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GI cancer surgery

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  • Gastrointestinal (GI) Cancer is a collective term which include all the cancers of digestive system

  • Any organ of the GI tract can be involved by cancer

  • GI cancer can be hereditary or non hereditary

  • Symptoms of GI cancer vary depending on the site of cancer

  • Cancer can spread to lymph nodes through the lymphatics or other organs through the blood

  • All cancers are staged before treatment

  • Cancer treatment is based on the stage of the cancer

  • Earlier the cancer stage better is the outcome

  • When cancer is confined to the primary organ or adjacent lymph nodes they are said be resectable cancers and when the cancers spread to others organs or distant lymph nodes are called as metastatic cancers

  • Surgery is the main modality of treatment for resectable GI cancers

  • After surgery additional treatment in the form of chemotherapy or radiotherapy may be needed depending on the final biopsy report of the surgical specimen

What are the common cancers of the gastro-intestinal system?

  • Esophageal cancer

  • Stomach (Gastric Cancer)

  • Intestinal Cancers

    • Small Bowel Cancer

    • Colon (Large Bowel) Cancer

    • Rectal Cancer

    • Anal Cancer

  • HPB cancers

    • Liver Cancer

    • Gall Bladder & Bile duct Cancer

    • Pancreatic Cancer

  • Splenic Tumors

  • Retroperitoneal tumors

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How to suspect the gastro-intestinal (GI) cancers?

  • Symptoms of the GI cancer are site specific

  • Anorexia (loss of appetite) and weight loss are non specific symptoms and can be seen in any cancer

  • Depending on the site, symptoms can be

    • Esophageal cancer - Dysphagia (Difficulty in swallowing of food)

    • Stomach (Gastric Cancer)- Dysphagia in proximal cancers & vomiting  in distal cancer

    • Small Bowel Cancer - Pain abdomen, vomiting, abdominal distension, constipation etc

    • Colon (Large Bowel) Cancer - Pain abdomen, vomiting, abdominal distension, constipation, blood in the stool, fatigue or generalized weakness etc 

    • Rectal Cancer - Bleeding per rectum

    • Anal Cancer - Bleeding per rectum, mass 

    • Liver Cancer - Lump abdomen, pain, jaundice etc.

    • Gall Bladder & Bile duct Cancer - Lump abdomen, pain, jaundice etc

    • Pancreatic Cancer- Lump abdomen, pain, jaundice etc.

How to diagnose GI cancers ?​

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  • Depending on the patients  symptoms, once we suspect what could be the site of cancer, the same can be confirmed with either radiological (CT/MRI) or endoscopy and biopsy

  • In general, esophagus, stomach & colorectal cancers can be accessed by endoscopy. So, endoscopy & biopsy are the best method to diagnose these cancers

  • Liver, biliary, pancreas, spleen and small bowel tumours are generally diagnosed by radiological investigations (CT/MRI) as these sites are difficult access by endoscopy​​​​

    • Esophageal cancer - Endoscopy & BiopsyStomach (Gastric Cancer)- Endoscopy & Biopsy

    • Small Bowel Cancer - Mainly by CT or MRI scan ( biopsy is not always feasible)

    • Colon (Large Bowel) Cancer - Colonoscopy & biopsy

    • Rectal Cancer - Colonoscopy & biopsy

    • Anal Cancer - Proctoscopy & biopsy

    • Liver Cancer - CT / MRI

    • Gall Bladder & Bile duct Cancer - CT / MRI 

    • Pancreatic Cancer- CT / MRI

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Role of biopsy GI Cancer?

  • Biopsy, whenever feasible is the ideal method to confirm the cancer

  • However, in HPB malignancies such as liver, biliary and pancreatic cancer biopsy is not mandatory before surgery, if radiological images strongly suggest malignancy

  • Note - Biopsy is mandatory before chemotherapy or radiotherapy for any cancer

What are the treatment options for GI cancers ?

  • Surgery is the main modality of treatment for majority of GI cancers

  • Other options

    • Chemotherapy

    • Radiotherapy 

    • Monoclonal antibodies / Targeted therapy

How a doctor decides treatment of cancer?

  • After diagnosis of a cancer, next step would be to know the extent of disease (staging)

  • Cancer staging is usually done by CT, MRI or PET scan

  • Treatment is based on the stage of the cancer

What is palliative treatment?

  • Palliative treatment is considered when it is not possible to cure the disease completely either due to widespread or poor health condition of the patient

  • Treatment is done mainly for palliation of symptoms to improve the quality of life

What are the commonly done surgeries for GI cancers? 

  • Esophageal cancer - Esophagectomy

  • Stomach (Gastric Cancer) - D2 gastrectomy (total/partial)

  • Small Bowel Cancer - segmental resection

  • Colon (Large Bowel) Cancer - right / left hemi colectomy

  • Rectal Cancer - anterior resection, LAR, APR

  • Anal Cancer - Chemo- radiotherapy / APR

  • Liver Cancer - Hepatectomy

  • Gall Bladder & Bile duct Cancer - Radical cholecystectomy, Whipples' procedure , hepatectomy

  • Pancreatic Cancer- Whipplel' s procedure, pancreatectomy

  • Splenic tumors - splenectomy

  • Retroperitoneal tumor - tumor excision

Role of surgery, chemotherapy and radiotherapy in GI cancer?

  • Surgery is the main modality of treatment for majority of GI cancers

  • In some cancers combination therapy may be needed i.e addition of chemotherapy/radiotherapy  to surgery ( eg. - esophageal & rectal cancer)

  • Chemo/radiotherapy given before surgery is known as neo -adjuvant therapy & after surgery - adjuvant therapy

  • When cancer is non operable (metastatic) due to wide spread disease chemo/radiotherapy can be used as palliative treatment

What is curative treatment?

  • When the cancer treatment is done with the intent to cure the disease completely

Photo Gallery 

What are the risk factors for the development of gastrointestinal cancers ?

  • In general, advanced age (elderly), male sex, tobacco smoking and alcohol intake are usual risk factors for any cancer

  • Risk factors can be modifiable (eg.- smoking and alcohol) or non modifiable (eg. age, sex)

  • Certain risk factors can be genetic (eg. FAP & HNPCC syndromes in colon cancer)

  • Certain cancers are associated with particular risk factors

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  • Esophageal cancer

    • Smoking

    • Alcohol

    • Plummer-Vinson syndrome

    • Achalasia cardia 

    • Tylosis

    • Fanconi anemia

    • Corrosive esophageal stricture

    • Obesity

    • Barrett's esophagus

  • Stomach cancer

    • Salted or smoked meats

    • Low intake of fruits and vegetables

    • H. pylori infection

    • Li-Fraumeni syndrome

    • Red meat consumption

  • Liver and biliary cancers

    • Cirrhosis of liver due to any cause

    • Hepatitis B & C viral infections

    • Oral contraceptives

  • Gall bladder & bile duct cancer

    • APBJ (Abnormal Pancreatico-Biliary Junction)

    • Choledochal cysts

    • PSC

    • Porcelain gallbladder

    • Gall stones >3 cm

    • Recurrent pyogenic cholangitis

    • Thorotrast, asbestos exposure

  • Colon & rectal cancers

    • Familial adenomatous polyposis (APC gene mutation)

    • Lynch syndrome (mismatch repair gene mutations)

    • Excessive intake of red meat

    • Obesity

  • Pancreatic cancer

    • Tobacco smoking

    • Hereditary pancreatitis (PRSS1 and SPINK1 gene mutation)

    • Cystic fibrosis (CFTR gene mutation)

    • Peutz-Jeghers syndrome (STK11 gene mutation)

    • Hereditary breast and ovarian cancer (BRCA2 gene mutation)

Discussion 

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