Gastro – Intestinal Oncho Surgery

Gastrointestinal Oncology Surgeon Dr. Soumitra Chandra is always dedicated to preventing, diagnosing, treating, and managing cancers of the gastrointestinal system (also called the digestive system). These include cancers of the rectum, anus, pancreas and stomach. The specialized approach of Dr. Soumitra Chandra to treating gastrointestinal cancers provides patients with the exact type of services they need to battle their specific disease and its physical, emotional and social side effects.

Colorectal cancer is common in developed countries such as the USA and Japan, and lower in frequency in developing countries like Africa and Asia. The incidence is slightly higher in men than women, and is highest in African American men. Colon and rectal cancer is the third most common cancer in both women and men in the US.

Though not specific but there are warning signs like bleeding in stools, sensation of incomplete passage of stools, feeling of bloating or obstruction in intestine, unusual loss of weight and fatigue, alteration of bowel habits, blood and mucus in stools.

• If your diet has high fat content and low in fibers, fruits and vegetables
• If you have a close relative with cancer of colon and rectum
• If you have colonic polyps
• If you have inflammatory bowel disease like ulcerative colitis, crohn’s disease
• Familial polyposis syndromes
• Age more than 50 years

No specific intervention for primary prevention is known. However, the following dietary and lifestyle changes may play a role in prevention :

• physical activity
• folate
• fruits and vegetables
• calcium
• vitamin D
• high fiber diet
• weight reduction
• avoidance of red and processed meat
• stopping smoking.

For secondary prevention, 2 broad groups have been identified :
a. High risk individuals (those with a history of adenomas or cancers, family history or genetic syndrome, or inflammatory bowel disease). Among the high risk groups a colonoscopy should be done 3 years after removal of an adenoma/polyp and if this is normal then after 5 years the test should be conducted.
b. Average risk individuals (all others)

History: Rectal bleeding is the commonest symptom. Other symptoms include tenesmus, altered bowel habits and mucus discharge, weight loss and loss of appetite. For suspicious or high risk patients the best diagnostic tool is sigmoidoscopy or colonoscopy. These are endoscopies done through anal route to visualize the entire large intestine from inside. When colonoscopy is not possible other test recommended is Barium enema or CECT scan. USG, X Rays of Abdomen are the other tests recommended during diagnosis and staging the colorectal cancers.

Surgery, chemotherapy and pre-operative Radiotherapy (short course or long course) are used in the treatment protocol of colon rectum in different sequences depending on stage of disease. Out of these surgeries these are the primary treatment and curative treatment required in early stages.

• What kind of operation will it be?
• How will I feel afterward? If I have pain, how will you help me?
• Will I need a colostomy? Will it be temporary or permanent?
• How long will I be in the hospital?
• Will I have to be on a special diet? Who will teach me about my diet?
• When can I return to my regular activities?
• Will I need additional treatment?

Pancreas is a organ located on back side of abdomen behind stomach. Actually this is an active gland responsible for digestion of food and secrete Insulin for control of blood sugar. Acute pancreatitis is an important cause of acute upper abdominal pain associated with vomiting. The common causes include gall bladder stone disease, alcoholism and idiopathic- where no obvious cause is discernible. Fortunately the majority of cases of acute pancreatitis are mild and respond to conservative treatment. In less than 10% the disease is more severe and follows a vicious course with immense clinical and socio economic implications.

Causes and Risk factors for Cancer of Pancreas

• Age more than 50 years and male preponderance is often seen
• Cigarette smoking
• Heavy alcohol consumption
• Diet high in fat and protein contents
• Chronic pancreatitis
• Family history of cancer of pancreas

In a known case of alcohol induced pancreatitis the patient must be counseled about the role of alcohol and that abstaining from it will prevent a further episode of pancreatitis. Similarly avoidance of fatty food and early cholecystectomy in a known case of biliary or gall stone induced pancreatitis will prevent further attacks.

After detailed history, examination and routine tests Dr. Soumitra will advice certain specific tests like liver function tests, USG, CECT abdomen, MRCP, CA 19.9 or PET Scan if required.

Treatment depends on the stage and fitness of the patient. Surgery is the mainstay in this cancer particularly in early stage. The type of surgery depends on the location of tumor whether they are in head or body or tail of pancreas. It also depends on whether they have involved other surrounding organs or blood vessels. If they aren’t wide spreaded then localized surgery always have the potential for cure. Radiotherapy and chemotherapy is also employed either for unresectable tumors or after surgery for tumors which were not in very early stage.

Sometimes surgical removal of tumor is not possible ( locally advanced tumors with involvement of other organs or important blood vessels ) or not advisable ( due to dissemination of cancer ). In these situation cancer can be down staged by chemotherapy and Radiotherapy in certain percentages of patients and then operated. Otherwise they can be given the opportunity of selecting bile duct and /or Duodenal stenting or Triple bypass ( surgical method of bypassing the obstructed ( blocked ) bile duct and duodenum.

Stomach Cancer represents the fourth most common malignancy and the second leading cause of cancer related death. In Japan gastric cancer remains the most common type of cancer among men. Its incidence, however, has been declining globally since World War II. Gastric cancer is one of the least common cancers in North America. The incidence of proximal gastric cancer is on the increase while the distal gastric cancer is declining in North America. The five year survival rate of gastric carcinoma is low (10-20%).

The stomach is a J-shaped organ in the upper abdomen. It is part of the digestive system, which processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) in foods that are eaten and helps pass waste material out of the body. Food moves from the throat to the stomach through a hollow, muscular tube called the esophagus. After leaving the stomach, partly-digested food passes into the small intestine and then into the large intestine. The wall of the stomach is made up of 3 layers of tissue: the mucosal (innermost) layer, the muscular is (middle) layer, and the serosal (outermost) layer. Gastric cancer begins in the cells lining the mucosal layer and spreads through the outer layers as it grows.

Gastric Cancer refers to the malignant growth arising from the epithelial lining of the stomach. It is an aggressive tumor with vague early symptoms and spreads to the adjoining structures early in its course. Stromal tumors of the stomach begin in supporting connective tissue and are treated differently from gastric cancer.

Vast majority of Gastric Cancers are attributed to environmental factors, the most common being infection with Helicobacter Pylori. This organism has been found in almost 70% of the patients with Antral gastric cancer and is associated with nine fold increased risk of developing gastric cancer. Inoculation most likely occurs in childhood through the oro-fecal pathway and is transmitted from person to person.
Intake of certain food contents is also thought to be contributory; preserved diets with high salt contents, smoked foods and diets with low fresh fruits and vegetable contents have also been attributed to the increased incidence of gastric cancer.
Smoking and prolonged consumption of alcohol have also been attributed to the increased occurrence of gastric cancer. Better living standard, better dietary habits, eradication of Helicobacter Pylori infection, giving up of smoking and alcohol consumption may decrease the occurrence of gastric cancer.
1-3% of gastric cancers are associated with inherited gastric cancer predisposition syndromes. E-cadherin mutations occur in approximately 25% of families with an autosomal dominant predisposition to diffuse gastric cancers also called hereditary diffuse gastric cancer. This subset of persons may benefit from genetic counseling and prophylactic gastrectomy.

Multi-disciplinary treatment planning is mandatory for a better outcome of this rather dismal disease. Patients with Gastric cancer should be managed by an experienced team of Surgeons, Onco-physicians, Gastroenterologist, Radiation-Oncologist, Nutrion Specialist and Onco–Nurses.

Surgery remains the mainstay of treatment of gastric cancer. It is the only single modality treatment capable of curing the disease. The goal of surgical cure requires complete resection.

Subtotal (partial) gastrectomy: This type of surgery is often used by some of the best cancer hospitals in India if the cancer is only in the lower part of the stomach close to the intestines. It is also sometimes used for cancers that are only in the upper part of the stomach. Only part of the stomach is removed, sometimes along with part of the esophagus or the first part of the small intestine. Eating is much easier after surgery when only part of the stomach removed.

Total gastrectomy: This method is used if the cancer has spread throughout the stomach. It is also often used if the cancer is in the upper part of the stomach. The surgeon removes all of the stomach. The nearby lymph nodes are removed, and sometimes also the spleen and parts of the esophagus, intestines, pancreas, and other nearby organs. The end of the esophagus is then attached to part of the small intestine. People who have had a total gastrectomy can only eat a small amount of food at a time. Because of this, they must eat more often.

Surgery for stomach cancer is complex and can lead to problems. These could include bleeding from the surgery, blood clots, and damage to the nearby organs. Rarely, the new connections between the ends of the stomach and esophagus or small intestine may not hold together and can leak. These problems, which could be fatal, were more common in the past.
Other side effects may start after you have recovered from surgery these could include :

• Heartburn
• Abdominal pain
• Diarrhea (especially after eating)
• Shortages of some vitamins