Principles of Surgery (Cysts, Fistula & Sinus) PDF

Principles of Surgery (Cysts, Fistulae & Sinus, Wound Healing, and Palliative Care) Prepared by Dr Ibrahim Mousa Maaroof Higher Diploma student M.B.Ch.B. Dr Sarmad Nadhem Ismael Higher Diploma student M.B.Ch.B. Supervised by Assist. Prof. Dr Baderkhan Saeed Ahmed Assist. Prof. Dr Azhy Muhammed Dewan...

Principles of Surgery (Cysts, Fistulae & Sinus, Wound Healing, and Palliative Care) Prepared by Dr Ibrahim Mousa Maaroof Higher Diploma student M.B.Ch.B. Dr Sarmad Nadhem Ismael Higher Diploma student M.B.Ch.B. Supervised by Assist. Prof. Dr Baderkhan Saeed Ahmed Assist. Prof. Dr Azhy Muhammed Dewana 2 January 2024 1 CYSTS AND FISTULAE 2 January 2024 2 CYSTS A cyst is a collection of fluid in a sac lined by endothelium or epithelium, which usually secretes the fluid. • True cysts are lined by endo- or epithelium. • False cysts are the result of exudation or degeneration, e.g. pseudocyst of pancreas, cystic degeneration in a tumour. 2 January 2024 3 2 January 2024 4 CLASSIFICATION • CONGENITAL • ACQUIRED . 2 January 2024 5 CONGENITAL Sequestration dermoid. Due to displacement of epithelium along embryonic fissures during closure, e.g. skin. Sites include outer and inner borders of the orbit, midline of the body, and anterior triangle of the neck (branchial cyst; cf. implantation dermoid due to skin implantation from injury). • Tubulo- dermoid/ tubulo- embryonic. Abnormal budding of tubular structures, e.g. enteric cysts, post- anal dermoid, thyroglossal cyst. • Dilatation of vestigial remnants. e.g., urachal, vitellointestinal, paradental and branchial cleft cysts, hydatid of Morgagni, Rathke’s pouch 2 January 2024 6 ACQUIRED • Retention cysts. Due to blocking of a glandular or excretory duct, e.g. sebaceous cyst (sweat gland), ranula (salivary gland), cysts of the pancreas, gall bladder, parotid, breast, epididymis, Bartholin’s glands, hydronephrosis, hydrosalpinx. • Distension cysts. Due to distension of closed cavities as a result of exudation or secretion, e.g. thyroid or ovarian cysts, hygroma (lymphatic cysts), hydrocele, ganglia, bursae (false cysts). 2 January 2024 7 • Cystic tumours, e.g. ovarian cystadenoma or cystadenocarcinoma. • Parasitic cysts, e.g. hydatid cysts (Taenia echinococcus). • Pseudocysts. Due to necrosis of haemorrhage with liquefaction and encapsulation (e.g. necrotic tumours, cerebral softening) or coalescence of inflammatory fluid collections (e.g. pancreatic pseudocyst). 2 January 2024 8 CLINICAL FEATURES  Spherical and fluctuant when palpated in two planes, with the fingers at right angles to each other.  If tense contents, may produce pain.  If the fluid is clear, the swelling will transilluminate.  Ultrasound ± aspiration of contents are methods of determining whether a given swelling is cystic and may differentiate a cyst from a lipoma. May compress surrounding tissues.  They are also subject to infection, torsion if on a pedicle, haemorrhage, and calcification. 2 January 2024 9 TREATMENT • Not all need treatment. Rationale for treatment is if symptomatic, concern over diagnosis, e.g. malignant potential, or for cosmetic reasons. • Surgical options are: excision; marsupialization (de-roofing and suture of the lining to skin— for chronic or infected cysts); drainage (deep site; not done if concern over malignancy). 2 January 2024 10 SINUSES/ FISTULAE • A sinus is a blind epithelial track lined by granulation tissue extending from a free surface into the tissues, e.g. pilonidal sinus. • A fistula is an abnormal communication between two epithelial surfaces. It is lined by granulation tissue and colonized by bacteria, e.g. fistula- in- ano, pancreaticocutaneous, colovesical. 2 January 2024 11 CAUSES • Specific disease, e.g. fistula- in- ano from Crohn’s. • Abscess formation and spontaneous drainage, e.g. diverticular abscess discharging into the vagina (colovaginal fistula). • Iatrogenic, e.g. anastomotic leak discharging via wound. • Neoplastic. 2 January 2024 12 Persistence of a fistula/ sinus is due to the following: • Presence of foreign material, e.g. suture/ bone. • Inefficient/non- dependent drainage (e.g. long, narrow, tortuous track). • Distal obstruction of the viscus of origin. • Persistent discharge (absence of rest), e.g. faecal matter in fistula- in- ano. • Epithelialization of the track. • Continuing active infection, e.g. TB, actinomycosis. • Chronic inflammation (e.g. Crohn’s) or fibrosis. • Malignancy in the track. • Irradiation, e.g. rectovaginal fistula after radiotherapy for cervical cancer. • Systemic factors inhibiting healing, e.g. malnutrition, drugs, ischaemia. 2 January 2024 13 INVESTIGATIONS • MRI • And/or sinography/ fistulogram • And/or examination under anaesthesia (EUA) to establish anatomy. 2 January 2024 14 TREATMENT Principles of sinus treatment • Excise/lay open. • Remove granulations, infected/ non- viable tissue, and foreign bodies. • Biopsy sinus wall if concern over underlying pathology. 2 January 2024 15 Principles of fistula treatment • Treat any sepsis and fluid imbalances, and optimize nutritional state. • Ensure good drainage to prevent fistula extension. • Characterize the anatomy. • Biopsy the fistula if concern over underlying diagnosis. • Definitive surgical treatment requires excision of the organ of origin or closure of the site of origin; removal of chronic fistula track and surrounding inflamed tissue; and closure of ‘recipient’ organ if internal or drainage of external site if to skin. 2 January 2024 16 Wound Healing Skin Layers Wound • A wound may be defined as disruption of normal tissue continuity and structure due to trauma or disease processes Wound classification Wounds are classified by the depth of the injury. Superficial wounds involve the epiderm is only, partial thickness wounds involve the epiderm is and dermis , and full-thickness wounds are through the derm is and into the subcutaneous tissues or deeper. Principles of wound healing • Principles of wound healing are common to almost all soft tissues and result in the formation of a scar. • ‘Primary healing’ is achieved when the wound edges are approximated shortly after injury. • ‘Delayed primary’ healing refers to sharp debridement and direct closure of an old wound. • ‘Secondary healing’ occurs when a wound is left to heal spontaneously usually resulting in excessive fibrosis and an unsightly scar Wound healing by secondary intention Principles of wound healing • Conceptually, there are three phases of wound healing mediated by several growth factors including fibroblast growth factor (FGF), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and other factors. Inflammatory phase (Days 1–6) • The initial phase begins with immediate vasoconstriction and coagulation followed by vasodilation and increased vascular permeability that is mediated by histamine, nitric oxide (NO) and serotonin produced by platelets and endothelial cells. • Neutrophils (1–2 days), macrophages (2–4 days) and lymphocytes (5–7 days) coordinate the inflammatory and growth factor response Proliferative phase (Days 3–21) • Fibroblasts attracted to the wound by a process known as chemotaxis, arrive by day 3 and predominate by day 7. • They produce the collagen necessary for scar formation and remodeling. • Angiogenesis, the ingrowth of new blood vessels under the influence of VEGF and NO, occurs simultaneously and wound tensile strength increases steadily • Has four major elements Angiogenesis Granulation Contraction Epithelialization Maturation Collagen within granulation tissue is further remodeled through a process of creation and destruction via collagenases. • This process can take up to 2 years to complete but is primarily complete by 6 to l2 months. • The collagenases convert immature collagen (type III) to mature collagen (type I) . • The collagen realigns itself through an interaction of forces, both internal and external. Maturation • Internal alignment comes when the collagen attempts to match the collagen found at the wound edges . • External alignment is based on the forces applied to the wound • Skin and fascia usually recover only 80% of their original tensile strength. Factors that affect wound healing • Cause of wound: Sharply incised wounds heal faster than blunt traumatic wounds • Time since injury: Delay in presentation and cleaning can prolong the inflammatory phase and thus delay wound healing. • Size: Wounds heal from the periphery; thus, the larger the area affected, the longer it will take for the wound to progress through the phases of healing. • Temperature: Decreased temperature inhibits wound healing. • Hydration: Dry wounds progress through the phases of healing more slowly than those in a moist environment. • Foreign bodies: prolong the inflammatory phase and delay wound healing • Irradiation: causes endothelial cell damage and hypoxia. • Diabetes: impaired microcirculation and red cell function, resulting in poor blood flow to the wound. • Infection: prolongs inflammation and slows healing overall. • Age. • Nutrition. • Smoking. • Medications E.g.: Glucocorticosteroids, High-dose nonsteroidal anti-inflammatory drugs Wound management Description of the wound • Depth Superficial wounds (stage 1) Partial Thickness wounds (stage 2) full-thickness wounds (stage 3) Violating to the deep structures of muscle or bone (stage IV) • Dimension • Location • Presence of infection Purulence Erythema Crepitus Induration Debridement Benefits 1. Reduces bacterial load of a wound 2. Increases effectiveness of antibacterials applied to the wound 3. Improves action of leukocytes: provides an aerobic environment for the opsonization and phagocytosis of bacteria 4. Shortens the inflammatory phase of wound healing 5. Decreases the energy required for wound healing Debridement Indications for debridement • Necrotic, devitalized, and dead tissue • Foreign matter and debris • Disorganized, violet, and dusky-colored granulation tissue • Blisters, if they impede function. Contraindications for debridement • Organized, uniform, and brightly pink granulation tissue • Viable tissue • Deep tissue injuries • Healthy deep tissues Types of debridement • Sharp : removal of tissue with scalpel or scissors • Autolytic: removal of tissue by providing an environment for the body’s own defenses to work • Enzymatic: application of enzymes topically to the wound. • Mechanical Wet-to-dry dressings Whirlpool Scrubbing Cytotoxic should be avoided in open wounds. painful and traumatic to tissues Whirlpool Scrubbing Scars Keloid Hypertrophic scars • Characterized by an overabundance of collagen. Collagen formation outpaces the actions of collagenases. • Extends beyond the boundary of the original scar and invades the surrounding normal tissue • Can be considered a benign neoplasm • Treatment Steroid injection\Re-excision followed by radiation No single therapy with good results • Overabundance of collagen • Contained within the borders of the original scar • Treatment Re-excision, especially for wounds allowed to close by secondary intention Application of silicone sheets Pressure garments Steroid injections Keloid Scar Hypertrphic Palliative care Palliative Surgery • Palliative surgery is defined as surgical intervention targeted to alleviate a patient’s symptoms, thus improving the patient’s quality of life despite impact on the patient’s survival • By the careful balance between achieving symptom relief without the development of new symptoms from the intervention itself. Palliative surgery • Palliative surgery is indicated for obstruction and bleeding. Options include a gastric bypass (often done laparoscopically) for distal tumours, or palliative resection. • Should only be considered in fit patients with distal tumours who have not benefited from lesser interventions. • Palliative surgery should not be attempted in the presence of gross ascites or jaundice because of the poor outcome Common problems that may be palliated • Effusions: pleural and ascitic drains may control these chronic problems. In the case of pleural effusion pleurodesis may prevent reaccumulation • Thrombosis: increased coagulability and pressure on blood vessels make this a common problem in oncology. • Hypercalcemia: bisphosphonates may control the patient’s calcium level and regular infusions will be necessary when the underlying tumour process is not controlled by other means • Fatigue: this is often a difficult symptom, which is partly due to the tumour and partly due to its treatment, Encouraging aerobic exercise, even at a low level, can improve fatigue and also stimulate appetite • Weight loss: patients often lose their appetite and consequently lose weight. Eating little and often with food supplements as necessary may be effective in mitigating weight loss. • Fever: recurrent fevers are a feature of certain tumours such as lymphoma and renal cell cancer. Tumour fever must be distinguished from infection and this can often only be done by exclusion. End-of-life care • End-of-life care is distinct from palliative care. • Patients treated palliatively may survive for many years; end-oflife care concerns the last few months of a patient’s life • The End of Live care problems include: heightened sense of spiritual need, profound fear and the specific needs of those who are facing bereavement End-of-life care is worth considering in its own right and not as a mere appendage to palliative care. Issues at the end of life ● Appropriateness of active intervention ● Euthanasia ● Physician-assisted suicide ● Living wills ● Bereavement ● Spirituality ● Support to allow death at home REFERENCES • O'Connell, P.R., McCaskie, A.W., & Sayers, R.D. (Eds.). (2023). Bailey & Love's Short Practice of Surgery - 28th Edition • Brunicardi F, & Andersen D.K., & Billiar T.R., & Dunn D.L., & Kao L.S., & Hunter J.G., & Matthews J.B., & Pollock R.E.(Eds.), (2019). Schwartz's Principles of Surgery, 11e. 2 January 2024 45 Thank You 2 January 2024 46