Intestinal Cancer can be treated at every stage. It requires multidisciplinary consultation.

Intestinal Cancer can be treated at every stage. It requires multidisciplinary consultation.

Intestinal cancer is one of the commoner cancers. It mainly involves large intestine.

It is generally believed that in cancer once it reaches stage 4, it is untreatable and patient should be waiting for death.

But this is a biggest myth that our society is having. There is basic difference between curable and treatable. Curable means once after treatment cancer is completely gone and very less chance of recurring back. Yes, most of the times stage 4 cancers are not curable but they are definitely treatable that means by various treatments cancer can be controlled and patients can live a normal healthy life and their life can be extended for years, some times cancers can be kept in control for long time.

Patients should always look for treatment; even it is in advanced stage and should never loose hope.

With that background lest us move to stage wise treatment of intestinal cancer.

Stage 1,2:

Intestinal cancers in the stage 1,2 are essentially removed surgically, and patient should directly go for surgery.

Generally stage 1 cancers does not require post op chemotherapy.

Stage 2 cancer when obstructs the intestine or cancer breach intestinal muscular wall, patient generally requires postoperative chemotherapy.

Stage 3:

In stage 3 cancer ideal management of upper part of large intestine and lower part (rectum) is quite different.

Ideally upper part of large intestine first surgery should be done and then chemotherapy (adjuvant)

In lower part of large intestine (rectum) if we go directly for surgery there high chances of local recurrence, so before surgery patient should under go chemotherapy and radiotherapy (neoadjuvant chemoradiation) and after that surgery and then again chemotherapy.

Stage 4 cancer

Stage 4 means cancer has spread to other sites and out side intestine. Are these cances still treatable ?

Well, Answer is yes.

If cancer spread is limited to lung and liver. Cancers in the liver and lung can be removed and cancers are treatable.

IF cancer are detected simultaneously to liver and intestine, some doctors advised to remove liver cancer first and after that intestinal cancer (liver first approach) because there high risk and death and further spread of cancer from liver and not intestinals. ( for  further reading see my earlier blog in liver first treatment)

If cancer is spread to inside of abdominal wall (peritoneal), in some selected cases it can still be removed.

On 6^th November 2014 researchers in U.S. has published a report even when cancer spread to other cancer can not treated surgically, removing of primary intestinal cancer does giver survival advantage.

Take home message:

Intestinal cancer can be treated even if it is stage 4

Surgery is the gold standard treatment of acute gall bladder inflammation. (Acute Cholecystitis)

How to treat acute gall bladder infection?

As soon as patient come Initial treatment with antibiotics active against enteric bacteria should begin.

The definitive treatment for acute gall bladder inflammation (acute cholecystitis) is cholecystectomy. From the time this operation was first performed in 1882 by Langenbuch, open cholecystectomy has been the standard of care for patients with acute cholecystitis. With the advent of laparoscopic cholecystectomy in the 1980s, the standard approach has changed such that cholecystectomy is now routinely performed laparoscopically.

Only issue is timing of surgery.

The conversion rate to an open procedure is higher for patients with acute cholecystitis compared with patients undergoing elective operations but most patients with acute cholecystitis (>80%) can undergo laparoscopic cholecystectomy successfully.

Laparoscopic subtotal cholecystectomy (LSC) has also been evaluated as a means of decreasing the conversion rate to open procedure in patients with acute cholecystitis  This procedure involves leaving the wall of the gallbladder when it is significantly difficult to dissect from the liver bed, Indeed, in the face of severe inflammatory change, such an approach is safter than risking injury .Horiuchi and colleagues (2008) demonstrated a significant decrease in conversion rate to open procedure with the use of these techniques with no increase in postoperative complications. Laparoscopic cholecystectomy remains the standard therapy for definitive treatment of patients with acute cholecystitis, with conversion to an open procedure if necessary.

In patients with a high perioperative risk from sepsis or other underlying medical comorbidities, initial treatment of acute cholecystitis with percutaneous tube placement is preferred, These tubes can be placed using either sonographic or CT guidance. This procedure effectively decompresses the gallbladder, evacuating the infected bile and relieving the pain associated with gallbladder distension, and it is associated with a low complication rate After stabilization of the patient, and if the clinical situation otherwise warrants, delayed cholecystectomy should be performed, which often can be done laparoscopically. Akyürek and colleagues (2005) demonstrated decreased hospital stay and cost in high-risk patients undergoing percutaneous cholecystostomy followed by early laparoscopic cholecystectomy compared with those treated conservatively with intravenous (IV) antibiotics and bowel rest followed by delayed cholecystectomy.

Timing of Surgery

The optimal interval of time between the diagnosis of acute cholecystitis and definitive treatment with cholecystectomy has been the subject of many prospective randomized trials, nine evaluating open cholecystectomy and five evaluating laparoscopic cholecystectomy. The concern in operating on patients with early cholecystitis (typically defined as <3 days) is the potential for increased postoperative complications, including common bile duct injury. The risk of performing cholecystectomy late (weeks after the diagnosis of cholecystitis) is that a subset of patients have recurrent symptoms during the period between diagnosis and surgical treatment, which leads to recurrent hospital admissions and urgent surgery .In multiple randomized prospective trials evaluating the timing of open cholecystectomy, patients undergoing early operation experienced no increased perioperative complications and had a shorter length of hospital stay compared with patients undergoing delayed operation.

The majority of trials of early versus delayed laparoscopic cholecystectomy define “early” as within 72 hours of symptom onset. A recent nonrandomized, prospective study by Tzovaras and colleagues (2006) assessed 129 patients undergoing laparoscopic cholecystectomy for acute cholecystitis during the index admission. The patients were divided into three groups regarding the timing of their surgery from symptom onset: within 3 days, between 4 and 7 days, and after 7 days. They found no significant difference in conversion rate, or postoperative hospital stay among these groups and thus suggest that the benefits of early cholecystectomy are not limited to patients who present within 72 hours of symptom onset.

Take home points:

·      Cholecystectomy preferably laproscopic is gold standard treatment.

·      If expertise available early cholecystectomy should be done.

·      There is no hard and fast timing for cholecystectomy should be decided upon patient condition and expertise available.

·      Percutaneous cholecystectomy should be done in septic/sick patients not suitable for surgery.

·      Subtotal or partial cholecystectomy should be considered as a option before converting to open

·      End of the day goal should be to treat the patient and not the way or approach.

What to do if after your gall bladder surgery, your surgeon tells you that your gall bladder pathology has shown cancer??

What to do if after your gall bladder surgery, your surgeon tells you that your gall bladder pathology has shown cancer??

Many a times it happens that after your gall bladder surgery done for simple gall stones and when pathological reports comes, You are shocked to hear that actually you had gall bladder cancer.

What to do in such a situation?? Does a repeat surgery is required??  If yes when??

Is there any another way to manage?? How to follow up ???

Cancer of the gallbladder is the most common biliary malignancy, and it is the fifth most common gastrointestinal cancer. it is usually diagnosed at an advanced stage, resulting in an overall median survival of less than 6 months. However, advances in our understanding of its tumor biology accompanied by progress in diagnostic and surgical extirpative techniques have motivated a fresh, new approach to this once universally fatal disease; indeed, the possibility of cure is a real one for a subset of patients presenting with gallbladder cancer.

Surgery:

Gallbladder cancer is unfortunately highly resistant to chemotherapy, and its proclivity toward diffuse peritoneal spread limits the applicability of radiation therapy. Surgery is the only treatment for cure in case of gall bladder carcinoma. The standard template on which all operations for gallbladder cancer should be based is the so-called radical or extended cholecystectomy. which include gall bladder removal along with part of liver removal.

However sometime cancer is detected only in pathological examination after removal of gall bladder for gall stone diseases. This is known as incidental gall bladder cancer.

In this type of cancer need for further surgery or removal of part of liver or gall bladder bed is some time required for cure otherwise tumor might recur at any time.

Decision regarding this generally depends on pathological spread of cancer in the gall bladder wall.

It is divided in to 4 stages, as shown in figure. Here T1a means tumor limited in inside wall of gall bladder.

Generally no further treatment is required if cancer is of T1a stage that is limited to gall bladder inside wall.

For anything greater than T1a further surgery and removal of part of liver and lymphatic tissue are required to improve cure rates.

What is hepatobiliary surgery???

What is hepatobiliary surgery ??

Surgery of the Liver, Bile Ducts, and Pancreas (Hepatobiliary)
LIVER
The most common indication for liver surgery is to remove a cancerous tumor. Tumors of the liver may be metastatic, meaning they started at a different site (e.g. colon, kidney, etc.) or they may be primary, meaning they arise from within the liver (e.g. hepatocellular carcinoma or cholangiocarcinoma). Surgery to remove a liver tumor can relieve symptoms and restore health with potentially excellent long term results.


Liver adenoma is a benign but pre-cancerous tumor. Other types of benign (non-cancerous) liver tumors include hemangioma and focal nodular hyperplasia (FSH). Benign tumors may need to be removed surgically if they are pre-cancerous or when they cause symptoms such as pain or difficulty eating.

Liver cysts are collections of fluid within the liver. These are generally benign and often do not require surgery. When cysts are large they may cause pain or difficulty eating. Surgery can be used to cure symptoms when they impair quality of life or lead weight loss.

BILE DUCT
The bile ducts are tubes that carry bile that is made in the liver into the intestine. The bile helps you absorb food and provides the brown color of your stool. Blockage of the bile ducts can lead to yellowing of the skin (jaundice) and light colored stools.

Bile duct cysts (choledochoceles) are a risk factor for bile duct cancer. The treatment for most bile duct cysts includes surgical removal of the bile duct and liver bypass. Other indications for surgery of the bile duct include blockage from prior gallstones or as a result of previous surgery.

PANCREAS
Pancreatic cancer affects an estimated 38,000 people each year in the United States. The best results with treatment are achieved when surgery is used for removal of the tumor. Unfortunately, only about 20% of people diagnosed with pancreatic cancer will be a candidate for surgical removal of their tumor at the time of diagnosis.

Pancreatic neuroendocrine tumors (islet tumors) are more slow growing tumors of the pancreas that can be either benign or cancerous. Neuroendocrine tumors should be removed surgically when they are at risk being cancerous or when they cause symptoms (e.g. diarrhea, flushing, light headedness, ulcers, skin rash, low blood suger, pain, weight loss, etc.).

Pancreatic cysts are fluid collections within the pancreas. These can be benign (e.g. pseudocysts, serous cyst adenoma) or pre-cancerous (e.g. mucinous cystic tumors and intraductal papillary mucinous neoplasms [IPMN]). Pancreatic cysts should be removed when they are large, cause symptoms including pain, inability to eat or weight loss, or when they have a risk of becoming cancerous.

Pancreatitis refers to inflammation of the pancreas. This can be sudden (e.g. acute pancreatitis) or chronic (e.g. chronic pancreatitis). Pancreatitis can lead to blockage of the duct draining the pancreas resulting in diarrhea and weight loss. Other complications may include a build up of fluid around the pancreas (pseudocyst) and chronic pain. In cases of complicated pancreatitis, surgery may be helpful to treat your symptoms.