surgical anatomy of large bowel and appendix.pptx
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The document summarizes key details about the surgical anatomy of the large bowel and appendix. It discusses: 1) The lymphatic drainage patterns of different sections of the large bowel and how this informs the appropriate surgical resection for cancers in these areas. 2) The neural control of the gut wall, including sympathetic and parasympathetic innervation originating from different areas of the spinal cord and plexuses. 3) Hirschsprung's disease, where the absence of ganglion cells in a distal segment of the colon results in aganglionic megacolon, requiring resection within the ganglionated area.
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Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
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Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
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- 1. SURGICAL ANATOMY OF LARGE BOWEL AND APPENDIX
- 5. EXTERNAL FEATURES OF LARGE BOWEL Teniae coli absent in appendix
- 14. EPICOLIC -> PARACOLIC-> MESOCOLIC NODES
- 15. Resection of the large intestine should include the entire area served by a major artery as well as the lesion itself. Most of the lymphatic drainage will be included.
- 16. • Because the ileocecal artery always arises from the superior mesenteric artery and lymph node metastases of cecum cancer were limited to nodes along the ileocolic artery, cecum cancer can be cured by ileocecal resection. • The right colic artery has various origins, and ascending colon cancer shows various patterns of lymph node metastases. Therefore a right hemicolectomy should be performed for ascending colon cancer. • The middle colic artery forks into right and left branches, and each branch has different branching variations. If the right colic and middle colic arteries have a common trunk, a right hemicolectomy should be performed for transverse colon cancer on the right side. If the left branch of the middle colic artery has an independent replaced origin, lymph node dissection should be modified according to the variant origin. If the left colic artery and the first sigmoidal artery have a common trunk, the lymph nodes along the common trunk should be removed for sigmoid colon cancer and for descending colon cancer. • Of the patients with sigmoid colon cancer, 6.3% also had lymph node metastases along the superior rectal artery. Given that the lymph nodes along the superior rectal artery are skeletonized, sigmoid colon cancer can be also cured by partial sigmoidectomy
- 17. NEURAL CONTROL 0F GUT WALL
- 18. • Sympathetic Innervation • The sympathetic supply to the right colon originates from the lower six thoracic segments of the spinal cord. Preganglionic fibers pass through the sympathetic chain ganglia, then pass as thoracic splanchnic nerves to synapse in the celiac, aortic, and superior mesenteric plexuses. From the plexuses, postganglionic fibers pass with the arteries in the mesentery to the small intestine and the right colon. • On the left, preganglionic fibers arise from the first two (or three) lumbar segments of the cord, then travel as lumbar splanchnic nerves to the aortic plexus and the inferior mesenteric plexus. From ganglia in this diffuse plexus, postganglionic fibers follow branches of the inferior mesenteric artery to the left colon and the upper rectum. • Parasympathetic Innervation • Vagal fibers from the posterior trunk pass as the celiac division to and through the celiac ganglion without synapse. From the ganglion, preganglionic fibers pass on the superior mesenteric artery to the small intestine and the right colon, where they synapse with ganglion cells of the intramural plexuses. • The left colon receives parasympathetic fibers from pelvic splanchnic nerves, which arise from the 2nd, 3rd, and 4th sacral nerves. These fibers follow the course of the presacral nerve to reach the inferior mesenteric plexus. From this plexus, the preganglionic fibers follow the branches of the inferior mesenteric artery to the left colon and the upper rectum
- 20. • The caliber of the large bowel is greater close to the cecum; it gradually gets smaller toward the rectum, then dilates again at the rectal ampulla just above the surgical anal canal anterior cecal artery lies within it
- 36. CLINICAL IMPORTANCE • Congenital Aganglionic Megacolon (Hirschsprung's Disease) • Aganglionic megacolon is the result of an absence of ganglion cells in a distal segment of colon. • Neurenteric ganglion cells normally originate in the neural crest, enter the cranial end of the esophagus, and then follow vagus nerve fibers caudally until the entire gut is innervated. Why the migrating cells sometimes stop short of the rectum is unknown. • The line of resection must be within the area in which ganglion cells are present. Because aganglionosis is not the only cause of megacolon, a biopsy is necessary to demonstrate the absence of ganglion cells in the narrowed segment and their presence in the dilated segment.
- 37. THANK YOU