12. Laetrile
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Laetrile, also known as amygdalin, is a substance promoted as an alternative cancer treatment since the 1970s. It is derived from apricot pits and produces cyanide when metabolized. While some claim it selectively kills cancer cells, evidence shows it is toxic and there are no well-designed studies proving its effectiveness as a treatment. Reports of benefits are unreliable and risks include cyanide poisoning and unknown purity of sources being used. Many health authorities have banned its use due to lack of evidence and risks of toxicity.
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Evaluation of Complex Anal Fistula - EUA, EUAS OR MRI?
1. The document discusses different imaging modalities for evaluating complex anal fistulas, including endoanal ultrasound (EAUS), MRI, and their ability to classify fistulas and identify secondary extensions compared to clinical exam alone.
2. Several studies found EAUS and MRI to have higher sensitivity than clinical exam alone in identifying primary tracts, abscesses, horseshoe extensions, and internal openings.
3. Pre-operative MRI can alter surgical management by identifying complex tracts and internal openings and reducing recurrence rates when surgery follows the MRI findings.
The Management of Enterocutaneous Fistulae
Enterocutaneous fistulae are abnormal connections between the gastrointestinal tract and skin that usually develop postoperatively or due to conditions like inflammatory bowel disease. They require a multidisciplinary approach to management including resuscitation, controlling sepsis, optimizing nutrition, assessing for spontaneous closure, and potentially definitive surgery. Definitive surgery has around an 80% success rate when a formal resection is performed but recurrence is higher with complex fistulae. Abdominal wall reconstruction after surgery can be challenging and often requires techniques like components separation.
Does a Stoma Help to Prevent Leakage After a Low Anterior Resection
A stoma helps prevent leakage after a low anterior resection by diverting fecal content away from the anastomosis site. Anastomotic leak rates are lower and reoperation rates are reduced when a stoma is created. While stomas have morbidity risks of their own, they can help reduce local recurrence risks and improve survival outcomes by preventing direct seeding of cancer cells from a leak. Reinforcing the anastomosis with materials like oxidized regenerated cellulose may help reduce leak rates and diminish the need for a diverting stoma in some cases.
Cylindrical APR
Cylindrical abdominoperineal resection (APR) provides improved oncologic outcomes for low rectal cancer compared to standard APR. It involves a more extensive dissection in the pelvis during the abdominal phase and an extended perineal resection. This removes more tissue outside the muscularis propria of the rectum, reducing circumferential resection margin involvement and local recurrence rates. However, it may increase risks of perineal wound complications. Tips for the procedure include amputating a fatty sigmoid colon, taking care when reflecting an anteriorly attached tumor, placing an omental pedicle in the pelvis, and remembering to place a drain.
Surveillance for a Family History of Colorectal Cancer
Category 1 includes those at average risk, with no family history of colorectal cancer or a single first degree relative diagnosed over age 55. Screening is a fecal occult blood test every 2 years starting at age 50.
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Averse to surgery? : The (short) surgical career of John Keats
1. John Keats was an English poet who briefly studied and worked as a surgeon's apprentice and dresser at Guy's Hospital in London from 1815-1817.
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Screening, Surveillance And Diagnosis Of Colorectal Cancer
Screening and surveillance for colorectal cancer involves assessing risk based on family history and personal medical history to determine appropriate screening methods and schedules. The National Bowel Cancer Screening Program in Australia uses fecal immunochemical testing every 2 years for average risk individuals aged 50-74, with colonoscopy for positive tests. Participation rates are around 40-50% and cancer detection rates are around 5% for those undergoing colonoscopy. Ongoing evaluation aims to improve participation and outcomes.
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This document summarizes the management of colorectal cancer from the perspective of a colorectal surgeon. Key points discussed include the importance of total mesorectal excision surgery, developments in less invasive surgical techniques like laparoscopic surgery, the roles of radiotherapy and chemotherapy, and the increased focus on sphincter preservation and quality of life outcomes for patients. Advances in staging techniques such as endorectal ultrasound and MRI are also reviewed.
18. Smoking And Wound Healing
Smoking is an important risk factor for complications in wound healing. Smoking causes tissue hypoxia by reducing blood flow and impairing oxygen delivery, which inhibits collagen synthesis and decreases the body's ability to fight infection. Oxidative killing of neutrophils and reduction of wound infections can be partially restored within a few weeks of smoking cessation, but collagen synthesis may not recover as quickly. Existing evidence suggests short-term abstinence alone may not reduce complications from surgery or prevent disrupted wound healing.
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Oliguria is a decreased urine output that can be a sign of acute renal failure. The document discusses evaluating and managing oliguria in a postoperative patient. Common causes of postoperative oliguria include fluid loss, decreased renal perfusion, or intrinsic kidney injury. Assessment involves checking for dehydration, obstruction, or acute kidney injury risk factors. Initial management focuses on fluid resuscitation and stopping nephrotoxic drugs. Further treatment depends on whether the cause is pre-renal, renal, or post-renal.
15. Risk Of Pregnancy In Women With Congenital Heart
Women with congenital heart disease are at increased risk of complications during pregnancy due to the hemodynamic changes that occur. The risks depend on the type of heart defect and whether it involves cyanosis or pulmonary hypertension. While advances in treatment have improved survival, pregnancy remains risky especially for those with Eisenmenger syndrome or cyanotic heart disease with low oxygen saturation. Close monitoring during pregnancy is important to reduce maternal and fetal risks such as heart failure, arrhythmias, thromboembolism, preterm birth and growth restriction of the baby.
14. Ptq Injections For Faecal Incontinence
PTQ injections involve injecting silicone particles suspended in a hydrogel carrier into the internal anal sphincter to treat faecal incontinence. The silicone provides a "padding effect" to promote anal closure. Studies show PTQ injections improve anal sphincter pressures and short-term continence scores. Long-term follow up studies on larger numbers of patients are still needed to determine optimal techniques and long-term effectiveness.
13. Hyperplastic Polyposis Syndrome
Hyperplastic Polyposis Syndrome (HPS) is characterized by multiple hyperplastic polyps in the colon and rectum. While previously considered benign, hyperplastic polyps are now seen as potential precursors to colorectal cancer due to genetic mutations also found in cancer. Research shows patients with HPS have an increased risk of developing right-sided colon cancers that are MSI-high and associated with methylation of genes like hMLH1. Hyperplastic polyps may progress to cancer through either a mild or high mutator pathway involving genetic and epigenetic changes. Diagnosis of HPS requires meeting certain criteria regarding number and size of hyperplastic polyps. Management includes surveillance colonoscopies and potentially prophylactic
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Pseudomembranous colitis is caused by Clostridium difficile bacteria and is usually associated with antibiotic use. The bacteria releases toxins that damage the colon lining, causing symptoms like severe diarrhea. Risk factors include advanced age, hospitalization, and immunosuppression. Treatment involves stopping the culprit antibiotic if possible, rehydration, and antibiotic therapy targeted against C. difficile like vancomycin. Complications can include dehydration, perforation, and toxic megacolon requiring surgery in some cases.
9. Postoperative Ileus
Postoperative ileus is caused by neurogenic, hormonal, inflammatory, and pharmacological factors. Sympathetic overactivity and the release of corticotropin-releasing factor and nitric oxide contribute to the neurogenic and hormonal components. Inflammation is driven by macrophages and prostaglandins released during intestinal manipulation. Opioids inhibit intestinal motility pharmacologically by blocking excitatory neurons. Prevention strategies include laparoscopic surgery, which reduces inflammation, and alvimopan, a peripheral mu-opioid receptor blocker. Treatments include early enteral feeding and epidural analgesia to inhibit reflex arcs, though no single treatment is completely effective.
10. The Management Of Pseudomembranous Colitis
Pseudomembranous colitis is caused by Clostridium difficile and results in inflammation of the bowel wall. Initial management includes discontinuing antibiotics, supportive care, and isolation precautions. First line treatments are oral metronidazole or vancomycin, with metronidazole being effective in 86-90% of cases but having an 8-9% relapse rate. Vancomycin is more reliable with a 90-100% response rate and is used for patients who cannot tolerate or fail to respond to metronidazole. Relapses may require a second course of treatment or a tapering regimen of vancomycin. Surgery is indicated for complications like toxic megac
8. Cancer Metastasis Lymphatic Spread
(1) Cancer cells can metastasize by spreading through lymphatic vessels to nearby lymph nodes.
(2) The process of lymphatic metastasis involves cancer cells degrading the extracellular matrix, entering lymphatic capillaries, and traveling through the lymphatic system to lymph nodes.
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Patients with end-stage renal disease requiring dialysis have increased risks when undergoing surgery. Their medical management requires optimizing nutrition, fluid levels, blood pressure, and other factors. Careful evaluation is needed of the patient's comorbidities like cardiovascular disease. During surgery, special consideration must be given to anesthesia selection and pain management due to the patient's kidney function.
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