Surgery Flashcards
What are the different ways to treat cancer
– Endoscopic/ EUS – Surgical – Chemotherapy – Radiotherapy – Physiotherapy – Nutritional support – CNS & palliative care team
What are then national targets for cancer
2 Week SOPD for urgent referrals - 2 weeks from GP referral to when they are seen in clinic
62 Days to treatment
describe the cancer pathway
- diagnosis
- 1st UGI MDT meeting
- specialist clinics (surgical and oncology)
- Neoadjuvant therapy - e.g. chemotherapy before surgery in order to shrink the cancer
- re staging CT/PET and 2dn UGI MDT meeting
6, surgery in about 3 months from diagnosis
what are the type of cancer surgery’s that can take place
Diagnosis – biopsy
Staging – eg Laparoscopy –for small metastasis
Treatment - for cure of primary
Reconstruction - for example, breast reconstruction after a mastectomy
Palliation and tumour debulking
Resection for cure of metastasis and local recurrence
How do you diagnose cancer before surgery
microscopic diagnosis of the cancer is compulsory before surgery takes place
Name the types of biopsy methods
Transcutaneous
Endoscopic Biopsy
Laparoscopic Biopsy
Image-directed (with fine-needle aspiration or cutting needle)
–Ultrasonography
–Computerized tomography
–Magnetic resonance imaging
Open incisional (A portion of the tumor)
Open excisional (All tumor mass removed
what do you have to undertake in order before surgery takes place
- assessment of the risk to benefit ratio = this is to make sure that they are fit for surgery and will recover from the surgery
What things do you look for in assessment of the risk to benefit ratio before surgery
Nutritional status - have to increase there nutritional status, can do this by PEG or PN feeding
Co-mordbities –Hypertension –Diabetes –Congestive heart failure –Liver or renal insufficiency –Immunosuppresion
what are the two approaches to surgery in cancer and describe what they mean
- Zero order kinetics - 100% of cells are at risk and are killed with a single treatment
- first order kinetics - this is when you have radio and chemotherapy before hand - only a portion of cells at risk are killed during treatment which is followed by regrowth
what is a local resection used for
- this is form limited cancer than hasn’t grown or spread therefore you just take the cancer out
What is a radical resection
- this is resection of the cancer and the lymph nodes
What is a supra-radical resection
- this is when you remove the cancer, the lymph nodes and the organs that surround the cancer
How do spreads of cancer happen
Direct invasive - adjacent organ
Bloodstream.
Lymphatic system.
Implantation - avoid cutting/handling
What factors do you have to take into account for surgery
- spread of cancer
- stage of cancer
where does breast cancer spread and metastasis to
- spreads through the lymph nodes
- then goes through the blood stream and spreads into the lung and liver
What is staging
Staging is the clinical or pathological assessment of the extent of tumor spread
what does clinical and pathological mean in staging
Clinical = stage at onset
pathological = microscopic biopsy diagnosis and more specific stage
what is the most common stage system used
TNM
describe Dukes classification as a staging system
Duke’s A - spread into submucosa but not through muscle
Duke’s B - spread through muscle but nodes negative
Duke’s C - lymph node metastases present
What is dukes classification used for
- it is used for colon cancer
What is the benefits of staging cancer
Provides useful prognostic information
Allows decisions to be made regarding Neoadjuvant & adjuvant therapy
Allows comparison of treatment outcomes between different centres
How do you stage cancers pre operative and post-operative
Pre-operative
- Clinical
- Radiological
Post-operative
- Histopathological
Why do we do clinical and radiological pre op staging of cancer
This is mainly done to determine treatment options
- neoadjuvant chemo/radiotherpay
- curative surgery
- palliative surgery
- not for surgery
what does Post operative staging of cancer do
- Provides useful prognostic information
- Allows decisions to be made regarding adjuvant therapy
- Allows comparison of treatment outcomes between different centres
When is radical surgery be done along
It may be used alone or along with chemotherapy or radiation therapy, which can be given before or after the operation.
what is the complete removal of the surgery termed
Ro
What is Ro
this involves removal of all the tissue containing the tumour with an intact covering of unaffected tissue to leave the resection margin free from disease
Why can curative resection unsuccessful
Invasion of vital, unresectable structure
Seeding of tumour in peritoneal cavity
Undetectable micrometastasis in distal organ – imaging only picks up a certain amount of disease
Distal metastasis which cannot be safely removed
what are the principles for surgical resection of a tumour
Adequate margin of resection
Prevention of tumor spillage elsewhere
Minimal manipulation
Anatomical Reconstruction
What does TNM stand for
T describes the size of the original (primary) tumor and whether it has invaded nearby tissue,
N describes nearby (regional) lymph nodes that are involved,
M describes distant metastasis (spread of cancer from one part of the body to another).
describe the T part of the TNM staging
made up of four parts T1, T2, T3 and T4
describe - T1 and T2 - T3 - T4 surgical options
T1 and T2
- Radical surgery, the aim is to cure the disease and usually has a good prognosis if you have this
T3
- when the tumour has invaded some of the tissues underneath
- combined chemotherapy and radiotherapy and radical surgery
T4
- When the tumour has invaded distant organs
- radical and palliative surgery and combination treatment
- aim is to acheieve longer disease free survival
- minimise adverse effects from local recurrence
what are the N stages in the TNM staging system
NO - no spread to lymph nodes
N1 - spread to regional lymph nodes
N2 - spread between an extent to N1 and N3
N3 - spread to more distant and regional lymph nodes
What are the surgical treatment for the N stages of the TNM staging system
Node -ve (N0) – Usually don’t get any additional treatment
Node +ve (N1 – N2) – Usually get combination treatment with curative intent.
Node +ve (N3) - get combination treatment with palliative intent.
What are the M stages in the TNM system
M0 - no metastasis
M1 - Metastasis to distant organs beyond regional lymph nodes
how do you surgical treat the M1 stage in the TNM system
M1 – Usually need combination of Surgery, Radiotherapy and Chemotherapy.
What are the benefits of open surgery in cancer treatment
- get good access
- see all the tissues
- being able to feel the tissue
what are the advantage of minimally invasive surgery in cancer treatment
- lower mordbitiy
- go home much quicker and recover much more easily
What are the type of minimally invasive surgery in cancer treatment
Hand Assisted (MIS)
Laparoscopic Surgery
Robotic Assisted Surgery
Natural Orifice Surgery
what do you do in laparoscopic surgery
- less invasive surgery
- put gas in perineum in order to get a better view of the organs
what are the three types of complications of surgery
Anaesthetic
General
Specific
what are the complications with anaesthetics
Local trauma – teeth, throat from intubation
Drug related - reaction/Allergy
Aspiration of oesophageal/gastric contents
Anaesthetic line complication
- Arterial line – bleeding
- Central venous line complication
- Epidural catheter complication
Lung injury from high pressure ventilation
What are the general complications with surgery
Bleeding
Infection including hospital acquired infection
UTI
DVT/PE
Respiratory
Wound infection
Scar/Adhesion(scars withint he abdomen and can lead to small bowel obstruction as the bowel gets stuck where the scars are formed
Psychological
what are the specific things that can go wrong when doing surgery on the abdomen
Damage to liver/spleen/intestine – laproscopic intruments – need to make a hole in the abdomen and the risk is that you can just put it into the bowel
Abdominal adhesions & obstruction
Incisional hernia -
Nutritional deficiency
what are the specific complications that can go wrong when doing surgery on the chest
Anastomotic leak
Broncho-oesophageal fistula
Thoracic duct injury
Recurrent laryngeal nerve injury
Broncheal injury
Pericardial/heart injury
Rib fractures
Chest infection/effusion/collection
Where do solid cancers spread
Solid tumours spread to the lungs, bones, liver, and brain.
where does - lung cancer - colon cancer - prostate cancer - breast cancer metastasis to
Lung cancer often metastasizes to the brain or bones
Colon cancer frequently spreads to the liver.
Prostate cancer tends to spread to the bones.
Breast cancer commonly spreads to the bones, lungs, liver, or brain.
What can cause cancer recurrence
Micro-metastasis
New primary
Local excision of tumour and lymph node was inadequate
Primary tumour disrupted during operation
Exfoliated cancer cells implanted into
- the wound
- tumour bed
- anastomosis
How do you control recurrence of cancer
Adjuvant Treatment – additional treatment after potentially curative surgery
Neo-adjuvant Treatment - additional treatment before potentially curative surgery - therefore this is surgery and chemo or radiotherapy
What is the treatment that can be used for metastasis
Surgical Radiotherapy Chemotherapy Hormonal manipulation Combination
What does the treatment for metastasis depend on
Depend on tumour type, extent of metastasis, the patient overall condition etc.
What are the principles of treatment of metastasis
Curative
Palliative if cure not possible, relapse, or alleviate the symptoms of cancer.
what are the aims of palliative surgery
It is not intended to cure the cancer.
Used to treat complications of advanced cancer.
Must improve quality of life.
What are the goals of palliative surgery
Adequate control of pain
Relief gastrointestinal and biliary obstruction
Stop haemorrhage
Supplement poor nutrition
Airway obstruction
Renal failure
Rectal or urinary incontinence
What are alternative invasive treatments
Percutaneous radiofrequency ablation
Cryoablation
Embolisation
Photodynamic therapy
Endoscopic Treatment – Stenting/Laser etc
What does cryoablation involve
- The ablation of tumour by delivering subfreezing temperatures via penetrating or surface cryoprobes.
- be cooled –20º C to –30º C
- cell death by denaturing cellular protein, rupturing the cell membrane, dehydrating the cell, and causing ischemic hypoxia
What are the factors that influence the outcome of treatment
Patient related factors
Health care provider related factors
Socio-Environment related factors eg: cultural, socio-economic, ethical factors
