The gastrointestinal system includes organs like esophagus, stomach, small intestine, colon, rectum, anal canal, liver, bile ducts, pancreas and spleen. Gastrointestinal cancers are common cancers in our country and incidence varies from one region to another. The incidence of cancers like gallbladder cancer is quite high in North India compared to other countries. However, the incidence of cancers like colorectal, pancreas, esophagus and gastric cancer is lower compared to other parts of the world. The actual burden of these cancers is still significant, due to the enormous population coupled with an unequitable distribution of medical facilities in our country. Surgery plays a pivotal role in the treatment of these cancers. This article will explain the role and principles of surgery for these cancers and who best to approach for their surgical treatment.
How is the treatment of these cancers decided?
Prior to treating these cancers, the patient needs to be evaluated thoroughly to establish the diagnosis and clinical stage. This requires a detailed history and clinical examination and proper investigations, which vary, mainly depending on the organ involved and tumor type.
All cases should preferably be discussed in a multidisciplinary tumor board, which mainly comprises a gastrointestinal and HPB cancer surgeon, radiation oncologist, medical oncologist, radiologist and pathologist.
The treatment broadly depends on the
- Type of the cancer
- Stage of the disease
- Patient’s condition
- Associated medical problems
- Patient’s preference
What is the role of surgery for these cancers?
Surgery is the only treatment option that can potentially cure and therefore plays a pivotal role in the treatment of these cancers. However, not all patients are candidates for surgery. Surgery is the main treatment modality for early and locally advanced cancers and for some metastatic cancers like colorectal, neuroendocrine cancers. However, the majority of patients with unresectable or metastatic cancers and those who are not fit for a surgical procedure are treated with other modalities like chemotherapy, radiotherapy and/or targeted/immunotherapy.
Is surgery alone sufficient for the treatment of these cancers?
Surgery is the main treatment modality in early and locally advanced cancers. Surgery alone is sufficient for the cure of early-stage cancers. However, the majority of these cancers are advanced at presentation. There is robust scientific evidence that supports the combination of surgery with other forms of therapy, like chemotherapy, radiotherapy or their combination, to improve outcomes in locally advanced stages. Depending on the type of cancer, these therapies can be given either before surgery (neoadjuvant) or after surgery (adjuvant) e.g. the majority of locally advanced esophageal, stomach, rectal cancers are treated with neoadjuvant therapy followed by surgery and adjuvant chemotherapy after surgery is recommended for locally advanced colon cancers.
What are the principles of surgery for these cancers?
Surgery for these cancers is based on the tumor type, disease stage, the pattern of spread and tumor extent. Surgery for the majority of locally advanced cancers entails removal of the tumor containing organ with sufficient margins, surrounding lymph nodes and adjacent involved organ(s). The extent of margin and lymph node removal depends on the organ involved and the type of cancer. Properly selected early-stage cancers can be treated using lesser invasive modalities like endoscopic or transrectal resections. The best chance of cure is possible with complete removal, defined as R0 resection.
How safe is surgery for these cancers?
Surgery for these cancers is an invasive modality of treatment and is associated with the risk of mortality and complications. Advancement in anesthesia, critical care, intervention radiology and the advent of minimally invasive techniques like laparoscopic and robotic surgery have all contributed to a substantial improvement in surgical safety. It is also important to emphasize that proper surgical training and expertise in managing these cancers significantly improves outcomes.
Whom to approach for surgical treatment of these cancers?
In today’s day and age, oncology is moving towards organ-based specialization and practice. This has been shown to improve short and long-term outcomes. It is therefore important to consult a surgeon with specialized training and expertise in managing these complex cancers.
Dr. Abhishek Mitra | Senior Consultant – Gastroenterology – Surgical, Gastrointestinal Oncology, Liver Transplant & HPB Surgery, Oncology, Surgical Oncology | Dharamshila Narayana Superspeciality Hospital, New Delhi