Colon and Rectal Cancer

Cancer affects our cells, the body's basic unit of life. To understand cancer, it is helpful to know what happens when normal cells become cancerous.

The body is made up of many types of cells. Normally, cells grow, divide, and produce more cells as they are needed to keep the body healthy and functioning properly. Sometimes, however, the process goes astray -- cells keep dividing when new cells are not needed. The mass of extra cells forms a growth or tumor. Tumors can be either benign or malignant.

� Benign tumors are not cancer. They often can be removed and, in most cases, they do not come back. Cells in benign tumors do not spread to other parts of the body. Most important, benign tumors are rarely a threat to life.

� Malignant tumors are cancer. Cells in malignant tumors are abnormal and divide without control or order. These cancer cells can invade and destroy the tissue around them. Cancer cells can also break away from a malignant tumor. They may enter the bloodstream or lymphatic system (the tissues and organs that produce and store cells that fight infection and disease). This process, called metastasis, is how cancer spreads from the original (primary) tumor to form new (secondary) tumors in other parts of the body.

The Colon and Rectum

The colon and rectum are parts of the body's digestive system, which removes nutrients from food and stores waste until it passes out of the body. Together, the colon and rectum form a long, muscular tube called the large intestine (also called the large bowel). The colon is the first 6 feet of the large intestine, and the rectum is the last 8 to 10 inches.

Understanding Colorectal Cancer

Cancer that begins in the colon is called colon cancer, and cancer that begins in the rectum is called rectal cancer. Cancers affecting either of these organs may also be called colorectal cancer.

Colorectal Cancer: Who's at Risk?

The exact causes of colorectal cancer are not known. However, studies show that the following risk factors increase a person's chances of developing colorectal cancer:

� Age. Colorectal cancer is more likely to occur as people get older. This disease is more common in people over the age of 50. However, colorectal cancer can occur at younger ages, even, in rare cases, in the teens.

� Diet. Colorectal cancer seems to be associated with diets that are high in fat and calories and low in fiber. Researchers are exploring how these and other dietary factors play a role in the development of colorectal cancer.

� Polyps. Polyps are benign growths on the inner wall of the colon and rectum. They are fairly common in people over age 50. Some types of polyps increase a person's risk of developing colorectal cancer.

A rare, inherited condition, called familial polyposis, causes hundreds of polyps to form in the colon and rectum. Unless this condition is treated, familial polyposis is almost certain to lead to colorectal cancer.

� Personal medical history. Research shows that women with a history of cancer of the ovary, uterus, or breast have a somewhat increased chance of developing colorectal cancer. Also, a person who has already had colorectal cancer may develop this disease a second time.

� Family medical history. First-degree relatives (parents, siblings, children) of a person who has had colorectal cancer are somewhat more likely to develop this type of cancer themselves, especially if the relative had the cancer at a young age. If many family members have had colorectal cancer, the chances increase even more.

� Ulcerative colitis. Ulcerative colitis is a condition in which the lining of the colon becomes inflamed. Having this condition increases a person's chance of developing colorectal cancer.

Risk Factors Associated with Colorectal Cancer

� Age

� Diet

� Polyps

� Personal History

� Family History

� Ulcerative Colitis

Having one or more of these risk factors does not guarantee that a person will develop colorectal cancer. It just increases the chances. People may want to talk with a doctor about these risk factors. The doctor may be able to suggest ways to reduce the chance of developing colorectal cancer and can plan an appropriate schedule for checkups.

Colorectal Cancer: Reducing the Risk

The National Cancer Institute supports and conducts research on the causes and prevention of colorectal cancer. Research shows that colorectal cancer develops gradually from benign polyps. Early detection and removal of polyps may help to prevent colorectal cancer. Studies are looking at smoking cessation, use of dietary supplements, use of aspirin or similar medicines, decreased alcohol consumption, and increased physical activity to see if these approaches can prevent colorectal cancer. Some studies suggest that a diet low in fat and calories and high in fiber can help prevent colorectal cancer.

Researchers have discovered that changes in certain genes (basic units of heredity) raise the risk of colorectal cancer. Individuals in families with several cases of colorectal cancer may find it helpful to talk with a genetic counselor. The genetic counselor can discuss the availability of a special blood test to check for a genetic change that may increase the chance of developing colorectal cancer. Although having such a genetic change does not mean that a person is sure to develop colorectal cancer, those who have the change may want to talk with their doctor about what can be done to prevent the disease or detect it early.

Detecting Cancer Early

People who have any of the risk factors described under "Colorectal Cancer: Who's at Risk?" should ask a doctor when to begin checking for colorectal cancer, what tests to have, and how often to have them. The doctor may suggest one or more of the tests listed below. These tests are used to detect polyps, cancer, or other abnormalities, even when a person does not have symptoms. Your health care provider can explain more about each test.

� A fecal occult blood test (FOBT) is a test used to check for hidden blood in the stool. Sometimes cancers or polyps can bleed, and FOBT is used to detect small amounts of bleeding.

� A sigmoidoscopy is an examination of the rectum and lower colon (sigmoid colon) using a lighted instrument called a sigmoidoscope.

� A colonoscopy is an examination of the rectum and entire colon using a lighted instrument called a colonoscope.

� A double contrast barium enema (DCBE) is a series of x-rays of the colon and rectum. The patient is given an enema with a solution that contains barium, which outlines the colon and rectum on the x-rays.

� A digital rectal exam (DRE) is an exam in which the doctor inserts a lubricated, gloved finger into the rectum to feel for abnormal areas.

Recognizing Symptoms

� A change in bowel habits

� Diarrhea, constipation, or feeling that the bowel does not empty completely

� Blood (either bright red or very dark) in the stool

� Stools that are narrower than usual

� General abdominal discomfort (frequent gas pains, bloating, fullness, and/or cramps)

� Weight loss with no known reason

� Constant tiredness

� Vomiting

These symptoms may be caused by colorectal cancer or by other conditions. It is important to check with a doctor.

Diagnosing Colorectal Cancer

To help find the cause of symptoms, the doctor evaluates a person's medical history. The doctor also performs a physical exam and may order one or more diagnostic tests.

� X-rays of the large intestine, such as the DCBE, can reveal polyps or other changes.

� A sigmoidoscopy lets the doctor see inside the rectum and the lower colon and remove polyps or other abnormal tissue for examination under a microscope.

� A colonoscopy lets the doctor see inside the rectum and the entire colon and remove polyps or other abnormal tissue for examination under a microscope.

� A polypectomy is the removal of a polyp during a sigmoidoscopy or colonoscopy.

� A biopsy is the removal of a tissue sample for examination under a microscope by a pathologist to make a diagnosis.

Stages of Colorectal Cancer

If the diagnosis is cancer, the doctor needs to learn the stage (or extent) of disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, to what parts of the body. More tests may be performed to help determine the stage. Knowing the stage of the disease helps the doctor plan treatment. Listed below are descriptions of the various stages of colorectal cancer.

� Stage 0. The cancer is very early. It is found only in the innermost lining of the colon or rectum.

� Stage I. The cancer involves more of the inner wall of the colon or rectum.

� Stage II. The cancer has spread outside the colon or rectum to nearby tissue, but not to the lymph nodes. (Lymph nodes are small, bean-shaped structures that are part of the body's immune system.)

� Stage III. The cancer has spread to nearby lymph nodes, but not to other parts of the body.

� Stage IV. The cancer has spread to other parts of the body. Colorectal cancer tends to spread to the liver and/or lungs.

� Recurrent. Recurrent cancer means the cancer has come back after treatment. The disease may recur in the colon or rectum or in another part of the body.

Treatment for Colorectal Cancer

Treatment depends mainly on the size, location, and extent of the tumor, and on the patient's general health. Patients are often treated by a team of specialists, which may include a gastroenterologist, surgeon, medical oncologist, and radiation oncologist. Several different types of treatment are used to treat colorectal cancer. Sometimes different treatments are combined.

� Surgery to remove the tumor is the most common treatment for colorectal cancer. Generally, the surgeon removes the tumor along with part of the healthy colon or rectum and nearby lymph nodes. In most cases, the doctor is able to reconnect the healthy portions of the colon or rectum. When the surgeon cannot reconnect the healthy portions, a temporary or permanent colostomy is necessary. Colostomy, a surgical opening (stoma) through the wall of the abdomen into the colon, provides a new path for waste material to leave the body. After a colostomy, the patient wears a special bag to collect body waste. Some patients need a temporary colostomy to allow the lower colon or rectum to heal after surgery. About 15 percent of colorectal cancer patients require a permanent colostomy.

� Chemotherapy is the use of anticancer drugs to kill cancer cells. Chemotherapy may be given to destroy any cancerous cells that may remain in the body after surgery, to control tumor growth, or to relieve symptoms of the disease. Chemotherapy is a systemic therapy, meaning that the drugs enter the bloodstream and travel through the body. Most anticancer drugs are given by injection directly into a vein (IV) or by means of a catheter, a thin tube that is placed into a large vein and remains there as long as it is needed. Some anticancer drugs are given in the form of a pill.

� Radiation therapy, also called radiotherapy, involves the use of high-energy x-rays to kill cancer cells. Radiation therapy is a local therapy, meaning that it affects the cancer cells only in the treated area. Most often it is used in patients whose cancer is in the rectum. Doctors may use radiation therapy before surgery (to shrink a tumor so that it is easier to remove) or after surgery (to destroy any cancer cells that remain in the treated area). Radiation therapy is also used to relieve symptoms. The radiation may come from a machine (external radiation) or from an implant (a small container of radioactive material) placed directly into or near the tumor (internal radiation). Some patients have both kinds of radiation therapy.

� Biological therapy, also called immunotherapy, uses the body's immune system to fight cancer. The immune system finds cancer cells in the body and works to destroy them. Biological therapies are used to repair, stimulate, or enhance the immune system's natural anticancer function. Biological therapy may be given after surgery, either alone or in combination with chemotherapy or radiation treatment. Most biological treatments are given by injection into a vein (IV).

� Clinical trials (research studies) to evaluate new ways to treat cancer are an appropriate option for many patients with colorectal cancer. In some studies, all patients receive the new treatment. In others, doctors compare different therapies by giving the promising new treatment to one group of patients and the usual (standard) therapy to another group.


Research has led to many advances in the treatment of colorectal cancer. Through research, doctors explore new ways to treat cancer that may be more effective than the standard therapy. The NCI publication Taking Part in Clinical Trials: What Cancer Patients Need To Know provides information about how these studies work. PDQ(r), NCI's cancer information database, contains detailed information about ongoing studies for colorectal cancer. NCI's Web site includes a section on clinical trials at http://cancer.gov/clinical_trials. This section provides both general information about clinical trials and detailed information about specific ongoing studies for colorectal cancer.

The NCI's Cancer.gov(tm) Web site provides information from numerous NCI sources, including PDQ(r), NCI's cancer information database. PDQ contains current information on cancer prevention, screening, diagnosis, treatment, genetics, supportive care, and ongoing clinical trials. Cancer.gov can be accessed at http://www.cancer.gov on the Internet.

Side Effects of Treatment

The side effects of cancer treatment depend on the type of treatment and may be different for each person. Most often the side effects are temporary. Doctors and nurses can explain the possible side effects of treatment. Patients should report severe side effects to their doctor. Doctors can suggest ways to help relieve symptoms that may occur during and after treatment.

� Surgery causes short-term pain and tenderness in the area of the operation. Surgery for colorectal cancer may also cause temporary constipation or diarrhea. Patients who have a colostomy may have irritation of the skin around the stoma. The doctor, nurse, or enterostomal therapist can teach the patient how to clean the area and prevent irritation and infection.

� Chemotherapy affects normal as well as cancer cells. Side effects depend largely on the specific drugs and the dose (amount of drug given). Common side effects of chemotherapy include nausea and vomiting, hair loss, mouth sores, diarrhea, and fatigue. Less often, serious side effects may occur, such as infection or bleeding.

� Radiation therapy, like chemotherapy, affects normal as well as cancer cells. Side effects of radiation therapy depend mainly on the treatment dose and the part of the body that is treated. Common side effects of radiation therapy are fatigue, skin changes at the site where the treatment is given, loss of appetite, nausea, and diarrhea. Sometimes, radiation therapy can cause bleeding through the rectum (bloody stools).

� Biological therapy may cause side effects that vary with the specific type of treatment. Often, treatments cause flu-like symptoms, such as chills, fever, weakness, and nausea.

Several useful NCI booklets, including Chemotherapy and You, Radiation Therapy and You, and Eating Hints for Cancer Patients, suggest ways for patients to cope with their side effects during cancer treatment.
The health care team can explain the possible side effects of treatment. Patients should report severe side effects. Doctors and nurses can suggest ways to help relieve symptoms that may occur during and after treatment.

The Importance of Followup Care

Followup care after treatment for colorectal cancer is important. Regular checkups ensure that changes in health are noticed. If the cancer returns or a new cancer develops, it can be treated as soon as possible. Checkups may include a physical exam, a fecal occult blood test, a colonoscopy, chest x-rays, and lab tests. Between scheduled checkups, a person who has had colorectal cancer should report any health problems to the doctor as soon as they appear.

Providing Emotional Support

Living with a serious disease, such as cancer, is challenging. Apart from having to cope with the physical and medical challenges, people with cancer face many worries, feelings, and concerns that can make life difficult. Some people find they need help coping with the emotional as well as the practical aspects of their disease. In fact, attention to the emotional burden of having cancer is often a part of a patient's treatment plan. The support of the health care team (doctors, nurses, social workers, and others), support groups, and patient-to-patient networks can help people feel less alone and upset, and improve the quality of their lives. Cancer support groups provide a setting where cancer patients can talk about living with cancer with others who may be having similar experiences. Patients may want to speak to a member of their health care team about finding a support group. Many also find useful information in NCI fact sheets and booklets, including Taking Time and Facing Forward.

Questions for Your Doctor

This booklet is designed to help you get information you need from your doctor, so that you can make informed decisions about your health care. In addition, asking your doctor the following questions will help you understand your condition better. To help you remember what the doctor says, you may take notes or ask whether you may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor -- to take part in the discussion, to take notes, or just to listen.

Diagnosis

� What tests can diagnose colorectal cancer? Are they painful?

� How soon after the tests will I learn the results?

� Are my children or other relatives at higher risk for colorectal cancer?

Treatment

� What is the stage of my cancer?

� What treatments are recommended for me?

� Should I see a surgeon? Medical oncologist? Radiation oncologist?

� What clinical trials might be appropriate?

� Will I need a colostomy? Will it be permanent?

� What will happen if I don't have the suggested treatment?

� Will I need to be in the hospital to receive my treatment? For how long?

� How might my normal activities change during my treatment?

� After treatment, how often do I need to be checked? What type of followup care should I have?

Side Effects

� What side effects should I expect? How long will they last?

� What side effects should I report? Whom should I call?

The Health Care Team

� Who will be involved with my treatment and rehabilitation? What role will each member of the health care team play in my care?

� What has been your experience in caring for patients with colorectal cancer?

Resources

� Are there support groups in the area with people I can talk to?

� Where can I get more information about colorectal cancer?

SOURCE: National Cancer Institute

1. What is a splenectomy?
Splenectomy is a term referring to the surgical removal of the spleen.
2. What is the spleen and what functions does it serve in our body?
The spleen is a soft organ approximately the size of a fisted hand located behind the stomach in the left upper abdomen and is protected by the lower ribcage. It is part of the blood and lymph system. It functions as a filter, removing bacteria, foreign cells and old red blood cells from the circulation. It also produces red blood cells in children. In addition, spleen produces proteins that help in the immunity against certain bacteria.
3. Why remove the spleen then?
Like any other organ in the body, the spleen can be affected by diseases or injured. The commonest reason for removing the spleen is trauma to the spleen (such as road traffic accident or fall from height) resulting in internal bleeding. Removal of the spleen in such situation is necessary to stop the blood loss and save life.
Spleen may be involved in some blood disorders - causing low platelets counts (as in autoimmune thrombocytopenic purpura, AITP) and decreased life span of red blood cells (eg spherocytosis or other forms of chronic hemolytic anemia). It can also be affected by diseases such as cyst, abscess or hematological malignancy eg. Hairy cell leukemia. Sometimes the spleen can reach a massive size causing significant discomfort to the patient and is associated with increased risk of rupture.
Splenectomy can improve the blood profile of patients with specific blood disorders - in AITP, up to two-third of the patients can be rendered medication-free and have sustained normal platelets count following splenectomy. In hairy cell leukemia, splenectomy can improve the cell count and delay chemotherapy. In those with chronic hemolytic anemia, splenectomy helps to enhance red blood cell lifespan and therefore reduces transfusion requirement. And in those patients with massive enlargement of the spleen, splenectomy can relieve symptoms and eliminate the risk of rupture.
Removal of spleen affected by benign disease such as cyst, abscess or chronic infection can lead to cure of the disease. However, in malignant disease involving the spleen, splenectomy often does not confer a cure, but as part of overall staging (assessment of the severity) of the underlying malignancy.
4. How is the spleen removed?
The spleen is deeply position in the abdominal cavity and closely related to the stomach, the pancreas and the left kidney. These important organs need to be carefully separated from the spleen before it can be safely removed. The operation has traditionally been done via conventional open surgery i.e. through a large incision on the abdominal wall, through the skin and muscle. Now a day, splenectomy can be done laparosocpically. This is done with the patient under general anesthesia and in the right later position. The abdominal cavity is distended with carbon dioxide to create space for the operation. Visualization is achieved with a 10mm diameter telescope and the operation performed with two to three slim 5mm diameter instruments placed at just below the left ribcage.
5. What are the benefits of laparoscopic splenectomy?
The benefits include: -
" Smaller wounds and therefore less pain
" Shorter hospitalization stay
" Faster recovery and return to work
" Reduce overall hospitalization cost
" Better cosmetic outcome
However, in patients with very large spleen or those with severe bleeding tendency, the open operation would be more appropriate.
6. Are there potential complications associated with the operation?
Complications following splenectomy are not common, they include - wound infection, bleeding at surgical site, blood clots in the deep vein of the legs & embolism of the clot to the lungs, pancreatitis (inflammation of the pancreas), collapse of the lung and pneumonia.

7. How do I prepare for the operation?
Prior to the operation, radiologic imaging (commonly computerized tomography {CT scan} or Ultrasonography) of the spleen will be done to delineate the spleen and its congenital accessories.
You will be reviewed by an anesthesiologist to assess your general fitness for general anesthesia. Blood tests, chest X-ray and ECG are done during this review. We will also discuss with you on the pain control option you prefer after the operation.
You will need to have vaccinations to certain bacteria at least one week to 10 days prior to the operation.
You will be admitted to the hospital one day prior to the operation. Upon your admission, blood tests need to be repeated in order to arrange for blood or blood product necessary for the operation. You will meet the physiotherapist who will instruct you on the exercises to help you breathe better following operation.
There will be restriction on the diet and liquid laxative will be given to clear your bowel in preparation for the operation.
8. What is it like after the operation?
This can be broadly divided into 3 categories -
a. The after effects of general anesthesia - headaches, nausea and sore throat. There are medications that can help lessen these unpleasant feelings and they usually improve over the next 24-48 hours.
b. Wound pain - Pain from the laparoscopic wounds are usually minimal. Majority of patients find oral analgesics adequate in relieving pain. If need arise, additional patient-control-analgesia can be prescribed.
c. Surgical tubes and drains - This will include intravenous line for drip, nasogastric tube, urinary catheter as well as surgical drain for residual blood and fluid at the surgical site brought out through the abdomen near the surgical wounds. These tubes do cause some discomfort but are necessary for the first couple of days after operation. Please do bear with the discomfort and inconvenience; they will be removed as soon as they are not needed.
You will be allowed only small amount of clear fluid initially after the operation. As your condition improves and gut function returns, you can progress to more substantial diet.
You are likely to stay in the hospital for 3-4 days after the operation.
9. What should I look out for after discharge from hospital?
You should have recovered to a good extent from the operation when leaving the hospital. You should ambulate as much as the pain / discomfort in the wound permits and take a balance diet and ensure adequate fluid intake to avoid dehydration.
You will be given a date to remove the stitches (or metallic clips) from the skin wound approximately one week after the operation. This is a simple clinic procedure and will not be painful. Meanwhile, you should look out for redness, pain and discharge from the wound that may suggest infection. Consult your surgeon if you develop wound infection or if you have high fever especially when it's associated with abdominal pain.
After laparoscopic splenectomy, most patients are able to return to normal daily activities or deskwork by the end of first week. Strenuous physical exercise should be postponed until 4-6 weeks later. You should return for review with your surgeon and your primary physician on the scheduled date.
10. What are the long term effects of splenectomy?
The bone marrow and the other lymph nodes in the body will take over most of the splenic functions after splenectomy. However, there is still an increased in risk and susceptibility to infection by certain bacteria - pneumococci, meningococci and hemophilus influenza typeB etc. Young children are at a higher risk of infection than adults. Asplenic patients are also at increased susceptibility to malaria.
11. What can be done to reduce the risk of infection?
Awareness of the increased susceptibility to infection after splenectomy and vigilance to minor infection will help a great deal and may potentially be life saving. The following measures helps in reducing the risk of overwhelming infection -
a. Vaccination against pneumococci, meningococci and hemophilus influenza type B are now available and should be given at least one week prior to the operation. A booster is usually necessary every 5-10 years after that.
b. Antibiotic is given during the operation; this usually covers a broad spectrum of gut organisms.
c. Long term antibiotics, usually in the form of penicillin, are recommended in pediatric patients
d. Prophylaxis to malaria when traveling to malaria endemic region.
e. Be mindful of your increased risk to infection and vigilant to potential infective organism such as when you have high fever, severe sore throat, unresolved cough, sudden acute abdominal pain, severe headache and phobia to light or a skin rash. Seek medical attention early to prevent early infection from escalating to potentially fatal septicemia.
f. Seek medical attention early when bitten by animal as there is increased risk of infection. Antibiotic should be started early.
g. Always volunteer the information that your spleen had been removed when consulting a doctor or carry with you an information item stating you are without a spleen (eg information card from your surgeon or a bangle engraved with the information). This is especially important after laparoscopic splenectomy because the surgical wounds can become quite inconspicuous after some time. This will alert the medical personnel attending to you to be more vigilant with potential infection, and more aggressive in treating the infection once detected.

1. Am I morbidly obese?
The Body Mass Index (BMI) is probably the best way of assessing obesity. Calculate your BMI with this formula:
BMI = weight in kilograms / height in metres2
You are healthy if your BMI is between 20-23, overweight if between 23-27, obese if between 27-40 and morbidly obese if over 40. These cut-off values tend to be lower than those recommended for Caucasians as it has been found that Asians develop medical complications from obesity earlier. Obesity is related to chronic debilitating illnesses such as diabetes, hypertension, heart disease, some cancers, obstructive sleep apnoea and osteoarthritis. In general, if your weight exceeds 50% of your ideal body weight, the risk of an early death is doubled compared to someone who is not obese.
2. Do I need treatment if I am overweight or obese?
Yes, your quality of life will certainly improve with a weight management programme. We always recommend a combination of dieting, exercise, behavior modification and medication. All these work to a certain degree and may be sufficient if you are moderately overweight. Unfortunately, most studies have shown that they will not be effective in the long run for most people. The only treatment that achieves sustainable results seems to be some form of weight loss surgery.
3. What is weight loss surgery?
Weight loss surgery should be considered if the desired weight loss cannot be achieved by non-surgical methods and the obesity poses a serious threat to the patient's health. The main indications for surgery are a BMI of greater than 40, or greater than 32 in the presence of associated medical complications of obesity.
There are a variety of operations that can be done. All of these operations act either by producing early satiety from gastric restriction (eg gastric banding or vertical banded gastroplasty), or by creating a state of malabsorption in the gastrointestinal tract (eg gastric bypass or biliopancreatic diversion). All these operations can be performed by either conventional open surgery (as we used to do in the past) or laparoscopic surgery (the preferred approach nowadays).
We find that for Asian patients, the Laparoscopic Gastric Banding comes close to being an ideal operation as it is a simple procedure with low risks and is also highly effective. There are many types of gastric bands available commercially but our preference if the Swedish Adjustable Gastric Band (SAGB). Most bands are very similar in design but we like the SAGB as it is a soft band. The results of surgery with different bands are also very similar and it is probably best to let your surgeon choose the product he is most comfortable with.
4. How is the Swedish Adjustable Gastric Banding done?
The SAGB procedure is performed laparoscopically through keyhole incisions. The pliable band is inserted around the upper stomach and stiched into place. This creates a small gastric pouch that limits the quantity of food that the stomach can hold. This produces a feeling of satisfaction and fullness even after a small meal. As the band slows down the emptying of food from the pouch, you will remain full for a number of hours after each meal.
The band is attached to a reservoir port that is implanted under the skin over the breastbone. If required, we can inject some saline into this port to adjust the size of the band after surgery. The procedure can be done in the clinic and allows us to calibrate the amount of weight loss required.
5. How do I prepare for Laparoscopic Gastric Banding surgery?
All of our patients are put on a comprehensive weight loss programme. You will be assessed by an endocrinologist to exclude a hormonal problem which may be the cause of the obesity. You will also receive counseling by a dietician and, if necessary, referred to a psychologist for behavior medication and assessment of eating disorders. We will also perform a gastroscopy (to assess the anatomy of the stomach) and an abdominal ultrasound (to exclude gallstones).
6. What happens after surgery?
Most patients are admitted on the day of surgery and stay inpatient for 2 to 3 days after surgery. You will be put on a liquid diet for month after surgery. You will then be re-introduced to puree and solid foods slowly. In general, we target a weight loss of 0.5 to 1 kg a week. You will loss about 60% of your excess weight 2 years after surgery.
7. What are the risks of surgery?
Laparoscopic gastric banding is a safe procedure. Nevertheless, there are definite risks as in any operation for an obese patient. This may be related to the general anaesthesia or to the surgery itself. Specific complications related to the band include band slippage, erosion or infection.

1. What is the function of the Gallbladder?
The gallbladder is a small pear-shaped organ under the liver on the right side of the upper abdomen. It stores bile produced by the liver cells during resting state and squeezes it into the intestine via the bile duct to aid in digestion during a meal.
2. What are Gallstones and how are they detected?
Causes of gallstones formation are multi-factorial, involving bacteria infection of the bile, precipitation of constituents of the bile such as bile salt, calcium, bile pigment and cholesterol. The stones can be hard stones of varying sizes or they can be in the form of soft cholesterol stones or mid-like sludge. Ultrasound scan of the abdomen is the commonest method used in detecting gallstones; it is non-invasive and very accurate. Other methods in detecting gallstones include computerized tomography (CT) scan and oral cholecystography.
3. When do I need an operation to remove the Gallbladder?
Gallstones disease is a common occurrence in the population but majority of people are symptoms free and therefore unaware of their existence. An operation is recommended when the gallstones cause problems such as pain, jaundice (yellowing of skin) or infection. The current standard treatment entails removal of the diseased gallbladder together with gallstones.
4. What is Laparoscopic Cholecystectomy?
Laparoscopic cholecystectomy (removal of the gallbladder via key-hole operation) is conducted under general anesthesia. The procedure is carried out after distending the abdomen cavity with carbon dioxide insufflations to create space for the operation. A 10mm diameter telescope is then place through a small incision at the umbilicus for visualization. The actual operation on the gallbladder is performed with three slim instruments 3-5mm in diameters placed just below the right ribcage. Tiny clips are used to seal the blood vessels around the gallbladder and the cystic duct that connects the gallbladder to the bile duct. The gallbladder and the stones inside will be extracted at completion of operation as in conventional open operation.



5. What are the benefits of Laparoscopic Cholecystectomy?
The benefits include: -
• Less pain
• Shorter hospitalization stay
• Faster recovery and return to work
• Reduce overall hospitalization cost
• Better cosmetic outcome

6. What to prepare for the operation?
You will be review by an anesthesiologist before the operation to ensure that you are healthy and fit for general anesthesia. Routine blood tests, chest X-ray and ECG will be done when necessary.
The operation is generally a straightforward one. You can be admitted on the day of the operation but you need to fast for at least 6-8 hours prior to the operation. You should not have any food or liquid after midnight if your operation is scheduled in the morning. You can have a beverage early in the morning if your operation is scheduled for later in the afternoon.

7. What to expect after the surgery?
When you wake up from the surgery, you will find,
• Bandages on the incisions
• A tube that was inserted in your vein to give you fluids and medications

Post-anesthetic nausea, headache and sore throat are common symptoms experience by many patients. You will be prescribed medications to counter these symptoms. You can take liquid orally after you wake up fully from the general anesthesia and should be able to progress to diet in the evening if you tolerated the liquid well.

Pain from the small laparoscopic wounds is usually well tolerated. Majority of patients required only oral medication for adequate pain relief. Patient control analgesia will be available if you need.
Majority of patients recover from the operation very quickly and are ready to go home after a night rest in the hospital.
8. Are there potential complications associated with the operation?
Laparoscopic cholecystectomy is generally a safe operation and complications are rare, these include -

• Risks of anesthesia
• Wound infection
• Slight numbness around the incision
• Small risk (less than 1%) of Injury to the bile duct.

9. Are there any side effects after operation?
The gallbladder is not an essential digestive organ and its removal does not carry significant long-term side effect. Some patients experience loose stool and bloating with fatty food in the early period after the operation. This usually improves and resolves after a few weeks.
10. Care after discharge
• Care of the wound - dressing of the wound can be removed after couple of days. It is perfectly safe to leave the wound exposed and shower with soap and clean running water.
• Wound infection occurs rarely, this usually presents with discharge from the wound or redness and persistent pain at the wound. When this happens, please contact your surgeon or your family doctor for advice.
• Stitches will be removed after a week at the clinic
• Bloated sensation and occasional loose stools will be expected for a few days and up to a few weeks. Avoiding fatty food can help to lessen the problem.
• You should be able to resume normal daily routine at home or desk job at the office by the end of first week. You can do light exercises such as walking and swimming as long as the wound pain is tolerable. Strenuous exercises or lifting heavy objects is not advisable and should be delayed to at least 4-6 weeks later.

11. Are there any dietary restrictions?
Generally no. But preferably avoid fatty and oily food, avoid overeating and have more portions of fresh fruits and vegetables in your diet.
12. Please seek medical attention
If you have the following signs and symptoms, please do not hesitate to get help.

• Fever >38 C
• Severe pain, redness or discharges from at the wound site
• Jaundice (yellowing of skin)

Rationale for the Procedure
Pancreatic adenocarcinoma is diagnosed in just over 30,000 patients every year in the United States and has a dismal prognosis, with an almost identical yearly death rate. Surgery is the only modality that can lead to cure; however, most patients present with inoperable disease. The overall 5-year survival is <5%. Patients with localized disease have a 15% 5-year survival after curative resection. In a disease with such a poor prognosis even after curative resection, it is not only important to identify patients with resectable disease but also to spare patients with incurable disease the morbidity, inconvenience, and expense of an unnecessary operation. Thus, accurate staging of pancreatic adenocarcinoma is of paramount importance. A high quality CT scan of the pancreas is considered the best initial diagnostic modality for this disease. Nevertheless, even after appropriate preoperative imaging, 11-48% of patients are found to have unresectable disease during laparotomy. For this reason, many authors have introduced SL in the treatment algorithm of pancreatic adenocarcinoma patients in an effort to decrease the number of unnecessary laparotomies.
Technique
The feasibility of SL has been demonstrated in multiple studies with success rates ranging from 94-100% (level II, III). Dense adhesions that impair inspection and examination with the ultrasound probe are the main reason for technical failures. Nevertheless, even patients with adhesions can be examined; however, the extent and yield of the examination may be compromised. Conversions to open surgery are uncommon and have been reported to occur in <2% of patients in a large series (level III) [5].
The procedure is usually performed under general anesthesia, and the majority of reports have used 15 mm Hg insufflation pressures. A thorough evaluation of peritoneal surfaces is performed. The suprahepatic and infrahepatic spaces, the surface of the bowel, the lesser sac, the root of the transverse mesocolon and small bowel, the ligament of Treitz, the paracolic gutters, and pelvis are inspected with frequent bed position changes as necessary. In addition to visual inspection, peritoneal washings can be performed, ascitic fluid, if present, sent for cytology, and biopsy specimens of lesions suspected to be malignant obtained. When no metastatic disease is identified on inspection, a detailed laparoscopic ultrasound examination can be employed during which the deep hepatic parenchyma, the portal vein, mesenteric vessels, celiac trunk, hepatic artery, the entire pancreas, and even pathologic periportal and paraaortic nodes can be evaluated and biopsied. The addition of color flow Doppler can further assist in the assessment of vascular patency.
A controversy exists in the literature about the extent of SL for pancreatic adenocarcinoma patients. Advocates of a short duration procedure that is based only on inspection of abdominal organ surfaces argue that the procedure can be performed quickly (usually within 10–20 min), can be done through one port, does not require significant expertise, minimizes the risk of potential complications by the dissection near vascular structures, and has good diagnostic accuracy (level III) [1,2]. On the other hand, advocates of a more extensive procedure that includes opening the lesser sac and assessment of the vessels argue that the diagnostic accuracy of the procedure can be enhanced by detecting metastatic lesions in the lesser sac, vascular invasion by the tumor, or deep hepatic metastasis, often missed by visual inspection alone, and that it can be performed safely without a significant increase in morbidity and within a reasonable time (level II, III) [3-5].
It is very important, therefore, to consider these differences in the SL technique when evaluating reports of the diagnostic yield of this procedure in patients with pancreatic adenocarcinoma.
Indications
• As a staging procedure for pancreatic adenocarcinoma
• For detection of imaging occult metastatic disease or unsuspected locally advanced disease in patients with resectable disease based on preoperative imaging prior to laparotomy
• For assessment prior to administration of neo-adjuvant chemoradiation
• For selection of palliative treatments in patients with locally advanced disease without evidence of metastatic disease on preoperative imaging
Contraindications (Absolute or Relative)
• Known metastatic disease
• Inability to tolerate pneumoperitoneum or general anesthesia
• Multiple adhesions/prior operations
Risks
• False negative studies that lead to unnecessary exploratory laparotomies and unnecessary cost
• Procedure-related complications
Benefits
• Avoidance of unnecessary exploratory laparotomy with its associated higher morbidity and cost in patients with metastatic disease
• Appropriate selection of patients with true locally advanced disease and exclusion of patients with CT-occult metastatic disease from further unnecessary treatment (chemotherapy or chemoradiation) with its associated morbidity and cost
• Minimizes the delay of primary treatment (chemotherapy or chemoradiation) in the subset of patients whose disease is unresectable by avoiding laparotomy and its associated longer convalescence period
Diagnostic Accuracy of the Procedure
The reported median (range) sensitivity, specificity, and accuracy of SL in detecting imaging-occult, unresectable pancreatic adenocarcinoma in the literature is 94% (range, 93-100%), 88% (range, 80-100%), and 89% (range, 87-98%), respectively (level II, III) [2-23]. However, the procedure misses 6% (range, 5-25) of patients whose disease is identified as unresectable during an ensuing laparotomy (level II-III) [2-23]. Overall, in 4-36% of patients, an unnecessary laparotomy can be avoided (level II-III) [2-23].
A number of studies have also evaluated the added benefit of laparoscopic ultrasound at the time of laparoscopic staging indicating that the diagnostic accuracy of the procedure can be improved by 12-14% (level II-III) [3-8,19-22]. In addition, peritoneal washings have been reported to augment the yield of the procedure. Reports on the sensitivity of peritoneal washings have ranged widely (25-100%) [2,17,24-26]. The highest sensitivity for peritoneal cytology has been reported in patients with a disrupted ventral pancreatic margin (when peripancreatic fatty tissue cannot be differentiated from the tumor by helical CT scan) (level III) [26]. In addition, locally advanced pancreatic cancers have a higher incidence of positive cytology (level III) [12,17,27]. Importantly, studies have reported a 7-14% incidence of positive peritoneal washings in the absence of other findings of metastatic disease during preoperative imaging and SL (level III) [2,17]. This incidence seems to be lower in studies that include a variety of periampullary tumors (level II) [14].
The diagnostic yield of the procedure also depends on the histology, stage of disease, tumor size, and location. There is convincing evidence that the yield of SL is significantly higher in patients with pancreatic cancer compared with other types of periampullary tumors (level III) [11,12,16,23]. Furthermore, SL appears to have a higher yield in patients with locally advanced cancer compared with patients with localized disease. Identification of metastatic disease by SL in patients with locally advanced disease by high quality imaging studies has been reported in 34-37% of cases, which compares favorably with the identification rates of metastatic disease in patients with localized disease (level III) [1,27,28].
Tumors of the pancreas body and tail are associated with a higher chance for unsuspected metastasis found at laparoscopy (level III) [2,17]. Larger tumors appear to be associated with a higher incidence of imaging occult metastatic disease (level III) [12,23,29,30]. Although the tumor size at which the risk of occult M1 disease justifies the added time and cost of laparoscopy is currently unknown, some studies have suggested that tumors > 3 cm are more likely to be associated with metastatic disease at exploration (level III) [29,30]. Moreover, a Ca 19-9 level <150 has been associated with a lower chance for metastatic disease and consequently a lower yield for SL (level III) [31].
Procedure-related Complications and Patient Outcomes
Procedure-related morbidity has been reported to range 0 and 4% (level II, III) [1-30]. Most complications are minor and consist of wound infections, bleeding at port sites, or skin emphysema. Nevertheless, complications such as myocardial infarction, pulmonary embolism, and intestinal or vascular injury during the procedure have been described. The majority of the literature reports mortality rates of 0% (level II, III) [1-30]; however, at least one death has been reported due to a missed colonic injury during the procedure. Although studies comparing open and laparoscopic staging are scarce, the morbidity and mortality rates reported in the literature compare favorably to reports of negative exploratory laparotomies. No studies compare a short-duration inspection-only SL with a more extended procedure.
With regard to oncologic safety, initial concerns for more port-site recurrences after laparoscopic procedures in cancer patients have not been substantiated. Multiple studies report a 0-2% incidence of port-site recurrences after SL, which is similar to the incidence after open explorations of cancer patients (level III) [8,23,32]. In one comparative study of 235 patients who had undergone exploratory laparotomy or SL, laparoscopy was not associated with increased port-site recurrences or peritoneal disease progression (level III) [32]. Furthermore, there is evidence from the Surveillance Epidemiology and End Results (SEER) database suggesting no survival differences between pancreatic cancer patients who underwent a laparoscopic procedure compared with an open surgery (level II) [33].
Hospital length of stay after SL has been reported to range from 1 to 4 days [23]. Level III evidence suggests that the hospital stay is shorter after laparoscopic staging compared with open staging in pancreatic cancer patients [10].
In patients with locally advanced disease, SL has been reported to be superior to exploratory laparotomy, as it decreases length of hospital stay, increases the number of patients who receive chemotherapy, and shortens the time to initiation of such treatment (level III) [18,32].
Cost-effectiveness
Although high quality evidence on the cost effectiveness of SL is lacking, the literature suggests that SL is more cost-effective than open exploration when it is the only procedure required (i.e., in patients with unsuspected metastatic disease identified during SL) (level II) [34]. This is a consequence of decreased patient length of stays. On the other hand, the cost-effectiveness of SL when applied in the diagnostic algorithm of all pancreatic cancer patients appears to be linked directly to the yield of the procedure in identifying patients with imaging occult disease. In a cost utility analysis of the most effective management strategy for pancreatic cancer patients, at least a 30% yield was needed for SL to be more cost-effective than open exploration (level III) [35].
Literature Controversies
The main controversy regarding SL is whether it should be used routinely or selectively in patients with pancreatic adenocarcinoma deemed resectable on preoperative imaging. Proponents for the routine use of SL cite the high incidence of imaging occult metastatic disease found during laparoscopic examination of the abdominal cavity that leads to avoidance of unnecessary operations and thus benefits patients [3,20,27]. Proponents for the selective use of SL argue that when high quality imaging is used, only a small percentage of patients benefit from SL, and under these circumstances the procedure is not cost-effective [12,14]. As discussed in the technique section, there is also a controversy about whether to perform a limited or extended procedure.
Limitations of the Available Literature
The quality of the available studies on SL for patients with pancreas cancer is limited; no level I evidence exists. Furthermore, population-based data are very limited, as the majority of studies are single institution reports from highly specialized centers, making generalizations difficult and allowing institutional and personal biases to be introduced into the results.
In addition, reported data are not uniform across studies, making their analysis difficult. A number of studies assess the role of laparoscopy indirectly without having ever performed a single laparoscopic staging procedure (referred to as ‘phantom’ studies by some authors) and assume that only visible metastatic disease would have been detected at the time of laparoscopy, ignoring the value of laparoscopic ultrasound and cytology. Other studies do not clearly report the quality of preoperative imaging, the criteria used to define resectability, and the number of R0 resections. Importantly, studies often evaluate inhomogeneous patient samples, including patients with localized and locally advanced pancreatic cancers, with periampullary and other non-pancreatic cancers or even with benign disease and do not report results separately. Moreover, the information on the cost-effectiveness of the procedure is limited, and there are no studies that assess the quality of life of patients undergoing SL compared with patients undergoing open exploration.
Recommendations
Staging laparoscopy can be performed safely in patients with pancreatic adenocarcinoma (grade B). The procedure should be considered after high quality imaging studies have excluded metastatic disease in appropriately selected patients with either localized or locally advanced pancreatic adenocarcinoma (grade C). The use of laparoscopic ultrasound and peritoneal washings is encouraged, since they may improve the diagnostic accuracy of the procedure (grade C). Based on the available evidence, selective rather than routine use of the procedure may be better justified and more cost-effective (grade C). Patient selection may be based on the available evidence that suggests that the diagnostic accuracy of SL may be higher in patients with larger tumors, tumors of the neck, body, and tail or with clinical, laboratory (such as higher levels of Ca 19-9), or imaging findings suggestive of more advanced disease (grade C). Nevertheless, the effectiveness of such selection criteria needs to be verified by additional prospective studies.
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