Deze documenten bevatten samenvattingen van alle colleges die aan bod komen tijdens de minor Comprehensive Care and Anatomy. Alle samenvattingen zijn aangevuld met de bijbehorende literatuur en sommige lastige onderwerpen zijn verder uitgewerkt.
Het document bevat zowel Engelse als Nederlandse te...
Week 1
Lecture 1.4: introduction in palliative care
- In the Netherlands about 170,000 people die per year
- In about three quarter the deaths is not sudden and unexpected
- There is care provided in the last phase of life
- Virtually all physicians will attend for patients in the last phase of life
Goals of health care
- Looking at focus of care:
• Preventing and curing illness
• Providing care
• Supporting in management of disease
• Relieving burdensome symptoms
- Looking at face of life
• Coming into this world safely
• Keeping healthy people healthy
• Caring for and curing ill people
• Dying with dignity
Appropriate care in the last phase of life
Survey among public/patients/relatives, and care providers about examples of appropriate
care showed two main issues:
1. (failing) timely forgoing curative/ life-prolonging treatment
2. (in)sufficient/ (in)adequate care the last phase
Important themes in timely transitions
- Disease trajectories
- Treatment-decision making
- Shared decision making
- Advance care planning
WHO definition palliative care
“Palliative care is an approach that improves the quality of life of patients and their families
facing the problems associated with life-threatening illness, through the prevention and relief
of suffering by means of early identification and impeccable assessment and treatment of
pain and other problems physical, psychosocial and spiritual.
➔ Purpose: improving quality of life through prevention and relief of suffering
➔ Population it aims at:
• Patients with life threatening illness
• Their family
➔ Approach
• Early identification
• Impeccable assessment and treatment of physical, psychosocial and spiritual
problems
- Part of palliative care is also about opening the eyes of the patients that they are in the last
phase of their lives but also providing good care
Important themes in adequate palliative care
Quality of life:
- What is important for the patient?
,- Physical, psychological, social, spiritual domain
- Working interdisciplinary
- Follow the patients in all settings
Lecture 1.5: GE-CR 1 Anatomy and symptoms
“Plaatje colorectal surgery”
- Chirurgische anatomie gaat over dissectie en welke
vlakken je neemt
- Kanker 2 doelen: aan de ene kant probeer je
kwaliteit van leven te behouden en de andere kant
overleving te bewerkstelligen
- Ablatieve therapie → tumoren weghalen
- Incidentie: dikke darmkanker staat op de 3e plek
- Huidkanker ga je niet aan dood, behalve melanoom
- Borstkanker en longkanker gedeelde eerste plek
- Dikke darmkanker gaan bijna de meeste mensen
aan dood, ongeveer 5000 mensen
- Longkanker is voor 80% gerelateerd aan roken, je kan daar dus iets aan doen maar dikke
darmkanker niet
- Multidisciplinair team nodig
The big five
1. Huidkanker
2. Borstkanker
3. Longkanker
4. Protstaatkanker
5. Dikkedarmkanker
Patient pathway
- Diagnose → behandeling → follow-up
- Het is een groot team die er aan vast zit
Colorectal cancer
- Second cause of cancer related death
- Despite improvement
• Screening
• Surgery
• Neoadjuvant therapy
➔ About 40% is not alive after 5 years
Bevindingen in het lab bij dikkedarmkanker
• Ferriprieve anemie (bloedarmoede door ijzertekort)
• CEA prikken (= een eiwit, als het verhoogd is kan het wijzen op kanker)
- Mensen presenteren met een anemie (door onopgemerkt bloedverlies)
- Endoscopie wordt er gedaan en beeldvorming
(standaard is een CT om de kanker te stadiëren)
- Lokale stadiëring = T-stadiëring (op CT moeilijk te
zien)
- Je hebt T1 t/m T4
, • T1= mucosaal
• T2= muscularis propria
• T3 = mesocolon/rectum
• T4 = ander orgaan → hiervoor is de CT erg belangrijk voor
N-stadiëring → voor de lymfeklieren
- Stadiëring voor lymfe ook op de CT te zien maar minder betrouwbaar
M-stadiëring → hematogene metastasen en eventueel peritoneaal
- Metastase van coloncarcinoom naar lever via portale systeem → meeste levermetastase
- Bij de endeldarm heb je een anatomische afslag, dat het wel via de v.iliaca interna direct
in de v.cava komt en dan zie je ook veel meer longmetastasen!
Manieren waarop dikke darmkanker kan uitzaaien:
1. Lever: levermetastasen zijn veelvoorkomende vorm van uitzaaiing bij colonkanker,
omdat het bloed vanuit de dikke darm direct naar de lever stroomt via de poortader.
2. Lymfeklieren: kankercellen kunnen zich verspreiden naar de lymfeklieren in de buurt van
de dikke darm voordat ze zich verder verspreiden naar andere organen
3. Longen: colonkanker kan zich verspreiden naar de longen via de bloedbaan → door
v.iliaca interna direct naar v.cava → gaat naar de longen toe
4. Peritoneum
Stadiëring zegt veel over de overleving
Stadium 1: goede overleving → 95%
Stadium 2: 89%
Stadium 3: richting 60%
Stadium 4: heel slecht, < 25%
Staging colorectal cancer
Stage 0: superficially involves the mucosa, has not grown beyond
the mucosa
Stage I: invades through mucosa/submucosa
Stage II: invades through muscle layers, invades nearby tissue or
organs
Stage III: lymph nodes involved
Stage IV: distant spread
Overview procedures
- Laparoscopic surgery versus open surgery
- Benefits for short term
• Shorter recovery
• Less short term complications
• Equally effective in oncological outcome
- Benefits long term
• Obstructive ileus
• Less reinterventions; hernia surgery
Evolution of surgery
- Less invasiveness → better outcomes for patients!
- Enhanced imaging 3D, 4K, molecular imaging
- Enhanced intraoperative methods; endoscopy in theatre
Staging rectal cancer
- CT for distant staging (metastasis)
- MRI for local staging (T & N)
Rectal cancer → early rectal cancer
1. Normal epithelium
2. Hyperplasia
3. Adenomatous polyp
4. Adenocarcinoma
5. Metastatic cancer
Riskfactors of transanal microsurgery
Budding, clustering, lymphatic invasion, vascular invasion, differentiation, diameter, mucosal
invasion depths and diameter
Local therapy for rectal cancer
- Only for low risk tumours
- T1 without risk factors
- Risk features:
• Lymphatic invasion
• Deep/wide submucosal spread
• Budding
• Clustering
• Size > 3 cm
• T2+
Radical therapy for rectal cancer
Radicale chirurgie die erop gericht is de kanker te behandelen
omvat doorgaans de ablatie van een tumor alsook van de
structuren en de omliggende weefsels die door de kanker
getroffen kunnen zijn
- T1-3 N0 → surgery only
- Risk features → N2, T4 (first downstaging chemoradiotherapy)
- Surgical options
• Lower anterior resection → with anastomosis
• Abdominoperineal resection → end colostomy
Therapy for stage 4 colorectal cancer
- Liver metastasis
- Lung metastasis
- Peritoneal metastasis
➔ Resection if feasible
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