Gallstones and Gallbladder Surgery
The gallbladder is an organ situated underneath the liver. It is a storage reservoir for bile, which is required for fat digestion. Bile is a mixture of cholesterol, bilirubin, bile salts and lecithin. After eating fatty food, the body produces a hormone called Cholecystokinin which in turn promotes the gallbladder to squeeze additional bile into the gut via the bile duct. You can live without your gallbladder as bile can also directly enter the gut from the liver through the bile duct.
You don't need a gallbladder in order to digest food properly. If your gallbladder is removed, bile will flow directly from your liver through the bile duct and into the small intestine.
Gallstones are stone-like objects made of cholesterol or bilirubin. They can develop in the gallbladder or bile ducts. They can vary in size from sediment to very large stones.
Gallstones are found in approximately 10–20% of the global adult population, and >20% of people with gallstones will develop symptoms in their lifetime.
Gallstones are thought to develop because of an imbalance in the chemical make-up of bile inside the gallbladder.
Cholesterol Stones (90%) - Your bile contains too much cholesterol. Normally, your bile contains enough chemicals to dissolve the cholesterol excreted by your liver. But if your liver excretes more cholesterol than your bile can dissolve, the excess cholesterol may form into crystals and eventually into stones.
Pigment Stones (10%)- Your bile contains too much bilirubin. Bilirubin is a chemical that's produced when your body breaks down red blood cells. Certain conditions cause your liver to make too much bilirubin, including liver cirrhosis, biliary tract infections and certain blood disorders.
Genetics – A study in 43,141 Swedish twin pairs with gallstone disease indicated that approximately 25% of the risk of gallstone disease is determined by genetics.
Metabolic Syndrome: obesity, non-alcoholic fatty liver disease, insulin resistance and Diabetes Mellites, physical inactivity.
Pregnancy - Interestingly, in up to 60% of women, gallstones can disappear post-partum due to decreased levels of Oestrogen.
Medications - Oestrogens, Progesterone, Fibrates, Calcineurin Inhibitors and Octreotide.
Dietary factors - High-calorie intake, high-carbohydrate intake, high-glycaemic load, low-fibre intake, high-haem iron intake.
Rapid weight loss (that is, >1.5 kg per week by a very-low-calorie diet or after bariatric surgery caused gallstones in 30% of patients)
Prolonged Total Parenteral Nutrition (TPN)
Spinal cord injury
Gastrectomy (due to vagal nerve division)
Factors increasing enterohepatic bilirubin cycling - Liver cirrhosis; Crohn’s disease, Right Hemicolectomy
Biliary colic - if a gallstone becomes trapped at the neck of the gallbladder, it can trigger a sudden, intense pain under your rib cage lasting between 1 and 5 hours. It is usually triggered by the ingestion of fatty foods.
Cholecystitis (Inflammation of the gallbladder) - A gallstone that becomes lodged in the neck of the gallbladder can also cause inflammation of the gallbladder. Cholecystitis can cause severe pain and fever lasting for several days and may require antibiotics or gallbladder removal (cholecystectomy).
Obstructive Jaundice (blockage of the common bile duct) - gallstones can block the tubes (ducts) through which bile flows from your gallbladder or liver to your small intestine. Severe pain, jaundice and bile duct infection (cholangitis) can result.
Pancreatitis - A gallstone can cause a blockage in the pancreatic duct, which can lead to inflammation of the pancreas (pancreatitis). Pancreatitis causes intense, constant abdominal pain and vomiting and usually requires hospitalization.
Overall, 1–4% of individuals with previously diagnosed asymptomatic gallbladder stones develop symptoms every year. Of those who present with symptoms, biliary colic is often the main symptom. Based on a balance of benefits and harms, there is currently no evidence to support routine cholecystectomy in patients with asymptomatic gallbladder stones, except in cases of suspected gallbladder cancer such as a porcelain gallbladder or polyps greater than 1cm.
Suspected cancer
Biliary dyskinesia – Functional abnormality of the gallbladder
Acalculous cholecystitis with evidence of gangrene or perforation
Gallstones may have been present before pregnancy or can develop during pregnancy. Decision to proceed to cholecystectomy depends on the stage of pregnancy and the disease severity. In most women, supportive management of uncomplicated gallstones can delay cholecystectomy until the post-partum period. Cholecystectomy provides definitive management of problematic gallstones, but the stage of pregnancy must be considered. The second trimester is believed to be the optimal stage of pregnancy for cholecystectomy, with the lowest risk for foetal morbidity. Interestingly, in up to 60% of women, gallstones can disappear postpartum due to decreased levels of Oestrogen.
Make an appointment with your doctor if you have any signs or symptoms that worry you. Seek immediate care if you develop signs and symptoms of a serious gallstone complications including intense abdominal pain, jaundice and fever.
The most effective treatment for symptomatic gallstones found in the gallbladder is to remove the gallbladder surgically. Removal of the gallbladder is called a cholecystectomy. In the majority of cases this surgery can be performed as a keyhole operation (laparoscopic cholecystectomy).
Common bile duct stones either occur by migration from the gallbladder or (less frequently) develop in the bile duct. Coexistent bile duct stones are found in 3–16% of patients with symptomatic gallbladder stones, often with subsequent spontaneous passage to the duodenum.
If gallstones are present in the bile duct in addition to the gallbladder on pre-operative imaging, then the procedure of choice is to remove the gallstones from the bile duct with Endoscopic Retrograde Cholangiopancreatography (ERCP) prior to the gallbladder removal. Other options include removing the bile duct stones at the time of laparoscopic cholecystectomy, however cases need to be carefully selected.
Currently there is no evidence that medical dissolution treatment with Ursodeoxycholic Acid or Extracorporeal Shockwave Lithotripsy is effective in the treatment of gallbladder stones, as the rates of cure (that is, the permanent clearance of gallstones) are low and the recurrence rates of gallstones are high.
Laparoscopic Cholecystectomy is considered a relatively safe procedure but like all operations there is a risk of complications. General risks of laparoscopy are small but include infection, bleeding, damage to intra-abdominal organs, venous thrombo-embolism, myocardial infarction, stroke and incisional hernia. Risks specific to cholecystectomy include a 1 in 500 risk of bile duct injury. If this happens it needs fixing and nearly always involves a bigger operation and a longer recovery. Bile leaks can also occur and may require drainage +/- an Endoscopic Retrograde Cholangiopancreatography (ERCP) and stent insertion. Stones can also be retained in the bile duct and usually pass of their own accord but sometimes cause pain and jaundice and need an ERCP for removal in the post-operative setting. Approximately 5% of patients may experience diarrhoea postoperatively. In the majority of patients this settles down.
Removal of the gallbladder can alter bile acid metabolism. In particular, it raises the faecal concentration of deoxycholic acid, this bile acid being an agent that sensitises the rectum and can cause an urge to defecate. In most cases, the diarrhoea stops soon after the surgery but in approximately 5% of patients it can persist. A SeHCAT study can be used to diagnose Bile Acid Diarrhoea (BAD) secondary to cholecystectomy. Positive response to the medication, Cholestyramine, in these patients is approximately 80%.
It will take approximately 2 weeks to recover from Laparoscopic Cholecystectomy.
Daily activity – Mobilise as soon as possible after surgery and try to keep active.
Washing – You are free to shower any time after the operation as you will have a waterproof glue dressing on the skin. The glue can be peeled off on day 7. Avoid bathing, jacuzzi or swimming for the first 2 weeks after the operation.
Driving – Always check with your individual insurance company but most would advise abstaining for 1 to 2 weeks depending on whether you have stopped any strong pain killers such as Codeine and or can do an emergency stop without pain.
Exercise – safe to return to cardiovascular exercise at 4 weeks and lifting weights with caution at 6 weeks.
Hernia Surgery
A hernia occurs when an internal part of the body protrudes through a weakness in the wall of its containing cavity. It appears as an abnormal protrusion or lump usually found in the groin or abdominal wall. The lump can often be pushed back in, or disappears when you lie down. Coughing may make the lump reappear.
Types of hernias include:
Inguinal hernia – A common groin hernia, which often causes a dragging pain, made worse by activity. 25% of males and 2% of females will develop an inguinal hernia in their lifetime
Umbilical hernia – A hernia that protrudes at the belly button
Epigastric Hernia – A hernia that protrudes in the midline between the belly button and bottom of the rib cage
Hiatal Hernia – A herniation of the stomach up into the chest, which often causes symptoms of reflux.
Incisional Hernia – A hernia protruding through a weakness in a previous operation site
Hernias occur due to a weakness in the investing muscle wall of the abdominal cavity. The weakness eventually gives way and allows internal parts to protrude out. Raised intra-abdominal pressure leads to the rupture at the site of the weakness. Common sites of weakness in the abdominal wall include the inguinal canal and umbilicus. Causes for raised intra-abdominal pressure include obesity, lifting heavy objects, chronic cough and straining due to constipation. Poor nutrition, smoking, and overexertion can weaken muscles and contribute to the likelihood of a hernia.
Hernias can cause discomfort or pain, often made worse by activity. Groin hernias in particular can lead to a dragging sensation, which is often worse after long periods of standing or exercise. If bowel becomes stuck in the hernia sac, there is a chance that it may become obstructed/strangulated leading to severe abdominal pain and vomiting.
Small hernias can be asymptomatic but will likely cause symptoms as they enlarge. Two thirds of inguinal hernias will crossover in a period of ten years.
Strangulation or obstruction of bowel are the main risk of hernias. Strangulation is where a bowel loop becomes caught in a hernia sac and loses its blood supply on twisting. It eventually becomes gangrenous and requires an emergency operation for repair. Fortunately, this is not common, occurring in less than 5% of patients with inguinal hernias per year.
Hernias do not get better on their own.
The majority of hernias can be diagnosed with a clinical examination by a specialist, however on occasion a specialist may request an ultrasound or CT scan to confirm the diagnosis.
There are many causes for groin/abdominal pain. Your symptoms are best assessed by a specialist surgeon.
Hernias can be treated with an operation or watchful waiting.
With an operation, the hernia defect is repaired and often reinforced with mesh to reduce the risk of recurrence. Most people will go home on the same or the day after the operation. Types of operation include:
Keyhole (Laparoscopic) Hernia Repair– The surgeon makes several sub-cm incisions on the abdomen to allow surgical tools into the opening to perform a minimally invasive operation under General Anaesthetic.
Open Hernia Repair – The surgeon makes an incision near the hernia and repairs the rupture under General Anaesthetic
There is good evidence that keyhole repair reduces the time of post-operative recovery.
Some hernias, in particular those that are small and asymptomatic, can be managed without surgery. The need for surgery can be assessed by a specialist surgeon who can advise you appropriately.
The most common type of abdominal wall hernia after pregnancy is an umbilical hernia. The repair will not affect fertility, however the timing of the repair is crucial to reduce the chance of hernia recurrence. This will be based on chances of future pregnancies, the risks of strangulation and symptoms.
Inguinal hernia repair in men has not been shown to have an effect of long-term fertility unless the Vas Deferens (the tube that carries sperm) is inadvertently damaged during the operation. The risk of this is approximately 0.3%.
The use of mesh significantly reduces the risk of hernia recurrence in comparison to suture repair techniques.
In a Danish study of 13,674 primary inguinal hernia repairs (Bisgaard, et al) with an observation interval of 5 years or more, the risk of reoperation after mesh repair due to recurrence was a quarter of that after sutured repair. After 5 years, the reoperation rate increased continuously after sutured repair but not after mesh repair.
The implantation of meshes has been shown to significantly decreases the overall recurrence rate, the occurrence of chronic pain and the time of return to normal activity, as compared to non-mesh techniques.
There are case reports in the literature of mesh erosion into the bladder, vas deferens and bowel but these are extremely rare occurrences.
For many patients, surgical mesh reduces the actual time required in surgery and helps decrease post-surgery recovery time.
Hernia repair is a common and safe operation, however specific risks include:
Hernia recurrence (2%) - This risk is significantly increased if the repair is performed without mesh.
Wound infection (2%) – This is usually superficial and can be treated with antibiotics. Rarely the mesh may become infected, requiring removal (0.1%).
Bruising, haematoma and seroma (5%) - Seromas and haematomas are due to the collection of fluid or blood in the dead space that remains once a hernia sac has been reduced. It can present as significant swelling. They usually resolve of their own accord.
Chronic pain (4-10%) – This is pain at the repair site lasting for more than 3 months. In 1/3 of cases the pain resolves in 6 months. The pain may be caused by nerve entrapment or scar tissue.
Injury to testicular blood supply (0.3%) - Interference of the blood supply may cause testicular pain, shrinkage or swelling.
Injury to Vas Deferens (0.3%)
Urinary Retention (1-3%) - It is usually happens in elderly patients, especially if symptoms of prostatism are present.
Daily activity – Mobilise as soon as possible after surgery and try to keep active. Avoid lifting anything over 10kg for the first six weeks
Washing – You are free to shower any time after the operation as you will have a waterproof glue dressing on the skin. The glue can be peeled off on day 7. Avoid bathing, jacuzzi or swimming for the first 2 weeks after the operation.
Work – Manual Jobs requiring heavy lifting should be avoided for the first 6 weeks after surgery.
Driving – Always check with your individual insurance company but most would advise abstaining for 1 to 2 weeks depending on whether you have stopped any strong pain killers such as codeine and or can do an emergency stop without pain.
Exercise – safe to return to cardiovascular exercise at 4 weeks and lifting weights with caution at 6 weeks
Sex – safe to return to normal at two weeks to avoid wound infection.
GORD & Anti-reflux surgery
Patients experience gastro-oesophageal reflux disease (GORD) due to laxity or disruption of the lower oesophageal sphincter, which allows stomach acid to enter the oesophagus and cause the typical symptoms of heartburn or reflux. This disruption is commonly due to a hiatus hernia or laxity of the cardia.
The various types of anti-reflux surgery aim to restore the normal function of the lower oesophageal sphincter and prevent acid entering the oesophagus. To date, the ‘gold standard’ and the only operation with evidence for long term success is a fundoplication. The surgery involves repair of a hiatus hernia if present, followed by using the top part of the stomach to wrap around the lower oesophagus to form a functional lower oesophageal sphincter (reflux barrier).
Treatment of GORD should be tailored to your specific needs. By consulting an expert who can appropriately investigate and choose from a range of treatments, then the correct evidence-based option can be chosen.
Surgery is not a last resort and is a suitable option for: the long-term management of GORD rather than taking daily medication; persistent unresolved GORD symptoms or related damage to the oesophagus despite the use of medication; or for significant structural disruption at the hiatus (i.e. large hiatus hernia).
Laparoscopic/Robotic fundoplication is performed under a general anaesthetic and takes approximately 1.5 to 2 hours. It is performed as a keyhole operation through five small incisions (5-10mm). Post-operatively you may experience some shoulder tip pain and discomfort at the incision sites, which can be controlled with pain relief. You will require a one-night post-operative stay and will be discharged home with a modified diet for a period of 4 weeks. You can expect to go back to work or your normal routine in two weeks, depending on your job role. Vigorous exercise, sport, and lifting heavy objects should be avoided for about six weeks after surgery. You will have dissolvable sutures and adhesive dressings, allowing you to shower post-operatively.
As with any operation, general complications include a low risk of infection, bleeding, and venous thrombo-embolism (<1%). Although rare, specific complications include a risk of damage to surrounding organs such as the oesophagus, lung, or spleen.
Side effects specific to anti-reflux surgery may include difficulty in swallowing food, which often resolves spontaneously over a period of 6 to 12 weeks. Some patients experience symptoms of bloating and difficulty in belching, however the type of partial fundoplication we perform has been shown to reduce this. Other side effects include temporary weight loss.
Patients often experience complete resolution of their reflux symptoms post-operatively and medications are discontinued. Long term trials have shown that 90% of patients are symptom free at 10 years and 60% remain off medication at 17 years of follow-up. Approximately 5% of patients will require revisional surgery.
Oesophageal Cancer Surgery
The oesophagus (food pipe/gullet) is a muscular tube that connects the mouth to the stomach. There are two main types of oesophageal cancer:
• Squamous Cell Carcinoma (SCC) – this develops from the normal squamous lining of the food pipe
• Adenocarcinoma – this develops from glandular cells found in Barrett’s Oesophagus.
Oesophageal SCC has a higher global incidence, whereas adenocarcinoma has a higher incidence in the Western population.
Oesophageal cancer is the eighth most common malignancy worldwide. In the UK, around 9000 people are diagnosed with oesophageal cancer each year. It usually affects the 50-70 year age group and is more common in males than females.
Adenocarcinoma:
1. Gastro-Oesophageal Reflux Disease predisposes to Barrett’s Oesophagus and is a significant risk factor for the development of adenocarcinoma. Patients with Barrett’s have a 30-fold increased risk of developing adenocarcinoma in comparison to the general population; however their absolute annual risk is only 0.12%.
2. Obesity is an independent risk factor and is also related to GORD, increasing the chance of developing adenocarcinoma by 3 to 6 folds.
3. Current smokers have a 2 to 4 fold increased risk of developing adenocarcinoma.
Squamous Cell Carcinoma:
1. Current smokers have a nine-fold increased risk of developing SCC in comparison to the general population.
2. Moderate to high alcohol consumption has also been shown as an independent risk factor for SCC. The European Prospective Investigation into Cancer and Nutrition (EPIC) reported an increase risk of 35% for women and 18% for men, per 10g/day alcohol consumption.
3. A diet low in fruit and vegetables is also a significant risk factor
Oesophageal cancer is often detected at an advanced stage, with only 30% of patients amenable to curative treatment at the time of presentation. Signs and symptoms may remain absent during the early stages of cancer, making diagnosis difficult.
In the UK patients above the age of 55 or with alarm symptoms, are referred for rapid access endoscopy. The following alarm symptoms are associated with oesophageal cancer in order of frequency:
• Dysphagia The sensation of food getting stuck on swallowing
• Reflux New onset reflux symptoms in those over the age of 55
• Weight loss Occurs in ~20% of people
• Anaemia Low Red Blood Cells due to bleeding from the tumour
• Pain Epigastric/retrosternal pain
Upper Gastro-intestinal Endoscopy and biopsy is the investigation of choice for diagnosis of oesophageal cancer. A minimum of 6 biopsies is recommended for accurate histological confirmation. Endoscopy can also be augmented by Chromoendoscopy and Narrow Band Imaging (NBI).
Treatment recommendations will be undertaken by a dedicated Upper Gastrointestinal Multi-disciplinary Team (MDT). The team meets once a week to discuss patients with oesophageal and gastric cancers to ensure the correct treatment is given. The MDT is attended by multiple specialists including: Medical Oncologists, Clinical Oncologists, Radiologists, Surgeons, Gastroenterologists, Histopathologist, and Specialist Nurses.
The decision for treatment will fall into two categories: treatment with an intent to cure and treatment with an intent to palliate (not curative but with an intended purpose to extend life and relieve symptoms). This decision is based on the findings of the staging investigations, patient co-morbidities, nutritional status and patient preferences.
Curative treatment often involves Chemo/radiotherapy in combination with surgery. Median Five year survival of treatment with curative intent is approximately 45-50%.
The purpose of pre-treatment staging is to identify the depth of infiltration of the tumour into the oesophageal wall (T stage), the presence of regional lymph node metastases (N stage) and distant metastases (M stage). A combination of imaging modalities is used to determine the TNM stage. The TNM Stage can then be used to select appropriate patients for curative or palliative treatment modalities. Metastases is the spread of tumour to sites away from the primary tumour.
• CT (Computer tomography) of the chest/abdomen/pelvis
CT is often the initial staging investigation and takes about 15 minutes to perform. It is useful for detecting metastases in solid organs and distant lymph nodes. Detection is dependent on size of the lesion and there are also limitations in distinguishing metastatic from inflammatory enlargement.
• FDG-PET-CT (18F-fluoro-2-deoxy-D-glucose - Positron Emission Tomography - Computed Tomography)
Cancers preferentially uptake glucose for their metabolism. FDG-PET-CT involves injecting radio-labelled glucose into the bloodstream to highlight foci of cancer in the body. It improves the diagnostic capability of detecting smaller/occult metastases by 20% in comparison to CT alone. The procedure is very similar to CT but takes longer and you will be asked to starve for 6 hours before hand
• Endoscopic ultrasound (EUS)
This is a similar procedure to the endoscopy, except the probe has an ultrasound device on the end, which enables the doctor to examine the cancer and surrounding tissue in precise detail. It takes longer than an endoscopy and may require more sedation. EUS is the preferred imaging modality for clarification of the T stage and local lymph node involvement. In addition suspicious lymph nodes can be biopsied for histological confirmation.
• Staging laparoscopy
A keyhole examination of the abdomen under general anaesthetic is used for the detection of metastases that cannot be detected with scans. It also allows the surgeon to look at local invasion of the tumour into surrounding organs. The procedure is quick and patients usually go home on the same day.
Oesophagectomy is the main surgical treatment for esophageal cancer. It is performed to remove the cancer and the lymph nodes around it. During an Oesophagectomy, the surgeon removes all or part of the oesophagus through incisions in the neck, chest or abdomen. The oesophagus is replaced using another organ, most commonly the stomach but occasionally the small or large intestine.
Oesophagectomy can be performed with open surgery or minimally invasive surgery (including laparoscopy or robotic approaches) or a combination of both approaches. Minimal invasive approaches have been shown to reduce pulmonary complications and improve the rate of recovery.
Oesophagectomy is a major operation with a significant risk of morbidity. Post-operative hospital stay will be approximately 7 to 14 days if there is no complication. Potential complications of Oesophagectomy include: bleeding, infection, anastomotic leak, chyle leak, pulmonary complications, organ impairment, venous thrombo-embolism and mortality. These will described in more detail by your surgeon.
To reduce postoperative complications your recovery will be aided by a Prehabilitation Programme and Enhanced recovery Programme (ERP) designed to speed up your recovery and reduce complications.
After surgery you will be looked after in an intensive care unit for the first 5 days. You will have several lines for venous and arterial access, an epidural to control your pain, a naso-gastric tube, several chest drains, and a feeding tube inserted into the bowel (feeding jejunostomy). Other than the feeding jejunostomy the other lines and tubes will be removed sequentially over the next few days. Your oral liquid and food intake will also be reintroduced gradually over the next few days. Multiple teams of healthcare professionals will look after you including surgeons, intensivists, nurses, physiotherapists, dieticians, etc, with an aim to re-establish normal function as soon as possible. The jejunostomy tube will remain for several months after the operation to help supplement your nutrition, especially if you are to undergo chemotherapy after your operation. Post-operative hospital stay will approximately 7 to 14 days if there are no complications.
The most common symptoms experienced by patients include reflux and lethargy and alteration in eating habit which may lead to weight loss. Nutritional supplementation in the form of multi-vitamins will also be required after removal of the feeding jejunostomy.
It will take approximately six weeks before achieving good function and six months for full recovery.
For more information:
Cancer Research UK
Macmillan
Gastric Cancer Surgery
Gastric cancer is a cancer that develops from the lining of the stomach. The stomach is a muscular bag that attaches to the food pipe and at the other end to the intestine. It helps to mix and break down food prior to it entering the intestine. The majority of gastric cancers are adenocarcinomas (90%). Less common primary malignancies include, in order of frequency: gastro-intestinal stromal tumours, carcinoid tumours and lymphomas.
It is the fourth most common cancer in males and fifth most common cancer in females and is the second largest cause of cancer related deaths worldwide. Around 6,700 people are diagnosed with stomach cancer in the UK each year. It is more common in men than women.
It is the fourth most common cancer in males and fifth most common cancer in females and is the second largest cause of cancer related deaths worldwide. Around 6,700 people are diagnosed with stomach cancer in the UK each year. It is more common in men than women.
Risk factors for gastric cancer include Helicobacter pylori infection, cigarette smoking, high alcohol intake, excess dietary salt, inadequate fruit and vegetable consumption, pernicious anaemia and blood group A.
Hereditary gastric cancers are typically of the diffuse or Linitis Plastica histological type, as opposed to the more common intestinal histologic type. It has been estimated that 1–3% of stomach cancers occur as a result of inherited stomach cancer predisposition syndromes.
Signs and symptoms may remain absent during the early stages of gastric cancer, making diagnosis difficult. UK guidelines recommended that patients aged 55 years or more with new onset dyspepsia and all those with alarm symptoms should undergo urgent (within two weeks) upper gastrointestinal endoscopy.
• Dyspepsia - includes a broad range of symptoms including recurrent epigastric pain, heart burn, bloating, nausea or vomiting.
Alarm Symptoms:
• Unintended weight loss
• Upper or lower gastrointestinal bleeding
• Progressive dysphagia (food getting stuck on swallowing)
• Unexplained iron deficiency anaemia
• Persistent vomiting
• Palpable abdominal mass
• Jaundice
Upper Gastro-intestinal Endoscopy and biopsy is the investigation of choice for diagnosis of gastric cancer. A minimum of 6 biopsies is recommended for accurate histological confirmation. Endoscopy can also be augmented by Chromoendoscopy and Narrow Band Imaging (NBI).
Treatment recommendations will be undertaken by a dedicated Upper Gastrointestinal Multi-disciplinary team (MDT). The team meets once a week to discuss patients with oesophageal and gastric cancers to ensure the correct treatment is given. The MDT is attended by multiple specialists including: Medical Oncologists, Clinical Oncologists, Radiologists, Surgeons, Gastroenterologists, Histopathologist, and Specialist Nurses.
The decision for treatment will fall into two categories: treatment with an intent to cure and treatment with an intent to palliate (not curative with an intended purpose to extend life and relieve symptoms). This decision is based on the findings of the staging investigations, patient co-morbidities, nutritional status and patient preferences.
Curative treatment often involves Chemo/radiotherapy in combination with surgery in an attempt to improve survival. Median Five year survival of treatment with curative intent is approximately 45-50%.
The purpose of pre-treatment staging is to identify the depth of infiltration of the tumour into the oesophageal wall (T stage), the presence of regional lymph node metastases (N stage) and distant metastases (M stage). A combination of imaging modalities is used to determine the TNM stage. The TNM Stage can then be used to select appropriate patients for curative or palliative treatment modalities. Metastases is the spread of tumour to sites away from the primary tumour.
• CT (Computer tomography) of the chest/abdomen/pelvis
CT is often the initial staging investigation and takes about 15 minutes to perform. It is useful for detecting metastases in solid organs and distant lymph nodes. Detection is dependent on size of the lesion and there are also limitations in distinguishing metastatic from inflammatory enlargement.
• FDG-PET-CT (18F-fluoro-2-deoxy-D-glucose - Positron Emission Tomography - Computed Tomography)
Cancers preferentially uptake glucose for their metabolism. FDG-PET-CT involves injecting radio-labelled glucose into the bloodstream to highlight foci of cancer in the body. The procedure is very similar to CT but takes longer and you will be asked to starve for 6 hours before hand
• Endoscopic ultrasound (EUS)
This is a similar procedure to the endoscopy, except the probe has an ultrasound device on the end, which enables the doctor to examine the cancer and surrounding tissue in precise detail. It takes longer than an endoscopy and may require more sedation. EUS is the preferred imaging technique for clarification of the T stage and local lymph node involvement. In addition suspicious lymph nodes can be biopsied for histological confirmation.
• Staging laparoscopy
A keyhole examination of the abdomen under general anaesthetic is used for the detection of metastases that cannot be detected with scans. It also allows the surgeon to look at local invasion of the tumour into surrounding organs. The procedure is quick and patients usually go home on the same day.
Gastrectomy is a surgical operation to remove the whole (Total Gastrectomy) or part (Partial Gastrectomy) of the stomach. This is performed in combination with removal of the regional lymph nodes for the purpose of cancer treatment. After removal of part or the whole stomach, the gastrointestinal tract is reconstituted by using the small intestine. This is often termed a Roux-en-Y reconstruction. This a major operation performed under General Anaesthetic and can be undertaken through a classical open approach or using minimally invasive techniques such as laparoscopy or Robotics. Minimal invasive approaches have been shown to reduce pulmonary complications and the overall rate of recovery.
Gastrectomy is a major operation with a significant risk of morbidity. Uncomplicated post-operative hospital stay is approximately 5 to 12 days depending on the type of operation of performed. Potential complications of gastrectomy include: bleeding, infection, anastomotic leak, chyle leak, pulmonary complications, organ impairment, venous thrombo-embolism, dumping syndrome and mortality. Complications will described in more detail by your surgeon and will be addressed promptly if they are to occur in the post-operative period.
To reduce postoperative complications your recovery will be aided by a Prehabilitation Programme and Enhanced Recovery Programme (ERP) designed to speed up your recovery and reduce complications.
After surgery you will be looked after in an intensive care unit for the first 4 to 5 days. You will have several lines for venous and arterial access, an epidural or opioid PCA (patient controlled analgesia) to control your pain, a nasogastric tube, and one or two abdominal drains. These will be removed sequentially over the next few days and your oral liquid and food intake will also be reintroduced. Multiple teams of healthcare professionals will look after you including surgeons, intensivists, nurses, physiotherapists, dieticians, etc, with an aim to re-establish normal function as soon as possible.
Side effects include lethargy during the recovery period, eating problems which may cause weight loss, dumping syndrome which may cause abdominal discomfort and diarrhoea after eating certain foods.
After stomach surgery you may need to take extra calcium, vitamin D and iron. This is because the stomach absorbs these nutrients. You can’t absorb enough from your normal diet without all or most of your stomach. You will no longer be able to take in vitamin B12 from your food without most or all of your stomach. This is because your stomach produces a substance called intrinsic factor that means your body can use vitamin B12. Vitamin B12 helps us maintain a healthy blood supply. You will need vitamin B12 injections every 3 months.
It will take approximately six weeks before achieving good function and three months for full recovery.
For more information:
Cancer Research UK
Macmillan
Gastrointestinal Stromal Tumours
GISTs are rare sarcomas that arise in the gastrointestinal tract, anywhere from the oesophagus to the anus. A sarcoma is tumour that grows from either muscle, nerves, blood vessels or fat. GISTs are thought to arise from the pacemaker nerve cells of the bowel (Interstitial cells of Cajal). The most common sites are the stomach (60%) and the small intestine (25%). Less than 5% of GISTs arise outside of the gastrointestinal tract.
GISTS are found by investigation in approximately 1 in a 100,000 people a year. However, occult GISTs <1cm in size are observed in up to 20% of individuals in autopsy series. GISTs occur mostly in adults between the age of 65-69 and are equally common among the sexes.
The symptoms of GISTs are non-specific and depend on the size and location of the lesion. Small GISTs <2cm in size are usually asymptomatic and found incidentally during investigation for unrelated disease. The most common presenting symptom is gastrointestinal bleeding, which occurs in 50% of patients. Large tumours may also present as an abdominal mass, or with abdominal discomfort, gastrointestinal obstruction or weight loss.
GISTs are a type of cancer but the majority are very indolent and do not spread to other sites in the body. Their behaviour is determined by their genetic subtype. Approximately 10% of patients present with spread to other sites in the body, known as metastases. The most common sites of metastases are the liver, omentum and peritoneum.
GISTs are detected either incidentally in asymptomatic patients, or during the evaluation of the symptomatic patients. They have characteristic appearances across various imaging techniques. Your doctor will advise which tests are appropriate for you.
Endoscopy – To identify the location of the GIST and assess if there is any ulceration which may lead to bleeding.
CT – To characterize the tumour, assess involvement of surrounding organs and presence of metastases.
EUS +/- Biopsy – Useful for characterization and biopsy for confirmation of the diagnosis.
Localised GISTs <2cm in size (microGISTs or miniGISTs) can be surveyed with yearly Endoscopic Ultrasound, with intervention only recommended if there is a significant change in size. The larger the GIST, the more aggressively it is likely to behave and therefore benefiting from treatment.
Surgery is the primary treatment for localised GISTs >2cm that have not spread to other parts of the body. The operation can usually be performed with a minimally invasive approach such as laparoscopy or robotics. The aim of the surgery is to remove the tumour en-block without a breach of the capsule to reduce the risk of its recurrence.
A patient who presents with spread to other sites in the body (metastases) must not be operated on upfront but should receive Tyrosine Kinase Inhibitor (e.g. Imatinib) therapy as initial treatment. Approximately, 80% of GISTs respond to Tyrosine Kinase Inhibitors. Also, large localized tumours and/or those challenging to resect because of the involvement of adjacent organs may require upfront treatment with Tyrosine Kinase Inhibitors prior to surgery.
Decision making for GIST treatment should be subject to a Multi-disciplinary Team review and advise.
Risk assessment in localized GIST aims to identify tumours that are more likely to recur after curative surgery. The assessment is based on the following factors including: tumour size, tumour location, mitotic index (MI) and tumour rupture before or during surgery. If the risk score is high, patients may be offered Tyrosine Kinase Inhibitor therapy to prevent GIST relapse.