GI Cancers or Gastrointestinal Cancers Treatment By Dr Pradeep Jain -Chief of Department of GI at Action Cancer Hospital & Sri Balaji Action Medical Institute. Dr Pradeep Jain is an expert in Advance Laparoscopic GI, GI ONCO & Bariatric Surgery.
GI Cancers are cancers in organs of gastrointestinal tract and related organs like cancers of Esophagus ( food pipe ), stomach, small intestine, large intestine ( colon and rectum ), Liver, Pancreas and Biliary Tract.
Sign and Symptoms of GI Cancers :-
Though there are no specific sign or symptoms which conclusively point towards cancers, there are strong indicators like lump in abdomen, difficulty in swallowing, sever loss of appetite and weight, prolonged bleeding from the GI Tract(Bleeding per rectum in elderly age group), alteration in bowel habits, painless deep jaundice with white colored stools and itching, Intestinal obstruction in elderly, sudden detection of Diabetes with weight loss etc.
Colorectal Cancers Treatment By Dr Pradeep Jain :-
Surgery, Chemotherapy and Radiotherapy are used in the treatment protocol of colon rectum in different sequences depending on stage of disease. out of these Surgery is the primary treatment and curative in early stages. Details @http://www.drpradeepjain.in/
LAPAROSCOPIC GASTRECTOMY FOR CORROSIVE GASTRIC INJURY PERFORMED BY DR PRADEEP JAIN, ACTION CANCER HOSPITAL, DELHI.
Dr Pradeep Jain, the Chief of Department of GI at Action Cancer Hospital & Sri Balaji Action Medical Institute, has the wide spectrum of advanced laparoscopic surgery in GI surgical field. Among his specialties are Advanced Laparoscopic GI, GI Onco, and Bariatric surgery. He has often been able to deliver an accurate diagnosis, even in cases where the real diagnosis eluded other doctors in the same field. He has a strong sense of duty to the field of medicine and aspires to clinical excellence.
LAPAROSCOPIC COLORECTAL SURGERY BY DR PRADEEP JAIN :- GASTROENTEROLOGY AND HEPATOBILIARY SURGERY EXPERT
Laparoscopic hemicolectomy, anterior resection, APR done for cancers of rectum and colon in which the cancer bearing segment along with the draining Lymph nodes are removed en bloc.TheLaparoscopic Treatment By Dr Pradeep Jain for these cancers are almost on the verge of becoming Gold standard. if done by trained and expert. The oncological outcome is same as in open surgery and short term results are better. complications are lower than open surgery. Laparoscopic surgery for inflammatory bowel disease like Ulcerative colitis, Colonic tuberculosis, or for rectal prolapsed ( rectopexy ) are other indications.
LAPAROSCOPIC ESOPHAGECTOMY SURGERY BY DR PRADEEP JAIN
Thoraco / laparoscopic Esophagectomy is indicated in cancer of Esophagus or GE Junction. The complete esophagus with surrounding tissues and draining lymph nods are removed. It has definite lesser morbidity than open Thoracotomies and Laparotomies. Oncological superiorities are yet get established. Other benign conditions like Benign tumors or Diverticuli have excellent results.
LAPAROSCOPIC UPPER GASTROINTESTINAL SURGERY BY DR PRADEEP JAIN :
Gastroenterology and Hepatobiliary Surgery Expert Laparoscopic surgery for Hiatus Hernia and Achalasia Cardia are Gold standard in fundopication the diaphragmatic hiatus ( opening in the diaphragm ) is tightened and artificial valve is created by wraping the fundus of stomach around the lower part of esophagus ( food pipe ) Radical Gastrectomy for Cancer of stomach and other tumors like GIST, Leiomyomas, Lymphomas or other benign disorders are very much feasible with good outcome and low morbidity. The same kind of radicality is achieved by laparoscopy.
LAPAROSCOPIC PANCREATIC SURGERY BY DR PRADEEP JAIN :
In laparoscopic whippels surgery en bloc resection of head and neck of pancreas, gall bladder, Common bile duct, duodenum and proximal small intestine are removed en bloc along with lymph nodes. This is done for pancreatic, bile duct or duodenal cancers. Laparoscopic distal pancreatectomy is done for cancers of body and tail of pancreas, chronic pancreatitis or pancreatic cysts and pseudocysts. Laparoscopic pancreatic necrosectomy in infected pancreatic necrosis is feasible in selected patients either by transperitoneal or retroperitoneal approach.
Gastroenterology and Hepatobiliary Surgery Expert Liver surgery needs large incisions with significant morbidities. Laparoscopic liver resection are feasible but demanding and involve technical expertise. Laparoscopic liver surgery can be ranging from staging procedures to non anatomical resections to large anatomical resections. These are done for Primary liver tumors,cysts,hemangiomas,secondary tumors etc.
LAPAROSCOPIC SMALL BOWEL SURGERIES :
Common laparoscopic surgeries for small intestine are for perforations, small bowel inflammatory diseases like tuberculosis and crohn’s disease, small intestine tumors like lymphoma, adenocarcinoma, GIST, intestinal obstruction etc.
LAPAROSCOPIC RETROPERITONEAL SURGERIES :
Retroperitoneal tumors like soft tissue sarcomas, paraganliomas and adrenal tumors can excised with help of laparoscope with minimal morbidity.
Dr Pradeep Jain is currently appointed the Chief of Department GI, GI
Onco, Bariatric & MinimalAccessSurgery, at Action Cancer Hospital
& Sri Balaji Action Medical Institute .
Patient and Port position: Patient placed in modified Lloyd Davies position.
Pneumoperitoneum
created by veress needle through 10 mm Supraumbilical skin incision
which is later on converted into 10mm camera port. 10mm RIF port, 5mm
right and left lumbar ports, 12mm supraumbilical ports made.
STEPS: Initial
step is to visualize all quadrants of peritoneal cavity, liver
surfaces, pelvis for metastasis, lymphadenopathy and ascites.
The
left side of the patient is raised up to allow the small bowel to fall
out of the pelvis. The apex of sigmoid is held up and to left. The
sacral promontory is identified and the peritoneum over is incised on
the medial aspect of the mesosigmoid. A window is made in the mesocolon
over the IMA. IMA & IMV dissected, ligated and divided at just
distal to their origin the left ureter and gonadal vessels are
identified and carefully preserved during this part of dissection.
Descending colon mobilized from medial to lateral. The descending colon,
splenic flexure and the distal transverse colon are completely
mobilized at the end of this phase. This helps to obtain adequate length
of proximal colonic segment for tension free anastomosis. Rectum
dissected from surrounding structures in anatomical planes upto pelvic
floor. Course of ureter traced. Rectal division done by Endo GIA
staplers (green) just above ano rectal junction. Rectal mass along with
left colon delivered outside through 5cm transverse suprapubic
laparotomy. Specimen removed by dividing left colon. Anvil attached to
distal end of left colon and returned into peritoneal cavity. No. 29 CDH
stapler passed per anus and stapled anastomosis done. Loop ileostomy
created 20cm proximal to IC junction at RIF.
Laparoscopic Gastrectomy for Corrosive Gastric Injury performed By Dr Pradeep Jain, Action Cancer Hospital, Delhi.
Dr Pradeep Jain, the Chief of Department of GI at Action Cancer Hospital & Sri Balaji Action Medical Institute, has the wide spectrum of advanced laparoscopic surgery in GI surgical field. Among his specialties are Advanced Laparoscopic GI, GI Onco, and Bariatric surgery. He has often been able to deliver an accurate diagnosis, even in cases where the real diagnosis eluded other doctors in the same field. He has a strong sense of duty to the field of medicine and aspires to clinical excellence.
Laparoscopic Colorectal Surgery By Dr Pradeep Jain :- Gastroenterology and Hepatobiliary Surgery Expert
Laparoscopic hemicolectomy, anterior resection, APR done for cancers of rectum and colon in which the cancer bearing segment along with the draining Lymph nodes are removed en bloc.The laparoscopic treatment for these cancers are almost on the verge of becoming Gold standard. if done by trained and expert. The oncological outcome is same as in open surgery and short term results are better. complications are lower than open surgery. Laparoscopic surgery for inflammatory bowel disease like Ulcerative colitis, Colonic tuberculosis, or for rectal prolapsed ( rectopexy ) are other indications.
Thoraco / laparoscopic Esophagectomy is indicated in cancer of Esophagus or GE Junction. The complete esophagus with surrounding tissues and draining lymph nods are removed. It has definite lesser morbidity than open Thoracotomies and Laparotomies. Oncological superiorities are yet get established. Other benign conditions like Benign tumors or Diverticuli have excellent results.
Laparoscopic Upper Gastrointestinal Surgery By Dr Pradeep Jain :
Gastroenterology and Hepatobiliary Surgery Expert Laparoscopic surgery for Hiatus Hernia and Achalasia Cardia are Gold standard in fundopication the diaphragmatic hiatus ( opening in the diaphragm ) is tightened and artificial valve is created by wraping the fundus of stomach around the lower part of esophagus ( food pipe )
Radical Gastrectomy for Cancer of stomach and other tumors like GIST, Leiomyomas, Lymphomas or other benign disorders are very much feasible with good outcome and low morbidity. The same kind of radicality is achieved by laparoscopy.
Laparoscopic Pancreatic Surgery By Dr Pradeep Jain :
In laparoscopic whippels surgery en bloc resection of head and neck of pancreas, gall bladder, Common bile duct, duodenum and proximal small intestine are removed en bloc along with lymph nodes. This is done for pancreatic, bile duct or duodenal cancers.
Laparoscopic distal pancreatectomy is done for cancers of body and tail of pancreas, chronic pancreatitis or pancreatic cysts and pseudocysts. Laparoscopic pancreatic necrosectomy in infected pancreatic necrosis is feasible in selected patients either by transperitoneal or retroperitoneal approach.
Gastroenterology and Hepatobiliary Surgery Expert Liver surgery needs large incisions with significant morbidities. Laparoscopic liver resection are feasible but demanding and involve technical expertise. Laparoscopic liver surgery can be ranging from staging procedures to non anatomical resections to large anatomical resections. These are done for Primary liver tumors,cysts,hemangiomas,secondary tumors etc.
Laparoscopic small bowel surgeries :
Common laparoscopic surgeries for small intestine are for perforations, small bowel inflammatory diseases like tuberculosis and crohn's disease, small intestine tumors like lymphoma, adenocarcinoma, GIST, intestinal obstruction etc.
Laparoscopic retroperitoneal surgeries :
Retroperitoneal tumors like soft tissue sarcomas, paraganliomas and adrenal tumors can excised with help of laparoscope with minimal morbidity
Dr Pradeep Jain — Laparoscopic surgery is a form of minimal access surgery, which involves making a very small incision on the body of the patient and using a thin and lighted tube to pass through this incision, in order to perform the procedure. The most common problem where this procedure is used is for abdominal disorders like gall bladder stones and gynecological troubles in women such as fibroids and cysts in female reproductive organs. Laparoscopy surgery has become a feasible alternative to open surgeries as well as laparotomy surgeries, which involve larger incisions in the abdominal areas. The treason for popularity of laparoscopy is that it is less complicated and expensive as compared to conventional surgery as there is no hospitalization required in such cases and wherever required, the length of hospital stay is very short. Additionally, the surgery is less painful and complicated and the recovery time is much shorter than conventional techniques.
Preparation of Laparoscopic Surgery
Though laparoscopic surgery is a simple and easy procedure, still some preparation is needed for making it a success. Here are some tips to prepare yourselves for a laparoscopic surgery in india:
1. Being armed with proper knowledge and information about the procedure is the first step for being prepared for it. The patient has full right to ask all kinds of questions from his surgeon, as well as clarify his doubts before the surgery is performed. Proper understanding will remove his phobia and make him more comfortable about the surgery as well as confident about the doctor who is going to perform it.
2. They should also inform the surgeon about all the medical conditions he is undergoing such as diabetes and hypertension. The surgeon also needs to be informed about the medication he is taking regularly, such as aspirin, which may hamper the blood clotting process after the surgery. This will enable the doctor to tackle any complications which may surface during the surgery.
3. The patient must not eat or drink anything at least eight hours before the surgery, as in case of other types of surgeries. The operation is done under anesthesia and the patient must also discuss the possibility of drug allergies with the anesthesiologist.
4. Another thing which the patient needs to take care of on the day of the surgery is not to wear any valuable jewelry as it has to be taken off during the process. Also, he needs to take off stuff like dentures, contact lenses and glasses during the procedure.
5. Finally, the patient must take into consideration that fact that laparoscopic surgeries are mostly done on outpatient basis and he is most likely to be discharged on the same day. Since the patient might not feel strong enough after the surgery, he must arrange for a friend or family member to drive him home after the procedure is completed.
In a nutshell, laparoscopic surgery is a much simpler process for the patient as it offers very speedy recovery. But being well prepared can make things even easier for the patient.
Dr. Pradeep Jain has wide experience of GI, GI Once and Minimal Invasive Surgery.
The esophagus is a muscular tube also known as food pipe in general public transmits food material from mouth (base of pharynx) to the stomach. Carcinoma of esophagus is one of the deadliest malignancies of human body. The incidence of this malignancy is increasing in general population due to life style modification as well as changes in environment.
Carcinoma of esophagus is divided into two types -
1. Squamous cell carcinoma - Cancer that forms in tissues lining the esophagus. Mostly found in upper and middle 1/3rd of esophagus. Incidence increases with age with most common age group between 55-60 years with male preponderance.
2. Adenocarcinoma - cancer that begins in esophageal lining cell that secret mucus. Most commonly found in lower esophagus and at the meeting point of esophagus and stomach. Commonly presented in patients with age group 50 years or younger.
Risk factors for Esophageal malignancy -
1. Smoking and alcohol - smoking for a long duration and chronic alcohol consumption
2. Esophageal inner mucosal lining damage from physical agents -
long term ingestion of hot liquids
caustic ingestion (corrosive poisoning)
radiation induced damage
3. Carcinogens in food and water - nitrates, nitrite, nitrosamine, smoked opiates, fungal toxins in pickled 4. Obesity - increased risk for adenocarcinoma of esophagus. Incidence of gastroesophageal reflux increased in obesity due to lax lower esophageal junction to stomach which leads to Barrett's esophagus. If condition is not reverted with time Barrett's esophagus turns into malignancy. 5. Chronic iron deficiency anemia in females leading to plummer Vinson Syndrome 6. Congenital hyperkeratosis of palms and sole 7. Helicobactor pylori infection 8. Achalasia Cardia - long standing 9. Dietary deficiencies of molybdenum, Zinc, Vitamin A
Symptoms of esophageal malignancy
1. Dysphagia - Dysphagia is the most common presentation. Patient may have difficulty in swallowing of solid food in early stage of disease and solid as well as liquid food in the late stage of disease. 2. Weight loss - recent onset and significant. 3. Coughing and choking during meal. 4. Change in voice - hoarseness. 5. Weakness and easy fatigability. 6. Pain behind sternum - occasional 7. Heart burn and reflux 8. Malena and sometimes haematemesis.
Diagnosis of esophageal malignancy
The patient is evaluated on the basis of history, symptoms and clinical signs. Along with routine blood test and X-ray some endoscopic and radiological investigations are done which include -
1. Barium sallow x- ray - thin barium is allowed to shallow and x-ray of esophagus taken. This shows the site and outline of tumor.
2. Endoscopy - the endoscope is passed through mouth to esophagus to see the inner lining of esophagus and tumor. If it shows any abnormal growth then a small piece of tissue from the growth is taken for confirmation of the diagnosis. These tissues are examined under a microscope for the presence of cancer.
3. Bronchoscopy - in cases of advanced tumor arising from upper ½ of esophageal an endoscope is passed into trachea (wind pipe) to rule out local spread of the tumor to lungs
4. Endoscopic Ultrasound - for early tumor endoscopic ultrasound is passed in esophagus to find out local spread of tumor.
5. For tumor staging radiological investigation like computed tomography (CT) scans of chest and abdomen and positron emission tomography (PET) scan are performed to determine outer spread of esophageal tumor to surrounding vital organs and distant spread to other organs.
6. Thoracoscopy and Laparoscopy - By this methods detection rate of lymphnodal and distal spread of esophageal malignancy is high.
Staging of esophageal tumors
Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.
According to AJCC Cancer Staging Manual, Seventh Edition (2010) cancer growth and spread can be staged by TNM system
Tumor (T) - means how deep the tumor has grown into the wall of the esophagus
Node (N) - tumor spread to lymph nodes
Metastasis (M) - metastasis (distal spread) to other part of the body
Based on combined results of T, N and M staging of cancer determined.
Tumor (T) is classified into TX: tumor cannot be evaluated T0: cancer is not detected in the esophagus Tis: this is also called carcinoma in situ that means very early cancer T1: tumor spread to the lamina propria and submucosal layers of esophagus T2: tumor spread to muscular is propria T3: tumor spread to the adventitia, the outer layer of the esophagus T4: tumor has spread to surrounding structures of the esophagus, including the aorta, pericardium, large blood vessel, trachea, diaphragm, and pleural lining of the lung
Node (N) : N stands for Lymph nodes. Lymph nodes close to esophagus is called regional lymph nodes and those located in other part of body are distant lymph nodes. NX: lymph nodes cannot be evaluated N0: cancer cells not detected in lymph nodes N1: cancer cells has spread to 1-2 lymph nodes in the chest, near the tumor N2: cancer cells has spread to 3-6 lymph nodes in the chest, near the tumor N3: cancer cells has spread to 7 or more lymph nodes in the chest, near the tumor
Distant metastasis (M):
this indicates whether the cancer cells has spread to other parts of the body MX: Metastasis cannot be evaluated M0: cancer cells has not spread to other parts of the body M1: cancer cells has spread to another part of the body
Grading of esophageal tumor
G1: well differentiated G2: mildly differentiated G3: poorly differentiated G4: not differentiated
Esophageal Cancer stageing
There are separate staging systems for both squamous cell carcinoma and adenocarcinoma of esophagus.
Staging of squamous cell carcinoma of the esophagus
Stage IIIC: T4a, N1 or N2, M0 T4b, any N, M0 any T, N3, M0
Stage IV : any T, any N, M1
Treatment of Esophageal cancer
Patients with esophageal cancer are managed based on its staging. Overall general condition of the patients affects management.
Stage I -
Tis and T1aN0 stage - Endoscopic therapy like mucosal resection or submucosal dissection with the help of endoscopic ultrasound (EUS),
Photodynamic therapy, Radiofrequency ablation T1b N0 & T2 N0 stage - Surgery (esophagectomy) to remove the part of esophagus that contains the cancer
Stages II-III -
Chemoradiation followed by surgery (trimodal therapy) Patient with squamous cell carcinoma with well preserved general condition chemotherapy and radiotherapy started before definitive surgery. Patients with adenocarcinoma of lower end esophagus where stomach meet (gastroesophageal junction) are only chemotherapy is given before surgery. For smaller tumor (< 2 cm) only surgery is advised. Patients with serious co-morbidities who are not candidate for surgery are managed with chemoradiation.
Stage IV -
Chemotherapy/ Radiotherapy or symptomatic and supportive care Treatment is given only for palliation to relieve the symptoms like pain, difficulties in swallowing etc.
Esophageal stenting (plastic/metallic) is done in situations where the patient is totally dysphagic and having esophagobroncheal fistula. Patient who are unable to tolerate oral feeds a nasogastric tube may be required to continue feeding. Some times gastrostomy/jejunostomy tube is required where patients become intolerant to nasogastric tube or tend to aspirate food. Laser therapy is done in cases in which esophagus is totally occluded by cancer and the cancer cannot be removed by surgery. The relief of a blockage by laser can help to reduce dysphagia and pain
Chemotherapy:
Chemotherapy may be given after surgery (adjuvant) to reduce risk of recurrence or before surgery (neoadjuvant) to down stage the disease. Chemotherapy is cisplatin-based (or carboplatin or oxaliplatin) every three weeks with fluorouracil (5-FU) either continuously or every three weeks. Recently epirubicin regimens is used in advanced nonresectable cancer. Patients with adenocarcinoma with HER2 positive treated with targeted targeted therapy like trastuzumab.
Radiotherapy :
Radiotherapy is given before, during or after chemotherapy or surgery. It is also used in palliation to control pain.
Surgery is contraindications in following situation :
1. Locally advanced cancer engulfing adjacent vital structures like trachea, lung, pericardium, aorta recurrent laryngeal nerve 2. Esophageal Cancer with wide dissemination ( metastasis) to distant lymph nodes and vital organs 3. Severe co-morbidity involving cardiovascular and respiratory system
Surgical options :
Surgery is performed by either open or minimal invasive method depending upon patient's general condition and availability of experts. Now a days minimal invasive approach of esophagectomy has become very popular among surgeons because of low surgical morbidity, short hospital stay and similar onchological outcomes.
Types of esophagectomy-
1. Transhiatal esophagectomy (THE) 2. Transthoracic esophagectomy (TTE) - thoraco abdominal Mc Keown's & Ivor Lewis esophagectomy
In thoracoabdominal approach - both the abdominal and thoracic cavities opened together.
Ivor Lewis esophagectomy - two-stage approach involves an initial laparotomy and construction of a gastric tube, followed by a right thoracotomy to excise the tumor and create an esophagogastric anastomosis
McKeown esophagectomy - three-stage approach which include incision in the neck to complete the cervical anastomosis. Details @ http://www.dr-pradeep-jain.in/
