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-1^st 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 2^nd 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:

              1^st 48 hrs – cuffed tube, mandatory to use t.tube with inner & outer tubes, this facilitates cleaning

             The 1^st 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 1^st tube change.

       06. Care of the inflatable cuff:

            If its pressure exceeds the systolic blood pressure-ischemic necrosis.

            Cuff should be inflated for the 1^st 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 1^st 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 4^th or 5^th 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 1^st 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 2^nd 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 1^st 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 1^st 2 years.