Laparoscopic Thoracoscopic Ecophagectomy

Laparoscopic and thoracoscopic esophagectomy –

oesophagectomyA fifty five year male patient presented with complain of dysphagia (the feeling of food getting stuck several secondsafter swallowing, initially for solid food progressing to inability to eat even solid and liquid diet) was presented to our department of laparoscopic GI & GI OncoSurgery :
Dr. Pradeep Jain and Dr Ashish Bhanot. Patient was evaluated carefully and thoracoscopic Esophagectomy was performed. Laparoscopic mobilization of stomach and thoracoscopic mobilization of esophagus was performed and stomach tube was created and brought out through cervical incision and anastomosis of cervical esophagus was performed in neck. The procedure was performed without any major incisions on chest and abdomen. Patient was able to walk very next day and recovered very well without any significant pain and other surgery related complications.

2017Esophagectomy is the partial or complete surgical removal of the esophagus. It is most often performed to remove esophageal cancer or benign lesions. Often the procedure follows courses of chemotherapy and radiation, which might also be continued postoperatively. For decades; surgeons have approached this procedure via open thoracotomy, a large incision in the chest. Via open or laparoscopic approach, this surgery and anesthetization is complex because of the anatomical structures involved. Depending on the length of esophagus to be removed stomach tube or colon is mobilized to make a tube and esophagogastrostomy or colonic transposition is performed. Procedure carries high morbidity because of multiple large incisions causes’ severe pain and take long time to heal in debilitated patients who are already down in health because of cancer. Thoracoscopic esophagectomy is routinely performed by our GI Surgery team and has markedly reduced morbidity in esophageal cancer surgery.

Our GI & Bariatric Surgery experts Dr Pradeep Jain & Dr Ashish Bhanot are also performing laparoscopic colorectal cancers, Bariatric, Pancreatic cancer surgery as well hepatobiliary and other GI surgeries by minimally access surgery techniques.

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Laparoscopic Surgeries By Dr Pradeep Jain

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.

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.

Laparoscopic Liver Surgery By Dr Pradeep Jain :

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.

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Dr Pradeep Jain – Best GI Surgeon In Delhi

Dr Pradeep Jain , is the Chief of Department of GI and GI Oncology, Bariatric & Minimal Access Surgery at Action Cancer Hospital & Sri Balaji Action Medical Institute, New Delhi. Dr. Pradeep Jain is one of the most experienced cancer surgeons in India specializing in Gastroenterology surgery including pancreas, liver, bariatric, laparoscopic colorectal and laparoscopic oncology surgery.

Dr. Pradeep Jain is an acclaimed doctor in GI, GI Once and Minimal Invasive Surgery. He was also the departmental head of Fortis Healthcare in the department of Laparoscopic, GI and GI Oncology Surgery. The department of Laparoscopic GI, GI Onco surgery and Bariatric surgery in Fortis Healthcare, is one and only department in the whole Delhi city and National Capital Region which has been offering full Spectrum of Gastrointestinal and Hepatobiliary Pancreatic surgery with the aid of invasive techniques.



Gastrointestinal Cancer Treatment By Dr. Pradeep Jain

Gastrointestinal Cancer Treatment By Dr. Pradeep Jain Dr. Pradeep Jain at Action Cancer Hospital, is an experienced and praised laparoscopic gastrointestinal surgeon. As a pioneer in his field, Dr. Pradeep Jain has performed life-changing surgeries to help patients battle gastrointestinal cancers.Dr. Pradeep Jain works passionately to leverage the power of these surgeries to help patients overcome health concerns.

Dr Pradeep Jain is a well known and popular GI surgeon in North West and fondly known as Trouble shooter in surgical fraternity.

Gastrointestinal tract runs from the mouth to the anus, and includes the stomach,small bowel or intestine, and the large bowel (colon and rectum).Gastrointestinal cancer (cancer of the digestive system) includes cancers of the gallbladder, liver, pancreas, stomach, small intestine, esophagus large intestine.

Diagnosis is delivered using the latest techniques and technologies.These techniques confirm or identify your patient’s cancer type, and allow us to recommend the therapies which will be most effective in treating their individual cancer.

Everyone has risk of developing cancer but most cancer is not familial, ie. it does not run in families. A small proportion of cancer thought to be due to inherited factors.Sometimes there is family history but the diagnosis occurred at an older age and there is no clear pattern from parent to child. Although the cancer may appear to be more common than you would expect to see in these families this may not be due to inherited factors. It can be due to shared environmental factors such as diet, smoking and exercise as families tend to have similar habits.

GI Cancers or Gastrointestinal Cancers


Q1. What are GI Cancers?

Ans. 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.

Q2. Are They very common in India?

Ans. These cancers are not uncommon and the incidence of these cancers are growing except stomach cancers

Q3. What are the sign and symptoms of GI Cancers?

Ans. 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.

Q4 Do these cancers spread from one person to another?

Ans. No! these cancers are not contagious like infectious diseases

Colo Rectal Cancer


Q1. What are the symptoms of colorectal cancers?

Ans. Though not specific but there are warning signs like bleeding in stools, sensation of incomplete passage of stools, feeling of bloating or obstruction in intestine, unusual loss of weight and fatigue, alteration of bowel habits, blood and mucus in stools.

Q2. Do I have a high risk of developing colorectal cancers?

Ans. Yes if have following situations.
If your diet have high fat content and low in fibers, fruits and vegetables
You have a close relative with cancer of colon and rectum
You have colonic polyps
You have inflammatory bowel disease like ulcerative colitis, crohn’s disease
Familial polyposis syndromes
Age more than 50 years

Q3. What are the diagnostic tests?

Ans. When suspicious or in high risk patients the best diagnostic tool is sigmoidoscopy or colonoscopy. these are endoscopies done through anal route to visualize the entire large intestine from inside. when colonoscopy is not possible other test recommended is Barium enema or CECT scan. USG, X Rays of Abdomen are the other tests recommended during diagnosis and staging the colorectal cancers.

Q4. What are the treatments of colorectal cancers?

Ans. 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.

Q5. What should I know before surgery?

Ans. What kind of operation will it be?
How will I feel afterward? If I have pain, how will you help me ?
Will I need a colostomy? Will it be temporary or permanent?
How long will I be in the hospital ?
Will I have to be on a special diet ? Who will teach me about my diet ?
When can I return to my regular activities ?
Will I need additional treatment ?

Gastric cancers


Q1. What should I know before surgery?

Ans. Though they are not specific symptoms but they may suggest presence of stomach cancer and warrant a consultation with physician.
  Indigestion or a burning sensation (heartburn)
  Discomfort or pain in the abdomen
  Nausea and vomiting
  Diarrhea or constipation
  Bloating of the stomach after meals
  Loss of appetite
  Weakness and fatigue
  Bleeding (vomiting blood or having blood in the stool)

Q2. What are the causes and risk factors for stomach cancer?

Ans. Diet – Foods that are smoked, salted fish and meat, pickled vegetables, and foods that are at the same time high in starch and low in fiber have been identified as possible risk factors. Diet – Foods that are smoked, salted fish and meat, pickled vegetables, and foods that are at the same time high in starch and low in fiber have been identified as possible risk factors.

Tobacco and alcohol abuse – Increases the risk of cancers in the upper portion of the stomach

After surgery, more nitrite – producing bacteria are present in the stomach. Nitrites can be converted by other bacteria into compounds that have been found to cause stomach cancer in animals
Several close blood relatives who have or had stomach cancer increases a person’s risk.

An infection that, if long-term, can lead to chronic atrophic gastritis, which is inflammation of the stomach’s inner layer. Chronic atrophic gastritis is a possible precancerous change to the lining of the stomach

Also, risk may be increased, to varying degrees, for people with pernicious anemia, achlorhydria, Menetrier’s disease, familial cancer syndromes, stomach polyps and blood group A.

Q3. How can Physician diagnose my cancer stomach?

Ans. Your doctor can conduct certain tests like UGI endoscopy to visualize the internal lining of stomach and duodenum ( beginning part of small intestine ) it can not only see the tumor but also take the biopsy for final diagnosis. Barium meal test can be done if endoscopic is not possible CT scan is required for the staging purpose Tumor markers are not specific but can give a fair idea of diagnosis

Q4. What should I ask from my doctor?

Ans. Your doctor can conduct certain tests like
What is my diagnosis?
What is the stage of the disease?
What are my treatment choices?
What are the chances that the treatment will be successful?
What are the risks and possible side effects of each treatment?
How long will my treatment last?
Will I have to change my normal activities?
What is the treatment likely to cost?

Q4. What about treatment?

Ans. Surgery is the primary treatment for gastrointestinal cancer. Total gastrectomy, or removal of the entire stomach, is the most common treatment. However, sub-total – or removal of most, but not all, of the stomach – is also performed, depending on the location of the tumor. Surrounding lymph nodes are also removed during surgery. The gastrointestinal tract is then reconstructed to restore continuity.

Chemotherapy and radiation therapy are used after surgery to minimize the risk of recurrence. A doctor may use just one method or combine methods to treat the cancer most effectively.

Pancraetic cancers


Q1. What is Pancreas?

Ans. Pancreas is a organ located on back side of abdomen behind stomach. Actually this is an active gland responsible for digestion of food and secrete Insulin for control of blood sugar.

Q2. What are the causes and risk factors for cancer of pancreas?

Ans. Pancreas is a organ located on back side of abdomen behind stomach. Actually this is an active gland responsible for digestion of food and secrete Insulin for control of blood sugar.

  Age more than 50 years and male preponderance is often seen
  Cigarette smoking
  Diabetes Mellitus
  Diet high in fat and protein contents
  Chronic pancreatitis
  Family history of cancer of pancreas

Q3. What doctor will do detect my cancer?

Ans. After detailed history, examination and routine tests he/she will advice certain specific tests like liver function tests, USG, CECT abdomen, MRCP, CA 19.9, or PET Scan if required.

Q4. What is the treatment?

Ans. Treatment depends on the stage and fitness of the patient. Surgery is the mainstay in these cancer particularly in early stage. the type of surgery depends on the location of tumor whether they are in head or body or tail of pancreas. It also depends on whether they have involved other surrounding organs or blood vessels. If they do not have wide spread and localized surgery always have the potential for cure. Radiotherapy and chemotherapy is also employed either for unresectable tumors or after surgery for tumors which were not in very early stage.

Q5. What can be done if my tumor is not resectable?

Ans. Some times surgical removal of tumor is not possible (locally advanced tumors with involvement of other organs or important blood vessels ) or not advisable ( due to dissemination of cancer ). In these situation cancer can be down staged by chemotherapy and Radiotherapy in certain percentages of patients and then operated. Otherwise they can be given the opportunity of selecting bile duct and /or Duodenal stenting or Tripple bypass (surgical method of bypassing the obstructed ( blocked ) bile duct and duodenum.

Liver cancers


Q1. What is liver cancer?

Ans. Liver is the largest internal organ of the body. it is located on the right side of abdomen and protected the rib cage. large number of cancerous and non cancerous tumors can occur in liver. Cancer can arise primarily in liver itself ( of its own ) which is known as primary liver cancer or it can come from other cancer of other organs as part of dissemination which are known as secondaries. The most common primary cancer is Hepatocellular carcinaoma.

Q2. What is the cause and risk factors of liver cancer?

Ans. There are many causes and risk factors which lead to liver cancer.

Viral Hepatitis – Chronic Hepatitis B and C are the major risk factors for Hepatocellular carcinaoma. They are risk factors even if there is no cirrhosis. nearly 10-20% of these patients will eventually develop Hepatocellular carcinoma Cirrhosis irrespective of any reason ( whether Hepatitis B or C, alcoholic or any genetic defect ) is a risk. 10-20% of these patients will develop HCC.

Exposure to aflatoxin – This is a carcinogenic (cancer-causing) substance that can be found in molds that may contaminate peanuts, corn, grains and seeds. In tropical and subtropical regions, measures have been taken to change and improve storage in order to reduce exposure to aflatoxins.

Exposure to chemicals like vinyle chloride and thorium dioxide (thorotrast) – Exposure to these chemicals is more likely to cause angiosarcoma of the liver, a different type of cancer than HCC. They increase the risk of developing HCC to a far lesser degree.

Some old generation oral contraceptives, anabolic steroids and Arsenic are also risk factors for liver tumors

Q3. What are the symptoms for liver cancer ?

Ans. These symptoms might be caused by liver cancer :
  Unexplained weight loss
  Anorexia (persistent lack of appetite)
  Early satiety (feeling very full after a small meal)
  Persistent abdominal pain
  Increasing abdominal girth (swelling of the “stomach” area) with or without breathing difficulty
  Sudden jaundice (yellow-green coloration of the skin and eyes) with no apparent reason
  Dramatic change in the overall condition of a patient with chronic hepatitis or cirrhosis
  Liver enlargement or a mass that can be felt in the area of the liver

Most of these symptoms are non-specific and may be caused by other cancers or less serious conditions. The only way to find out is to receive a medical evaluation. The sooner the symptoms are diagnosed, the sooner appropriate treatments can begin and the more effective treatment is likely to be.

Q4. How will my doctor diagnose the liver cancer ?

Ans. Once the clinician suspects the liver cancer, after taking detailed medical and family history and examination he/she can advice many investigations like alpha-fetoprotein (AFP) blood test, ultrasonography (ultrasound), computed tomography (CT), magnetic resonance imaging (MRI), angiography, laparoscopy and biopsy.

Q5. What about treatment? What should I ask ?

Ans. Three kinds of treatment are used to treat liver cancer :
Surgery – taking out the cancer in an operation
Chemotherapy – using antidrugs to kill cancer cells
Radiation therapy – aiming high-energy rays at the cancer to destroy it
A doctor will usually combine methods to treat the cancer most effectively. These are some questions a person may want to ask his/her doctor before treatment begins:

What is my diagnosis?
What is the stage of the disease?
What are my treatment choices? Which do you recommend for me? Why?
What are the chances that the treatment will be successful?
Would a clinical trial be appropriate for me?
What are the risks and possible side effects of each treatment?
How long will my treatment last?
Will I have to change my normal activities?
What is the treatment likely to cost?

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Gastrointestinal Neuroendocrine Tumors Treatment By Dr Pradeep Jain

Gastrointestinal Neuroendocrine Tumors

Neuroendocrine Tumors (NETs) are neoplasms that arise from cells of the endocrine and nervous systems. Neuroendocrine cells make hormones that control digestive juices and the peristalsis used in moving food through the stomach and intestines. Digestive tract neuroendocrine tumors are slow growing rare tumors comprising less than 2 percent of gastrointestinal malignancies with location of the primary tumors in the lining of the gastrointestinal tract, most often in the stomach, appendix, small intestine, or rectum and pancreas.

Types of neuroendocrine tumour

NETs most often develop in the gut or pancreas. These tumours are sometimes grouped together and called gastroenteropancreatic neuroendocrine tumours (GEP NETs).

NETs of the gastrointestinal tract are most often arising from the lining of stomach, appendix, small bowel, and rectum. They are also called carcinoid tumours of gastrointestinal tract. Carcinoids most commonly affect the small bowel, particularly the ileum, and are the most common malignancy of the appendix.

NETs that develop in the pancreas are also called endocrine tumors of the pancreas.

These are all rare types of tumor and include –

  • Insulinoma – secrets insulin causes hypoglycemia with concurrent elevations of insulin, proinsulin and C peptide.
  • Gastrinoma- produces excessive gastrin causes Zollinger-Ellison Syndrome (ZES) with peptic ulcers and diarrhea.
  • Glucagonoma- produce glucagon which produces adverse effects on body like rash, sore mouth, altered bowel habits, venous thrombosis, and high blood glucose levels.
  • VIPoma – produce vasoactive intestinal peptide which may cause profound chronic watery diarrhea and resultant dehydration, hypokalemia, and achlorhydria (WDHA or pancreatic cholera syndrome).
  • Somatostatinoma – produces the hormone somatostatin which causes hyperglysemia, achlorhydria, cholelithiasis, and diarrhea.


Neuroendocrine tumors are divided into –

1. Well differentiated neuroendocrine tumors- cells do not look very abnormal and are not multiplying rapidly. These tumors tend to be less aggressive.

2. Poorly differentiated neuroendocrine tumor- cells that look very abnormal and are multiplying more rapidly. Poorly differentiated tumors tend to be more aggressive.

3. Moderately differentiated tumors- differentiation of cells in between well differentiated and poorly differentiated..

Risk factor

Generally, the causes of NETs are unknown
Probable causes are-

Family history – multiple endocrine neoplasia type 1 (MEN1) syndrome, neurofibromatosis type 1 (NF1) syndrome, Von Hippel-Lindau syndrome (VHL)

For gastric NETs – atrophic gastritis, pernicious anemia, Zollinger-Ellison

Symptoms and signs

Majority of neuroendocrine tumors are asymptomatic, or they produce symptoms related to the mass effect of the tumors. The symptoms are usually nonspecific and mimic a variety of diseases. They may be discovered incidentally during routine computerized tomographic examinations (CT-scan) of the abdomen for unexplained symptoms, or during removal of the appendix. Neuroendocrine tumors of pancreas can be classified into functional or non-functional tumors. Functional neuroendocrine tumors are associated with symptoms related to the secretion of specific hormones by the tumor such as hypoglycemia in patients with insulinoma, or hyperglycemia in patients with glucagonoma.

Non-functional neuroendocrine tumors, on the other hand, are associated with symptoms related to the mass effect of the tumors such as intestinal obstruction and abdominal pain.

Symptoms of GI neuroendocrine tumors may include the following:
  Abdominal pain
  Change in stool color
  Weight loss and weakness for no known reason
  Feeling bloated
  Blood in the stool
  Pain in the rectum

Carcinoid syndrome –

this may occur if the tumor spreads to the liver or other parts of the body and the liver enzymes cannot destroy the extra hormones made by the tumor, high amounts of these hormones may remain in the body and cause carcinoid syndrome.
Symptoms of carcinoid syndrome include the following :

Redness or a feeling of warmth in the face and neck
Abdominal pain
Feeling bloated
Fast heartbeat


Patient’s medical history is evaluated in detail and a physical examination is done.
If a carcinoid tumor is suspected, blood and urine tests may be used to look for abnormal amounts of hormones and peptides produced by the tumor, including chromogranin A in blood and 5HIAA (a byproduct of serotonin) in the urine.

Newer markers –

N-terminally truncated variant of Hsp70 is present in NETs but absent in normal pancreatic islets.

High levels of CDX2, a homeobox gene product essential for intestinal development and differentiation, are seen in intestinal NETs.

Neuroendocrine secretory protein-55, a member of the chromogranin family, is seen in pancreatic endocrine tumors but not intestinal NETs.

Imaging tests

Ultrasound, CT-scans and MRIs may be performed to confirm the diagnosis, and to determine the exact location and size of the tumor, if it has spread to other organs, and whether it can be surgically removed

Triphasic CT Scanning –

provides images during three different phases of blood flow through the liver, offer a more accurate diagnosis than routine CT. These tests are often used to determine whether the tumor has spread to the liver or nearby lymph nodes. Barium X-rays- a barium X-ray is done to check for the presence of carcinoid tumors in digestive tract. Several types of barium studies are done depending on symptoms which include barium swallow/upper GI, barium enema and enteroclysis.

OctreoScan –

Neuronedocrine tumours express somatostatin receptors providing a unique target for imaging. Octreotide is a synthetic modifications of somatostatin with a longer half-life., also called somatostatin receptor scintigraphy (SRS or SSRS), utilizes intravenously administered octreotide that is chemically bound to a radioactive substance, often indium-111, to detect larger lesions with tumor cells that are avid for octreotide.

Gallium-68 receptor PET-CT –

Somatostatin receptor imaging can now be performed with positron emission tomography (PET) which offers higher resolution, three-dimensional and more rapid imaging is much more accurate than an OctreoScan.

Fluorine-18 fluorodeoxyglucose (FDG) PET –

This scan is performed by injected radioactive sugar intravenously. Tumors that grow more quickly use more sugar. Using this scan, the aggressiveness of the tumor can be visualized

MIBG Scintiscan –

Some neuroendocrine tumors absorb the hormone norepinephrine. In this nuclear imaging technique involves giving patients an injection of MIBG, a protein similar to norepinephrine that is combined with a radioactive substance.

Radiation-sensitive imaging tests reveal how much MIBG has been absorbed, indicating the presence of a carcinoid tumor.

Upper endoscopy :

An endoscope is inserted through the mouth and passed through the esophagus into the stomach. Sometimes the endoscope also is passed from the stomach into the small intestine to see the abnormal tissue growth. In case of obvious growth, biopsy is taken to confirm the diagnosis.

Colonoscopy :

A colonoscope is inserted through the rectum into the colon to see abnormal growth. A biopsy from abnormal tissue is always taken to confirm the diagnosis.

Endoscopic ultrasound (EUS) :

A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. An ultrasonic probe is attached at the end of the endoscope.

Capsule endoscopy :

this is a noninvasive procedure to see all of the small intestine. The patient swallows a capsule that contains a tiny camera. As the capsule moves through the gastrointestinal tract, the camera takes pictures and sends them to a receiver worn on the outside of the body.

Biopsy :

Tissue samples may be taken during endoscopy and colonoscopy from abnormal tissues. The biopsied tissuesis viewed under a microscope to confirm the diagnosis.


Treatments may be aimed at curing the disease or at relieving symptoms (palliation).

Localized tumors

Surgery is the primary treatment for localized tumors and might be curative. Surgical removal of the tumor is usually the first treatment for gastrointestinal carcinoid tumors. Tumors that have not spread may be removed along with a small portion of healthy tissue surrounding the tumor. Depending on the location of the tumor and whether it has spread, additional surgery may be required to remove portions of the affected organ or nearby lymph nodes.

Surgery can be done by either open or minimal invasive method to remove neuroendocrine tumors and nearby lymph nodes. In minimal invasive method, a laparoscope is inserted into the abdomen through a small incision. Benefits of minimal invasive method includes reduce postoperative pain, short hospital stay, less wound complications and faster recovery. Metastatic and recurrent disease

In certain circumstances, complete removal of the tumor may not be possible. Role of surgery in metastatic disease is to reduce the tumor mass and can be performed before or concomitantly with medical treatment. Other means of cytoreductive procedures are available, such as radiofrequency ablation, laser therapy and embolization of liver metastases.

Chemotherapy –

Cytotoxic treatment has been the standard for advanced neuroendocrine pancreatic tumors. The standard combination chemotherapy regimens include the following:

1. 5-FU, dacarbazine and epirubicin in standard or intensified dosage
2. Lomustine and 5-FU combination
3. streptozoocin ± 5-FU ± doxorubicin combinations
4. cisplatinum and etoposide combination for poorly differentiated endocrine pancreatic tumors.

Biological treatment –

Somatostatin analogues and a interferons has proved effective in control of associated clinical syndromes related to hormone production and release (carcinoid syndrome, gastrinoma, glucagonoma, etc.) in up to 60% of patients. Tumor-targeted radioactive treatment is an option in the selected group of patients with tumors that present a high grade of uptake of [111In] pentaoctreotide (octreoscan) scintigraphy.
Biological treatments with a promising prospect include sunitinib, everolimus and bevacizumab when associated with capecitabine and oxaliplatin.

MIBG Radiolabeled Therapy

Some neuroendocrine tumors absorb a hormone called norepinephrine. These tumors may respond to a nuclear medicine technique called MIBG radiolabeled therapy. In this treatment, the patient is given an intravenous dose of MIBG, a protein that is similar to norepinephrine and is attached to a radioactive substance. The MIBG is absorbed by the tumor, permitting the radioactive substance to selectively destroy tumor cells.


Patients should be followed at 3-monthly intervals during treatment with cytotoxic agents or biological therapy in order to assess response to treatment. Patients undergoing curative surgery should be followed every 3-6 months for at least 5 years in order to detect eventual surgically removable recurrences. Examination should include specific or non-specific biochemical markers depending on the associated (or lack of) clinical syndrome. Imaging is based on CT or MRI every 6 months.


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Preparing for Laparoscopic Surgery by Dr Pradeep Jain

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.

Laparoscopic Surgery

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.

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Carcinoma Esophagus – Esophageal Cancer Treatment In Delhi


Carcinoma Esophagus

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 0: Tis, N0, M0

Stage IA: T1, N0, M0

Stage IB:
T1, N0, M0
T2 or T3, N0, M0

Stage IIA:
T2 or T3, N0, M0
T2 or T3, N0, M0

Stage IIB:
T2 or T3, N0, M0
T1 or T2, N1, M0

Stage IIIA:
T1 or T2, N2, M0
T3, N1, M0
T4a, N0, M0

Stage IIIB:
T3, N2, M0

Stage IIIC:
T4a, N1 or N2, M0
T4b, any N, M0
any T, N3, M0

Stage IV : any T, any N, M1

Staging of adenocarcinoma of the esophagus

Stage 0: Tis, N0, M0

Stage IA: T1, N0, M0

Stage IB:
T1, N0, M0
T2, N0, M0

Stage IIA:
T2, N0, M0

Stage IIB: 
T3, N0, M0
T1 or T2, N1, M0

Stage IIIA:
T1 or T2, N2, M0
T3, N1, M0
T4a, N0, M0

Stage IIIB: 
T3, N2, M0

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 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.

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