Surgery Medical School Crash Course (Unabridged) - 08 A_T_F

Surgical oncology involves various types of cancer surgeries, including curative surgery, staging surgery, debulking surgery, and surgery to reduce cancer symptoms. General surgeons perform most cancer surgeries, while specialized surgeons focus on specific high-risk cancers. Cancer surgeries are usually open surgeries under general anesthesia, but some may involve local or spinal anesthesia. Cryosurgery and laser surgery are alternatives to traditional surgeries, using extreme cold or laser beams to treat cancer. Hyperthermia cancer surgery uses high temperatures to ablate cancer cells. Photodynamic therapy uses drugs activated by light to kill cancer cells. Cancer surgery is most effective for localized solid tumors, and it carries risks such as pain, infection, and bleeding. Patients may have surgery at a surgery center, outpatient clinic, or hospital, and post-op care may be outpatient. Prior to surgery, patients may need to fast or take special bowel prep. Surgical treatment may b Chapter 5, Surgical Oncology. This chapter involves a discussion of oncological surgery. There are many types of cancer that are treated primarily with surgery as part of the treatment for their cancer. Cancer surgery does not have to be curative. There are other reasons for cancer surgery, including surgery to stage a cancer, surgery to debulk an incurable cancer, and surgery to reduce the symptoms of cancer in a terminal cancer patient. Surgery Basics. Most cancer surgery is performed by general surgeons, although there are some surgeons who specialize in the surgical removal of certain high-risk cancers. Thoracic surgeons tend to remove cancers related to the heart and lungs, while neurosurgeons are primarily the surgeons involved in removing brain tumors. General surgeons often treat patients with abdominal cancers, and orthopedic surgeons specialize in the removal and subsequent management of patients with skeletal cancers. Most cancer surgery is done as an open surgery, which allows for full visualization of the cancer, surrounding lymph nodes, and many areas of metastases that might be found at the time of surgery. Surgeons use scalpels and other sharp instruments to open body cavities or areas where cancer is suspected. Most cancer surgeries are done under general anesthesia, however high-risk patients may have spinal or epidural anesthesia, and this type of surgical anesthesia is used when the surgery involves the lower extremities or pelvis. If a surgical biopsy is obtained, such as a biopsy of a breast mass, the surgeon often uses local anesthesia to numb an area of the skin and soft tissue, so that the biopsy can be safely obtained without pain. There are other cancer surgeries that don't involve a scalpel or an open incision. One of these is cryosurgery. The surgeon uses extremely cold instruments and liquid nitrogen or argon gas to destroy cancerous tissue. Cryosurgery is often done in early-stage skin cancer, pre-cancerous lesions on the skin or cervix, and retinoblastomas. This type of cryosurgery can ablate the cancer or pre-cancerous lesions to have destruction of the lesion without having to cut into the tissue. Laser surgery is also a type of cancer surgery. Very strong beams of light are used to cut through tissue with very minimal blood loss. Very small laser incisions can be made for extreme precision in doing the surgery. Most laser surgeries are preferred for surgeries that are located near the skin surface or cancers that line internal organs. Common surgeries used with laser surgery include basal cell skin cancers, pre-cancerous changes in the cervix, esophageal cancer, cervical cancer, vaginal cancer, and small cell lung cancer. Hyperthermia cancer surgery involves using high temperatures to ablate cancer cells. Cancer cells treated with thermal therapies are more sensitive to having chemotherapy treatments or radiation treatments. Low-frequency ablation is one kind of thermal treatment that involves high-energy radio waves that produce heat. This type of therapy is considered experimental and is not common use for patients with cancer. Photodynamic therapy is a type of cancer treatment that uses drugs that react to a certain wavelength of light. When a tumor is exposed to light, these drugs are activated and can kill nearby cancer cells. Photodynamic therapy is most often used to treat or relieve cancer symptoms associated with non-small cell lung cancer, mycosis fungoids, and certain skin cancers. Cancer surgery works best for solid cancers that are contained in a specific area. Cancer surgery is local treatment that removes the solid tumor, any nearby involved lymph nodes, and possibly metastatic lesions. It cannot be used for blood cancers or bone marrow cancers and sometimes isn't used when the cancer is so advanced that it is spread to many distant areas of the body. In such cases, open cancer surgery is reserved for patients who have symptoms that would be improved if some of the cancer was removed. There are risks to any surgery, and cancer surgery is no exception. The main risks of cancer surgery include pain, which will be related to the area of the body where the surgery took place and the extensiveness of the surgery. Highly extensive cancer surgery will be more painful after the procedure than a mild or moderate surgery. Unfortunately, there are many treatments for cancer pain and few patients with cancer need to worry about not getting enough pain medication for post-operative pain, as there is no risk of addiction even for high-potency opioid analgesic medications. Infection is another problem associated with cancer surgery. Most patients who have open surgeries for cancer removal or for staging will receive antibiotics at the time of surgery, which will minimize the incidence of surgically related infection. If an infection does occur after surgery, sometimes the surgeon must do another surgery to remove abscesses that might have accrued. If there are no abscesses, antibiotics need to be used to treat the post-operative infection. Bleeding is another risk of cancer surgery. This is especially the case when large cancers are removed or when the cancer is highly vascular. Surgeons often use laser scalpels or electrocautery to minimize blood loss during cancer surgery. But if these things do not work, intravenous fluids or blood transfusions are given to replace the lost blood. There is some risk to having a blood transfusion, including a transfusion reaction, but blood is screened extensively before being allowed to be used for a transfusion, so that things like blood-borne diseases are extremely rare when getting a blood transfusion. Patients who have cancer surgery may have their surgery at a freestanding surgery center, an outpatient clinic, or in a hospital. Just because a patient needs to have a hospital-based surgery doesn't necessarily mean they need to stay overnight at the hospital. Many hospital surgeries are outpatient procedures that are simply performed for convenience in the hospital. The patient who awakens from anesthesia and has adequate pain control and the availability of someone to drive them home after surgery and care for them after surgery may be able to go home and follow up with the surgeon in the outpatient clinic the next day or a few days after surgery to discuss biopsy results and to see if the patient is recovering from surgery. Prior to cancer surgery, most patients are notified by a hospital staff member who will instruct the patient on the preparations necessary for surgery. Most patients only need to prepare for surgery by fasting the night before, but patients having bowel surgery may need to take a special bowel prep that will clean the bowels before the procedure is done. All patients having cancer surgery will have a thorough history and physical examination. Many will have blood tests to make sure they aren't anemic before surgery. Older patients will have a chest X-ray and an electrocardiogram to evaluate their heart and lungs before the surgical procedure. While the surgery is taking place, the surgeon will remove as much of the cancer as possible, along with the surrounding healthy tissue, to make sure that the entire tumor was removed. Lymph nodes are biopsied and some are removed if cancer is suspected to be present in the lymph nodes. In some cases, the actual diagnosis of the cancer isn't known until the surgery takes place. In such cases, the surgeon may take a sampling of the cancer and will ask for a frozen section to be obtained and immediately evaluated in the histology laboratory so the surgeon can treat the cancer with knowledge of what kind of cancer is present and how aggressive the cancer appears to be under the microscope. Following cancer surgery, some patients go home, while others need to stay in the hospital to recover. In some cases, surgical treatment is the only treatment necessary to manage the cancer, while in other cases the cancer requires additional treatment, such as staging surgery, chemotherapy, brachytherapy, or external beam radiation therapy. Sometimes the surgeon knows immediately after surgery what other treatments will be recommended. In general, however, the surgeon waits for the final biopsy report to make a referral to a radiation oncologist or a specialist in chemotherapy to further manage the cancer. Cancer patients often have special dietary needs. Cancer treatments may affect the patient's ability to eat normal food because of radiation or chemotherapy side effects. Even so, things like malnutrition can adversely affect the cancer outcome, so dietary referrals are often made so that after recovering from surgery, the patient can begin eating foods that build their nutritional status, which will improve their ability to survive the rigors of cancer treatments. In general, malnourished patients have more problems fighting off cancer than patients who are well-nourished, so the patient's nutritional status should be carefully monitored and maximized as the cancer treatments proceed. About 60% of patients with cancer will be surgical candidates and will have some type of surgery to control their cancer. In some cases, surgery is the only necessary treatment for cancer, while in other cases, surgery is done before chemotherapy and or radiation. Some patients will have radiation or chemotherapy before their surgery because the cancer is too big to be removed surgically as it is, and the use of these treatments will make the surgery safer and more effective. Types of Cancer Surgery There are several types of cancer surgery a person may have. These include the following. Curative Surgery This involves removing the entire cancerous tumor. It works best on cancers that are localized to one area of the body, are relatively small, and have no evidence of any metastatic disease. Even though the surgery is considered curative, it may still be necessary to have radiation treatments or chemotherapy treatments to make sure any cancerous cells that were left behind during the surgical procedure are further destroyed without a need for a second surgery. Preventive Surgery This is a type of surgery done for the express purpose of keeping a cancer from happening. A typical example of this would involve surgery to remove precancerous polyps of a colon that would ultimately become cancerous if they were not removed by the surgeon. Another example is the removal of precancerous lesions of the cervix. The cervix is generally infected with the human papillomavirus and would become cancerous if the bulk of the cervix is not removed surgically. Some women with known genetic mutations that put them at a high risk for ovarian cancer and breast cancer choose to have their normal ovaries and normal breasts removed before any type of cancer can begin. Reconstructive Surgery This is surgery that is often done after cancer surgery and other treatments for cancer. Once it becomes clear that the cancer has resolved, some patients request reconstructive surgery to restore a natural appearance to their body. Women who have breast reconstructive surgery after cancer of the breast can have implants or other types of breast reconstruction so they don't have to live with a single breast. Men can have testicular implants after testicular cancer to have normal appearing testicles. Facial reconstructive surgery is done on patients who have large skin cancers of the face that would cause significant disfigurement if reconstructive surgery is not done to restore the appearance of the facial structures. Staging Surgery This is surgery that is solely done to find out the extent of the cancer. Some staging surgery is an open surgery in which the doctor opens the chest or abdomen to see how much cancer is present. Nowadays, many staging surgeries are done using a laparoscope or an endoscope that will look at the internal structures and can stage the surgery with a minimal incision and very little post-operative recovery period. Supportive Surgery This is surgery done on cancer patients that have nothing to do with removing the cancer or otherwise treating the cancer with surgery. Examples of supportive surgery include surgeries to implant pain control pumps or venous access ports that allow patients with poor veins to receive chemotherapy, which often requires a significant and long-lasting venous access to regularly give chemotherapy treatments. Palliative Surgery This is surgery done to improve the patient's quality of their remaining life by removing cancerous areas that are causing uncontrollable pain or cancers that are obstructing the bowels or the urinary tract. The goal of this type of surgery is just comfort and has nothing to do with any attempts at curing the cancer or even prolonging the patient's life. It is usually done on patients who have otherwise inoperable terminal cancer. Minimally Invasive Surgery This type of surgery is being done more commonly for cancer treatment than in the past. The patient undergoes general anesthesia but has their surgery removed through laparoscopic surgery or other endoscopic surgery that involves very small incisions. Some minimally invasive surgeries are done robotically, where the surgeon sits at a console and uses computers to allow robotic instruments to precisely remove cancerous lesions through very small incisions so that there is little disruption of the skin and otherwise healthy tissue. Minimally Invasive Surgery More and more cancer surgeries are being done with minimally invasive surgical techniques that can effectively remove cancerous tissue with minimal disruption of normal tissue and a significantly faster recovery time. This is also known as keyhole surgery or laparoscopic surgery. An incision is made for a tiny camera to be inserted into the body cavity. Other incisions, all of which are less than one inch in length, are made for the insertion of scalpels and probes that can effectively dissect away the cancerous lesion and surrounding tissue without having to open the patient completely. Even lymph node biopsies and lymph node removal procedures can be done through this type of surgery. The major instrument used in minimally invasive surgery is the laparoscope. It contains the camera lens that can microscopically evaluate the affected tissue. Air is also introduced into the abdomen through the laparoscope to keep the organs separated and to make viewing and dissection of the tissues an easier procedure to do. The major advantages of minimally invasive surgery include much less blood loss, a decreased need for an intraoperative blood transfusion, faster recovery times, less pain medications needed after surgery, faster return to normal activities, and better cosmetic outcomes as these tiny incisions heal with tiny scars but heal with less scarring than a major surgical procedure would entail. As mentioned, robotic surgery can be done as a minimally invasive surgery. One or more robotic arms are under the complete control of the surgeon. One of the robotic arms has the camera attached to it so the surgeon can see what is being done while the other robotic arms contain extremely small instruments that are operated remotely like how a person would operate a joystick in a video game. The biggest advantage in doing this type of surgery is that it doesn't fatigue the surgeon who might tire and make a mistake in a long, complex procedure done laparoscopically. Transoral Laser Microsurgery Transoral Laser Microsurgery, or TLM, is used to treat very small tumors of the throat and larynx. A laser beam that makes use of carbon dioxide is used to cut through delicate tissues that might be injured if a larger surgery is done or if a scalpel is used to treat the cancer. The surgeon uses an endoscope that is passed through the oral cavity to see the cancerous site in the throat or larynx. A microscope is attached to the end of the endoscope, which aids in guiding the laser beam used in the procedure. Pulses or bursts of energy are sent out through the laser, generating a small amount of heat that helps cauterize the tissues. There is minimal damage to the structures of the throat and larynx responsible for speaking and eating. As cautery is done at the same time as the incision is made, the healing time is faster and there is virtually no bleeding. Stereotactic Radiosurgery Stereotactic Radiosurgery, or SRS, is a non-invasive surgical procedure that makes use of dozens of small radiation beams that are primarily used in the management of brain tumors. The surgery is not technically surgical because no incisions are made and no anesthesia is required. The operator uses a computerized tomography, CT, or magnetic resonance imagery, MRI device, to accurately locate the brain tumor and to determine its dimensions. The exact radiation dose necessary to kill the tumor is determined and given by up to 200 radiation beams. The radiosurgeon can accurately target the brain tumor without affecting any normal brain tissue. If there is more than one brain tumor or cancer, this type of surgery can perform whatever treatments are necessary. Stereotactic radiosurgery is an outpatient procedure that usually takes just one treatment. This has the advantage of destroying brain cells in one single procedure rather than having the patient return for multiple radiation treatments that would require relocalizing the tumor every time the radiation is applied. Patients can go home and may resume normal activities with minimal side effects and no risk of bleeding. One type of stereotactic radiosurgery involves what is known as a gamma knife. This is a photon-based radiosurgical tool that can be used for the treatment of many types of brain lesions, including cancers at the base of the skull, metastatic brain tumors, malignant gliomas, meningiomas, pituitary tumors, and acoustic neuromas. Ablation Therapy Ablation therapy is a surgical technique that uses cold or heat therapy to destroy or ablate cancers. Without having to do any type of invasive surgery, the surgeon makes use of special probes that deliver heat, cold, or laser treatments to the cancer, using computer imaging techniques to guide the probes to the correct place in the body, and to monitor the effectiveness of the ablation treatment. The main advantages of doing this type of procedure is that there is minimal pain involved and a much shorter recovery time than any other treatment for cancer. Most patients can have surgery and can go home the same night. Cryoablation is also called cryotherapy or cryosurgery. The surgeon inserts a special probe that is inserted directly into the cancer and then cooled to a very low temperature that freezes and destroys the cancer. It is not as invasive as open surgery and is an outpatient procedure. Prostate cancers and kidney cancers are the main tumors treated with cryoablation therapy. The disadvantage to using this type of procedure on patients with prostate cancer is that 80% of the time, the man will become impotent after the surgery. If a man is already impotent, however, there is nothing to lose, and this offers a convenient way to treat prostate cancer. Radiofrequency ablation, or RFA, can also be done. Instead of cold treatments, radiofrequency waves are directed at the tumor, heating the tissue until it is completely destroyed. RFA is currently being employed in many types of cancers, including metastatic bone cancer, liver cancers, renal cancers, and lung cancers. High-intensity focused ultrasound for prostate cancer, or HIFU, is specifically used to treat prostate cancer. A probe with high-frequency ultrasound treatments produce enough heat to kill the prostate cancer cells. The probe is inserted into the patient's rectum and is computer-guided to get to the cancer. The entire prostate can be ablated in this procedure, or the ultrasound can be used in a more focused way to destroy only part of the cancer. The main disadvantage of this procedure is that it can take up to four hours to do, which is much longer than other treatments for prostate cancer. Key takeaways. Cancer surgery may be an open surgical procedure, a laparoscopic procedure, a robotic procedure, or a radiosurgical procedure. Cancer surgery may be designed to cure the cancer, stage the cancer, treat the cancer symptoms, restore the person's anatomy after cancer surgery, or to provide supportive devices that aid in cancer management. Ablationally invasive surgery is being used more often for the treatment of cancer. It involves the use of much smaller incisions and the ability to remove cancer with less blood loss and a better cosmetic result. Ablation surgery can involve the use of heat, lasers, ultrasound, or cold to get rid of cancers by destroying the cancerous tissue. Quiz. Number one. What is the main disadvantage of using a high-intensity focused ultrasound for treating patients with prostate cancer? A. It rarely removes the entire cancer. B. It can only be used for palliative prostate cancer treatment. C. It does not allow for inspection of the lymph nodes. D. It takes much longer to do than most prostate cancer surgeries. Answer, D. The main disadvantage of high-intensity focused ultrasound for prostate cancer treatment is that it takes up to four hours to perform, which is longer than most prostate cancer treatments. Number two. What is the main disadvantage of doing cryoablation surgery on the prostate gland for prostate cancer? A. There is more bleeding in this procedure than in a transurethral resection of the prostate. B. It does not get all the tumor, so chemotherapy is invariably required. C. It leads to impotence in most of the men who have the procedure. D. It causes more rectal pain than having a total prostatectomy for prostate cancer. Answer, C. The main disadvantage of doing cryoablation procedure on the prostate gland is that most men who have this procedure are rendered impotent after the surgery is completed. Number three. What is the main type of cancer treated with stereotactic radiosurgery? A. Brain cancer. B. Bone cancer. C. Liver cancer. D. Renal cancer. Answer, A. The main type of cancer treated with stereotactic radiosurgery is brain cancer. It can be a primary tumor or multiple metastatic tumors that can be successfully treated with this procedure. Number four. What is the main goal of supportive surgery for patients with cancer? A. It relieves symptoms related to the size of the cancer. B. It places ports or pain control devices that aid in the treatment of surgery. C. It ablates small cancerous lesions without having to use a large incision. D. It is used for cancer patients because they don't have to stay in the hospital afterward. Answer, B. The main goal of supportive surgery for patients with cancer is to insert venous ports or pain control devices that aid in the treatment of surgery but don't directly deal with the cancer. Number five. What type of cancer is best treated with transoral laser microsurgery? A. Esophageal cancer. B. Brain cancer. C. Laryngeal cancer. D. Stomach cancer. Answer, C. The main type of cancer treated with transoral laser microsurgery is laryngeal cancer as it is a very precise surgery that spares the speaking and eating parts of the pharynx. Number six. What is the main advantage of robotic surgery? A. It has less blood loss than laparoscopic surgery. B. It involves smaller incisions than laparoscopic surgery. C. It more effectively removes the cancer when compared to laparoscopic surgery. D. It reduces surgeon fatigue in long or complex laparoscopic surgeries. Answer, D. The main advantage of robotic surgery is that it allows the surgeon to do the surgery with a joystick so there is less surgeon fatigue in long or complex laparoscopic surgeries. Number seven. What type of cancer can effectively be treated with cryoablation surgery? A. Brain cancer. B. Renal cancer. C. Liver cancer. D. Stomach cancer. Answer, B. The two main cancers that are best treated with cryoablation surgery are prostate cancers and renal cancers. The other surgeries cannot be treated using this method. Number eight. Why might a surgeon perform a palliative surgery on a cancer patient? A. To extend their lifespan by debulking the tumor. B. To make the tumor smaller so chemotherapy works better. C. To resolve a painful intestinal blockage caused by inoperable colon cancer. D. To take a biopsy through a small incision so the cancer can be identified. Answer, C. Palliative surgery will not prolong the patient's life but is done to improve symptoms. For example, a patient with inoperable colon cancer might have an intestinal blockage that would be extremely painful and uncomfortable if the obstruction isn't resolved. Number nine. What type of cancer treatment involves removing normal tissue that might later become cancerous? A. Ablation surgery. B. Cryotherapy. C. Preventative surgery. D. Laparoscopic or keyhole surgery. Answer, C. Preventive surgery is done on normal tissue that has the potential to become cancerous so it is removed before there is actually any cancer. Number ten. What type of cancer surgery might be the only treatment necessary for the patient to have? A. Curative surgery. B. Staging surgery. C. Cryoablation surgery. D. Laparoscopic robotic surgery. Answer, A. Patients who have curative surgery have the entire cancer and any affected lymph nodes removed so depending on the grade of the cancer may be the only treatment recommended for the cancer treatment.