Most oral cancers begin in the tongue and in the floor of the mouth. Squamous cells
Lips Lining of your cheeks Salivary glands (glands that make saliva) Roof of your mouth (hard palate) Back of your mouth (soft palate and uvula) Floor of your mouth (area under the tongue) Gums and teeth Tongue Tonsils
Found during regular dental check up
PAINLESS SORE OR MASS that will not heal SORE THROAT
White patches (leukoplakia) are the most common Mixed red and white patches (erythroleukoplakia) are more likely than white patches to become malignant Red patches (erythroplakia) are brightly colored, smooth areas that often become malignant.
Dental x-rays : An x-ray of your entire mouth can show whether cancer has spread to the jaw. Exfoliative cytology: A procedure to collect cells from the lip or oral cavity. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the lips, tongue, mouth, or throat. The cells are viewed under a microscope to find out if they are abnormal.
oral and maxillofacial surgeons, otolaryngologists (ear, nose, and throat doctors), medical oncologists, radiation oncologists, and plastic surgeons.
Neck Dissection is an operation designed to remove groups of neck lymph nodes for treatment of cancer that has spread from a primary site elsewhere in the head and neck region. Neck Lymph Nodes Neck Nodes are divided into seven different levels. There are 5 levels in the lateral compartment and 2 in the central compartment. The 5 lateral levels are shown below Primary tumours in various individual sites tend to spread to different nodal levels often in a predictable manor. For example skin tumours from the lip and anterior face tend to spread to Level I and Level II and/or other levels subsequently, while melanomas on the posterior scalp tend to spread to nodes at levels 2-5, and thyroid cancers tend to most commonly involve nodes at levels 4 and 6. Outcome is affected by the number, size, and position of lymph nodes involved. Cancer also has the ability to grow beyond the confines of the lymph node capsule into surrounding tissues: this is known as extranodal spread (ENS) or extra-capsular spread (ECS) and it is a bad prognostic factor. Usually the larger the node the higher the chance of extra-nodal extension. Primary Tumours The types of Head and neck cancers that spread to neck lymph nodes include: Squamous Cell Skin Cancers and Melanoma of the face, scalp, and neck Thyroid Cancers Salivary Gland Cancers Mouth and Throat Cancers Principles of Neck Dissection Neck Dissections are performed in two situations (a) where neck lymph nodes are known to definitely be involved with cancer (Therapeutic Neck Dissection) or (b) if there is a high probability that lymph nodes will be involved based on the type of primary cancer and its site even though there are no obvious involved nodes (elective neck dissection). Elective neck dissections are usually performed if the risk of metastatic disease to lymph nodes occurring is greater than 25%. If there are multiple nodes involved or if there is extranodal extension present adjuvant treatment with radiation may be required to minimize recurrence. Types of Neck Dissection There are several types of Neck Dissection: Selective Neck Dissection Level I-III (Supraomohyoid) Level I-IV (Extended supraomohyoid) Level II-IV (Lateral) Level II-V (Posterolateral) Level VI (Central) Level VII (Superior mediastinal) Comprehensive Neck Dissection Modified Radical Radical Comprehensive Neck Dissection A comprehensive neck dissections involve removal of all five lateral lymph node levels (levels I-V) and is usually performed for clinically detectable neck metastases particularly if these are multiple or large nodes at several levels. A Radical Neck Dissection involves removal of lymph node from levels I-V, as well as the sterno-mastoid muscle, the internal jugular vein and the spinal accessory nerve. Radical neck dissection is largely of historic interest and has largely been replaced by the Modified neck dissection which involves sparing one or more of the above non lymph node structures. This can usually be done and usually means sparing the accessory nerve, the internal jugular vein and at least part of the sternocleidomastoid muscle. The results of conservative neck dissection are equivalent to the results for radical neck dissection but the morbidity is much less (complications of shoulder pain, neck swelling, and deformity) Selective Neck Dissection During the 1980's it became apparent that recurrence rates were no different between selective dissections and more radical procedures but the morbidity of the “ selective” procedures was shown to be less. In addition, data are now available indicating likely levels of nodal involvement for individual cancer sites e.g., lip spreading to Level 1,2 &3, posterior scalp melanoma spreading to levels 2-5, while the most common sites for facial and anterior scalp melanoma to spread to are nodes in the parotid salivary gland and level 2 -4. Selective Neck Dissection is the emerging as the procedure of choice for treating occult or early clinical neck metastases. Technique Selective Neck Dissection The incision is dependent upon which nodes are to be resected. For Levels 1-4, a ‘ hockey stick’ incision is usually made from the mastoid muscle extending down the neck and anteriorly. If parotid nodes also require dissection, this can be included as shown in Fig 1 below. For dissection of Levels 2-5, for example in the treatment of a posterior scalp melanoma with regional disease, an incision similar to Fig 2 below is required. The incision is deepened to form flaps, important nerves are avoided and relevant nodes resected. Usually the internal jugular vein and sternomastoid muscle and the eleventh cranial nerve can be preserved but if they are involved by the cancer they also require resection. A drain is briefly required and hospital stay is usually 2-3 days. Complications Complications include: Bleeding Nerve injury Prolonged lymph leak Seroma (fluid collection deep to skin flaps). NB: Although all of the above may occur, major and/or prolonged complications are unusual. Outcome is usually satisfactory and survival following such surgery is mainly dependent on the extent of the cancer at the time of treatment. Central Neck Compartment Lymph Nodes These nodes are of particular importance with respect to thyroid surgery. Level 6 nodes are those immediately adjacent to the thyroid, while level 7 nodes are those below the thyroid behind the sternum (Breast bone). See Fig below:
artial Glossectomy For a partial glossectomy, the surgeon removes the part of the tongue that is cancerous. Once this is cut out, your remaining tongue is sewn so that there is no hole left. Sometimes a small graft of skin is used to fill this hole, and is sewn into place. Total Glossectomy This is a more complicated surgery. For this procedure, the surgeon removes the diseased tongue. A piece of skin from your wrist is also removed and then placed in the hole left by the tongue. Blood vessels are attached from the graft to any remaining tongue to ensure blood flow. Sometimes the lymph nodes in the neck are also removed
Failure of flap—when surgery transfers a flap of skin to the tongue and the transplanted skin or flap doesn’t get enough blood flow
Coughing. Esophageal cancer can erode your esophagus and create a hole into your windpipe (trachea). Known as a tracheoesophageal fistula, this hole can cause severe and sudden coughing whenever you swallow. Preparing for your appointment Risk factors
Stage I. This cancer occurs only in the top layer of cells lining your esophagus. Stage II. The cancer has invaded deeper layers of your esophagus lining and may have spread to nearby lymph nodes. Stage III. The cancer has spread to the deepest layers of the wall of your esophagus and to nearby tissues or lymph nodes. Stage IV. The cancer has spread to other parts of your body.
Surgery to remove a portion of the esophagus (esophagectomy). Your surgeon removes the portion of your esophagus that contains the tumor and nearby lymph nodes. The remaining esophagus is reconnected to your stomach. Usually this is done by pulling the stomach up to meet the remaining esophagus. In some situations, a portion of the colon is used to replace the missing section of esophagus. Surgery to remove part of your esophagus and the upper portion of your stomach (esophagogastrectomy). Your surgeon removes part of your esophagus, nearby lymph nodes and the upper part of your stomach. The remainder of your stomach is then pulled up and reattached to your esophagus. If necessary, part of your colon is used to help join the two.
Helicobacter pylori infection : H. pylori is a bacterium that commonly infects the inner lining (the mucosa) of the stomach. Infection with H. pylori can cause stomach inflammation and peptic ulcers. It also increases the risk of stomach cancer, but only a small number of infected people develop stomach cancer. Long-term inflammation of the stomach : People who have conditions associated with long-term stomach inflammation (such as the blood disease pernicious anemia) are at increased risk of stomach cancer. Also, people who have had part of their stomach removed may have long-term stomach inflammation and increased risk of stomach cancer many years after their surgery. Smoking : Smokers are more likely than nonsmokers to develop stomach cancer. Heavy smokers are most at risk. Family history : Close relatives (parents, brothers, sisters, or children) of a person with a history of stomach cancer are somewhat more likely to develop the disease themselves. If many close relatives have a history of stomach cancer, the risk is even greater. Poor diet, lack of physical activity, or obesity : Studies suggest that people who eat a diet high in foods that are smoked, salted, or pickled have an increased risk for stomach cancer. On the other hand, people who eat a diet high in fresh fruits and vegetables may have a lower risk of this disease. A lack of physical activity may increase the risk of stomach cancer. Also, people who are obese may have an increased risk of cancer developing in the upper part of the stomach. Most people who have known risk factors do not develop stomach cancer. For example, many people have an H. pylori infection but never develop cancer. On the other hand, people who do develop the disease sometimes have no known risk factors.
otal gastrectomy reconstruction with a Roux-en-Y procedure to prevent bile from entering esophagus
A colostomy and an ileostomy are two kinds of surgery. These surgeries are done when a part of your intestine is diseased or damaged and doesn't work right. The surgeon makes a hole in your belly and connects part of the small or large intestine to that opening in the skin. This opening is called the stoma. After you have a colostomy or ileostomy, waste leaves your body through the stoma instead of the anus. There is no muscle around the stoma, so you are not able to control when waste or gas passes out of your body. To collect the waste, an odor-proof plastic pouch (an ostomy pouch) is connected to the stoma and held to your skin with an adhesive.
A colostomy attaches the colon to an opening in the wall of the abdomen to create a stoma. It is performed for intestinal problems such as cancer of the colon, obstructive tumors, diverticular disease, and severe abdominal wounds. It may be temporary or permanent. Patients lead normal lives and learn how to empty their colon by using a special collecting device. They also learn about necessary dietary changes and how to clean and care for the stoma and its protective cover. An ileostomy connects the small intestine to an opening in the wall of the abdomen to create a stoma. It is required when the large intestine and rectum must be removed due to disease or abnormality. The opening becomes an artificial anus for expelling solid waste. The patient continuously wears a disposable bag that collects the semiliquid waste. The frequent passage of similiquid waste can cause the skin around the opening to become irritated. A variation exists for patients with intact anal muscles. It involves joining the small intestine to an inside pouch just above the anus. This pouch may be called a J-pouch or W-pouch. Careful skin care and a well-fitting bag can help to protect the skin. This allows for elimination of solid waste in a more normal way.
An Overview of Ileoanal Reservoir (Pouch) Surgery Linda B. Hurd, RN, MSN The ileoanal reservoir procedure is a surgical treatment option for chronic ulcerative colitis, colon cancer and familial polyposis patients who need to have their large intestine (colon) removed. An ileoanal reservoir (or pouch) is an internal pouch formed of small intestine. This pouch provides a storage place for stool in the absence of the large intestine. Anal sphincter muscles assist in holding in the stool. Several times a day, stool is passed through the anus. Ileoanal reservoir surgery is a widely accepted surgical treatment for ulcerative colitis or familial polyposis because it eliminates the disease, gives the patient control of bowel movements and does not require a permanent ileostomy. Each patient considering this surgery is carefully evaluated to determine if this procedure is appropriate for them. This procedure is performed in one, two or three stages, but is most often done in two stages, usually 2-3 months apart. Stage I: The first surgery removes the entire large bowel and the lining of the rectum, but leaves the rectal muscle intact. A reservoir or "pouch" is made out of small intestine and then is connected to the anus. Next, a temporary ileostomy is made. An ileostomy is a surgically created opening between the small bowel and the skin of the abdomen through which stool and gas are passed. This temporary ileostomy diverts the stool; protecting the reservoir (pouch)while it heals. (See figures 1, 2 and 3) What to expect after the first surgery: In the initial weeks after surgery, waste material coming through the ileostomy is liquid but then begins to thicken. A good diet with increased fluid intake is needed to keep well hydrated and nourished. Patients wear an ileostomy appliance over the ileostomy that collects the waste as it passes through the ostomy (or opening) on the abdomen. Learning to care for the ileostomy is a little tricky but with practice becomes very manageable. Patients also may occasionally pass small amounts of mucus or blood through the rectum. Approximately four to six weeks after the first surgery, an x-ray study of the pouch is performed. If the study shows that the pouch is healed, then the second surgery can be scheduled. Stage II: The second surgery (usually done 2-3 months after the first) "takes down" or removes the ileostomy and reconnects the bowel. The pouch now becomes functional so that waste passes into the pouch, where it is stored. When an "urge" is felt, the stool can be passed through the anus, out of the body. In most cases, the second surgery can be done at the ileostomy site without re-opening the first incision. The skin at the former ileostomy site is usually left to close on its own. (See figure 4) What to expect after the second surgery: Once a patient starts passing stool through the anus, stools are frequent and liquid. There may be accompanying urgency and leakage of stool. All of these aspects improve over time as the anal sphincter muscles strengthen and the pouch adapts to its new function. Stools become thicker as the small intestine absorbs more water. In addition, medications to decrease bowel activity and bulk-forming agents to thicken the stool may be prescribed. Patients can help during this adaptation process by avoiding foods that may cause gas, diarrhea and anal irritation. Careful skin care around the anus will protect the skin from the irritation of frequent stools. Continuing anal sphincter muscles exercises ( Kegel Exercises ) during this time is also beneficial. After six months, most people can expect about five to six semi-formed bowel movements during the day and one at night. The pouch takes up to one year to fully adapt. In most patients, functioning of the pouch continues to improve over time. General Considerations: When considering and undergoing this surgery, all patients and their loved ones have concerns and questions. Sometimes they feel isolated and frightened. It is helpful for all involved to receive general information about this surgery and understand what to expect during the course of these procedures. In addition, patients and family members may be interested in contacting an ileoanal support group, which provides a place to learn more about this surgery and to meet others with similar concerns and experiences. Be sure to talk with your gastroenterologist, surgeon or ET nurse about these issues and keep in close contact with them during the surgeries and throughout the rehabilitation process. Patient satisfaction with this surgery is high and with both ulcerative colitis and familial polyposis patients, their disease is cured!
Ileal pouch reconstruction surgery performed by UW Health surgeons patients with conditions such as ulcerative colitis, familial polyposis and certain types of colon cancer to avoid living with a permanent ileostomy and external appliance after colectomy. The J-, S-, and W-reservoirs are the most common types of pouches used in ileal pouch reconstruction. The number of limbs and the amount of small bowel used to create them distinguishes the various types of pouches and reconstruction procedures.
Digestive & gastrointestinal system
Digestive & Gastrointestinal SystemMaria Hazel Organo-Rosario, RN,MAN Clinical Instructor College of Nursing, UNP
-Occurs in the mouthand throat-Highly curable if discovered early
begin in the tongue and in the floor of the mouth • mouth • part of the throat • back of the mouth • Lips • Lining of cheeks • Salivary glands • Roof of the mouth • Back of the mouth • Gums & teeth • Tongua • tonsils
RISK FACTORS • Smoking • Drinking alcohol • Sun exposure • personal history of head and neck cancer
PATHOPHYSIOLOGY RISK FACTORS ↓ SQUAMOUS CELLS ↓ CELL DAMAGE ↓ CELLULAR CHANGES ↓ MALIGNANCIES ↓ LIPS FLOOR OF LATERAL ASPECT THE MOUTH OF THE TONGUE
-Occur anywhere in the esophagus-Common in men
TYPES• Adenocarcinoma –cells of mucus-secreting glands in the esophagus• Squamous cell carcinoma –flat, thin cells that line the surface of the esophagus
RISK FACTORS• Drinking alcohol, smoking• Having bile reflux• Chewing tobacco• Achalasia• Drinking very hot liquids• Eating few fruits and vegetables• GERD• Being obese• Barretts esophagus• Undergoing radiation treatment
RISK FACTORS • Being male • Being between the ages of 45 and 70
PATHOPHYSIOLOGY SQUAMOUS CELL EPIDERMOID ESOPHAGEAL MUCOSA LAYERS AND LYMPHATICS OBSTRUCTION PERFORATION TO THE EROSION INTO THEMEDIASTINUM GREAT VESSELS
CLINICALMANIFESTATIONS 1. ADVANCED ULCERATED LESION 2. DYSPHAGIA 3. A SENSATION OF A MASS IN THE THROAT 4. SUBSTERNAL PAIN 5. REGURGITATION OF UNDIGESTED FOODS 6. FOUL BREATH 7. HICCUPS 8. HEMORRHAGE 9. WEIGHT LOSS 10. LOSS OF STREGTH 11. RESPIRATORY DIFFICULTY
COMPLICATIONS • Obstruction of the esophagus. • Cancer pain. • Bleeding in the esophagus. • Severe weight loss. • Coughing.
DIAGNOSTIC EXAMS A. ENDOSCOPY B. EGD C. BRONCHOSCOPY D. ENDOSCOPIC UTZ E. MEDIASTINOSCOPY F. BARIUM SWALLOW
VAGOTOMY SYNDROME • No boost or ensure! • Occur 20 mins-2 hrs after meal • Severe abdominal pain & watery diarrhea • Remain upright 2 hrs after meals
ZOLLINGER- ELLISON SYNDROME / GASTRINOMA- severe peptic ulcers
ZOLLINGER ELLISON SYNDROME • rare condition characterized by excessive production of gastric acid due to slow growing tumor in the pancreas • ETIOLOGY: – result from gastrin secreting tumor – excessive gastrin in the blood62 – continued secretion of gastrin
ZOLLINGER ELLISON SYNDROME • CM: – increased serum gastrin levels – large amts of HCL acid – Steatorrhea – Increased parietal cell mass – Hypertrophied duodenal glands – Malignant gastrinomas in the pancreas – Ulceration in any portion of the64 stomach or duodenum
CLINICALMANIFESTATIONS • EARLY STAGE: symptoms may be absent or may resemble those of pts with benign ulcers (pain relieved with antacids)
ClinicalManifestations • Early – Indigestion – Loss of appetite, especially for meat • Late • Abdominal pain or discomfort in the upper abdomen • Nausea and vomiting • Diarrhea or constipation • Bloating of the stomach after meals • Weight loss • Weakness and fatigue • Bleeding (vomiting blood or having blood in the stool • Dysphagia
DIAGNOSTIC EXAMS 1. ENDOSCOPY WITH CYTOLOGIC WASHING 2. BARIUM X-RAY OF UGIT 3. CT-SCAN 4. BONE SCAN 5. LIVER SCAN
MEDICAL MGT• Removal of the gastric carcinoma –Curative if tumor can be removed while still localized to the stomach
THERAPEUTIC INTERVENTIONSA.SURGERY 1. RADICAL SUBTOTAL GASTRECTOMY 2. TOTAL GASTRECTOMY 3. SLEEVE & MINI SLEEVEB.CHEMOTHERAPY
duodenum Transverse colonAscending colon Small intestinescecum Descending colon A sigmoid P rectum P E D I82 x anus
COLORECTAL CANCER • Starts as benign polyp and become malignant and spread most often to the liver
RISK FACTORS1. AGE >85 y/o2. FAMILIAL HISTORY FOR COLON CANCER OR POLYP3. CHRONIC ULCERATIVE COLITIS4. HIGH-FAT, CHON, LOW FIBER DIET5. GENITAL CANCER6. BREAST CANCER IN WOMEN7. HISTORY OF BOWEL DISEASE
THERAPEUTIC INTERVENTION 1. Surgery 1. laparoscopic colostomy with polypectomy 2. neodymium / yttrium-al-garnet (nd:yag) laser 3. resection with anastomosis 1. Segmental resection with anastomosis 2. Abdominoperineal resection with permanent sigmoid colostomy 3. Temporary colostomy followed by segmental resection and anastomosis and subsequent reanastomosis of the colostomy 4. Permanent colostomy or ileostomy 5. Construction of a coloanal reservoir 6. colonic j-pouch
• COLOSTOMY –attaches the colon to an opening in the wall of the abdomen to create a stoma• ILEOSTOMY –connects the small intestine to an opening in the wall of the abdomen to create a stoma
J-pouch• Ileoanal reservoir surgery• is an internal pouch formed of small intestine• provides a storage place for stool in the absence of the large intestine• Anal sphincter muscles assist in holding in the stool.
Ileal pouch types • J Pouch: The J-reservoir is made from two side-by-side limbs stapled together to create a J-loop
NURSING DIAGNOSES1. IMBALANCED NUTRITION: LBR2. RISK FOR FLUID-VOLUME DEFICIT3. ANXIETY4. RISK FOR INEFFECTIVE THERAPEUTIC REGIMEN MANAGEMENT5. IMPAIRED SKIN INTEGRITY6. DISTURBED BODY IMAGE7. INEFFECTIVE SEXUALITY PATTERNS
NURSING CARE1. PREPARATION FOR SURGERY A. PROVIDE INFORMATION B. CLEANSING AND STERILIZING C. IMPROVE NUTRITION D. PROPHYLACTIC ANTIBIOTICS E. LAXATIVES F. ENEMAS G. COLONIC IRRIGATION H. I & O MONITORING I. ANTIEMETICS J. ABDOMINAL GIRTH K. ASSESS HYDRATION STATUS L. ASSESS SKIN INTEGRITY M. ASSESS KNOWLEDGE LEVEL ABOUT THE CONDITION
NURSING CARE2. PROVIDE EMOTIONAL SUPPORT3. PROVIDE POST OPERATIVE CARE4. MAINTAIN OPTIMAL NUTRITION5. PROVIDE WOUND CARE6. MONITORING AND MANAGING COMPLICATIONS7. PROVIDE AND TEACH ON COLOSTOMY CARE8. SUPPORT (+) BODY IMAGE9. DISCUSS SEXUALITY ISSUES