Sunday, September 4, 2011

A Note On Surgical Management of Oral Cancer...


Oral epithelium
      Squamous cell carcinoma
      Basal cell carcinoma
      Malignant melanoma
Salivary glands
      Benign
      Malignant
Muscles
Bone
Metastatic tumours
Nerves
Blood Vessels, Lymphatics





Multidisciplinary approach in the management
OMF Surgeon
        Oncologist
        Pathologist
        Anaesthetist
        Prosthodontist
        Psychologist
        Nursing staff
        Cancer care workers
        Others
Available treatments
1.Curative treatment
2.Paliative treatment
3.Terminal care
Curative treatments
             Surgical treatment
             Radiotherapy (curative,Adjuvant,Neo adjuvant)
             Chemotherapy
               Chemo prevention
               Chemotherapy
            Combination
             Gene therapy
             Photo sensitisation
      Pre operative care
            Investigations
General medical condition:
              Hematological- FBC (Hb,PCV), Clotting profile…
              Bio chemical- Liver function, BU, SC, SE, FBS, UFR
              CXR, ECG, 2D ECHO….
Primary lesion:
              Adjuncts  to biopsy- methelene blue, Vel scope
              FNAC, Biopsy, EUA
              Endoscopy
              Plain x-rays, CT, MRI, PET, Frozen section
Regional extension: Neck
              USS, USS guided FNAC, sentinel node Bx, CT,MRI
Distant metastasis:
             CXR, USS abdomen, Liver function, Brain CT, Bone scan
Donor site:
              X rays, Doppler, Alan’s test.

Patient preparation
Consent
            Appropriate referrals
            Nutrition
            Drugs: warfarin, Heparin, Anti
        hypertensives, diabetic drugs….
            General hygiene
            Oral hygiene
           Withdrawal syndrome
            Orientation
            Plates
            Blood
            Shaving
            Avoid pricking on donor sites
            Allen’s test
           Doppler study
           Surgical plates / obturators
           Antibiotics
    Surgical treatment
        Excision of primary tumour
        Neck dissection
        Reconstruction
        Rehabilitation
        Social
        Physical
        Psychological
        Follow up
       Primary tumour resection
       cheek resection(buccal mucosa only or full thickness)
        mandibulectomy (alveolectomy, segmental, hemi)
       Tongue- partial, hemi, subtotal
       Maxillectomy
       Composite defect


      Reconstruction

       Local flaps
      Random ---- Advancement---Burrows ,VY,transpo
                   ---- Pivot principle---rotational,transposion
      Axial   ---- fore head, naso labial
      Distant flaps
      Deltopectoral
      PMMC
      Latisimus Dorsi
      Sternomastoid
      Trapezius
      Free flaps: RFFF, FFF, LD, R.ab, lat th
    
                                                                                                                    Karapandzic flaps

                                                                                                                    Bernard’s Technique

                                                                                                                   Free flaps

                                                                                                                    Naso labial  flap

      Micro vascular surgery


       Anesthetic considerations
         Temperature
         Pain control
         Blood pressure
         Hb
       Primary and secondary ischemic time
       Postoperative Care
        01. Postoperative nursing care:
      Trained nurse-1st 24-48 hrs, sterile suction,humidification, rescue stitch-facilitate tube replacement, slate/pad,pen.
       02. Fixation of the tracheostomy tube:
              Dif if dislodged within 48hrs, stitch to skin. Tapes are enough for 2nd tube, put on neutral position, knots one each side of the neck (1/3,2/3), should not tight-lymphatic obs, donot put across the pedicle.
       03. Removal of secretions:
            Excess secretions are inevitable, tube act as f.body,exposed to cold, dry air. Oozing blood. Suck every 30min, 4hrly-immediate post opp period.
       04. Humidification:
               Warming, humidification-prevent crusting of secretions. Hot water humidifiers, nebulizers through masks or   T tube to trachy tube. Instillation of saline into the trachea.
       05. Changing of tracheostomy tube:
              1st 48 hrs – cuffed tube, mandatory to use t.tube with inner & outer tubes, this facilitates cleaning
             The 1st two changes in after 48hrs, slightly smaller tube can be inserted.
             Thereafter twice a week to avoid infection & crusting.
          Ask the pt to breath in & out, ask him to hold the breath in expiration (maximum diameter), then insert a tube.
          Within 48hrs, insert a catheter in to the old tube as guide. Tracheal dilators, laryngoscope. Doctor should be present at 1st tube change.
       06. Care of the inflatable cuff:
            If its pressure exceeds the systolic blood pressure-ischemic necrosis.
            Cuff should be inflated for the 1st 12 hrs following surgery & during this time deflated for 5min every hour.
            After 12-24 hr if there is no bleeding, or not ventilated, let down.
             New high volume, low pressure cuffs are now available.
        07. Breathing exercises:
            Physiotherapist,
        Is secretions are excessive, vigorous treatment by intermittent positive pressure breathing or inflated Ambu bag after suction has been performed.
            Block for 24 hrs. if no difficulties-can be withdrawn. Wound dressings.
       08. Dressings:
            Changing regularly.
       09. Drains:
           Vacume should be maintained.
       10. Leaking drains:
           Saliva, air or infected secretions are accumulated underneath the skin flap.
           Infection and wound breakdown.
           Local packing with saline soaked swabs or jelonet rolls.
           If exit hole is there-pursestring suture, push the tube in??, Opsite spray,adhessives to cover the hole.
       11. Type of drainage:
          After a radical ND:- within 1st 24-48hrs entirely blood appro 200ml/day.
         After 48-72hrs become serous,
         After 4 days – usually only 25 ml in 24 hrs.
        If a localized fistula occur pack & allow to heal by 2ry intention.
         Presence of chyle or lymphatic leak within the d.tube. ????
      12. Removal of drains:
          Remove when it stops draining?????
         If there is a problem-blockage-remove it-otherwise infection.
         Should not be removed until the drainage is less than 25ml, colour become blood red to serum.
         Sucking serum from capillaries.
         Remove by the 4th or 5th day if the daily drainage has been consistent for 48hrs.
      13. Intravenous fluid:
       Head & neck Sx pts: NG tube, PEG, open gastrostomy or Jejunostomy. Usually not require parental feeds, can fed within 48hrs of operation.
           In 1st 48hrs pt must not given too much water & salts----pulmonary oedema.
      Between the end of operation & next day morning---IV fluids (responsibility of the anesthetist & surgical team).
            Blood & fluids if required. Through CVP line.
          CVP can be removed if the pt – if Hb & electrolytes are normal, NG tolerating, CVP is not needed for any other solutions or antibiotics.
             Urinary output ? Early hrs, fluid balance??
      14. Oral feeding:
        In major abdominal Sx-after GIT function.
         H&N sx – can be given if bowel sounds have returned.
        Can be fed from day 1.
    NG tube, PEG, open gastrostomy or Jejunostomy where enteral feeding is anticipated for short period after Sx.
           For longer periods-Preopp PEG under LA with sedation. PEG is helpful if the pt need post opp RT.
           Full strength feeds providing about 2400 kcal in 24 hrs can be achieved on the 2nd day.
        Pts who do not have above methods-IV nutrition (parental nutrition-TPN) for several day after sx. Cost??? Sepsis ???
        15. DVT prophylaxis:
           Pt assessment for high, moderate & low risk.
           Low risk pts – mobilize early.
            Moderate risk pts – early mobi, TED-graduated compression stokings.
      High risk pts – including all H&N oncology pts – perioperative & post operative Sc LMW heparin (Tinzaparin 3500 units daily), until the pt mobile, along with TED.
       16. Monitoring of flaps:
       Local flaps:- require observation, distant pedicled flaps-observe for 1 week. (gross vascular changes…), revision may required.
             MV free flaps:- constant monitoring, often go wrong in the 1st 48 hrs
Medications:
           Antibiotics:
           Prophylactic AB cover is indicated in a number of situations.
           It is not required for clean Sx-superfi,parotidectomy, MRND. Last for < 3hrs.
            Longer procedures, shaving-within 24hrs: short AB prophylactic cover (48hrs)
           Co-amoxiclav or Cefuroxime.
          Specific indications: anti MRSA therapy.
          Main indication for prophylactic AB in H&N sx for-mouth pharynx,larynx, upper oesophagus.
          Gram +ve cocci & anaerobes.
          Gram –ve cocci- seldom present, colonize the mouth within 2-3 days.
          Co-amoxiclav or Cefuroxime and Metronidazole.
           Erythromycin – significant GIT upset, not tolerated IV.
          If risk of post opp infection continue for 5 days.
          If infected – swabs, culture & ABST.
          Chest infection should be prevented.
           Oral hygiene – important.
          Thyroid & parathyroid replacement:
          After total thyroidectomy, parathyroidectomy—Ca balance, thyroid hormone repla
        Half life of thyroxine is 10 days, can start 1 week after the sx. Thyroxine 100ug/day, in elderly 50ug/day. On discharge 150ug/day
Dressings & Sutures:
           Wound dressings- several ADR;
           Make the wound warm
           Macerated & liable to infection
            Haematomas?
            Small amount of gauze dressing to prevent small leak. Removed after 12-24 hrs.
            Not a good idea to apply pressure bandages around the neck;
           Occlude venous return via vertebral veins.
            But  has a value after parotidectomy for 24hrs-prevent haematoma.
           Sutures:
           Skin sutures can be removed in 7 days,
           Extend to 10 days if he received previous RT,
           After laryngectomy 10 days to 2 weeks: tension, dif to remove with laryngectomy tube,
           Monofilaments synthetic sutures can be left longer than silk,
           (silk-micro abscesses within 72 hrs),
           Intra oral Vicryl do not need  to be removed.
            Post operative examination:
           Twice a day:- H&N, chest, abdomen and calves.
           Getting up:
            As soon as possible after Sx,pt can propped up in bed at 45 degree to avoid lymphatic stasis.
            Bilateral ND-never lie flat. Danger of cerebral oedema.
            After carotid blow out pt must be nurse flat for 48hrs. Then raise by 1 pillow per day.
            Pt should be walking freely around the ward within 72 hrs. helps to prevent post op chest infection & DVT.
Follow up:
        risk of developing recurrent disease,
             Should be followed up at regular intervals,
             In each follow up visit-examine;
             Primary site for recurrence
             Neck for LN
             LN met is more likely to present within 1st 2 years.

2 comments:

  1. Thanks for the post.It was really helpful to solve my confusion,

    Occupational Medicine

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