, as well as the prognosis. Only about 14% of cases are considered surgical.
Anesthesia: endotracheal tube with two lumens is used to isolate the lung to be operated on from the ventilatory circuit during anaesthesia. The central line is put on the opposite side of the lung that will be operated on. The arterial line and the urine catheter have been placed. A thoracic epidural catheter is frequently used to provide effective regional analgesia.
Procedure: In the case of bronchial tumours, rigid bronchoscopy is performed after induction of anaesthesia. Prophylaxis with antibiotics is used. The ribs are gradually distracted during a thoracotomy (typically performed posterolaterally with the patient in a lateral decubitus position). The lung is mobilised, and the tumor's location and lymph nodes are examined. The bronchial tree, pulmonary artery, and vein are identified, and if necessary, a lobectomy is performed (60 percent of resections). In the right lung, a bilobectomy can be performed while the upper or lower lobes are preserved. To avoid pneumonectomy, sleeve resection is used (involves partial resection and reconstruction of bronchi). One lung is removed in a pneumonectomy (which accounts for 25% of resections). Air is drained through an anterior apical drain, and blood or fluid is drained through a posterior basal drain.
Non-operable: Survival improves with multimodality therapy, which includes radiation and chemotherapy. Docetaxel is a drug that is regularly used. Erlotinib (inhibitor of epidermal growth factor receptor, EGFR) is a biological medication used as a second-line chemotherapeutic drug.
Palliative and end-of-life care: Includes bronchial tumour laser therapy, endobronchial stents, complication management, and pain control.
Local invasion (e.g., brachial plexus, sympathetic chain, recurrent laryngeal nerve, SVC), metastases (most commonly liver, bone, and brain), pleural effusion, pulmonary haemorrhage, lobar or lung collapse, and paraneoplastic syndromes (especially common in small-cell carcinomas, e.g., SIADH or ectopic ACTH production; squamous cell carcinomas are associated with hyper Surgery: The lesion was not surgically resectable (should be 5 percent ). Air leaks are prevalent after lobectomy and may necessitate re-operation.
Pneumonectomy: Significant physiological strain due to cardiac output passing entirely through one lung, hazards of cardiac arrhythmias, failure, or MI, atelectasis, and pneumonia, pulmonary oedema, bronchopleural fistula, haemorrhage, and pulmonary embolus.
Is dependent on the stage, however it is usually poor. Small-cell carcinoma is frequently spread when it is discovered. Overall, just 5% of people survive five years. 5-year survival after resection for early stage cancer is about 25%. The mortality rate for lobectomy is 2%, whereas the mortality rate for pneumonectomy is 8%.
What Is Surgery – Benign Tumor in Breast
Physiopathological lesions of the epithelial, stromal, fat, or vascular components of the breast, also known as non-malignant diseases of the breast.
Fibroadenoma: A fibroadenoma is a benign tumour that develops from the hyperplasia of a breast lobule and contains both epithelial and connective tissue features. Irregular and necrotic adipocytes, amorphous debris, and inflammatory cells, including foreign body giant cells, can all be mistaken for cancer in fat necrosis.
Sclerosing adenosis is a type of involution that is abnormal. When central ducts become dilated with duct secretions, duct ectasia occurs.
If leakage occurs into periductal tissue, an inflammatory reaction occurs (periductal mastitis).
Under endocrine regulation, breast tissue undergoes a variety of alterations. Fat necrosis is a complication of trauma. The ANDI classification (aberrations of normal development and involution) organises benign disorders by aetiology and degree of abnormality.
RISK FACTORS/ASSOCIATIONS It's possible that those who take the contraceptive pill have a lower risk. Periductal mastitis can be caused by smoking.
EPIDEMIOLOGY Only 10–20 percent of cases are histologically diagnosed,Diffuse fibrocystic alterations are highly frequent, affecting up to 60% of women, and 70% of them suffer from mastalgia.
Fibroadenomas are more prevalent in women between the ages of 15 and 25, whereas breast cysts are more common in women between the ages of 40 and 50, and both vanish after menopause unless they are treated with hormone replacement therapy (HRT).
Breast discomfort or pain (cyclical or non-cyclical mastalgia), edoema, or lump are all possible symptoms. Nipple discharge (malignancy should be detected if blood is seen). Family history, menstruation history, pregnancies, and use of OCP or hormone replacement treatment are all risk factors for breast cancer that should be ascertained.
Breast nodularity, either focal or widespread. Smooth, well-circumscribed, movable lumps (1–2 cm in diameter, 'breast mouse') are typical of fibroadenomas. Nipple discharge (yellow/green) (duct ectasia). Dimpling, peau d'orange skin alterations, and enlarged axillary lymph nodes are not present, indicating no malignancy.
Usually used in conjunction with a triple assessment: 1. A clinical examination is performed. 2. Mammography (craniocaudal and oblique mediolateral views with spot compression and magnification) or USS in younger patients (under 35 years). Calcification is less common in benign tumours (microcalcifications are highly indicative of malignancy). MRI scanning is also a viable option. 3. Cytology/histochemistry: FNA (fine-needle aspiration) cytology, trucut or excision biopsy
Conservative: Mastalgia is treated with symptomatic treatments such as analgesics and evening primrose oil (a rich source of gammalinoleic acid). Wearing a supportive bra and eating a healthy diet are two suggestions (reduced dietary fat). Danazol is a therapy that is used as a last resort. (17-a-ethinyl testosterone inhibits ovarian steroid synthesis, reduces gonadotropin production, and stops LH surge).
Fibroadenomas can be handled conservatively or surgically removed if they are large or if the patient requests it. Simple cysts do not require aspiration unless clinically indicated, and should dissolve fully after aspiration. If it's not a breast lump, it should be handled as such.
Surgery: Removal or excision biopsy of a breast mass; if there is any suspicion that it is not benign, a wide local excision should be performed.
Intraductal papillomas are treated with microdochectomy. In duct ectasia, Hadfield's (or Adair's) procedure excises central ducts.
Recurrence of pain.
Although recurrence is common, this is a good result. Fibroadenomas: In women with simple FA, there is no increased risk of cancer, and there is no increased family history of breast cancer.
What is Surgery – Early Symptoms of Breast Cancer
Breast cancer is a malignant tumor from the tissue of the breast. AETIOLOGY A combination of genetic and environmental factors has resulted in this condition. Genetics: The majority of cases involve polygenic risk, with hereditary variables accounting for 5–10% of cases. In 2% of instances, BRCA-1 (17q) and BRCA-2 (13q) gene alterations are found (carriers have lifetime risk up to 87 percent ). Li–Fraumeni syndrome (TP53), Cowden's syndrome (PTEN), Peutz–Jeghers syndrome (STK11/LKB1), ataxia-telagiectasia (ATM), and Muir–Torre syndrome (MSH2/MLH1) are all rare hereditary breast cancer syndromes.
Age, prolonged exposure to female sex hormones (especially oestrogen), nulliparity, early menarche, late menopause, menopausal hormone replacement treatment, obesity, and alcohol are all factors that contribute to menopause.
The main cause of cancer death in women worldwide (second only to lung cancer in the United States). In the United Kingdom, the lifetime risk is one in nine. Incidence is highest in people aged 40 to 70. In men, it's uncommon (1 percent of all breast cancers).
It's possible that screening will reveal it. Breast lump (typically painless), changes in breast form, and nipple discharge are all key symptoms. Secondary symptoms include: Axillary lump, bone discomfort, weight loss, and paraneoplastic disorders are all common symptoms (e.g. cerebellar syndrome).
Examines the patient's breasts while they are upright and supine, looking for asymmetry, oedema, dimpling or tethering, nipple scaling or inversion, or ulceration in advanced cases. Palpation in a clockwise radial pattern (for hard, irregular, fixed lumps). Palpable axillary and supraclavicular lymph nodes, chest anomalies, hepatomegaly, and bone discomfort are all examined.
A standardised strategy to analysing a breast lump that includes a clinical examination, imaging (mammography, ultrasound, MRI), and tissue diagnosis (cytology or biopsy). Mammogram. A useful screening tool for women over the age of 35. Screening begins after the age of 50 in the United Kingdom. The craniocaudal and mediolateral oblique views are the most common. Branching or linear microcalcifications, as well as spiculated lesions, are signs of malignancy. Ultrasound is used to distinguish between benign cystic lesions and dangerous solid lesions.
Women over the age of 35 find it more useful. Fine-needle aspiration is a minimally invasive procedure that enables for cytology of discrete breast masses and cyst drainage. Core biopsy: Image-guided biopsy that allows for histological diagnosis. A radioactive tracer and/or blue dye is injected near the breast lesion, and a nuclear scan detects the sentinel node, which is then biopsied to check for spread.
For metastases, CT (chest, abdomen, pelvis), PET, or bone scans are used. FBC, U&Es, Ca2+, bone profile, LFT, tumour marker in the blood (CA-15-3). Histology: Carcinoma in situ: ductal or lobular cancer in situ — non-invasive with intact basement membrane (DCIS, LCIS). Ductal carcinoma is the most prevalent type of invasive malignancy (75 percent of breast cancers).
Others are lobular ( 10-15% indian filling' arrangement of cells) tubular, mucinous, medullary, cribriform, papillary, and Paget's disease of the nipple (ductal carcinoma in situ infiltrating the nipple). Phlloides are benign or malignant fibroepithelial tumours. Oestrogen and progesterone receptors (ER, PR) as well as HER-2 expression (20–30 percent of tumours) are excellent prognostic indications that guide treatment.
The S-phase fraction and DNA content (ploidy) are measured using flow cytometry (cell proliferation rate).
Grading: A prognostic indication is the Nottingham modification of the Bloom and Richardson grading system. Tubule development, nuclear size/pleomorphism, and the number of mitoses were all evaluated. Grades 1 (well differentiated) to 3 (poorly differentiated) are created using scores.
The UICC TNM-staging system is used for staging. T1: 2 cm; T2: 2–5 cm; T3: >5 cm; T4: any size with chest wall or skin extension. N1: ipsilateral mobile axillary; N2: ipsilateral fixed axillary; N3: ipsilateral internal mammary nodes. M0 indicates that there are no distant metastases; M1 indicates that there are distant metastases.
Breast surgeons, radiologists, oncologists, and breast care nurses are all part of the multidisciplinary team. Surgery to remove the cancer is dependent on the size, location, kind, and stage of the disease, as well as the wishes of the particular patient.
Wide local excision/segmental mastectomy (single cancer, 5 cm, can be removed as a whole and patient is willing to endure radiation) is a breast-conserving procedure. Radiological wire localization may be required for smaller lesions.
Total mastectomy with axillary lymph node dissection in a modified radical mastectomy. Axillary surgery spans from sentinel node biopsy (three nodes removed on average) to level III clearance (lymph nodes up to and including the pectoralis minor muscle).
Breast reconstruction is usually done later, however it can also be done at the same time as surgical excision. Breast prosthesis, latissimus dorsi or transverse rectus abdominis myocutaneous flaps, and latissimus dorsi or transverse rectus abdominis myocutaneous flaps are some of the techniques employed.
External beam radiation is used after breast-conserving surgery, as neoadjuvant therapy, and in the palliation of advanced tumours.
Chemotherapy can be used as a neoadjuvant, adjuvant, or palliative treatment or in rapidly progressing disease, visceral involvement, oestrogen receptor-negative tumours, or where hormonal treatment has failed or in premenopausal women. Combination regimens, such as cyclophosphamide, methotrexate, and 5-fluorouracil (CMF), are custom-made for each patient.
Hormonal therapy such as Selective oestrogen receptor modulators, such as tamoxifen, are the most common first-line therapy for oestrogen receptor-positive tumours. Aromatase inhibitors, such as anastrozole or letrozole, are used in postmenopausal women, as are ovarian ablation with LHRH-analogues, such as goserelin, and selective oestrogen receptor downregulators, such as fulvestrant and progestins.
Biological Therapy such as Trastuzumab (Herceptin) is a monoclonal antibody against the HER-2 receptor (cell growth promoter) that has been found to increase disease-free and overall survival in node and HER-2-positive cancer patients when administered in combination with chemotherapy.
Significant psychological or physical morbidity as a result of the diagnosis or operation. Metastases can result in bone discomfort, hypercalcemia, cord compression, and complications in the cererbal, abdomen, or lungs. Endometrial cancer and venous thrombosis are two side effects of tamoxifen. Aromatase inhibitors can cause joint and muscle pain, as well as osteoporosis. Cardiotoxicity is a side effect of Herceptin. Wound infection, haematoma, lymphoedema, shoulder pain, sensory loss (the intercostobrachial nerve is usually sacrificed, resulting in numbness on the inner, upper arm), and local recurrence are all possible side effects of surgery. Fatigue, skin abnormalities, and lymphoedema are among side effects of radiation.
PROGNOSIS It is dependent on the type, grade, and stage. Overall 5-year survival is 100% if breast cancer is localised, 50–90% if nodes are positive, and 20% if distant metastases are present.
What is surgery – Breast Abscess Symptoms
Infection in the breast tissue with pus accumulation. Puerperal (lactational) and non-puerperal are the two basic types.
Lactational: Milk stasis caused by infection, usually caused by Staphylococcus aureus or coagulase-negative staphylococci. S. aureus and anaerobes, most commonly enterococci or Bacteroides spp., are non-puerperal (TB and actinomycosis are rare causes). Smoking, mammary duct ectasia/periductal mastitis, and inflammatory breast cancer associated with it should all be ruled out. Infections after breast surgery, diabetes, and steroid medication are also linked to this condition.
Lactational breast abscesses are prevalent and usually appear shortly after starting to breastfeed and shortly after weaning, when inadequate emptying of the breast causes stasis and engorgement. Non-lactational abscesses are more common in smokers and individuals between the ages of 30 and 60.
The patient is experiencing discomfort and has developed a severe swelling in a breast location. She may complain of being unwell and having a temperature. Systemic upset is frequently less apparent in women with a non-puerperal abscess who have a history of previous infections.
EXAMINATION Local: Swollen, warm, and tenderness are present in the breast area. The skin above it may be irritated, and a nipple examination may reveal cracks or fissures. There may be scars or tissue deformation from prior occurrences in non-puerperal patients, as well as symptoms of duct ectasia, such as nipple retraction. Pyrexia and tachycardia are systemic symptoms.
INVESTIGATIONS Imaging: Microscopy, culture, and sensitivity of pus samples using ultrasound and aspiration.
Medical: Antibiotics (flucloxacillin in lactational abscesses, plus metronidazole in non-puerperal abscesses) may be used in the early cellulitic phase. Breast drainage should be done on a regular basis to avoid milk stasis. Surgical: Lactational: Daily needle aspiration with antibiotic cover seemed to be effective.
Larger abscesses (>5 cm) require a formal incision and drainage. The incision should allow for complete drainage and is cosmetically pleasing; the loculi are investigated and broken down. The wound can be softly packed and left open, with daily packing, or it can be closed completely. Breastfeeding should be continued from the non-affected breast, with the afflicted breast emptied manually or with a breast pump. Advice on how to keep your nipples from cracking. Non-puerperal: Open drainage or drainage through a minor incision should be avoided. Once the infection has subsided, the affected duct system should be excised for definitive treatment.
Slow wound healing, breastfeeding difficulties, poor cosmetic outcome, and mammary fistula formation; overlaying skin necrosis is rare.
A breast abscess will eventually develop and discharge onto the skin surface if left untreated. Non-puerperal abscesses are more likely to reoccur than puerperal abscesses.
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