The document discusses tumors of the small bowel, including both benign and malignant types. It provides details on the incidence, risk factors, presentations, diagnostic approaches, and treatment options for common tumors such as gastrointestinal stromal tumors (GISTs), adenomas, neuroendocrine tumors, and adenocarcinoma. The document emphasizes that small bowel tumors often present nonspecifically, making preoperative diagnosis challenging, and outlines various imaging modalities that can help in diagnosis. Surgical resection is typically the main treatment for localized tumors.
1) Carcinoma of the rectum arises from the adenoma-carcinoma sequence and risk factors include red meat, alcohol, smoking, and inflammatory bowel disease.
2) Evaluation involves digital rectal exam, rigid proctoscopy, colonoscopy, CT, MRI, and lab tests to stage the tumor and check for metastases.
3) Treatment depends on tumor stage but commonly includes total mesorectal excision surgery with clear margins and may involve radiation or chemoradiation to downstage the tumor preoperatively.
This document provides an overview of renal cell carcinoma (RCC). It discusses the epidemiology, clinical presentation, management, and prognosis of RCC. RCC arises from renal tubular epithelium and accounts for 80-85% of kidney cancers. Risk factors include genetic predispositions, smoking, occupational exposures, and obesity. Clinical evaluation involves history, exam, lab tests, and imaging studies. Management depends on staging and may include surgery, targeted therapy, immunotherapy, or palliative care. Prognosis depends on stage, grade, size and histological type of the tumor.
- Gallbladder polyps are common findings that require evaluation to determine if they are true polyps with malignant potential or pseudopolyps which are benign.
- Transabdominal ultrasound is usually the initial imaging study, while EUS may help in certain cases, though evidence is limited.
- Polyps greater than 10mm or those exhibiting certain high risk features like being sessile or in patients over 50 years old typically warrant cholecystectomy.
- For smaller polyps, follow up imaging is reasonable if they lack concerning characteristics, though risk of malignancy increases with size.
The retroperitoneum is the compartmentalized space located behind the posterior abdominal wall. It is divided into three compartments - the anterior pararenal space, perirenal space, and posterior pararenal space. The perirenal space contains the kidney and related structures. A variety of pathologies can occur in the retroperitoneum including sarcomas like liposarcoma, neurogenic tumors, and benign lesions such as schwannomas or lipomas. Imaging plays an important role in characterizing these retroperitoneal masses.
This document discusses liver lesions and their appearance on various imaging modalities. It covers benign lesions like hemangioma, focal nodular hyperplasia and hepatic adenoma. Malignant primary lesions discussed are hepatocellular carcinoma and hepatoblastoma. Imaging features of hypervascular and hypovascular lesions on multiphasic CT are summarized. Hepatocellular carcinoma risk factors and clinical presentation are outlined. Imaging appearance of HCC on ultrasound, CT and MRI is described in detail. Hepatic metastases are also discussed along with hypervascular metastatic lesions.
Benign Neoplasms of Liver
This document provides an overview of benign liver tumors, including their epidemiology, etiology, classification, clinical features, diagnosis and treatment. The main benign liver tumors discussed are hepatocellular adenoma, cavernous hemangioma, and focal nodular hyperplasia. Hepatocellular adenoma is more common in females using oral contraceptives and can present with pain or rupture. Cavernous hemangioma is the most common benign liver tumor and often asymptomatic. Larger hemangiomas can cause pain, jaundice or complications. Imaging such as MRI is used for diagnosis, while treatment depends on size and symptoms, and may include resection, ablation or e
The document discusses various tumors and conditions of the small intestine. The common benign and malignant tumors of the small intestine are listed. Details are provided about carcinoid tumors, including their classification and characteristics. Megaolon is described as a dilatation of the colon that can be congenital or acquired. Hirschsprung's disease is mentioned as a congenital form. Other topics covered include the carcinoid syndrome, Meckel's diverticulum, volvulus, and intussusception - the telescoping of one segment of intestine into another.
1. Small bowel neoplasms are rare, comprising about 1-2% of gastrointestinal tumors. The most common benign tumors are leiomyomas, adenomas, and gastrointestinal stromal tumors (GISTs), while the most common malignant tumor is adenocarcinoma.
2. Risk factors for small bowel tumors include Crohn's disease, familial polyposis syndromes, and Peutz-Jeghers syndrome. Diagnosis is often difficult but can involve imaging like CT, capsule endoscopy, or surgical exploration.
3. Treatment depends on whether the tumor is benign or malignant and its size and location. Resection is often curative for localized benign and malignant tumors, while
1) Carcinoma of the rectum arises from the adenoma-carcinoma sequence and risk factors include red meat, alcohol, smoking, and inflammatory bowel disease.
2) Evaluation involves digital rectal exam, rigid proctoscopy, colonoscopy, CT, MRI, and lab tests to stage the tumor and check for metastases.
3) Treatment depends on tumor stage but commonly includes total mesorectal excision surgery with clear margins and may involve radiation or chemoradiation to downstage the tumor preoperatively.
This document provides an overview of renal cell carcinoma (RCC). It discusses the epidemiology, clinical presentation, management, and prognosis of RCC. RCC arises from renal tubular epithelium and accounts for 80-85% of kidney cancers. Risk factors include genetic predispositions, smoking, occupational exposures, and obesity. Clinical evaluation involves history, exam, lab tests, and imaging studies. Management depends on staging and may include surgery, targeted therapy, immunotherapy, or palliative care. Prognosis depends on stage, grade, size and histological type of the tumor.
- Gallbladder polyps are common findings that require evaluation to determine if they are true polyps with malignant potential or pseudopolyps which are benign.
- Transabdominal ultrasound is usually the initial imaging study, while EUS may help in certain cases, though evidence is limited.
- Polyps greater than 10mm or those exhibiting certain high risk features like being sessile or in patients over 50 years old typically warrant cholecystectomy.
- For smaller polyps, follow up imaging is reasonable if they lack concerning characteristics, though risk of malignancy increases with size.
The retroperitoneum is the compartmentalized space located behind the posterior abdominal wall. It is divided into three compartments - the anterior pararenal space, perirenal space, and posterior pararenal space. The perirenal space contains the kidney and related structures. A variety of pathologies can occur in the retroperitoneum including sarcomas like liposarcoma, neurogenic tumors, and benign lesions such as schwannomas or lipomas. Imaging plays an important role in characterizing these retroperitoneal masses.
This document discusses liver lesions and their appearance on various imaging modalities. It covers benign lesions like hemangioma, focal nodular hyperplasia and hepatic adenoma. Malignant primary lesions discussed are hepatocellular carcinoma and hepatoblastoma. Imaging features of hypervascular and hypovascular lesions on multiphasic CT are summarized. Hepatocellular carcinoma risk factors and clinical presentation are outlined. Imaging appearance of HCC on ultrasound, CT and MRI is described in detail. Hepatic metastases are also discussed along with hypervascular metastatic lesions.
Benign Neoplasms of Liver
This document provides an overview of benign liver tumors, including their epidemiology, etiology, classification, clinical features, diagnosis and treatment. The main benign liver tumors discussed are hepatocellular adenoma, cavernous hemangioma, and focal nodular hyperplasia. Hepatocellular adenoma is more common in females using oral contraceptives and can present with pain or rupture. Cavernous hemangioma is the most common benign liver tumor and often asymptomatic. Larger hemangiomas can cause pain, jaundice or complications. Imaging such as MRI is used for diagnosis, while treatment depends on size and symptoms, and may include resection, ablation or e
The document discusses various tumors and conditions of the small intestine. The common benign and malignant tumors of the small intestine are listed. Details are provided about carcinoid tumors, including their classification and characteristics. Megaolon is described as a dilatation of the colon that can be congenital or acquired. Hirschsprung's disease is mentioned as a congenital form. Other topics covered include the carcinoid syndrome, Meckel's diverticulum, volvulus, and intussusception - the telescoping of one segment of intestine into another.
1. Small bowel neoplasms are rare, comprising about 1-2% of gastrointestinal tumors. The most common benign tumors are leiomyomas, adenomas, and gastrointestinal stromal tumors (GISTs), while the most common malignant tumor is adenocarcinoma.
2. Risk factors for small bowel tumors include Crohn's disease, familial polyposis syndromes, and Peutz-Jeghers syndrome. Diagnosis is often difficult but can involve imaging like CT, capsule endoscopy, or surgical exploration.
3. Treatment depends on whether the tumor is benign or malignant and its size and location. Resection is often curative for localized benign and malignant tumors, while
This document presents a radiologic pictorial review of Crohn's disease. It includes 25 images from barium enema, CT, MRI, and ultrasound studies that demonstrate various findings in Crohn's disease, including aphthoid lesions, cobblestoning, deep ulcerations, fistulas, sacculations from mesenteric fibrosis, transmural inflammation, strictures, and extraintestinal manifestations like perianal fistulas. The images illustrate features of both active inflammatory disease and chronic fibrostenotic complications.
Primary neoplasms of the small bowel are uncommon, accounting for only 1-5% of gastrointestinal neoplasms. Over 40 histologic types of both benign and malignant tumors have been identified in the small bowel. The most common benign neoplasms are adenomas, gastrointestinal stromal tumors (GISTs), lipomas, and hemangiomas. Malignant neoplasms include adenocarcinoma, carcinoid tumors, malignant GISTs, lymphomas, and metastases from other sites. Imaging with CT enterography, CT enteroclysis, MR enterography, or small bowel follow through can help identify and characterize small bowel neoplasms.
Abdominal tuberculosis is caused by swallowing of sputum or spread of the bacteria via the bloodstream. It most commonly affects the ileum, ileocaecal valve, and caecum due to their abundant lymphatic tissue. Symptoms include abdominal pain, distension, and complications like obstruction or bleeding. Diagnosis involves imaging tests showing thickening and narrowing of the affected intestines. Treatment consists of a 6-month course of anti-tuberculosis drugs, sometimes alongside surgery to address complications.
This document discusses recurrent pyogenic cholangitis (RPC), a condition characterized by recurrent bacterial cholangitis, intrahepatic pigmented stones, and biliary strictures. It is seen predominantly in Southeast Asia. Parasitic infections and bacterial infections both contribute to the formation of stones within the bile ducts. Patients typically present with recurrent episodes of cholangitis. Imaging studies can identify stones and bile duct abnormalities. Treatment involves stone removal, antibiotics, and sometimes surgical interventions like duct clearance or liver resection to prevent long-term complications like cirrhosis or cancer. Recurrence rates remain high even after treatment.
Peritoneal carcinomatosis refers to the spread of cancer to the peritoneal cavity. It has traditionally had a poor prognosis with best supportive care or chemotherapy alone. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) has emerged as a treatment approach that can provide long-term survival or cure in properly selected patients. Key factors in patient selection include ensuring no distant metastases, thorough staging to determine peritoneal cancer index and completeness of cytoreduction, and histology of primary tumor. The goal of CRS is to remove all visible tumor nodules followed by HIPEC or EPIC to treat any remaining microscopic
This document provides information on cholangiocarcinoma (CCA), a malignant tumor of the bile ducts. It discusses the epidemiology, risk factors, classification, molecular pathogenesis, clinical features, diagnosis and imaging of CCA. CCA can be intrahepatic, perihilar or distal. Risk factors include primary sclerosing cholangitis, hepatolithiasis, liver fluke infections and bile duct cysts. Diagnosis involves tumor markers like CA19-9 and imaging modalities like ultrasound, CT and MRI to detect lesions. Molecular testing helps characterize mutations in genes like KRAS, TP53 and IDH1/2 involved in CCA pathogenesis.
Presacral tumors are rare lesions located in the retrorectal space. They can be congenital, neurogenic, osseous, or other types. MRI is the best imaging modality to evaluate these tumors. Surgical resection is usually required given the risk of malignancy. The surgical approach depends on the location and extent of the tumor, and may involve the abdomen, perineum, or a combined approach. Complete resection with negative margins while preserving function is the goal.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
This document summarizes the management of common bile duct stones. It discusses that bile duct stones occur in 6-12% of gallstone patients and are more common in older adults. Stones can be primary or secondary in origin. Clinical manifestations include pain, jaundice, cholangitis or pancreatitis. Investigation involves blood tests, ultrasound, MRCP, EUS or ERCP. ERCP allows both diagnosis and treatment. Endoscopic sphincterotomy with stone extraction is the first-line treatment but may require adjuncts like balloon dilation or cholangioscopy. Laparoscopic exploration is also used. Complications include post-ERCP pancreatitis. Proper management of coagulopathy is important before sphinct
This document discusses solitary liver lesions, categorizing them as benign tumours, infections, trauma, malignant tumours or other. It provides detailed information about cavernous haemangioma, including that it is the most common benign liver tumour, often appearing as a well-defined hypodense lesion on imaging with characteristic enhancement. Hepatic abscesses and hydatid cysts are also described, noting ultrasound, CT and MRI findings help differentiate bacterial vs parasitic abscesses and stages of cyst growth.
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
Gallbladder polyps are abnormal growths that can develop on the lining of the gallbladder. While most gallbladder polyps are non-cancerous, some polyps have the potential to become malignant. The document discusses the epidemiology, classification, pathology, diagnosis, and management of gallbladder polyps. Polyps larger than 10mm or those demonstrating changes in size have a higher risk of cancer and often require surgical removal of the gallbladder.
1. The document discusses various potential causes of a mass in the right iliac fossa, including appendicitis, appendicular abscess, carcinoid tumors of the appendix, mucoceles, adenocarcinoma, tuberculosis, Crohn's disease, carcinoma of the caecum, actinomycosis, amoebiasis, mesenteric cysts, intussusception, iliopsoas abscess, retroperitoneal tumors, aneurysms, and more rare causes.
2. Diagnostic tools mentioned include ultrasound, CT, colonoscopy, and biopsy. Treatment depends on the underlying cause but may include antibiotics, surgery, chemotherapy, and ATT.
3
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
MRI is useful for staging rectal cancer and assessing tumor involvement of surrounding structures. It can determine the depth of tumor invasion beyond the muscularis propria (T stage), evaluate the circumferential resection margin (CRM) distance between the tumor and mesorectal fascia, and identify suspicious lymph nodes. A tumor-mesorectal fascia distance of less than 1mm on MRI indicates a positive CRM, which is associated with higher rates of local recurrence. MRI is also used to assess nodal metastases based on node size, borders, and signal intensity. Accurate pre-treatment staging with MRI allows for optimal surgical planning and identification of patients who may benefit from neoadjuvant chemoradiation.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
This document summarizes key information about duodenal injuries:
- The duodenum is 12 inches long and located retroperitoneally behind the liver and pancreas. It has four parts and is vulnerable to trauma due to its location and proximity to other abdominal organs.
- Duodenal injuries can be from penetrating or blunt trauma. Diagnosis involves imaging like CT scans and upper GI series. Management principles involve restoring intestinal continuity, decompressing the duodenum, providing drainage, and nutritional support.
- Treatment options depend on the severity of injury and include primary repair, diversion procedures like gastrojejunostomy, or pancreaticoduodenectomy for severe injuries involving other structures. Complications can include
This document discusses tumors of the appendix. It outlines different types of appendix tumors including mucocele, primary adenocarcinoma, cystadenocarcinoma, and carcinoid tumors. Mucocele occurs when the appendix lumen becomes blocked, causing a fluid-filled cyst. Ruptured mucocele or adenocarcinoma can lead to pseudomyxoma peritonei, where mucus accumulates in the abdominal cavity. Carcinoid tumors are the most common appendix tumors but are generally not aggressive. Management depends on tumor type but often involves surgical removal of the appendix or part of the colon.
Sites of the highest risk are the duodenum, for adenocarcinomas, and the ileum, for carcinoids and lymphomas.
In industrialized countries, small bowel cancers are predominantly adenocarcinomas;
In developing countries, lymphomas are much more common.
The incidence of small bowel cancer rises with age and has generally been higher among males than among females.
The risk factors for small bowel cancer include
Dietary factor
Cigarette smoking,
Alcohol intake,
Medical conditions -Crohn's disease, familial adenomatous polyposis, cholecystectomy, peptic ulcer disease, and cystic fibrosis.
The protective factors may include rapid cell turnover, a general absence of bacteria, an alkaline environment, and low levels of activating enzymes of precarcinogens.
This document discusses duodenal anatomy, tumors, and surgical management. It covers the following key points in 3 sentences:
Benign duodenal tumors include adenomas, lipomas, and neuroendocrine tumors. Malignant tumors are mostly adenocarcinomas. Surgical approaches depend on tumor location and include pancreaticoduodenectomy for periampullary or distal tumors, and segmental resection for proximal tumors.
This document presents a radiologic pictorial review of Crohn's disease. It includes 25 images from barium enema, CT, MRI, and ultrasound studies that demonstrate various findings in Crohn's disease, including aphthoid lesions, cobblestoning, deep ulcerations, fistulas, sacculations from mesenteric fibrosis, transmural inflammation, strictures, and extraintestinal manifestations like perianal fistulas. The images illustrate features of both active inflammatory disease and chronic fibrostenotic complications.
Primary neoplasms of the small bowel are uncommon, accounting for only 1-5% of gastrointestinal neoplasms. Over 40 histologic types of both benign and malignant tumors have been identified in the small bowel. The most common benign neoplasms are adenomas, gastrointestinal stromal tumors (GISTs), lipomas, and hemangiomas. Malignant neoplasms include adenocarcinoma, carcinoid tumors, malignant GISTs, lymphomas, and metastases from other sites. Imaging with CT enterography, CT enteroclysis, MR enterography, or small bowel follow through can help identify and characterize small bowel neoplasms.
Abdominal tuberculosis is caused by swallowing of sputum or spread of the bacteria via the bloodstream. It most commonly affects the ileum, ileocaecal valve, and caecum due to their abundant lymphatic tissue. Symptoms include abdominal pain, distension, and complications like obstruction or bleeding. Diagnosis involves imaging tests showing thickening and narrowing of the affected intestines. Treatment consists of a 6-month course of anti-tuberculosis drugs, sometimes alongside surgery to address complications.
This document discusses recurrent pyogenic cholangitis (RPC), a condition characterized by recurrent bacterial cholangitis, intrahepatic pigmented stones, and biliary strictures. It is seen predominantly in Southeast Asia. Parasitic infections and bacterial infections both contribute to the formation of stones within the bile ducts. Patients typically present with recurrent episodes of cholangitis. Imaging studies can identify stones and bile duct abnormalities. Treatment involves stone removal, antibiotics, and sometimes surgical interventions like duct clearance or liver resection to prevent long-term complications like cirrhosis or cancer. Recurrence rates remain high even after treatment.
Peritoneal carcinomatosis refers to the spread of cancer to the peritoneal cavity. It has traditionally had a poor prognosis with best supportive care or chemotherapy alone. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) or early postoperative intraperitoneal chemotherapy (EPIC) has emerged as a treatment approach that can provide long-term survival or cure in properly selected patients. Key factors in patient selection include ensuring no distant metastases, thorough staging to determine peritoneal cancer index and completeness of cytoreduction, and histology of primary tumor. The goal of CRS is to remove all visible tumor nodules followed by HIPEC or EPIC to treat any remaining microscopic
This document provides information on cholangiocarcinoma (CCA), a malignant tumor of the bile ducts. It discusses the epidemiology, risk factors, classification, molecular pathogenesis, clinical features, diagnosis and imaging of CCA. CCA can be intrahepatic, perihilar or distal. Risk factors include primary sclerosing cholangitis, hepatolithiasis, liver fluke infections and bile duct cysts. Diagnosis involves tumor markers like CA19-9 and imaging modalities like ultrasound, CT and MRI to detect lesions. Molecular testing helps characterize mutations in genes like KRAS, TP53 and IDH1/2 involved in CCA pathogenesis.
Presacral tumors are rare lesions located in the retrorectal space. They can be congenital, neurogenic, osseous, or other types. MRI is the best imaging modality to evaluate these tumors. Surgical resection is usually required given the risk of malignancy. The surgical approach depends on the location and extent of the tumor, and may involve the abdomen, perineum, or a combined approach. Complete resection with negative margins while preserving function is the goal.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
This document summarizes the management of common bile duct stones. It discusses that bile duct stones occur in 6-12% of gallstone patients and are more common in older adults. Stones can be primary or secondary in origin. Clinical manifestations include pain, jaundice, cholangitis or pancreatitis. Investigation involves blood tests, ultrasound, MRCP, EUS or ERCP. ERCP allows both diagnosis and treatment. Endoscopic sphincterotomy with stone extraction is the first-line treatment but may require adjuncts like balloon dilation or cholangioscopy. Laparoscopic exploration is also used. Complications include post-ERCP pancreatitis. Proper management of coagulopathy is important before sphinct
This document discusses solitary liver lesions, categorizing them as benign tumours, infections, trauma, malignant tumours or other. It provides detailed information about cavernous haemangioma, including that it is the most common benign liver tumour, often appearing as a well-defined hypodense lesion on imaging with characteristic enhancement. Hepatic abscesses and hydatid cysts are also described, noting ultrasound, CT and MRI findings help differentiate bacterial vs parasitic abscesses and stages of cyst growth.
1) Duodenal injuries are uncommon and difficult to diagnose and repair due to the duodenum's retroperitoneal location. The mortality rate for duodenal injuries is high.
2) Diagnosis of duodenal injuries requires a high index of suspicion as there is no single, fully accurate diagnostic test. CT scans, upper GI studies, and exploratory laparotomy can help diagnose duodenal injuries.
3) Treatment depends on the grade of the duodenal injury. Lower grade injuries may be treated with primary closure, tube duodenostomies, or jejunal patching. Higher grade injuries involving complete wall disruption may require duodenal resection or diversion procedures like duodenal divertic
Gallbladder polyps are abnormal growths that can develop on the lining of the gallbladder. While most gallbladder polyps are non-cancerous, some polyps have the potential to become malignant. The document discusses the epidemiology, classification, pathology, diagnosis, and management of gallbladder polyps. Polyps larger than 10mm or those demonstrating changes in size have a higher risk of cancer and often require surgical removal of the gallbladder.
1. The document discusses various potential causes of a mass in the right iliac fossa, including appendicitis, appendicular abscess, carcinoid tumors of the appendix, mucoceles, adenocarcinoma, tuberculosis, Crohn's disease, carcinoma of the caecum, actinomycosis, amoebiasis, mesenteric cysts, intussusception, iliopsoas abscess, retroperitoneal tumors, aneurysms, and more rare causes.
2. Diagnostic tools mentioned include ultrasound, CT, colonoscopy, and biopsy. Treatment depends on the underlying cause but may include antibiotics, surgery, chemotherapy, and ATT.
3
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
MRI is useful for staging rectal cancer and assessing tumor involvement of surrounding structures. It can determine the depth of tumor invasion beyond the muscularis propria (T stage), evaluate the circumferential resection margin (CRM) distance between the tumor and mesorectal fascia, and identify suspicious lymph nodes. A tumor-mesorectal fascia distance of less than 1mm on MRI indicates a positive CRM, which is associated with higher rates of local recurrence. MRI is also used to assess nodal metastases based on node size, borders, and signal intensity. Accurate pre-treatment staging with MRI allows for optimal surgical planning and identification of patients who may benefit from neoadjuvant chemoradiation.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
This document summarizes key information about duodenal injuries:
- The duodenum is 12 inches long and located retroperitoneally behind the liver and pancreas. It has four parts and is vulnerable to trauma due to its location and proximity to other abdominal organs.
- Duodenal injuries can be from penetrating or blunt trauma. Diagnosis involves imaging like CT scans and upper GI series. Management principles involve restoring intestinal continuity, decompressing the duodenum, providing drainage, and nutritional support.
- Treatment options depend on the severity of injury and include primary repair, diversion procedures like gastrojejunostomy, or pancreaticoduodenectomy for severe injuries involving other structures. Complications can include
This document discusses tumors of the appendix. It outlines different types of appendix tumors including mucocele, primary adenocarcinoma, cystadenocarcinoma, and carcinoid tumors. Mucocele occurs when the appendix lumen becomes blocked, causing a fluid-filled cyst. Ruptured mucocele or adenocarcinoma can lead to pseudomyxoma peritonei, where mucus accumulates in the abdominal cavity. Carcinoid tumors are the most common appendix tumors but are generally not aggressive. Management depends on tumor type but often involves surgical removal of the appendix or part of the colon.
Sites of the highest risk are the duodenum, for adenocarcinomas, and the ileum, for carcinoids and lymphomas.
In industrialized countries, small bowel cancers are predominantly adenocarcinomas;
In developing countries, lymphomas are much more common.
The incidence of small bowel cancer rises with age and has generally been higher among males than among females.
The risk factors for small bowel cancer include
Dietary factor
Cigarette smoking,
Alcohol intake,
Medical conditions -Crohn's disease, familial adenomatous polyposis, cholecystectomy, peptic ulcer disease, and cystic fibrosis.
The protective factors may include rapid cell turnover, a general absence of bacteria, an alkaline environment, and low levels of activating enzymes of precarcinogens.
This document discusses duodenal anatomy, tumors, and surgical management. It covers the following key points in 3 sentences:
Benign duodenal tumors include adenomas, lipomas, and neuroendocrine tumors. Malignant tumors are mostly adenocarcinomas. Surgical approaches depend on tumor location and include pancreaticoduodenectomy for periampullary or distal tumors, and segmental resection for proximal tumors.
This document provides information about gallbladder cancer, including:
- It most commonly occurs in the 6th-7th decade of life and is more common in women. The 5-year survival rate is less than 5%.
- Risk factors include gallstones, which are present in 90% of cases. Other risk factors include gallbladder polyps, typhoid carriers, and hepatitis infections.
- Staging includes the Nevin system and AJCC/TNM system. Spread is usually direct to the liver or through lymphatic or blood vessels.
- Diagnosis involves ultrasound, CT, MRI, tumor markers, and biopsy if needed. Surgical resection offers the only chance of cure, and
This document discusses benign and malignant kidney tumors. It summarizes key details about common benign tumors including adenomas, oncocytomas, and angiomyolipomas. For malignant renal cell carcinoma, it covers risk factors, histologic subtypes, clinical presentation, diagnostic imaging, staging, and prognosis. Surgical treatment options are mentioned for both benign and malignant kidney tumors.
This document summarizes information about gastric carcinoma (stomach cancer). It covers the epidemiology, anatomy, pathology, risk factors, clinical presentation, staging, and treatment of gastric cancer. Key points include:
- Gastric cancer was previously a leading cause of cancer death but now ranks fourth most common. Incidence is highest in China and Japan.
- The stomach has extensive lymphatic drainage involving 16 lymph node stations.
- 95% of gastric cancers are adenocarcinomas. Other rare types include squamous cell carcinoma and carcinoid tumors.
- Risk factors include smoking, obesity, and H. pylori infection. Symptoms are often vague but may include weight loss, abdominal pain,
1) Acute appendicitis is caused by obstruction of the appendix lumen and is most common in the second and third decades of life. Complications include gangrenous appendicitis, perforation, peri-appendiceal abscess, peritonitis, and bowel obstruction.
2) Appendicular neoplasms occur in about 1% of cases and include carcinoid tumors, goblet cell carcinomas, lymphomas, and adenocarcinomas. Treatment depends on tumor size and involvement of surrounding tissues.
3) Appendiceal mucoceles are mucus-filled cysts of the appendix that can be neoplastic or non-neoplastic. Surgery is required
Gallbladder carcinoma is the most common malignancy of the extrahepatic biliary tract. It is more common in women and is strongly associated with gallstones, which are present in 95% of cases. Chronic inflammation from gallstones or infections is thought to contribute to cancer development. Most gallbladder cancers are adenocarcinomas and are discovered at an advanced stage, when the cancer has usually invaded the liver or spread to other organs. Presenting symptoms like abdominal pain are often indistinguishable from gallstones. Surgical resection offers the only chance of effective treatment when the cancer is discovered early enough before spreading, but chemotherapy may also be used.
This document discusses gastrointestinal (GI) tract metastases from various primary cancers. It notes that melanoma, lung cancer, and breast cancer most commonly metastasize to the GI tract. The presentation of GI metastases can be variable and nonspecific, with gastrointestinal bleeding or abdominal pain being most common. Endoscopically, metastases may appear as solitary or multiple nodules, ulcers, or subepithelial masses. Diagnosis can be difficult due to the often prolonged time between primary tumor and metastasis, as well as benign-appearing lesions that can mimic primary GI cancers. Advanced imaging like CT and EUS-guided biopsy help confirm diagnoses. Familiarity with metastatic patterns from common primary cancers aids in detection and prevents misdiag
1) Familial adenomatous polyposis (FAP) is an autosomal dominant condition characterized by the development of hundreds to thousands of colonic polyps.
2) It is caused by a mutation in the APC gene and results in nearly 100% risk of colon cancer if left untreated.
3) Treatment involves prophylactic colectomy with either ileorectal anastomosis or restorative proctocolectomy with ileal pouch-anal anastomosis to remove the pre-cancerous colonic mucosa.
This document provides tips and instructions for using a PowerPoint presentation (ppt) on anal cancer:
1. The ppt can be freely downloaded, edited, and modified. It contains blank slides for notes that students can fill in.
2. The instructor should show blank slides, ask students what they know, and then show slides with information to fill gaps in an active learning session repeated three times.
3. The ppt is also useful for self-study with notes and bibliography provided.
Colon cancer is the second leading cause of cancer death. Screening and early detection are important as the 5-year survival rate is 55% but increases to 90% if detected early. Risk factors include diet, family history, inflammatory bowel disease, and certain genetic conditions. Colon cancer typically presents with bleeding, pain, or changes in bowel habits. Diagnosis involves colonoscopy and biopsy. Treatment depends on staging but commonly includes polypectomy, surgery, and chemotherapy or radiation. Regular screening is recommended starting at age 50 or earlier for those at higher risk.
Colon cancer is the second leading cause of cancer death. Screening allows early detection when cancer is highly curable. Colon cancer arises from adenomatous polyps. Risk factors include diet, family history, and conditions like inflammatory bowel disease. Symptoms vary depending on tumor location but may include bleeding, pain, and changes in bowel habits. Diagnosis involves history, exam, labs, and imaging like colonoscopy. Staging determines prognosis and treatment. Precise preoperative staging is important for rectal cancers.
The document discusses urothelial (transitional cell) bladder tumors, which make up over 90% of bladder cancers. Risk factors include smoking, industrial exposures, and certain genetic mutations. Grossly, tumors appear papillary or flat/indurated and histologically are classified as papillomas, carcinoma in situ, papillary urothelial neoplasms of low malignant potential, or urothelial carcinoma (low or high grade). Staging involves assessing tumor invasion from the mucosa to surrounding tissues. Less common non-epithelial bladder tumors include both benign and malignant mesenchymal variants such as leiomyoma or rhabdomyosarcoma.
This document discusses germ cell tumors of the ovary. It begins by explaining that germ cell tumors originate from primordial germ cells and make up about 90-95% of ovarian malignancies in young women. It then covers the various subtypes of germ cell tumors, including their incidence rates, typical patient demographics, clinical presentations, diagnostic markers, pathological classifications, treatment approaches, and prognosis. Dysgerminoma is discussed as the most common subtype, while immature teratoma, endodermal sinus tumor, embryonal carcinoma, and choriocarcinoma are also described in terms of their defining characteristics and management. Throughout, the focus remains on applying knowledge from testicular germ cell tumor research
The patient, a 63-year-old man, has noted increasing back pain for 7 months and has had recurrent respiratory infections. Laboratory tests show decreased kidney function with proteinuria. A renal biopsy shows deposits of pink amorphous material in the glomeruli, interstitium, and arteries. These findings are most consistent with a diagnosis of multiple myeloma.
This document provides information on carcinoma of the colon, including:
- Risk factors include red meat consumption, smoking, alcohol, certain medical conditions, and lack of protective factors like dietary fiber and aspirin.
- Most colorectal cancers develop through the adenoma-carcinoma sequence, where benign polyps transform into malignant carcinomas over time.
- Screening methods like colonoscopy can detect and remove precancerous polyps, reducing colorectal cancer incidence.
A 30-year-old female presented with a one month history of left iliac fossa pain, anorexia, weight loss, and vomiting for one week. Examination revealed a tender palpable mass in the left iliac fossa. CT scan showed sigmoid colon cancer with liver metastases. At laparotomy, a perforated sigmoid colon mass was found adhered to surrounding structures with pus collection. A sigmoid colectomy with end colostomy was performed.
Principles of Laparoscopic Surgery and SAFE Cholecystectomy.pptxAkshaySarraf1
This document provides information on laparoscopic surgery presented by Dr. Akshay Sarraf. It defines laparoscopic surgery and lists its advantages over traditional open surgery such as less pain, shorter hospital stays, and faster recovery times. The document discusses the principles, setup, instruments, and techniques used in laparoscopic surgery including maintaining pneumoperitoneum and port placement. It specifically addresses laparoscopic cholecystectomy as the gold standard procedure for gallbladder removal and emphasizes the importance of safely dissecting Calot's triangle.
Neurofibromatosis is a genetic disorder that causes tumors to form in nerve tissue. There are three main types: NF1, NF2, and schwannomatosis. NF1 is the most common type and is characterized by multiple café-au-lait spots and benign tumors called neurofibromas. The disorder is caused by mutations in the NF1 gene which codes for the neurofibromin protein. Clinical features include skin abnormalities, tumors of the nervous system, and bone abnormalities. Diagnosis is usually made clinically but genetic testing can help in some cases.
1) Septic shock is a life-threatening condition defined as sepsis with circulatory and metabolic abnormalities causing significantly higher mortality than sepsis alone.
2) Screening for sepsis involves assessing signs of infection and organ dysfunction using tools like qSOFA, lactate levels, and vitals.
3) Early management of septic shock focuses on rapid fluid resuscitation of at least 30mL/kg within 3 hours, maintaining a mean arterial pressure of 65mmHg, admitting patients to the ICU within 6 hours, administering appropriate antimicrobial therapy including coverage for MRSA in high risk patients, and monitoring for signs of adequate resuscitation like rising blood pressure and falling lactate levels.
Etiopathogenesis and Risk factors of Ca Breast.pptxAkshaySarraf1
Breast cancer is the most common cancer in women worldwide. Risk factors include both modifiable factors like obesity, lack of breastfeeding, alcohol consumption, as well as non-modifiable genetic factors. Genetic mutations in BRCA1 and BRCA2 account for up to 70% of hereditary breast cancer cases. Histologically, breast cancer usually arises from the milk ducts or lobules and can range from non-invasive to invasive carcinoma. Molecular markers like estrogen receptor, progesterone receptor, and HER2 status are used to classify breast cancer subtypes and predict treatment responses. Risk assessment models evaluate personal and family history to provide individualized lifetime breast cancer risk estimates.
Anatomy of Anterior Abdominal wall.pptxAkshaySarraf1
The anterior abdominal wall has nine layers including skin, fascia, muscles and peritoneum. The muscles include the external oblique, internal oblique and transversus abdominis which overlap and their aponeuroses form the rectus sheath enclosing the rectus abdominis muscle. The inferior epigastric artery supplies the lower abdominal wall. Hernias occur when abdominal contents protrude through weaknesses in the abdominal wall layers.
Classification and staging of Lung Cancer.pptxAkshaySarraf1
This document discusses lung cancer classification and staging. It begins by outlining the burden of lung cancer worldwide and risk factors like smoking. It then covers the pathological classification of lung cancers into small cell lung carcinoma and non-small cell lung carcinoma (NSCLC), with NSCLC further divided into adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and others. The staging system used is the TNM system which evaluates the tumor size (T), nodal involvement (N), and metastasis (M). Imaging and invasive testing are used to clinically and pathologically stage lung cancers to determine prognosis and guide treatment.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
#cALL# #gIRLS# In Dehradun ꧁❤8107221448❤꧂#cALL# #gIRLS# Service In Dehradun W...
Tumors of small bowel.pptx
1. Tumors of Small Bowel
Presenter-
Dr. Akshay Sarraf
2nd Year Resident
Dept. of General Surgery
1
2. Introduction
• Small intestine contains over 90% of the mucosal surface area of the GI
tract but only 1.1% to 2.4% of all GI malignancies.
• The incidence of small bowel cancer has increased an average of
approximately 2% each year during the past 15 years.
• The 5-year survival for localized small bowel cancer is approximately
85%(vs. 42% in distant disease).
• Mean age at presentation- 62 years for benign tumors and approximately
57 years for malignant tumors.
2
3. • The incidence of small bowel cancer is particularly low in India,
Romania, and other parts of Eastern Europe.
• Most benign neoplasms are asymptomatic and often identified as an
incidental finding.
• Malignant neoplasms account for 75% of symptomatic lesions that
lead to surgery.
3
4. • Stromal tumors and adenomas are the most frequent of the benign
tumors and appear to be more common in the distal small bowel.
• Adenocarcinoma is the most common malignant neoplasm.
• Neuroendocrine tumors (NETs) account for 25% to 30% of small
intestine malignant neoplasms.
4
5. • Risk factors-
1. Familial Adenomatous Polyposis (FAP) 6. Prior peptic ulcer disease
2. Hereditary Nonpolyposis Colorectal Cancer 7. Cystic fibrosis
3. Peutz-Jeghers syndrome 8. Biliary diversion (i.e., previous cholecystectomy)
4. Crohn disease 9. Smoking, heavy alcohol consumption
(>80 g/day of ethanol),
5. Gluten-sensitive enteropathy (i.e., celiac sprue) 10. Consumption of red meat or salt cured
foods.
5
6. • Genetics
• KRAS gene mutation.
• Deletion of 5q (APC gene), 17q (p53 gene), and 18q (DCC [deleted in colon
cancer] and DPC4 [SMAD4] genes).
• DNA mismatch gene repair is inactivated.
• Microsatellite instability (MSI-H)- typical of small bowel carcinomas
associated with celiac disease.
• Epidermal growth factor receptor and vascular endothelial growth factor
(VEGF) expression.
6
7. • Presentation
• Most patients with benign neoplasms remain asymptomatic.
• Often vague and nonspecific and may include dyspepsia, anorexia, malaise,
and dull abdominal pain, often intermittent and colicky.
• Pain, most often related to obstruction, is the most frequent complaint.
• Bleeding is usually occult; hematochezia or hematemesis may occur.
7
8. • Diagnosis
• High index of suspicion must be present for these neoplasms to be diagnosed.
• Correct preoperative diagnosis is made in only 50% of symptomatic patients.
• Plain X-Ray- just for confirming obstruction.
• Small bowel follow-through yields an accurate diagnosis in 53% to 83% of
patients with malignant neoplasms
8
9. • CT of the abdomen can prove particularly useful in detecting extraluminal
tumors, such as GISTs.
• Ultrasonography has not proved effective for preoperative diagnosis of small
bowel neoplasms.
• CT enteroclysis appears to be a more sensitive technique, with a diagnostic
accuracy of approximately 95%.
• MRI enteroclysis has a sensitivity and specificity of 98% and 97%,
respectively.
9
10. • Flexible endoscopy- duodenal lesions; the colonoscope can be advanced into
the terminal ileum for visualization and biopsy.
• Capsule endoscopy in the setting of obscure bleeding is highly sensitive and
specific.
• CT Angiography is of value in diagnosing and localizing tumors of vascular
origin.
• Diagnosis of a small bowel tumor is often achieved only at the time of surgical
exploration.
10
11. Benign Tumors
• The most common benign neoplasms include benign stromal tumors,
adenomas, and lipomas.
• Adenomas are the most common benign tumors reported in autopsy
series.
• Stromal tumors are the most common benign small bowel lesions that
produce symptoms.
• At operation, a thorough search of the remainder of the small bowel is
warranted because multiple tumors are not uncommon.
11
12. • Stromal Tumors-
• GIST make up 20% of all soft tissue sarcomas occurring throughout the
gastrointestinal tract
• Most prevalent in the stomach (60%) and jejunum and ileum (30%), and rarely
in duodenum (5%).
• Arise from the interstitial cell of Cajal, an intestinal pacemaker cell of
mesodermal descent.
• GISTs can be malignant tumors and nearly 20% of patients are found to have
metastatic disease, most commonly in the liver.
12
13. • Median age of diagnosis is 65 years of age, no sex predilection.
• A median size of 6 cm at diagnosis; some GISTs can even be larger than 20
cm.
• Symptoms include abdominal pain, fullness, bowel obstruction, or tumor
hemorrhage resulting in anemia, melena, or hematemesis.
• The workup of GIST is often initiated with a CT scan.
13
14. • An endoscopic core biopsy with immunohistochemical staining for KIT (95%)
and anoctamin-1 (98%) confirms the diagnosis.
• More than 95% of stromal tumors express CD117, and 70% to 90% express
CD34.
• Stromal tumors are firm, gray-white lesions with a whorled appearance noted
on cut surface.
• Microscopic examination demonstrates well-differentiated smooth muscle
cells.
14
15. • May grow intramurally and cause obstruction.
• Sometimes achieve considerable size and eventually outgrow their blood
supply, resulting in bleeding manifestations.
• The mitotic index is classified as low (<5 mitoses/50 hpf ) or high (>5
mitoses/50 hpf ).
• Tumors larger than 5 cm, regardless of mitotic index, have higher rates of
metastasis and recurrence
• Surgical resection is necessary for appropriate treatment.
• Higher-risk GIST lesions may require adjuvant therapy after resection.
15
16. • Adenomas:
• Account for approximately 15% of all benign small bowel tumors.
• Three primary types: true adenomas, villous adenomas, and Brunner gland
adenomas.
• 20% in the duodenum, 30% are found in the jejunum, and 50% are found in
the ileum.
• Are asymptomatic; most occur singly and are found incidentally at autopsy.
• most common presenting symptoms are pain, bleeding and obstruction.
16
17. • Villous adenomas: rare, premalignant; are most commonly found in the
duodenum
• May be associated with the familial polyposis syndrome.
• malignant potential is reportedly between 35% and 55%.
• Endoscopic ultrasound is a useful modality in the preintervention evaluation
and may help guide management planning.
17
18. • The options for treatment are endoscopic and surgical.
• In the jejunum and ileum, the treatment of choice is segmental resection.
• Surgical management has potential morbidity (20%–30%) associated with
duodenal resection by pancreaticoduodenectomy or pancreas-preserving
duodenectomy.
• Endoscopic resection (i.e., snare excision, thermal ablation, argon plasma
coagulation, or photodynamic therapy) is a safe alternative.
18
19. • Lifelong risk of recurrence is approximately 50% after endoscopic treatment
• Endoscopic mucosal resection(EMR) for the treatment of duodenal adenomas
and Brunner gland tumors has a high success rate for complete removal.
• The risk of delayed bleeding a/w EMR is significant
• Invasive changes or a recurrence after polypectomy necessitates a more
definitive approach (e.g., pancreaticoduodenectomy).
19
20. • Adenomas a/w FAP
• Adenomas in the duodenum can be found in 50% to 90% of cases.
• Increasing age is an independent risk factor for adenoma development.
• 5% lifetime risk for development of duodenal adenocarcinoma.
• For direct surveillance and treatment, patients are classified by the Spigelman
classification.
• Screening endoscopy is performed at regular intervals with biopsy of all
suspicious, villous, or large (>3 cm) adenomas.
20
22. • Peutz-Jeghers Syndrome:
• Inherited syndrome of mucocutaneous melanotic pigmentation and
gastrointestinal hamartomatous polyps.
• Autosomal dominant, with a high degree of penetrance.
• Brown or black spots located in the circumoral region of the face, buccal
mucosa, forearms, palms, soles, digits, and perianal area.
• Hamartomas are most commonly found in the jejunum and ileum
22
23. • The most common symptom is recurrent colicky abdominal pain, a palpable
mass in 1/3 patients.
• Hemorrhage as a result of autoamputation of the polyps may occurs.
• Adenomatous changes have been reported in 3% to 6% of hamartomas.
• Extracolonic cancers are common, occurring in 50% to 90% of patients (small
intestine-m/c, stomach, pancreas, ovary, lung, uterus, and breast).
23
24. • Treatment is directed at bowel obstruction or persistent gastrointestinal
bleeding
• Resection should be limited to the segment of bowel that is producing
complications
• Because of the widespread nature of intestinal involvement, cure is not
possible; therefore, extensive resection is not indicated.
24
25. • Hemangiomas-
• Developmental malformations consisting of submucosal proliferation of blood
vessels.
• Can occur at any level of the gastrointestinal tract; jejunum is the most
commonly affected small bowel segment.
• 3% to 4% of all benign tumors of the small bowel and are multifocal in 60% of
patients.
• A/w Osler-Weber-Rendu disease and Turner syndrome.
25
26. • The most common symptom of small bowel hemangiomas is intestinal
bleeding.
• Angiography and technetium Tc-99m red blood cell scanning are the most
useful diagnostic studies.
• If a hemangioma is localized preoperatively, resection of the involved
intestinal segment is warranted.
• Intraoperative transillumination and palpation may help to identify a
nonlocalized hemangioma.
26
27. Malignant Neoplasms
• Incidence of malignant neoplasms of the small intestine has increased
steadily during the past three decades.
• Neuroendocrine neoplasms (NENs) increased more than fourfold.
• 5-year survival rate is 34.9% compared to 51.5% survival rate for
colorectal cancer
27
28. • Almost always produce symptoms, the most common of which are
pain and weight loss.
• Obstruction develops in 15% to 35% of patients as a result of tumor
infiltration and adhesions
• Gastrointestinal bleeding, manifested by anemia and occult blood-
positive stools or occasionally by melena or hematochezia.
• A palpable mass may be felt in 10% to 20% of patients, and
perforations develop in approximately 10%.
28
29. • Neuroendocrine Neoplasms:
• Arise from enterochromaffin cells (Kulchitsky cells).
• “carcinoid” has become a misnomer, as all NENs have
malignant potential.
• Reported in a number of organs, including lungs, bronchi,
and the gastrointestinal tract.
• Median age for gastroenteric NEN of 63 years.
29
30. • Divided into NETs and neuroendocrine carcinomas.
• The distinction between a G3 well-differentiated NET and a G3 poorly
differentiated NEC can be difficult and may require additional pathologic
confirmation or immunohistochemical staining. 30
31. • Midgut NETs are characterized by having high serotonin production.
• The most prominent neuropeptide- serotonin and substance P
• Almost always occur within the last 2 feet of the ileum.
• Carcinoid syndrome- cutaneous flushing (80%); diarrhea (76%);
hepatomegaly (71%); cardiac lesions, most commonly right-sided heart
valvular disease (41%–70%); and asthma (25%) and are present mostly in
those patients with hepatic metastases.
31
32. • Found in five typical sites: small intestine (38%), rectum (34%), colon (16%),
stomach (11%), and unknown sites (1%).
• Are multicentric in 20% to 30% of patients.
• The malignant potential is related to location, size, depth of invasion, and
growth pattern.
• 3% of appendiceal NETs, 35% of ileal NETs are associated with metastasis.
• GI NETs of <1 cm in diameter(75%) have 2% chance of metastasis, NETs 1 to
2 cm -50% and larger than 2 cm are associated with metastasis 80% to 90% of
cases.
32
34. • After invasion of the serosa, the intense desmoplastic reaction produces
mesenteric fibrosis, intestinal kinking, and intermittent obstruction.
• Larger mesenteric mass caused by nodal disease and desmoplastic invasion of
the mesentery, which is often mistaken for the primary tumor.
• Frequent coexistence of a second primary malignant neoplasm of a different
histologic type, usually a synchronous adenocarcinoma.
• As mesenteric and nodal extension progresses, local venous engorgement and,
ultimately, ischemia of the affected segment of intestine.
34
35. • Rarely diagnosed preoperatively.
• Elevated urinary levels of 5-HIAA measured during 24
hours are highly specific although not sensitive.
• Chromogranin A (CgA) is elevated in more than 80% of
patients with NETs. (specificity of 95%, sensitivity 55%)
35
36. • Radiologically a solid mass with spiculated borders and radiating surrounding
strands that is associated with linear strands within the mesenteric fat and
kinking of the bowel, a diagnosis of gastrointestinal NET can be made fairly
confidently.
• Scintigraphic(indium(111In)-labeled pentetreotide) localization has a higher
sensitivity than CT for delineating and localizing NETs.
• MRI can be helpful in diagnosing metastatic disease, especially in the liver.
• FDG is taken up only in highgrade NETs (e.g., high Ki-67 expression),
whereas most NETs have low Ki-67 expression
36
37. • Treatment small bowel NETs is based on tumor size, location, and presence of
metastatic disease.
• primary tumors smaller than 1 cm in diameter without evidence of regional
lymph node metastasis, a segmental intestinal resection is adequate
• wide excision of bowel and mesentery- lesions >1 cm, multiple tumors, or
with regional lymph node metastasis.
• Lesions of the terminal ileum are best treated by right hemicolectomy.
37
38. • Small duodenal tumors can be excised locally; however, more extensive
lesions may require pancreaticoduodenectomy.
• In cases of mesenteric disease aggressive surgical resection and debulking
achieve relief of 93% of obstruction and 83% of mesenteric vessel
encasement.
• In contrast to metastases from other tumors, there is a definite role for surgical
debulking, which often provides beneficial symptomatic relief.
• Metastasectomy (Liver) provides the most durable survival benefit compared
with other treatment modalities.
38
40. • NETs have the best prognosis of all small bowel tumors.
• Resection of a NET localized to its primary site approaches a 100% survival
rate.
• Five-year survival rates are approximately 65% in patients with regional
disease and 25% to 35% in those with distant metastasis
• Tumors recur in 40% to 60% of patients.
• An elevated level of CgA is an independent predictor of an adverse prognosis.
40
41. • Adenocarcinoma-
• Constitute ~40% of the malignant tumors of the small bowel.
• Median age at diagnosis is in the sixth decade of life, M>F.
• Most of these tumors are located in the duodenum and proximal jejunum.
• Those associated with Crohn disease tend to occur at a somewhat younger age,
and more than 70% arise in the ileum.
41
42. • May have important gene mutations- APC, β-CATENIN, EGFR, VEGF-A,
KRAS, HER2, TP53.
• m/c familial causes include FAP, Lynch syndrome, and Peutz Jeghers
syndrome.
• Tumors of the duodenum manifest early because of the earlier presentation of
symptoms, which are usually jaundice and chronic bleeding.
• Jejunum and ileum- nonspecific symptoms like vague abdominal pain and
weight loss, Intestinal obstruction and chronic bleeding; Perforation is
uncommon.
42
44. • Treatment
• Is determined by location and stage.
• An R0 resection of the primary tumor with locoregional lymph node resection
is the only curative treatment.
• Regional lymphadenectomy of the periduodenal, peripancreatic, and hepatic
lymph nodes as well as involved vascular structures is necessary.
• Neoadjuvant chemotherapy- if there is tumor invasion into adjacent structures.
44
45. • Jejunal and ileal adenocarcinomas require surgical resection with regional
lymphadenectomy and jejunojejunal or ileoileal anastomosis.
• Ileocecectomy with right hemicolectomy with ligation of the ileocolic artery
and subsequent regional lymphadenectomy for terminal ileum lesion.
45
46. • Poorly differentiated cancers or those who had incomplete lymph node
resections (<10 nodes identified) should at least be considered for adjuvant
chemotherapy.
• Adjuvant fluoropyrimidine and oxaliplatin may increase overall survival in
patients with advanced disease.
• BALLAD trial- proposes adjuvant chemotherapy will result in an
improvement in disease-free survival and overall survival compared with
observation alone after potentially curative surgery for patients with stage I, II,
and III small bowel adenocarcinoma.
46
47. • Metastatic disease- studies have determined that using FOLFOX (oxaliplatin,
5-FU, and leucovorin) and FOLFIRI (irinotecan, 5-FU, and leucovorin) as
first-line therapy.
• Unresectable metastatic disease may require surgical intervention for
uncontrolled bleeding, bowel obstruction, or perforation.
• Prognosis of small bowel adenocarcinoma is poor.
• Five-year survival rates are typically in the 14% to 33% range.
• Duodenal adenocarcinoma has a 5-year survival rate of 50%.
47
48. • Stage III- >3 positive lymph nodes 5-year disease-free survival rate was 37%; 1 or 2
positive lymph nodes was 57%.
• Advanced age, advanced stage, ileal location, recovery of fewer than 10 lymph nodes,
and number of positive nodes are significant predictors of poor overall survival.
• Any attempts at curative resection should always include an extensive regional
lymphadenectomy.
48
49. • Lymphoma-
• Primary or as a manifestation of systemic disease.
• One-third of gastrointestinal lymphomas occur in the small bowel, accounts
for 5% of all lymphomas.
• 25% of small bowel malignant tumors in the adult; most common intestinal
neoplasm in children younger than 10 years.
• Most commonly found in the ileum, d/t greatest concentration of gut-
associated lymphoid tissue.
• Primary small bowel lymphomas was associated with celiac disease and
immunodeficient states (e.g., AIDS).
49
50. • Usually large, with most greater than 5 cm and may extend beneath the
mucosa.
• There is often diffuse infiltration of the intestinal wall.
• Symptoms include pain, weight loss, nausea, vomiting, and change in bowel
habits.
• Perforation may occur in up to 25% of patients.
• Fever is uncommon and suggests systemic involvement.
50
52. • Treatment
• A combination of surgery, chemotherapy, and radiation therapy is used for all
small bowel tumors.
• In the absence of symptoms, small bowel lymphomas are often chemo
responsive and do not require surgery.
• B-cell lymphomas are more chemosensitive have high remission rates with or
without surgery.
• T-cell lymphomas are traditionally more resistant to therapy and will progress
to symptoms of obstruction or perforation if not resected.
• Five-year survival of 50% to 60% can be expected and is dictated by response
to systemic therapy.
52
53. • GIST-
• Constitute about 20% of malignant neoplasms of the small bowel.
• More common in the jejunum and ileum.
• Typically are diagnosed in the fifth and sixth decades of life with slight male
predilection.
• Larger than 5 cm at the time of diagnosis in 80% of patients.
• Mostly arise from the muscularis propria and generally grow extramurally.
• Most common indications for surgery include bleeding and obstruction, free
perforation as a result of hemorrhagic necrosis in large tumor masses.
53
54. • Invade locally or spread by direct extension into adjacent tissues and
hematogenously to the liver, lungs, and bone; lymphatic metastases are
unusual
• The treatment regimen is based on localized versus metastatic disease.
• Surgical management includes complete resection of localized GISTs
• If capsule rupture occurs, patients should receive adjuvant therapy
• A laparoscopic approach in patients with large tumors is strongly discouraged.
• Radiologic criteria for unresectability include infiltration of the celiac trunk,
superior mesenteric artery, or portal vein.
54
55. • Current guidelines suggest that patients with high-risk disease should receive 3
years of adjuvant treatment with imatinib.
• Imatinib- Tyrosine kinase inhibitor that blocks the unregulated mutant c-kit
tyrosine kinase and inhibits the BCR-ABL and PDGF tyrosine kinases.
• Not recommended for low-risk patients after an R0 resection.
• Neoadjuvant imatinib should be considered for patients requiring extensive
surgery to allow for tumor shrinkage prior to resection.
• Deletions affecting exon 11, codon 557/558 of the c-kit gene, and D842V
PDGFRα mutations have a higher risk of recurrence within the first 3 to 4
years after surgery.
55
57. • Nilotinib is a second-generation tyrosine kinase inhibitor active in chronic
myeloid leukemia and has an inhibitory effect on ckit and PDGF
• Phase 3 trials have shown minimal differences between this drug and imatinib
or sunitinib.
• Sorafenib is a VEGF, c-kit, PDGFR, and BRAF inhibitor and has been
effective in imatinib- and sunitinib-resistant tumors.
• The combination of imatinib and doxorubicin has shown some benefit in
patients with wild-type GISTs.
57
58. Metastatic Neoplasm
• Much more common than primary neoplasms.
• usually arise from other intraabdominal organs, including the uterus
cervix, ovaries, kidneys, stomach, colon, and pancreas.
• By direct extension or implantation of tumor cells.
• May be found in patients with adenocarcinoma of the breast and
carcinoma of the lung.
• Cutaneous melanoma is the most common extraabdominal source
58
59. • Common symptoms of metastatic disease include anorexia, weight
loss, anemia, bleeding, and partial bowel obstruction.
• Palliation to relieve symptoms or, occasionally, a bypass if the
metastatic tumor is extensive and not amenable to resection.
• Nonoperative palliation includes endoscopic or radiologic placement
of self-expandable metal stents.
• Gastrostomy and jejunostomy tubes also may be placed to provide
decompression when other palliative methods are not possible.
59
60. References
1. Bailey & Love’s Short Practice of Surgery, 28th Edition.
2. Sabiston Textbook of Surgery, 21st Edition.
3. Schwartz’s Principles of Surgery, 11th Edition.
60
with the highest cancer rates found among the Maori of New Zealand and ethnic Hawaiians.
, accounting for 30% to50% of malignant neoplasms of the small intestine
may be present for months or years before diagnosis.
, although life-threatening hemorrhage is uncommon
can provide helpful information about the staging of malignant cancers
between 89% and 95% and between 75% and 95%, respectively.
Despite these sophisticated imaging and diagnostic modalities,
c-kit proto-oncogene, which cause KIT to become constitutively activated, presumably leading to persistence of cellular growth or survival signals. Because the interstitial cells of Cajal normally express KIT
GISTs are often large, with
KIT proto-oncogene protein that is a transmembrane receptor for the stem cell growth factor, the human progenitor cell antigen.
GIST with spindle-cell features
however, some series showed that the
however, the risk of delayed bleeding is significant. 17% risk of other complications, including perforation, hemorrhage, and pancreatitis.
therefore,routine lifelong surveillance is a priority.
The presence of high-grade dysplasia, carcinoma in situ, or a Spigelman stage IV classification necessitates pancreaticoduodenectomy or pancreas-preserving duodenectomy.
usually the result of intermittent intussusception. Lower abdominal pain associated with
but infrequently, and is most commonly manifested by anemia.
whereas changes in the frequency of adenocarcinomas, stromal tumors, and lymphomas are less pronounced.
is more common with GISTs.
%, usually secondary to lymphomas and sarcomas.
neural crest cells situated at the base of the crypts of Lieberkühn.
term Karzinoide to indicate the carcinoma-like appearance and the presumed lack of malignant potential.
may be benign or of the well-differentiated malignant type and are further subdivided into three groups, low grade (grade 1, G1), intermediate-grade (grade 2, G2), or highgrade (grade 3, G3) tumors, based on the appearance, mitotic rates, behavior (invasion of other organs, angioinvasion), and Ki- 67 proliferative index. On the other hand, neuroendocrine carcinomas are all G3, poorly differentiated malignant tumors
Nuclear non histone protein present in all proliferating cells as a proliferation marker
These tumors may derive from the foregut (respiratory tract, thymus), midgut (jejunum, ileum and right colon, stomach, proximal duodenum), and hindgut (distal colon, rectum).
5-Hydroxy indoleacetic acid (5-HIAA) is the primary metabolite of serotonin. Serotonin is broken down into 5-hydroxy indoleacetic acid within the liver
, secondary to serotonin or tachykinin production-
these tumors are small, firm, submucosal nodules that are usually yellow on the cut surface
They may be as subtle as a small whitish plaque seen on the antimesenteric border of the small intestine
tend to grow very slowly, but
Barium radiographic studies of the small bowel may exhibit multiple filling defects as a result of kinking and fibrosis of the bowel
5-Hydroxy indoleacetic acid (5-HIAA) is the primary metabolite of serotoni
F-fluorodeoxyglucos
Jejunal adenocarcinoma. Large circumferential mucinous adenocarcinoma of the jejunum. (
(A) Malignant tumors should be resected with a wide margin of normal bowel and a wedge of mesentery to remove the immediate draining lymph nodes. (B) End-to-end anastomosis of the small bowel and repair of the mesentery.
A prospective international phase 3 trial
Probably because of the delayed presentation and presence of advanced disease at diagnosis.
probably because of the earlier symptom presentation and diagnosis.