Surgery - Penile Carcinoma
Introduction The most frequent type of penile cancer is squamous cell carcinoma. Etiology The primary risk factor is : -Human papillomavirus Condyloma acuminata & Balanitis, a persistent foreskin infection, and smoking - Balanitis xerotica obliterans (a type of lichen sclerosus, a chronic inflammatory illness of the glans or foreskin); -Bowen's disease (intraepithelial carcinoma of the penile shaft); -Erythroplasia of Queyrat (a type of cancer in situ of the glans skin). Epidemiology In developed nations, uncommon (<0.5% of adult male cancer cases). more prevalent in South America and Africa. Most frequently observed in older men (aged 50–70). History The patient may describe a gradually growing lesion that is frequently painless, delaying seeking medical assistance. There can be discharge or bleeding in addition. Examination Most frequently appears on the inner surface of the foreskin or glans penis. It starts off as a painless red lesion and progresses to an exophytic or nodular growth or ulcer. A secondary infection that frequently results in a discharge or disagreeable odor is also common. Up to 50% of cases had inguinal lymphadenopathy, which is frequently brought on by an infection or inflammation, but only 30–60% of these cases show indications of tumor dissemination. Pathogenesis These are G1–G3 histological grades of squamous cell carcinomas. Jackson categorization of Stage I: Limited to the foreskin or glans. Stage II: The corpora's involvement. Stage III: Inguinal nodes are reached. Remote metastases are in Stage IV. TNM staging is also included. Giant condyloma of Buschke-Lowenstein is a variation that exhibits a distinctive strongly defined deep boundary and spreads locally. Investigations Punch or excisional biopsy is used to make the diagnosis (condylomata acuminata, syphilitic chancre, or infrequently chancroid are the differential diagnoses). Imaging: looking for signs of spread using CT or MRI scanning. biopsy of sentinal lymph nodes. Management Localized disease: 5-fluorouracil cream, laser photocoagulation, or cryosurgery for glans or Bowens disease on the shaft (carcinoma in situ). Operative: Wide local excision, Mohs microsurgery, stage I and II, and partial penectomy with 2 cm proximal disease-free margins are recommended for the early stage. Complete penectomy combined with the creation of a perineal urethrostomy in more complex instances. If impalpable, occult metastases occur in 20–25% of inguinal nodes. Metastases may not be the cause of palpable nodes. If a scanning results in suspicion, bilateral lymphadenectomy. More recently, limited inguinal node dissection superficial to the fascia lata or sentinel node biopsy. Radiotherapy: As part of a combination modality therapy for the palliation of advanced-stage cancer, or locally for early-stage disease if the tumor is not big, invasive, or involves the urethra. Chemotherapy: Usually limited to cases when the cancer has spread systemically; medications like cisplatin and irinotecan be utilized. Prevention: The number of newborns who need to be circumcised to prevent one case of cancer is reduced by 909. Maintaining proper cleanliness and receiving the right care for Queyrat erythroplasia. Complications Following surgery: urethral stricture, wound disintegration, infection, and lymphoedema. Penectomy's psychological side effects. Prognosis frequently arrive late out of shame or neglect. The five-year survival rate for in situ disease is >90%; for invasive disease that has not progressed to lymph nodes, it is 80%; for nodal involvement, it is roughly 50%; and for distant metastases, it is less than 20%.
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Surgery - Hydrocoele
Definition A fluid accumulation in the scrotum between the tunica vaginalis's parietal and visceral layers. A fluid collection in a portion of the processus that is closed off to the peritoneal cavity and tunica vaginalis is known as a hydrocoele of the cord (rare). Etiology Congenital: most often idiopathic; acquired: most usually congenital communication (or communicating, due to a patent processus vaginalis, the peritoneum that follows the fall of the testicle into the scrotum, with failure of obliteration leaving a tiny communication and peritoneal fluid routes into the tunica vaginalis). Secondary reasons: Tumor, trauma, underlying torsion of the testicle or testicular appendage, parasite infection such as Wuchereria bancrofti or filariasis, or epididymo-orchitis may all be causes of infection. Risk Factors Children's indirect inguinal hernias. In the UK, epididymo-orchitis is a frequent cause. In nations where filariasis is highly prevalent, enormous hydrocoeles are caused by the disease. Epidemiology In male infants, a patent processus vaginalis is frequently present; by the time a child reaches two years old, it usually disappears. In older males, hydrocoeles are prevalent. The most frequent cause among adults worldwide is filariasis. History enlargement of the scrotum. often asymptomatic, but depending on the underlying etiology, it may be accompanied by discomfort or urine symptoms. Examination Scrotal enlargement (stiff or doughy), which can be surpassed; typically trans-illuminates and makes it challenging to feel the related testicle separately. Investigational studies Anechoic fluid accumulation encircling the testis's anterolateral aspect is visible on the ultrasound. utilized to check for underlying tumors in the testicles as well. Urine: MSU for infection, Dipstick. Blood: If testicular tumors are suspected, markers (aFP, b-HCG) may be used. Management Most babies resorb on their own, and ligation of the patent processus at the deep ring via an inguinal approach is not performed until the child is one year old, frequently in conjunction with the correction of an inguinal hernia. Aspiration of the hydrocoele is not advised in adults because it tends to re-accumulate, introduces infection, or results in a haematocoele. Surgical: The scrotal technique is typically utilized on adults. Extraneous tunica vaginalis can be removed, and the remaining tissue can be treated with either a Lord's treatment, which plicates the sac, or a Jaboulay procedure, which everts the sac. It is necessary to treat the underlying cause of secondary hydrocoeles. Complications discomfort and swollen penis. Infection, hemorrhage, damage to spermatic cord nerves or structures, and recurrence are among the surgical risks. Prognosis The recurrence incidence of idiopathic hydrocoeles is 1%–2% after surgical therapy, making them typically chronic. Once the predisposing condition has been treated, acute secondary hydrocoeles usually go away. Surgery - Orchitis and Epididymitis
Introduction inflammation (orchitis) of the testes or epididymis. Most occurrences of orchitis are linked to epididymitis, while 60% of epididymitis cases are linked to orchitis. Etiology While one-third of cases are idiopathic, the majority have infectious origins. Bacterial: less than 35 years, usually gonococcus or chlamydia. Most frequent organisms for more than 35 years are coliforms. Rarely: tertiary syphilis, tuberculosis. Viral: coxsackie, EBV, mumps (orchitis frequently follows recent parotitis). Fungal: If immunocompromised, Candida, for example. Inflammatory conditions include post-vasectomy and Behcet's illness. maybe connected to a testicular tumor underneath. Epidemiology Typical. Obviously exclusive to men.fifty to thirty years old. H HISTORY Testicles or epididymis that are sore, swollen, and sensitive (typically unilateral). The most significant variation is that testicular torsion is more acute than onset. Fever and penile discharge are possible side effects. It's crucial to find out about past sexual experiences and any parotitis history. Examination Scrotal erythema and edema. painful and swollen testicles and/or epididymis. It could hurt to walk or even to trigger a cremaster response. Check for parotid enlargement or soreness by palpating the parotid glands. Pyrexia. Prehn's sign: Pain in orchitis and epididymitis is relieved by elevating the scrotum, but not in torsion of the testicles. Investigational studies Midstream pee: MC&S; early urine collection in the morning (for AFB if TB risk exists). Blood: mumps serology, elevated WCC, elevated CRP, and U&E. Doppler ultrasonography of the testicles: To rule out torsion and local abscess. Ultrasound of the abdomen: May be required to rule out bladder outflow restriction. After the acute episode has been treated, follow-up imaging should be done to rule out testicular cancer. Management Medication: If necessary, antibiotics. For two weeks, young patients should take quinolones that are active against chlamydia (levofloxacin, ofloxacin). As an alternative, think about doxycycline. pain relief and scrotal assistance. Elderly patients: Quinolones for two weeks, such as ciprofloxacin. An antituberculous treatment is required if TB is suspected. pain relief and scrotal assistance. It is advised to follow up in order to rule out testicular cancer. Surgical: If testicular torsion cannot be ruled out or if a pyocoele or abscess develops that needs to be drained, a scrotal exploration may be required. Possibly required if a patient with tuberculosis does not improve with medication. Public health: tracking down a contact, particularly if they are sexually active. Complications Infection and Fournier's gangrene could spread if the pain and abscess are not addressed. little danger to fertility if it is treated alone. Fifty percent of cases of mumps orchitis result in testicular atrophy (higher risk of infertility if bilateral). Prognosis I'm usually okay if I'm taken care of. It could take up to two months for the swelling to go away entirely. Surgery - Bladder Cancer
Introduction Urinary bladder epithelial cancer. The majority are bladder epithelium-changing transitional cell carcinomas. Others include adenocarcinomas that originate in the urachal remnant or squamous cell carcinomas linked to long-term inflammation (such as inschistosomiasis). Less common are leiomyosarcomas, carcinosarcomas, and small cell carcinomas (neuroendocrine). Etiology A number of genetic anomalies are linked to superficial tumors, such as chromosome 9 mutations in p15 and p16. Mutations in p53, p21, ras, c-myc, and c-jun are among the others. Risk Factors Smoking, exposure to benzidine and naphthylamines in the rubber, leather, and dye industries, treatment with cyclophosphamide (10% risk after 12 years of exposure), pelvic irradiation (for example, cervical cancer), persistent urinary tract infections, and schistosomiasis—early menopause has been demonstrated to raise risk by 50%. Adenocarcinoma is linked to patent urachus. Epidemiology 2% of malignancies, the second most prevalent genitourinary system cancer; men are affected 2-3 times more frequently than women; rare <50 years; mean age at diagnosis in the sixties. History most frequently, macroscopic haematuria without discomfort. Urgency or nocturia, frequent urination, and recurrent UTIs are other symptoms. Pain from ureteral blockage, clot retention, or pelvic extension is infrequent. Examination Not many signs. Palpable lymphadenopathy or bulk may indicate an advanced stage. Investigational studies Urine: Microscopy and culture in cytology. Cystoscopy: Enables the tumor to be seen and removed or biopsied. As tumors might have several locations, USS and IVU are used to evaluate the upper and lower urinary tracts. MRI or CT scan: To stage. TNM setting: That is, in situ flat cancer; T1, submucosal invasion of lamina propria; T2, muscle invasion; T3, perivesical tissue invasion; T4, invasion of neighboring organs or pelvic wall; N, nodal involvement; and M, metastases. T1a is a papillary tumor above the lamina propria. 70% are only superficial when they are first diagnosed. G1, well-differentiated; G2, moderately-differentiated; and G3, poorly-differentiated are the three classifications. Management Depending on the tumor's grade and stage. Tumors on the surface (Tis, T1): Bladder tumor transurethral resection (TURBT). To lower recurrence rates, provide BCG injections as part of intravesical immunotherapy or mitomycin C-based intravenous chemotherapy. close monitoring using recurrent cystoscopy and bladder cytology every three months for two years, then every six months for another two years, and finally once a year. The optimum treatment for high grade T1 tumors might be a cystectomy. Nephro-ureterectomy may be necessary due to upper tract illness. T2 and higher invasive tumors: radical cystectomy if localized (this involves bilateral salpingo-oopherectomy and hysterectomy in females, and cystoprostatectomy in males with ileal conduit urine diversion, orthoptic reconstruction, and pelvic lymph node dissection). Robotic-assisted or laparoscopic surgeries can be performed by specialised centres. Chemotherapy or radiation therapy: If surgery is not an option, radical radiation therapy with salvage cystectomy is an alternative for post-radiation relapse. In cases of metastatic disease, palliative radiotherapy and chemotherapy are utilized, such as M-VAC (methotrexate, vinblastine, doxorubicin, and cisplatin). Complications hydronephrosis brought on by blockage of the ureteric orifice, haematuria, and clot retention. Surgery: Early: rectal damage, ileus, intestinal blockage, infection, and bleeding. Late: fistula, hernia, nephrolithiasis, pyelonephritis, and bowel obstruction. Radiation therapy: hemorrhage, bladder contraction, and post-radiation cystitis. Prognosis Of those who undergo TURBT, 75% will develop further tumors, although only 10% will advance to an invasive illness. T1 90–100%, T2 70–70%, T3 30–65%, and T4 10–20% five-year survival rates. 5 year survival with distant metastases is 6%. Surgery - Benign Prostatic Hyperplasia
Introduction The most common cause of lower urinary tract symptoms in adult males is nodular hyperplasia of the prostate gland's periurethral (transitional) zone, which progresses gradually. Etiology Unknown exact cause; linked to age, exposure to testosterone and dihydrotestosterone. A pseudocapsule of compressed peripheral zone glandular tissue envelops the epithelial and stromal hyperplasia of the prostate's periurethral transition zone. Epidemiology Frequent: West>Far East, Afro-Carribean>Caucasian men are more likely than East men to have histological benign prostate hypherplasia (BPH), which affects 70% of men over the age of 70. Of them, 50% have substantial symptoms. History Hesitancy, a weak or irregular stream, terminal dribbling, and incomplete emptying are examples of obstructive signs. Frequency, urgency, urge incontinence, and nocturia are indicative of irritation/storage. An assessment tool for symptoms and therapy response is the International Prostate Symptom Score. Acute retention is characterized by an abrupt inability to urinate and excruciating pain. Chronic retention: Frequency and painless passage of tiny amounts of pee, particularly during night. Examination The prostate is frequently enlarged during digital rectal examination; however, there is frequently little relationship between the size and symptoms, and if the prostate is noduled, prostate cancer should be feared. Acute retention manifests as enlarged, palpably felt bladder and suprapubic discomfort. Chronic retention: A large, distended bladder that is painless (residual volumes greater than 1 L), possibly accompanied by indications of renal failure. Investigational studies Bloods: PSA, U&Es for kidney function. Urine: For sensitivity, culture, and microscopy. Imaging: Renal tract ultrasound imaging to look for upper urinary tract dilatation. Pre- and post-voiding volumes are measured using bladder scanning. Transrectal ultrasound: To guide biopsies and quantify prostate size. Histopathology: Prostate periurethal transition zone epithelial and stromal hyperplasia is encircled by a pseudocapsule made of compressed peripheral zone glandular tissue. Flexible cystoscopy: To see changes in the bladder, such as trabeculation, and the bladder outlet. Others: Flowmetry investigations of urinary flow. Management Depending on how severe the symptoms are and whether there are any consequences. Urinary catheterization in cases of acute retention is an emergency. Conservative: If symptoms are moderate, monitoring them with the IPSS questionnaire while exercising caution may be necessary. Health: Alfuzosin and tamsulosin are examples of selective a-blockers that relax the smooth muscle of the prostate capsule and the internal (bladder neck) sphincter. 5 a-reductase inhibitors, such as finasteride, work by preventing the conversion of testosterone to dihydrotestosterone; they can lower prostate growth by 20%, but results may not be seen right away. Surgery: Prostate excision from within the urethra is known as transurethral resection of the prostate (TURP), and it can be accomplished using a number of techniques, including laser and electrocautery. Usually reserved for very large glands (>60 g), open prostatectomy (retropubic or suprapubic approaches) can be carried out via open surgery, laparoscopic, or robot-assisted surgery. Complications urinary stasis, bladder stones or diverticulae, acute or chronic urine retention, recurrent urinary infections, obstructive renal failure, and post-obstructive diuresis. From TURP, the following conditions are common: retrograde ejaculation; hemorrhage (primary, reactionary, or secondary 2–10%); clot retention; incontinence; TUR syndrome (seizures or cardiovascular collapse caused by hypervolaemia and hyponatraemia due to absorption of glycine irrigation fluid); erectile dysfunction; late: urethral stricture. Prognosis Medical treatments can help with mild symptoms, but surgical surgery typically provides great relief for patients with more severe problems. Surgery - Gastric Volvulus
Indications The abnormal rotation of all or part of the stomach above 180 degrees, known as gastric volvulus, can cause blockage. Based on the axis of rotation, they can be categorized as subdiaphragmatic (1/3) or supradiaphragmatic (2 /3, linked to diaphragmatic defects): Mesenteroaxial: Rotation along an axis perpendicular to its longitudinal axis; Organoaxial: Rotation along a longitudinal axis via the gastroesophageal junction and the stomach. Combination types are possible. Etiology Abnormal laxity of the gastrosplenic, gastroduodenal, gastrohepatic, and gastrophrenic ligaments is referred to as subdiaphragmatic (more prevalent in adults). Supradiaphragmatic: Paraoesophageal hernia; congenital or acquired anatomical defects of the diaphragm. Epidemiology The most prevalent kind is organoaxial; mixed occurrences are uncommon. Children, typically under a year old, account for ten to twenty percent of instances. Seldom seen in adults under 50. History Severe epigastric or chest pain, ineffective retching, and rarely hemomatemesis or respiratory difficulty are the emergency symptoms of acute volvulus. Chronic volvulus: in children, feeding difficulties and stunted growth; epigastric pain and fullness after meals. Examination discomfort and distention in the upper abdomen. The trio of Borchardt syndrome is pain, retching, and difficulty passing a nasogastric tube. Investigations CXR: If intrathoracic, a gas bubble appears behind the heart. AXR: A highly enlarged viscus gas shadow. Acute case diagnosis via barium swallowing or CT scanning. Management General: Nasogastric decompression trial and resuscitation. Although it is controversial, endoscopic reduction can be tried as a temporary solution for patients who are at high risk of surgery. Surgical: Volvulus reduction, either open or laparoscopic. The viability of the stomach is evaluated, and if gangrenous, a partial, subtotal, or total gastrectomy may be necessary. Anterior gastropexy is done in conjunction with the repair of any related diaphragmatic defect in order to prevent recurrence. Complications Vascular compromise include ulceration, bleeding, perforation, and strangling and necrosis. Prognosis The high non-operative death rate is typically caused by a delayed diagnosis, particularly in cases of acute presentations. With proper care, mortality is currently less than 16%. Surgery - Pyloric Stenosis
Introduction pylorus hypertrophy in newborns, which obstructs the stomach's outflow. Etiology Uncertain, but maybe connected to anomalies in the smooth muscle, interstitial cells of Cajal, or pyloric innervation that cause the pyloric smooth muscle to enlarge and become hyperplasia. linked to 2% of cases of jaundice because to a hepatic glucuronyl transferase activity deficiency that goes away following surgery. Epidemiology 3 cases per 1000 annually; less common in Asian and African populations. The male to female ratio is 4:1; it usually manifests in the first two to twelve weeks of life, however premature babies may experience it later. H HISTORY The baby vomits milk violently, like a "projectile." This vomiting is not bilious, but if it persists, it could stain the baby's oesophagus with blood. The infant appears hungry and healthy at first, but over time, it becomes dehydrated and lethargic. Examination In addition to showing symptoms of dehydration (sunken fontanelles, dry mucous membranes, low skin turgor, and 5–15% body weight), the baby may appear healthy or underweight. Gastric peristaltic waves from the left to the right upper quadrant can be seen on an abdominal examination. A hard, olive-sized lump in the epigastrium is known as a pyloric "tumour" when the pylorus becomes hypertrophied. Investigational studies Blood: U&Es, capillary gases, and metabolic alkalosis with decreased K+ and Cl-—the latter indicating the degree of dehydration—are used to assess metabolic disturbance. Imaging: An ultrasound shows that the pyloric canal has constricted (wall thickness > 4 mm, overall diameter > 10 mm, length > 18 mm) and the pylorus muscle has thickened. Management General: IV fluids are used to correct biochemical imbalances and rehydrate patients before to any operation; otherwise, there is a danger of apnea following anesthesia due to a loss of respiratory drive brought on by lower H+ from alkalosis and reduced CO2 from ventilation. To stop the stomach contents from aspirating, an NG tube is placed. Operative: The final treatment, known as a Ramstedt's pyloromyotomy, is often performed in a specialized pediatric surgical department. can be carried out laparoscopically or through open incisions in the stomach or circumumbilical region. After identifying the pylorus and cutting the serosa with a knife or diathermy, the circular muscle splits along the anterior wall and descends to the mucosa. To make sure the mucosa has not been punctured, the stomach is next inflated with air; if this is the case, the defect needs to be sutured and an omental patch should be placed over the mucosa. Complications hunger, thirst, gastritis and oesophagitis, hypochloraemia, hypokalaemia, metabolic alkalosis, aspiration, and respiratory distress syndrome. surgical site infections, incisional hernias, and mucosal perforations. 10% of patients experience chronic vomiting after surgery, however this normally goes away (may be linked to reflux illness). Prognosis Usually very good. In surgical patients, morbidity is less than 3% and mortality is less than 0.5%. Surgery - Peptic Ulcer Disease
Introduction GI tract ulceration brought on by exposure to pepsin and stomach acid. mostly duodenum and stomach (may also develop in the oesophagus and Meckel's diverticulum). Etiology The cause is an imbalance between the mucosal defense systems and the harmful effects of pepsin and acid. Although there is a clear association with Helicobacter pylori infection, the exact mechanism by which the bacteria induces ulcer formation remains unknown. NSAID use and H. pylori, which is linked to 95% of duodenal and 70–80% of stomach ulcers, are common. Zollinger-Ellison syndrome (ZE) is uncommon. Epidemiology Typical. The incidence is roughly 1-4/1000 per year. more typical among men. The average age of gastric ulcers is in the fifties, but the average age of duodenal ulcers is in the thirties. The majority of cases of H. pylori are acquired during childhood, and the prevalence is approximately correlated with age. History Antacids: Provide relief from epigastric belly pain. The link between symptoms and food varies: if they worsen shortly after eating, they are more likely to be gastric ulcers; if they worsen several hours later, they are more likely to be duodenal. Complications (e.g., haematemesis, melaena) may manifest. Examination There might not be any tangible results. soreness in the stomach area. indications of problems (such as anemia or a succession splash in pyloric stenosis). Investigational studies Blood tests: clotting screen (if GI bleeding), amylase (to rule out pancreatitis), FBC (for anemia), LFT, cross-match if bleeding is occurring. If ZE is suspected, consider the secretin test: intravenous secretin elevates serum gastrin in ZE patients but not in controls. Endoscopy: Duodenal ulcers do not require a biopsy; four quadrant stomach ulcer biopsies are necessary to rule out cancer. According to Rockall scoring (see Gastrointestinal Haemorrhage, Upper), a GI bleeding's severity score indicates the prognosis: <3 indicates a positive prognosis; >8 indicates a high chance of death. Test for H.pylori The 13C-Urea breath test is used to test for H. pylori. Radiolabelled urea is administered orally, and 13C is found in the exhaled air. Serology: H. pylori-specific IgG antibody; indicates exposure but not eradication. stool antigen examination. Test for organisms similar to Campylobacter. A pH indicator and urea substrate are used for the gastric biopsy. If H. pylori is present, the urea produces ammonia and the sample's color changes from yellow to red. Biopsia histology: H. pylori is difficult to see, hence its usefulness is restricted. Imaging: To look for signs of a perforation, set up a CT or CXR. Management Acute: Providing endoscopic or surgical treatment and resuscitation if bleeding or punctured. Endoscopy: Electrocoagulation, laser, or injectable sclerotherapy hemostasis. Surgical: If an ulcer is ruptured, it can be covered with an omental patch or oversewn. Suturing the damaged vessels (usually the gastroduodenal artery) stops the bleeding. Trans-arterial embolization, vagotomy, and/or partial gastrectomy may be used in chronic situations where ulcer-related bleeding is uncontrollable. Medical: "Triple therapy" to eradicate H. pylori for 1-2 weeks: It is advised to use one PPI/ranitidine bismuth sulphate and two antibiotics in different combinations (e.g. metronidazole ÷ tetracycline; clarithromycin ÷ amoxicillin). PPIs or H2-antagonists can be used to treat if H. pylori is not involved. If you must use an NSAID, stop using them, especially diclofenac. Instead, try misoprostol, an analogue of prostaglandin E1. Complications Major complications, such as haematemesis, melaena, iron deficiency anemia, perforation, obstruction/pyloric stenosis (caused by scarring), and pancreatitis, occur at a rate of 1% annually. Prognosis Lifetime risk overall: 10%. Generally excellent since H. pylori-related peptic ulcers can be healed with removal. Surgery - Esophageal Perforation
Introduction rupture of the oesphogeal wall, frequently resulting in mediastinum contents spilling out. Etiology The Boerhaave syndrome is spontaneous. In the absence of underlying illness, barogenic disruption of the oesophageal wall is most frequently brought on by violent vomiting and sometimes strong Valsalva maneuvers, such as parturition or intense weightlifting. Iatrogenic: During dilatation or upper gastrointestinal endoscopy, for example. Trauma: foreign bodies, penetrating wounds, and infrequently blunt injuries. Caustic: Consuming acid or alkali "lye" increases the risk of perforation and causes liquefactive or coagulative necrosis. Epidemiology Males > females (4: 1), a rare case of Boerhaave's condition. History abrupt, intense chest pain that usually follows a period of elevated intra-abdominal pressure and vomiting. It takes a great degree of suspicion. Examination The Mackler trinity, which includes vomiting, chest pain, and subcutaneous emphysema, includes tachypnea, tachycardia, and epigastric tenderness. Rarely does haematemesis occur. Pathogenesis In the distal oesophagus, spontaneous perforations typically manifest as a longitudinal tear that happens posterolaterally. Gastric contents are drawn into the mediastinum and pleural cavity by negative intrathoracic pressure, which results in chemical mediastinitis and quickly progresses to severe sepsis. Ten to twenty percent are linked to underlying disorders of the oesophagus, such as infection, cancer, or peptic ulcer. Investigational studies Imaging: Pleural effusion, air-fluid collections, pneumothorax, pneumediastinum, and subcutaneous emphysema can all be seen with a CXR or CT scan. Swallow a water-soluble contrast agent to identify leaks (10% false negatives). Oesophagogastroscopy: Should only be carried out in a suitable facility by skilled endoscopists. able to verify the damage site, degree, and presence of any underlying pathology. permits the nasogastric tube to be inserted for gastric drainage as well. Management Emergency: ABC resuscitation: oxygen, ventilation, and circulatory support; IV fluids; catheterization of the urinary tract; stringent fluid management; IV proton pump inhibitors; early intensivist review; interdisciplinary treatment; and close observation in an ICU or HDU. Control of sepsis: no oral medication, starting broad-spectrum antibiotics and antifungal medications, maintaining adequate chest drainage, and continuing feeding. best treated in a dedicated oesophagogastric unit. Non-operative management: Only in few instances with low contamination or cervical perforations, early detection, and limited harm. It is reported that some early perforations were clipped endoscopically. Thoracotomy, devitalized oesophageal tissue, drainage, and debridement of contaminated area are the surgical procedures. Primary repair and reinforcement, such as flap pleura or intercostal muscle (which may fail and leak), repair over T-tube (which permits formation of a controlled oesophagocutaneous fistula), oesophageal resection with either immediate or delayed reconstruction (a major undertaking), and exclusion and diversion (which forms an oesophagostomy and requires reconstruction later) are among the available treatment options. It is necessary to create a feeding jejunostomy for enteral feeding. Complications Subcutaneous emphysema, pleural effusion, severe sepsis, shock, multiple organ failure, and death are possible outcomes. Prognosis 20% overall high death rate (up to 60% in cases of late presentations; 10% with early diagnosis and treatment). Surgery - Esophageal Carcinoma
Introduction malignant tumor developing in the mucosa of the oesophagus. Adenocarcinoma and squamous cell carcinoma are the two main histological forms. Etiology Alcohol, tobacco, specific vitamin and trace element deficiencies, HPV infection, achalasia, Paterson-Kelly (Plummer-Vinson) syndrome, tylosis (Howel-Evans syndrome), scleroderma, coeliac disease, lye stricture, history of prior thoracic radiation therapy or upper aerodigestive squamous cancer, and dietary nitrosamines are all associated with squamous. Adenocarcinoma: 0.5–0.7% of cases of adenocarcinoma each year are associated with intestinal metaplasia of the distal oesophageal mucosa, or GORD, Barrett's oesophagus. Epidemiology Eighth most frequent cancer (7000–8000 cases annually in the UK). Male to female ratio: 3–4:1. Squamous carcinoma is more prevalent globally, yet there is significant regional heterogeneity (high prevalence in northern China, Iran and southern Russia). Adenocarcinoma is becoming more prevalent in westernized nations (65% of cases in the UK), growing at a rate of 5–10% year. Peak case frequency: 60–70 years. History Early: Reflux symptoms or asymptomatic. Subsequent symptoms include dysphagia, which is initially worse with solid food, regurgitation, coughing or choking after eating, pain (odynophagia), exhaustion, and hoarseness of voice (which may be a sign of recurrent laryngeal nerve palsy). Examination There might not be any outward indications of weight loss.Hepatomegaly and supraclavicular lymphadenopathy are possible symptoms of metastatic illness. Indirect tracheobronchial involvement or aspiration may be the cause of respiratory symptoms. Pathogenesis The mid-upper oesophagus is more commonly affected by squamous cell carcinomas. Usually, adenocarcinomas originate in the gastro-oesophageal junction (GOJ) or the lower oesophagus. Invasive carcinoma, high-grade dysplasia, and low-grade dysplasia can develop from Barrett's intestinal metaplasia. Since the oesophagus lacks a serosa, spread is usually first direct and then longitudinal, traveling through a vast network of submucosal lymphatics to reach nodes in the tracheobronchial, mediastinal, celiac, stomach, or cervical regions. Leiomyosarcoma, melanoma, and lymphoma are uncommon oesophageal tumors. Investigational studies endoscopy: biopsy and localization of tumor. Narrow band imaging, magnification, and chromoendoscopy are examples of endoscopic procedures that improve early identification of high-grade dysplasia and malignancy. T (depth of tumor involvement) and N (perioesophageal node) involvement can be determined by endoscopic ultrasonography. Imaging: Barium swallow, CT (chest, abdomen, pelvis), and PET can identify distant metastases that were previously undetected. Other: bone scan if there are signs of skeletal involvement, bronchoscopy (if there is a possibility of tracheo-bronchial invasion). Thoracoscopy, laparoscopy, and peritoneal washings. thorough evaluation of the heart and lungs if surgery is intended. Management Most effectively run in specialized facilities with interdisciplinary knowledge. Endoscopic therapy, such as endoscopic submucosal dissection and endoscopic mucosal excision, are becoming more common for early (mucosal) localized illness. Merely thirty percent are appropriate for surgical resection. Before surgery, neoadjuvant chemoradiotherapy (cisplatin, 5-fluorouracil, etc.) can help downstage tumors. Surgery: The surgical strategy is determined by the location of the tumor and the desired lymphadenectomy's extent. Transthoracic approach: laparotomy and Ivor-Lewis right thoracotomy (middle-to lower-third tumors). Transhiatal approach: oesophagogastric anastomosis (upper third tumors) is performed by laparotomy, blunt dissection of the thoracic oesophagus, and cervical incision. McKeown tri-incisional technique, involving the abdomen, right chest, and neck. Reconstruction involves creating a conduit, usually gastric, based on the right gastroepiploic and gastric arteries' vascular pyramid; colon or jejunum are less frequently used (for GOJ tumors with extensive stomach involvement). It is common practice to conduct a feeding jejunostomy for postoperative enteral nutrition and a pyloroplasty for stomach drainage. Studies have indicated that a more thorough lymphadenectomy (three fields as opposed to two) improves survival. Increasingly popular minimally invasive techniques include laparoscopic and thoracoscopic dissections. Squamous cell carcinomas are more radiosensitive than adenocarcinomas when it comes to radiation and chemotherapy. In individuals with localized illness, chemoradiotherapy or radical radiotherapy may be used if surgery is not an option. When tolerated, neoadjuvant and adjuvant chemotherapy with a regimen centered on cisplatin is administered. Palliation: It is customized based on the tumor and symptoms of each patient. Luminal recannulization can be accomplished using photodynamic therapy, laser ablation, or inflatable stents. Chemotherapy and/or radiotherapy, such as 5-fluorouracil, epirubicin, and cisplatin, are linked to varying response rates. Complications malnourishment, aspiration pneumonia, haematemesis, and oesophago-bronchial fistula related to the tumor; ascites and pleural effusions related to metastatic illness. Of oesophagectomy: morbidity up to 40%; mortality <5% in specialized centers. The most frequent consequences are pulmonary in nature, such as pneumonia and atelectasis. Anastomotic leakage (5–15%) and conduit failure are examples of serious consequences; other risks include chylothorax and recurrent laryngeal nerve injury. Prognosis Depending on the stage. The 5-year survival rate is 20–25% overall; it is <5% in cases of advanced illness. |
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