Minimally-invasive surgery has gained significant popularity because of its advantages over traditional open surgical techniques, such as less post-operative pain, less analgesics requirements, a short hospital stay, early return to work, fewer complications and better cosmesis.
Conventional minimally-invasive techniques involve accessing organs through naturally existing body cavities or anatomical planes, percutaneously, for visualisation and instrumentation, thereby leaving behind a few external scars permanently.
Natural orifice transluminal endoscopic surgery(NOTES) is a recent concept, originating as an extension of interventional endoscopy, but more recently being adopted by laparoscopic surgeons and surgical endoscopists as a less invasive form of laparoscopy.
Principles of NOTES:
Access to the intra-abdominal organs is gained through natural orifices such as the mouth and vagina, although there are reports of access through the rectum and urinary bladder. The stomach or vagina is punctured and carbon dioxide is insuflated through the endoscope. The pneumoperitoneum created is maintained, thus developing a working space for the performance of intra-abdominal procedures.
Advantages of NOTES over conventional Laparoscopic Surgery:
• Improved cosmetic appearance
• Less postoperative pain
• Reduction in the MRSA infection
• Reduced incidence of wound site hernias
• Reduction in the psychological impact of the trauma and discomfort of surgery.
This procedure is available at present for select female patients with appendicitis & gallbladder stone
Anal fissures are small tears in the epithelium of the anus that can be intensely painful. Most anal fissures are caused due to straining during bowel movements, constipation or repeated diarrhoea.
Who are at risk:
Complications: may arise if left untreated.
Initial management is directed at minimising further local trauma, providing adequate pain relief, relaxing the anal sphincter spasm and avoiding further constipation.
Surgical techniques are commonly used for anal fissures which are resistant to medical therapy. They are aimed to relax the internal sphincter. They include:
Surgery is consistently superior to medical management options, although it should only be considered in people with chronic, non-healing anal fissures where medical treatments have failed. There is a slight risk of flatus and faecal incontinence following surgery.
Anal fistula or fistulain ano is an abnormal communication between the anorectal canal and the perianal skin that is lined with granulation tissue.
It is almost always a consequence of an anorectal abscess that was drained. While the abscess represents the acute phase of the disease, fistula represents the chronic phase.
How does it develop?
Infection of glands in the intersphincteric space of the anal canal is thought to underlie both acute anorectal abscesses and anal fistulas —the ‘cryptoglandular hypothesis’
How are fistulas classified?
A variety of classification systems have been described, but the most useful and widely accepted classification is that described by Parks. This classification system is based on the relation between the primary track—the main tunnel that constitutes the fistula—and the sphincter muscles around the anal canal.
Do not traverse the external sphincter, run along the longitudinal muscle layer between the internal and external sphincters towards the perineal skin.
Fistulas track upwards through the intersphincteric space and then arch downwards and cross the levator muscle, reaching the ischiorectal fossa and then the skin.
The track crosses the external sphincter into the ischiorectal fossa before heading down to the perineum
Have a more proximal origin, and cross the levator muscles to reach the ischiorectal fossa. There is no involvement of the anal canal or the anal sphincter complex.
Considering the origin of the disease, anal fistulas may be classified as:
MRI is considered the “gold standard” for imaging fistula anatomy.
The cumulative incidence of anal fistula in patients with Crohn’s disease is 20-25%.
Fistulas are often complex and multiple; this makes the treatment difficult. In this cases use of the anti-tumour necrosis factor α antibody, infliximab is considered then first line treatment.
Surgical options are considered if medical treatment fails, but because of the poor rate of wound healing in active Crohn’s disease, a defunctioning colostomy is a more common strategy.
Tuberculosis may be the cause of anal fistula in some cases.
Tuberculosis should be suspected in patients who fail to respond to standard treatment or who develop recurrent fistulas. Diagnosis is made through the histological finding of granulomatous disease and the positive identification of acid fast bacilli.
Antituberculous drugs are the first line treatment.
Gastroesophageal reflux disease (GERD) is the result of a disordered valve mechanism between the esophagus (swallowing tube) and the stomach where the stomach contents—which are acidic and contain digestive secretions—can flow back into the esophagus. This reverse flow (reflux) of food, acids and the digestive enzymes, can cause damage to the esophageal lining and resulting heartburn.
Risk Factors FOR GERD
This safe test involves passing a slim, flexible tube (endoscope) equipped with a light and tiny camera into the esophagus.
Barium X-ray (upper GI series):
A barium drink coats the lining of the upper digestive tract so it can be seen on an X-ray.
24-hour pH monitoring:
A small tube (catheter) equipped with a pH sensor is positioned in the esophagus. The sensor monitors the acidity in the esophagus over a 24-hour period and the data is stored on a small computer worn around the waist for later analysis.
Esophageal motility study (EMS):
A small tube (catheter) equipped with a sensor is positioned in the esophagus. During this test, the sensor measures movement and pressure within the esophagus and stomach and can evaluate if the LES is functioning properly.
Indications for surgery are
Nissen fundoplication surgery is performed laparoscopically (through small incisions in the upper abdomen) to tighten the LES and prevent the reverse flow of stomach contents into the esophagus.
Complications of GERD
GERD is a chronic disease and so treatment usually needs to be maintained on a long-term basis, even after symptoms have been brought under control. Untreated GERD can sometimes result in serious damage to the esophagus. A narrowing (stricture) of the esophagus may occur from chronic scarring and an esophageal ulcer and bleeding may develop from repeated exposure to stomach acid. Some patients with prolonged, uncontrolled GERD may have Barrett’s esophagus, a condition that results in changes to the esophageal lining which increase the risk of developing esophageal cancer
Alarm symptoms are not typical of GERD and can signal additional, more serious health concerns. Consult a doctor if you notice a change in your current symptoms or experience any of the following:
The esophagus enters the abdomen through the diaphragmatic hiatus. The hiatus is vulnerable to visceral herniation because it is directly subject to pressure stress between the abdomen and the chest.
Hiatus hernia is a condition involving herniation of the contents of the abdominal cavity, most commonly the stomach, through the diaphragmatic hiatus into the mediastinum.
Hernias are most common (95%),sliding hiatal hernias, where the gastroesophageal junction migrates above the diaphragm. The stomach remains in its usual position and the fundus remains below the gastroesophageal junction.
Hernias are pure para-esophageal hernias (PEH); the gastroesophageal junction remains in its normal position but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the esophagus.
Hernias are a combination of Types I and II, with both the gastroesophageal junction and the fundus herniating through the hiatus. The fundus lies above the gastroesophageal junction.
Hiatal hernias are characterized by the presence of a structure other than stomach, such as the omentum, colon or small bowel within the hernia sac.
Small hernias — Most small hiatal hernias cause no problems.
Large hernias — Larger hernias may cause the following signs and symptoms when stomach acids back up into your esophagus.
These signs and symptoms tend to become worse when you lean forward, strain, lift heavy objects or lie down, and they can also worsen during pregnancy.
In rare cases, sometimes, the part of your stomach that protrudes into your chest cavity may become twisted (strangulated) or have its blood supply cut off, leading to:
Endoscopy: The clinical indications for endoscopy of the upper gastrointestinal tract include
Radiologic imaging: Hiatus hernia can be diagnosed by radiology of the upper gastrointestinal tract, albeit with poor sensitivity for mucosal complications. Radiology is usually indicated in the presurgical evaluation.
High resolution manometry and reflux monitoring: Functional esophageal testing using manometry (assessment of esophageal contractile function using an esophageal catheter) and reflux monitoring (assessment of reflux of gastric content into the esophagus using an esophageal catheter) is indicated when surgery is being considered to control symptoms of gastroesophageal reflux related to hiatal hernia.
pH testing: has limited relevance in the diagnosis of a hiatal hernia, but is critical to identify the presence of increased esophageal acid exposure in patients with sliding hiatal hernias that might benefit from antireflux surgery.
Alleviation of the symptoms of GERD is the cornerstone for treatment of hiatus hernia. This is usually achieved indirectly with Proton pump inhibitors (PPIs). Histamine 2 receptor antagonists and antacids are alternatives to PPIs.
A few people with a hiatal hernia may need surgery. This is usually considered only when medications and lifestyle changes fail to relieve severe reflux symptoms, or if you have complications such as chronic bleeding or narrowing or obstruction of your esophagus.
Large hiatal hernias may also need repair if they cause symptoms such as shortness of breath, difficulty breathing or swallowing, or chest pain.
Currently, this is the standard procedure. The essential components of this technique are mobilization of the distal esophagus, reduction of the associated hiatus hernia, and either partial (Toupet 270°) or complete (Nissen 360°) fundoplication around the esophagus. With this procedure, the risk of major complications or death is about 1-2%.
Achalasia is a motility disorder of the oesophagus, of unknown cause, which results in degeneration of the myenteric nerve plexus of the oesophageal wall resulting in deranged oesophageal peristalsis and loss of lower oesophageal sphincter function.
The diagnosis of achalasia is typically suspected in a patient with dysphagia to both solids and liquids with associated regurgitation of undigested food. The following are the diagnostic modalities often employed in achalasia.
Most patients presenting with dysphagia require esophagogastroduodenoscopy (EGD) primarily to rule out a mechanical obstruction due to cancer that can mimic achalasia both clinically and manometrically.
Esophageal dilation with a gradual taper down to the gastroesophageal junction giving a “bird’s beak” appearance is the classic description of achalasia on barium esophagram. Timed barium esophagogram (TBE) is an objective way to determine esophageal emptying
It is the gold standard for the diagnosis of achalasia. It functions to assess esophageal pressures along the length of a flexible catheter inserted into the esophagus. High resolution manometry can display pressure data as esophageal topography plots.
Endoluminal Functional Lumen Imaging Probe (EndoFLIP)
EndoFLIP works on the principle of impedence planimetry and allows the measurement of gastroesophageal junction(GEJ) distensibility in real time. This may be a better parameter than LES pressure to evaluate the efficacy of treatment.
It can be managed but not cured. There are 5 major treatment modalities
Oral pharmacologic therapies are considered the least effective treatment option for achalasia. The clinical response to these agents is short lived and their side effect profile is unfavorable. The two most commonly employed medications are calcium channel blockers and long-acting nitrates.
Botulinum toxin is a useful treatment strategy for patients who are unable to tolerate more invasive therapies, such as pneumatic dilatation or surgical myotomy. The technique involves injecting up to 100 units of toxin with a sclero-needle just proximal to the squamo–columnar junction evenly distributed over four quadrants. The response rate in the first month of treatment is high at 80%–90%; however, the therapeutic effect wanes rapidly over time such that ∼50% of patients are symptomatic at 1 year. Thus, repeat treatments every 6–12 months are often required.
Pneumatic Dilation (PD)
Surgical myotomy, a technique involving the division of the circular muscle fibers of the LES, was initially performed via an open thoracotomy and laparotomy approach.
But,with time, old open approach was replaced with more minimally invasive techniques; first with thoracoscopy which was subsequently replaced with Laparoscopic Heller Myotomy (LHM) because of improved morbidity and faster recovery time. Now, LHM is accepted as the standard of surgical management for AC.
“End-stage” achalasia, characterized by a dilated and tortuous esophagus (megaesophagus or sigmoid esophagus), is often unresponsive to conventional treatments for achalasia. Although PD is ineffective, surgical myotomy should still be considered the initial treatment before consideration of the more morbid esophagectomy.
Advances in treatment for achalasia
Peroral endoscopic myotomy: Peroral endoscopic myotomy (POEM) is a novel endoscopic procedure that uses the oral cavity as a natural orifice entry point to perform myotomy of the LES. After tunneling an endoscope down the esophagus toward the esophageal gastric junction, a surgeon performs the myotomy by cutting only the inner, circular LES muscles through a submucosal tunnel created in the proximal esophageal mucosa.
POEM differs from laparoscopic surgery, which involves complete division of both circular and longitudinal LES muscle layers. The dysfunctional muscle fibers that prevent the LES from opening are cut in order to allow food to enter the stomach more easily.
Chronic pancreatitis (CP) is a benign inflammatory process of the pancreas characterized by progressive and irreversible damage to the organ that eventually leads to pain and/ or exocrine and endocrine insufficiency as well as malnutrition.
Etiologic factors: TIGAR-O classification
Clinical signs and symptoms:
Various complications include pseudocysts, biliary or duodenal obstruction, internal or external pancreatic fistulae, left-sided portal hypertension and pancreatic malignancy.
How to diagnose chronic pancreatitis?
Management Strategies in Chronic Pancreatitis
The essential aspects of managing a patient with CP involve: (1) amelioration of pain; (2) maintain nutrition and control maldigestion; and (3) tackle complications.
Control of abdominal pain: The goal of therapy is to control pain to that level that it may not hamper patient’s life as complete relief of pain is not expected. The following modalities are used to control the pain:
Hemorrhoids are clusters of vascular tissues, smooth muscles, and connective tissues that lie along the anal canal in three columns—left lateral, right anterior, and right posterior positions. Hemorrhoids are present universally in healthy individuals. Hemorrhoids aid in the process of bowel movement. Nonetheless, the term “hemorrhoid” is commonly invoked to characterize the pathologic process of symptomatic hemorrhoid disease instead of the normal anatomic structure.
As the supporting tissue of the anal cushions weakens, downward displacement of the cushions can occur, causing venous dilation and prolapse.
What Causes Hemorrhoids?
There’s no single cause of hemorrhoids. Most often, though, they are caused by too much pressure on the anal canal. This can be due to:
Classification of a hemorrhoid:
located below the dentate line and are covered with anoderm, composed of squamous epithelium, and are innervated by somatic nerves supplying the perianal skin and thus producing pain.
lie above the dentate line and are covered by columnar epithelium, innervated by visceral nerve fibers and thus cannot cause pain.
Symptoms and Presentation:
A total of 40% of individuals with hemorrhoids are asymptomatic. For symptomatic hemorrhoids, there is great variance in the constellation of symptoms.
For internal hemorrhoids,
In contrast, in external hemorrhoids,
Conservative Medical Treatments
Lifestyle and dietary modification are the mainstays of conservative medical treatment of hemorrhoid disease. Specifically, lifestyle modifications should include increasing oral fluid intake, reducing fat consumptions, avoiding straining, and regular exercise.
Diet recommendations should include increasing fiber intake, which decreases the shearing action of passing hard stool.
Nonsurgical Office-based Procedures
Rubber Band Ligation
Rubber band ligation is the most commonly performed procedure in the office and is indicated for grade II and III internal hemorrhoids
Sclerotherapy is indicated for patients with grade I and II internal hemorrhoids and may be a good option for patients on anticoagulants.
Infrared coagulation refers to direct application of infrared light waves to the hemorrhoidal tissues and can be used for grade I and II internal hemorrhoids
Based on the concept that freezing the internal hemorrhoid at low temperatures can lead to tissue destruction
For symptomatic Grade ΙΙΙ-ΙV hemorrhoids and hemorrhoids resistant to nonoperative procedures, a surgical approach can be adopted. This is required in only 5-10% of patients.
There are two major types of hemorrhoidectomy:
Ferguson, or closed hemorrhoidectomy and
Milligan–Morgan, or open hemorrhoidectomy
An alternative to operative hemorrhoidectomy is stapled hemorrhoidopexy, in which a circular stapling device is used to resect and fixate the internal hemorrhoid tissues to the rectal wall. This technique is also known as ‘procedure for prolapse and hemorrhoids (PPH)’. PPH is significantly less painful and allows quicker recovery.
Doppler-guided Hemorrhoidal Artery Ligation
It involves a Doppler transducer allowing sequential identification of the position and depth of superior rectal arterial branches, which are then selectively ligated 2-3 cm above the dentate line. The interference with the blood supply suppresses the bleeding and volume of the hemorrhoids and symptomatic relief is usually evident within 6-8 weeks.
The anal canal is defined as the terminal part of the large intestine, beginning at the upper surface of the anorectal ring and passing through the pelvic floor to end at the anus.
The most frequent neoplams of this region are HPV-associated squamous cell carcinomas (SCC) and adenocarcinomas.
In most settings, SCC compromises more than 70% of cases. In the general population, anal cancer is uncommon, with age-standardized incidence rates mostly between 1 and 2 per 100000 per year. However, the incidence of anal SCC is increasing by 1-3% per year in developed country settings. High-risk HPV types can be detected in 80-90% of all anal SCC cases, making it second only to cervical cancer in the closeness of its association with this virus.
The Risk Factors
• HPV infection with high risk genotypes
• Cervical dysplasia, cervical cancer, or genital warts
• HIV seropositivity and low CD 4 count
• Cigarette smoking
• Anoreceptive intercourse
• Immune suppresion following transplant (100x increase in KTX)
• Rectal bleeding- 45% of patients
• Pain or sensation of mass- 30%
• No symptoms- 20%
• Pruritus ani or bleeding plaques associated with anal margin skin cancers- Paget’s disease
The diagnostic Workup
• Physical exam- rectal and nodes
• Biopsy- used to differentiate squamous cell (anal ca) from adenocarcinoma (rectal ca) does not have to be excisional
• CT scan to evaluate for metastatic disease
• EUS to evaluate for sphincter involvement and perianal lymph nodes
• PET scan since 25% of patients have metastatic disease by PET not seen on CT and 20% of inguinal nodes negative by CT are PET positive.
Planning of the treatment involves an inter-disciplinary team of medical professionals.
The treatment will usually combine intervention methods that:
The main goal of treatment is to obtain a cure with locoregional control, concomitant with the preservation of anal sphincter function and maintaining the best possible quality of life.
Squamous cell Carcinoma:
SCC represents the majority of anal canal tumors (85%). Initially, up to the 1980s surgery was the treatment for all anal carcinomas, mainly with abdominoperineal resection (APR) with 5 years survival rates achieved for 38-71% of patients and recurrence developing is 27-43%.
But now,the standard treatment for non-metastatic squamous cell carcinoma of the anal canal has been a combination therapy, with chemotherapy and radiotherapy with a radiation providing a complete regression in 80–90% of patients. Approximately, 15% of patients will have persistent disease initially while a further 15% will develop late locoregional recurrence. The 5 years survival figures of 60-80%, along with an 80% preservation of anal function, makes non-surgical management an attractive option for anal canal tumors.
Surgery (abdominoperineal resection and permanent colostomy) in SCC is reserved for patients with residual or recurrent disease after a complete treatment of chemo radiotherapy.
Surgery after recurrence allows a local control in 60% of cases and a survival at 5 years of 30–60%
Adenocarcinoma of the anal canal are rare tumors (15%) and are thought to arise in the ducts or the intramuscular anal glands, and in the long-standing fistulas. These neoplasm affect older age groups and have no sexual predominance. Most of these lesions are slow growing, locally aggressive, and rarely metastasize. The abundant mucin production of these tumors may explain their tendency to dissect soft tissue planes. A wide local excision may be performed for small and well-differentiated carcinomas that have not invaded sphincter mechanism. Otherwise, APR is indicated.
The anal canal is the third most common site of melanoma, exceeded only by the skin and the eyes, representing 0.3-1.6% of all melanomas. The mean age of occurrence is in the fifth decade, and females are affected more frequently than males. Surgery provides the only hope for cure, but significance differences in survival between patients treated with local excision and those with APR have not been demonstrated. However, APR seems to provide better local control of the disease. Unfortunately, local recurrence in these cases was often accompanied by the appearance of distal or regional metastases as well. Radio-chemotherapy has demonstrated little benefit in this disease. Patients treated in a curative fashion have a survival of 6-20%.
Treatment of Locally Recurrent and Metastatic Disease with Chemotherapy:
Different regimens of salvage chemotherapy may be used for metastatic anal carcinoma, although the most common regimens at present employ Cisplatin and 5-FU.4
The pancreas is an organ located in the abdomen behind the stomach. It produces both digestive enzymes and insulin.
Pancreatic cancer, in spite of arising as a thirteenth cancer worldwide, is the fourth most common cause of death due to cancer. The incidence and mortality rates of PC have been increasing year by year worldwide.
Most pancreatic tumors are exocrine tumors, including ductal adenocarcinoma, acinar cell carcinoma, cystadenocarcinoma, adenosquamous carcinoma, signet ring cell carcinoma, hepatoid carcinoma, colloid carcinoma, undifferentiated carcinoma, pancreatoblastoma, and pancreatic mucinous cystic neoplasm. And the most common form is ductal adenocarcinoma characterized by moderately to poorly differentiated glandular structures, comprising 80% to 90% of all pancreatic tumors.
The possible risk factors for PC include gender, age, smoking, alcohol abuse, obesity, physical activities, diabetes, chronic pancreatitis, vitamin D, genetic alterations, dietary, and reproductive factors.
Diagnosis and Staging:
Early and accurate diagnosis of PC, which often can be challenging, is important because it helps doctors choose the effective and timely treatment option for patients. It is usually based on a combination of imaging techniques such as computer tomography (CT) and endoscopic ultrasonography (EUS), tumor markers such as carbohydrate antigen 19-9 (CA19-9), clinical presentations, and the “gold standard” diagnosis-biopsy.
To date, lack of symptoms is the main cause of its late diagnosis and therapy. The appearance of clinical presentations usually indicates an advanced stage and the most frequent presentations are progressive weight loss, anorexia, abdominal pain, and jaundice. These symptoms of PC are nonspecific and varied in different parts of pancreas.
The tumor in the head of the pancreas (75%) produces symptoms such as weight loss, painless jaundice, nausea, and vomiting. The mass of pancreatic head causes blockage of the common bile duct, which results in jaundice, dark urine, light stool color, and itching. Weight loss may be related to malabsorption of nutrients due to PC. Nausea, vomiting, and poor appetite, due to cancer-related gastric outlet (duodenum) obstruction, may also contribute to weight loss.
If cancer is located at the body/tail of the pancreas, patients usually present with abdominal pain that radiates to the sides or the back.
Over the years, imaging techniques, such as transabdominal ultrasound (US), CT, magnetic resonance imaging (MRI), positron emission tomography- (PET-) CT, endoscopic retrograde cholangiopancreatography (ERCP), and EUS, play a vital role in PC detection and staging.
Surgery remains the only possibility for curing of PC, though there are only 20% of patients with operable PC. The selection of an operative procedure for PC is based on factors such as the tumor location, tumor size, and tumor staging.
The classic Whipple procedure (pancreatoduodenectomy), which involves removing the pancreatic head, as well as the curve of the duodenum, the gallbladder, and the common bile duct, is the most common operation for cancers of the head and/or neck of pancreas.
When cancer involves the body and tail, distal/subtotal pancreatectomy is suggested. About 35% of the patients with body/tail PC were observed at the time of surgery, finding that the tumors have spread to surrounding tissues. In such cases, extended resection should be advisable. For patients with locally advanced pancreatic cancer (LAPC), multivisceral resection is technically feasible. Based on recent publications, perioperative mortality (3%) and morbidity (35%) did not differ between two groups of patients who underwent standard resection or multivisceral resection. Although laparoscopy for PC treatment is controversial, laparoscopy in diagnosis and staging of PC is known to be critical, safe, and reliable. Refinements in surgical techniques will reduce perioperative morbidity and improve the outcomes.
For unresectable PC, chemotherapy is being extensively used, such as GEM/erlotinib, FOLFIRINOX,GEM/NAB-paclitaxel,GEM/capecitabine, and capecitabine/oxaliplatin (XELOX). However, PC is characterized by a dense desmoplastic reaction which promotes resistance to chemotherapy
For unresectable PC, there is little evidence to support the efficacy of radiotherapy. However, radiotherapy can be used as a palliative treatment option for those unresectable locally advanced tumors. It can kill cancer cells and keep them from growth and recurrence.
ill defined. Data evaluating the use of adjuvant chemotherapy for CC are limited, and for the most part, combine patients with intrahepatic and extrahepatic CC, gallbladder cancer, and ampullary and pancreatic cancer.
Gallbladder cancer (GBC) is a rare though notoriously lethal malignancy with marked ethnic and geographical variations. In India, GBC is most prevalent in the northern and northeastern states of Uttar Pradesh, Bihar, Orissa, West Bengal and Assam. It is twice more common in women than in men and is the commonest digestive cancer in women in northern India.
Apart from gallstones, female gender, ethnicity, genetic susceptibility and lifestyle factors are associated risk factors in the development of GBC.
The presenting symptoms are typically vague and are akin to other diseases such as cholelithiasis and cholecystitis. There are no biochemical tests of importance for early diagnosis. A raised bilirubin is a sign of advanced disease.
Tumor markers – CEA and CA 19-9 do not have much role in diagnosis as these are not specific for GBC. Various imaging tools available include Ultrasound (USG), Computed Tomographic (CT) scan, and Magnetic Resonance Imaging (MRI) with Magnetic Resonance Cholangiopancreatography(MRCP) and Magnetic Resonance Angiography (MRA).
Amidst very poor prognosis i.e. 5% 5-year survival in GBC, complete surgical resection (R0) is the only hope for long term survival.
The approach to surgical management of GBC (extended cholecystectomy) is influenced by mode of spread of GBC to liver, lymphatic and vascular invasion; direct spread to contiguous organs and intraperitoneal seeding and luminal through the cystic duct (intraductal).
Esophageal cancer is a tumor that forms in tissue lining the esophagus. The esophagus or gullet is the muscular tube through which food passes from the throat to the stomach.
The two main types of esophageal cancer are squamous cell carcinoma and adenocarcinoma. Both types occur at about the same frequency.
Squamous cell carcinomas are most prevalent in Asia, whereas adenocarcinomas are more prevalent and increasing rapidly in Western countries. Most esophageal cancers occur in people older than 65.
Squamous cell carcinomas are mainly associated with alcohol intake and smoking whereas adenocarcinomas are mainly associated with gastroesophageal reflux which is more related to obesity.
The main risk factors of esophageal squamous cell carcinoma are:
Tobacco use,Alcohol consumption,Low intake of fresh fruits and vegetables,Drinking maté, Betel quid chewing, certain medical conditions e.g; Achalasia, tylosis and Plummer-Vinson syndrome.
The main risk factors of esophageal adenocarcinoma are:
Barrett’s esophagus,Gastroesophageal reflux-disease,Obesity.
Tobacco use and alcohol consumption can both increase the risk of adenocarcinoma, although the effect is smaller than in squamous cell carcinoma.
Esophageal cancer can be suspected in different situations:
The diagnosis of esophageal cancer is based on:
• Clinical examination
• Endoscopic examination
• Endoscopic ultrasound
WHAT ARE THE TREATMENT OPTIONS?
Planning of the treatment involves an inter-disciplinary team of medical professionals.
The treatment will usually combine intervention methods that:
Surgery is the treatment of choice in fit patients. When nearby lymph nodes are affected, surgery is still the best treatment. However, affected lymph nodes hamper the chance for cure of the patients and therefore a combined treatment including chemotherapy or chemotherapy with radiotherapy should be discussed in a multidisciplinary team if an involvement of lymph nodes is suspected in initial staging.
The part of the esophagus containing the tumor will be removed during surgery.In addition to the removal of the esophagus, the surgeon will remove all nearby lymph nodes together with the esophagus. They will be examined by the pathologist to see if they contain cancer cells, which is important to define the stage.
An adjuvant therapy is a therapy given in addition to the main treatment, which, in this case, is the removal of the tumor by surgery. Chemotherapy used before surgery and, if possible, after surgery is the standard treatment. The combination of both radiotherapy and chemotherapy before surgery is another option.
Gastric cancer displays significant global variation in incidence; the highest rates are seen in Eastern Asia, Eastern Europe and South America, with lower rates in North America and Western Europe. Patients in Asian countries are frequently diagnosed with gastric cancer at an earlier stage than in non-Asian countries. In Japan and Korea, where the incidence of gastric cancer is much higher than in Western countries, screening for gastric cancer is routine.
Risk factors for gastric cancer include male gender (incidence is twice as high), Helicobacter pylori infection, tobacco use, atrophic gastritis, partial gastrectomy and Ménétrier’s disease.
Distal or antral gastric cancers that are associated with H. pylori infection, alcohol use, high-salt diet, processed meat and low fruit and vegetable intake are more common in East Asia.
Tumours of the proximal stomach (cardia) are associated with obesity, and tumours of the gastroesophageal junction are associated with reflux and Barrett’s oesophagus and are more common in non Asian countries.
Ninety per cent(90%) of gastric cancers are adenocarcinomas. The other types of gastric malignancies such as gastrointestinal stromal tumours (GISTs), lymphomas and neuroendocrine tumours are rarer.
Surgical resection of gastric cancer, specifically at early stages, is potentially curative. However, the majority of patients still relapse following resection, and therefore, combined modality therapies are standard for ≥ Stage IB disease.
Laparoscopic surgery has the potential benefit of decreased postoperative morbidity and reduced recovery time. Although concerns existed regarding the possibility of a inadequate lymph nodal clearance with a laparoscopic approach.
Trials from the Far East have reported equivalent results to open surgery for distal gastrectomy. Laparoscopic surgery is becoming one of the recommended options for patients with early gastric cancer.
Recommendation: For patients with ≥Stage IB gastric cancer who have undergone surgery without administration of preoperative chemotherapy (e.g. due to understaging before the initial decision for upfront surgery), postoperative chemoradiotherapy (CRT) or adjuvant chemotherapy is recommended. For patients having undergone preoperative chemotherapy, the addition of postoperative radiotherapy (RT) has no added benefit.
Cancer of the small bowel is rare, accounting for 1% of gastro-intestinal malignancies. Adenocarcinomas are the most common of small bowel malignancies, followed by carcinoid tumours, lymphomas, and leiomyosarcomas. Around half of all small bowel adenocarcinomas are located in the duodenum, making this the most favoured site.
Risk Factors for Small Intestine Cancer (Adenocarcinoma):
• Sex: Small intestine cancer occurs slightly more often in men than in women.
• Age: Cancers of the small intestine tend to occur more often in older people. They are most often found in people in their 60s and 70s.
• Smoking and alcohol use
• Diet: Some research has suggested that diets high in red meat and salted or smoked foods might raise the risk of small intestine cancer.
• Celiac disease
• Colon cancer: People who have had colon cancer have an increased risk of getting cancer of the small intestine.
• Crohn’s disease: Crohn’s disease is a condition in which the immune system attacks the gastrointestinal (GI) tract. This disease can affect any part of the GI tract, but it most often affects the lower part of the small intestine. People with this condition have a much higher risk of small intestine cancer (particularly adenocarcinoma).
• Inherited syndromes: People with certain inherited conditions have a higher risk of small intestine cancer (mainly adenocarcinoma).
• Familial adenomatous polyposis (FAP)
• Lynch syndrome (hereditary nonpolyposis colorectal cancer, or HNPCC)
• Peutz-Jeghers syndrome (PJS)
• Cystic fibrosis (CF): People with CF have an increased risk of small intestine cancer
The clinical presentation and diagnosis of SBA is usually delayed. The symptoms are initially rather non-specific.
Blood in the stool (feces)
A lump in the abdomen
Pain or cramps in the abdomen
Unexplained weight loss
Episodes of abdominal pain that may be accompanied by severe nausea or vomiting.
CT scans have an overall accuracy rate of 47%.
It should be pointed out that in a context of obscure bleeding after upper and lower endoscopy, a small bowel investigation should systematically be done. New investigation tools, such as CT enteroclysis, MR enteroclysis, capsule endoscopy now allow for an extensive exploration of small bowel and should thus make early diagnosis possible.
Complete resection (R0) of the primary tumour with loco-regional lymph node resection is mandatory. In the context of posterior invasion, pre-operative treatment should be considered, and resection reconsidered after 2–3 months of chemotherapy.
In the context of unresectable metastases, primary tumour resection is not recommended except in an emergency such as bowel obstruction, perforation or uncontrolled bleeding.
For duodenal tumours, a Whipple resection should be performed for a tumour in the second segment of the duodenum or for an infiltrating tumour in the proximal or distal duodenum.
A duodenal resection alone could be performed for a proximal duodenal tumour or a distal duodenal tumour with no infiltration of adjacent organs.
For jejunal and ileal tumours, an R0 resection with lymph node resection and jejuno-jejunal or ileo-ileal anastomosis should be performed.
If the last ileal loop or Bauhin’s valve are involved, an ileocoecal or right hemicolectomy should be performed with ligation of the ileocolic artery so as to allow for lymph node resection.
Cancer that develops in the large intestine.Colon cancer refers to cancer that develops in the colon, the longest part of the large intestine. Rectal cancer develops in the rectum, the final straight part of the large intestine that ends in the anus.
Colorectal cancer is more frequent in men than in women.Most patients with colorectal cancer are more than 60 years old at the time of the diagnosis, and colorectal cancer below the age of 40 years is rare
The main risk factors of Colorectal Cancer are:
Colorectal cancer causes complaints more often when it is advanced. Common symptoms are change in bowel habits, abdominal discomfort, fatigue, weight loss.Blood in stools could be a sign of alert. It could be visible to the naked eye or through a laboratory analysis of stools.
Endoscopy is an examination in which a lighted tube is inserted through the anus into the intestine. It allows seeing the inside of the intestine. When a tumour is found within 15 cm from the anus it is considered rectal tumour, further away it is considered colon tumour.
Special radiological tests also help to visualize the localisation and size of the tumour.
Blood analysis looking for carcinoembryogenic antigen (CEA), a tumour marker, might be useful in selected situations.
The confirmation of diagnosis is only given by laboratory analysis of the tumour and tissues affected (histopathology).
Planning of the treatment involves an interdisciplinary team* of medical professionals. This usually implies a meeting of different specialists, called multidisciplinary opinion.
The treatment will usually combine therapies that:
The extent of the treatment will depend on the stage of the cancer, on the characteristics of the tumour and on the risks for the patient.
Surgery aims to remove the primary tumour. In patients with advanced disease, surgery may also be performed to remove metastatic lesions.
Standardized resections are now considered more appropriate than segmental resections in the treatment of colon cancer. Depending on the location of the tumour, such standardized resection consists of removing either the ascending colon (right hemicolectomy*) or the descending colon (left hemicolectomy) or the sigmoid colon (sigmoid resection). Right and left hemicolectomy* are sometimes extended to the transverse colon and are then called extended (right or left) hemicolectomy*. The corresponding segment of the bowel is removed as well as the regional lymph nodes* and any part of the adjacent organs that are invaded by the tumour.In the case of rectal cancer the entire rectum, along with the mesorectum containing the regional lymph node is removed, the procedure is called total mesorectal excision (TME).
Surgical resections can be performed by laparotomy, but also by laparoscopy. Laparotomy refers to open surgery, meaning that the surgeon makes a large incision in the abdomen to perform the operation. During laparoscopy, fine lighted tubes and instruments are inserted through 3 or 4 small holes in the abdomen. After laparoscopy, patients experience a quicker and easier recovery then after laparotomy
Liver cancer is a tumour that initially forms in the tissue of the liver. Different types of liver cancer exist according to the type of cancerous cells. Hepatocellular carcinoma is the most frequent type of liver cancer. It accounts for 90% of all liver cancers. Hepatocellular carcinoma begins in hepatocytes, the main cells of the liver.
Liver cancer represents the sixth most common cancer worldwide. It is much more frequent in South-East Asia and Western Africa. This is mainly due to the fact that infection with the hepatitis B virus increases the risk of developing liver cancer and is more frequent in these areas. In the USA and in Southern Europe, the hepatitis C* virus is seen more frequently as a cause of liver cancer.
The median age at diagnosis is between 50 and 60 years, but in Asia and Africa it is usually between 40 and 50 years.
In most patients, cancers of the liver are preceded by cirrhosis of the liver. Liver cirrhosis is a consequence of a chronic liver disease, although only a limited percentage of patients with chronic liver disease will eventually develop cirrhosis.
The exact mechanisms and reasons why liver cancer occurs are not fully understood. However, cirrhosis and its causes are the main risk factors of hepatocellular carcinoma, the main type of liver cancer.
Causes of Liver Cirrhosis:
Most patients have liver cirrhosis and/or chronic hepatitis before developing liver cancer. People with liver cirrhosis need close surveillance to detect as early as possible a potential liver tumour.
The same surveillance is recommended for people infected with HBV who did not develop cirrhosis and for whom more than 10,000 copies of the virus (viral load) are found per milliliter of blood, and for people infected with HCV whose liver is in advanced stage of fibrosis.
Possible Symptoms of Liver Cancer:
Planning of the treatment involves a multidisciplinary team of medical professionals.The extent of the treatment will depend on the stage of the cancer, on the characteristics of the tumour and on the risks involved.
The main 3 options at these stages are:
Resection by surgery:Resection of the tumor by surgery is the preferred option for patients without cirrhosis and for whom a sufficient part of the liver can be preserved;patients with BCLC stage 0 or A whose performance status allows them to undergo surgery and who have a single liver tumor that does not cause any portal hypertension.
Liver transplantation: When a resection of the tumour is not possible, a liver transplantation should be considered either when there is a single tumour of less than 5 cm in diameter, or when there are 2 to 3 tumours, each measuring less than 3 cm in diameter. Those requirements are called the Milan criteria.
Local ablation methods:The goal of local ablation* is to destroy cancer cells by targeting them with chemical or physical means. The two main local ablation methods are radio frequency ablation (RFA) and percutaneous ethanol injection.
While these techniques are effective in destroying small tumours, they unfortunately do not prevent the occurrence of new lesions in the surrounding cirrhotic liver tissue.
They have been put forward as alternatives for surgery. In patients with BCLC stage 0 and who cannot undergo surgical resection or liver transplantation, these techniques are recommended.They are also recommended in the case of a long anticipated waiting time (>6 months) for liver transplantation.
Bile duct neoplasms are rare tumours with overall poor prognosis. The bile duct is a thin tube, about 10 centimetres to 15 centimetres long, that carries a fluid called bile from the liver and gallbladder to the small intestine. Here the bile helps digest the fat in your food. Bile duct cancer can start in any part of the bile duct.
The most common type of bile duct cancers is adenocarcinoma, also called cholangiocarcinona where cancer cells develop in mucus glands (group of cells that produce fluid) that line the inside of the bile duct.
Bile duct cancer is divided into 3 groups based on the cancer’s location:
• Intrahepatic bile duct cancers (within the liver)
• Perihilar bile duct cancers (ducts leaving the liver)
• Distal bile duct cancers (ducts closer to the small intestine)
• Jaundice (yellow skin)
• Itchiness all over your body
• Light-coloured stools or dark yellow urine
• Abdomen pain
• Appetite loss or weight loss
• Nausea or vomiting
Basic imaging methods for hepatobiliary tumours are:
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)
Further methods include Endosonography, Cholangiography (endoscopic or percutaneous), Positron Emission Tomography (PET), Cholescintigraphy and Angiography .
Serum tumour markers linked to bile duct carcinomas are:
• carcino-embryogenic antigen (CEA)
• carbohydrate antigen CA 19-9.
The latter has for values above 100 U/mL a sensitivity of 75 % and specifi city of 80 %.
Treatment can be curative (with intent to cure, aiming for long term survival) or palliative (aiming to prolong survival and/or improve life quality and postpone disease symptoms).
The only standard curative option is the complete surgical resection.
Unfortunately, most patients (nearly 90% according to some authors) are not candidates for curative treatment. It is usually for unresectable advanced/metastatic tumour. Some patients are not capable of radical surgery due to their performance status. In these and other cases that sadly form the majority of clinical situations, palliative care is the option.
Biliary drainage: Preoperative biliary drainage has proved to be beneficial in the presence of cholangitis, severe malnutrition, and coagulation abnormalities, and it is absolutely indicated for patients requiring major hepatic resection for curative surgery.
Prolonged preoperative jaundice is associated with increased postoperative morbidity and mortality after hepatic resection due to severe cholestatic liver dysfunction.
Portal vein embolization: Hilar cholangiocarcinoma usually requires extended hepatectomy (i.e. extended right hepatectomy, and right or left trisegmentectomy), which is related with a rather high rate of perioperative mortality (0% to 19%). This is partly due to the increased rate of postoperative liver failure with major hepatic resection. Portal vein embolization, which was first indicated for hilar cholangiocarcinoma by Makuuchi et al, is now widely accepted as a valuable preoperative measure in anticipation of extensive liver resection with a subsequent small liver remnant volume. Compensatory hypertrophy of the remnant liver parenchyma, usually an increase of 8% to 20% within 2 to 6 wk, is induced in association with atrophy of the future resected liver by selectively occluding the main portal branch to the liver parenchyma to be removed. In general, portal vein embolization can benefit patients requiring a future liver remnant volume of less than 25% to 35% of the original liver volume.
Surgical Management (resectable tumours) :
Pancreaticoduodenectomy (Whipple’s PD): Coupled with porta hepatis lymphadenectomy, is the standard treatment of choice for the complete removal of distal bile duct cancer.
Extended hepatectomy for hilar cholangiocarcinoma: Based on the mode of tumor extension and the radicality and simplicity of the procedure, extended right- or left hemihepatectomy is regarded as the standard radical operation for hilar cholangiocarcinoma.
Liver transplantation for hilar cholangiocarcinoma: For the treatment of locally advanced hilar cholangiocarcinoma beyond the indication for resection, orthotopic liver transplantation (OLT) may offer the advantage of resection of all structures involved by the tumor, including vessels within the hepatoduodenal ligament, all intraand extrahepatic bile ducts, and whole liver parenchyma.
Prognostic factors and markers:
Prognostic factors are:
• Completeness of resection,
• Lymph node involvement and
• Tumour diff erentiation.
These influence the long-term survival of the patient.