Upper Gastrointestinal Cancer and the Surgical Method

A poor diet, an unhealthy environment and the vagaries of heredity lead to a wealth of diseases, and the upper gastrointestinal tract is a prime target for these disorders. Ulcers develop in the esophagus, stomach or duodenum, occasionally turning into malignant tumors of the stomach or esophagus. Promoting regular patient esophagogastroduodenoscopies (EGDs) helps identify upper gastrointestinal problems early so that treatment can begin as soon as possible. Since the treatment of choice for upper gastrointestinal cancers is surgery, the EGD will be the first step in aggressively targeting malignancy.

During EGDs, additional procedures can be performed through the endoscope in place for diagnostic purposes. Polyps or tumors can be removed using a thin wire snare and electrocautery, and bleeding sites can be treated at once. However, once the pancreas, esophagus or stomach is identified to be in a cancerous stage, surgical intervention is a necessity.

Upper GI Cancers - General

The vast majority of cancers that arise in the GI tract come from adenocarcinomas that line the intestines, bile duct or pancreatic duct. These adenocarcinomas are difficult tumors to treat because they present at a later stage than more visible tumors and because of their aggressive nature.

Adenocarcinomas can cause substantial local problems for patients, such as blocking the GI tract, and surgical removal has traditionally been the only curative method. Surgery can also be used for palliative care in such cases.

Pancreatic Cancer

Approximately 28,000 Americans are diagnosed annually with pancreatic cancer, which is the fourth-leading cause of cancer deaths in this country. Most cases of pancreatic cancer occur between ages 65 and 79, and though its causes are unknown, links to smoking, pancreatitis and diabetes have been established.

Pancreatic cancer refers to several distinct cancers of the gland, although most begin in the ducts that carry pancreatic fluids to the small intestine. A rare type begins in the islet cells that produce insulin and other hormones. Islet cell cancers are usually small and well-circumscribed and rarely extend beyond the pancreas. Surgical resection followed by chemotherapy is the standard treatment regimen for islet cell carcinoma.

Surgical resection is performed for other types of pancreatic cancer, as long as the disease is localized. Diagnostic laparoscopy can identify patients who are candidates for curative surgical resection. The most common procedure is a pancreatoduodenectomy, which can be accomplished with some success if the disease has not spread beyond the pancreas. Pancreatoduodenectomy removes the right-most section of the pancreas as well as the gallbladder, part of the stomach, the lower half of the bile duct and part of the small intestine. The cut surfaces of the stomach, bile duct and remaining pancreas are joined to the small intestine, and the patient usually can continue to produce adequate amounts of insulin and digestive enzymes.

Surgery for pancreatic cancer can be very effective, with low risk of complications, and it is the standard treatment for tumors that can be removed, even in older patients. Research shows that pancreatic surgery can be performed in elderly patients with good outcomes comparable to those of younger patients.

When obstruction of bile ducts or the bowel is present and the cure is not within reach, surgical or endoscopic procedures may be done to at least relieve the obstruction.

Esophageal Cancer

Esophageal cancer can be treated by surgery alone or in combination with chemotherapy and radiation therapy, although surgery alone can be curative if the cancer has not metastasized.

For patients with early-stage, non-metastasizing esophageal cancer, an esophagectomy removes the affected parts of the esophagus and the nearby lymph nodes. The remaining esophagus is reconnected to the stomach to preserve the ability to swallow. For patients with Barrett's disease with in-situ cancer, this can be accomplished without the need for thoracotomy.
 

An esophagogastrectomy includes removal of part of the esophagus along with nearby lymph nodes and part of the stomach, and the remaining esophagus is reattached to the remaining stomach so food can continue to pass from the throat to the stomach. If necessary, part of the colon is used to connect the esophagus to the stomach. In both procedures, the lymph nodes that are removed are examined for cancer cells to assess metastasis.

Stomach Cancer

Stomach cancer is less common in the United States than many other forms of cancer, yet some 21,900 Americans are diagnosed with stomach cancer each year. About 13,500 die of the disease.

Factors that increase the risk of stomach cancer include infection with the Helicobacter pylori bacterium, which can lead to chronic inflammation of the inner layer of the stomach and possibly precancerous changes. A diet high in smoked and salted foods increases risk, while a diet high in fruits and vegetables decreases risk. Smoking, alcohol abuse, previous stomach surgery, pernicious anemia, family history of stomach cancer and stomach polyps indicate increased risk.

Surgery for stomach cancer can be performed safely. A subtotal gastrectomy involves removal of the portion of the stomach containing the cancer as well as any tissues or organs nearby that have been affected. Total gastrectomy indicates removal of the entire stomach and parts of the esophagus, small intestine and other tissue near the tumor; in this case, the esophagus may be connected to the small intestine so that the patient can continue to eat and swallow.

Removal of nearby lymph nodes and the spleen can also be removed to check metastasis.

Dr. William G. Cloud is a board-certified surgeon who has significant experience in treating cancer and performing laparoscopic, abdominal and gastrointestinal surgeries. For additional information, please call Dr. Cloud at 828.437.0847.