Diagnostic staging laparoscopy (DSL) is performed to determine the feasibility of cancer resection and complement preoperative imaging with its limitations. DSL has a high accuracy and yield in detecting unresectable disease. It identifies patients who may benefit from neoadjuvant therapy rather than upfront surgery. The risk of complications from DSL is low at 0-2.5% morbidity and no mortality. Laparoscopic ultrasound can further aid staging but does not clearly offer advantages over laparoscopy alone. DSL provides important information to guide management decisions for gastrointestinal malignancies.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
Tips and Tricks in Laparoscopic Dissection of AdhesionsGeorge S. Ferzli
The document provides information on laparoscopic dissection of adhesions. It discusses the historical perspectives on adhesions, adhesion pathophysiology, prevention of adhesion formation, complications related to adhesions, results of laparoscopic adhesiolysis for small bowel obstruction, operating room set up, laparoscopic management indications and outcomes, laparoscopic approach, peritoneal access and potential trocar injury, optical access trocars, and recommended tools for adhesiolysis.
Past present future - laparoscopic colorectal surgerypiyushpatwa
Laparoscopic colorectal surgery has become widely adopted, with up to 60% of elective colectomies performed laparoscopically. While technically demanding, laparoscopic surgery has been shown to be associated with lesser pain, earlier recovery, and shorter hospital stays compared to open surgery. For colorectal cancer, large randomized controlled trials found no differences in oncologic outcomes between laparoscopic and open surgery. New technologies like single-incision laparoscopy, robotics, and natural orifice translumenal endoscopic surgery continue to expand the applicability of minimally invasive approaches for complex colorectal procedures.
1) Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that uses an endoscope passed through natural openings like the mouth, vagina, or anus to perform internal surgery without external incisions.
2) NOTES was first described in animal models in the early 2000s and the first human transgastric cholecystectomy was reported in 2007.
3) While offering advantages over laparoscopy by avoiding external incisions, NOTES faces challenges of developing improved flexible instruments, closing access sites without leaks, and standardizing safe techniques.
Artificial Intelligence & Robotic Surgery 1.pptxLuqman Osman
1) Robotic surgery uses robotic systems like the da Vinci robot to allow surgeons to operate remotely through telemanipulators or computer control, enabling more precise procedures.
2) Artificial intelligence and machine learning are being used to help guide surgical planning, perform autonomous procedures, and generate automated reports from analysis of surgical tasks and outcomes.
3) Deep learning models are being developed and applied to areas like object detection, image classification, and segmentation to help analyze medical images and assess surgical skills.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Minimal invasive Surgery in Management of colorectal cancerpiyushpatwa
Laparoscopic Anterior resection. After insertion of ports with patient in steep trendelenburg position Inferior mesenteric artery was identified and high ligation done with division of left colic artery and then medial to lateral dissection was done. Subsequently inferior mesenteric vein was dissected and clipped and divided. Distal dissection proceeded just behind the superior rectal artery and after identification and preservation of the hypogastric nerves, upper rectum was mobilised. Division of bowel was done at upper rectum after giving adequate distal margin and end to end anastomosis was done using circular stapler.
Tips and Tricks in Laparoscopic Dissection of AdhesionsGeorge S. Ferzli
The document provides information on laparoscopic dissection of adhesions. It discusses the historical perspectives on adhesions, adhesion pathophysiology, prevention of adhesion formation, complications related to adhesions, results of laparoscopic adhesiolysis for small bowel obstruction, operating room set up, laparoscopic management indications and outcomes, laparoscopic approach, peritoneal access and potential trocar injury, optical access trocars, and recommended tools for adhesiolysis.
Past present future - laparoscopic colorectal surgerypiyushpatwa
Laparoscopic colorectal surgery has become widely adopted, with up to 60% of elective colectomies performed laparoscopically. While technically demanding, laparoscopic surgery has been shown to be associated with lesser pain, earlier recovery, and shorter hospital stays compared to open surgery. For colorectal cancer, large randomized controlled trials found no differences in oncologic outcomes between laparoscopic and open surgery. New technologies like single-incision laparoscopy, robotics, and natural orifice translumenal endoscopic surgery continue to expand the applicability of minimally invasive approaches for complex colorectal procedures.
1) Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that uses an endoscope passed through natural openings like the mouth, vagina, or anus to perform internal surgery without external incisions.
2) NOTES was first described in animal models in the early 2000s and the first human transgastric cholecystectomy was reported in 2007.
3) While offering advantages over laparoscopy by avoiding external incisions, NOTES faces challenges of developing improved flexible instruments, closing access sites without leaks, and standardizing safe techniques.
Artificial Intelligence & Robotic Surgery 1.pptxLuqman Osman
1) Robotic surgery uses robotic systems like the da Vinci robot to allow surgeons to operate remotely through telemanipulators or computer control, enabling more precise procedures.
2) Artificial intelligence and machine learning are being used to help guide surgical planning, perform autonomous procedures, and generate automated reports from analysis of surgical tasks and outcomes.
3) Deep learning models are being developed and applied to areas like object detection, image classification, and segmentation to help analyze medical images and assess surgical skills.
Natural Orifice Transluminal Endoscopic Surgery, NOTES.
"scarless" abdominal surgery with an endoscope passed through a natural orifice (MOUTH, URETHRA, ANUS, VAGINA) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.
Gastric cancer causes over 10,000 deaths per year in the United States. Surgical resection with D2 lymphadenectomy is the standard treatment and improves survival compared to D1 lymphadenectomy. Adjuvant chemotherapy or chemoradiation after surgery has also been shown to improve survival for locally advanced gastric cancer. Minimally invasive approaches for gastric cancer resection have been shown to be as effective as open surgery with benefits of reduced blood loss, shorter hospital stays, and improved quality of life.
this is early experiences of laparoscopic adrenal tumor removal in cmh Rawalpindi Pakistan which need more focus and innovation . it is less pain full and early recovery ensuere
This document discusses the history and essentials of laparoscopy, also known as minimally invasive surgery. Some of the key points covered include:
- Laparoscopy was pioneered in the early 1900s but gained popularity in the 1980s when procedures like laparoscopic cholecystectomy were developed.
- It allows surgeons to access the abdominal cavity through small incisions rather than large incisions, reducing trauma and recovery time for patients.
- Modern laparoscopy utilizes specialized instruments, high-definition cameras, 3D/4K imaging, and robotic systems to give surgeons better visualization and precision.
- It is now used diagnostically and therapeutically for many abdominal procedures, with
NOTES (Natural Orifice Transluminal Endoscopic Surgery)- By Dr. Onkardronkarsingh
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an experimental surgical technique that performs abdominal operations through natural orifices like the mouth, urethra, anus or vagina without external incisions. NOTES aims to reduce surgical trauma and pain for patients by avoiding incisions. It also shortens recovery time and eliminates risks of complications from external incisions like infections and hernias. While still in development, NOTES shows promise as a less invasive future of surgery.
Presentation describing surgical technique and principles of anastomosis, factors for good healing in the post operative phase, risk factors for leak and the role of staplers in modern day surgical practice, advantages over hand sewn anastomosis.
It has not changed the nature of disease
The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise
If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach
The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound.
We actually do not know what is there stored for us, but we believe that laparoscopy is trending towards advancement and nano and robotic technology is going to replace in future.
3D cameras have come into existence and various newer technologies are being invented.
EUS can be used to stage cancers of the esophagus, stomach, rectum, lung and diagnose pancreatic cancer. It allows evaluation of abnormalities in the GI tract wall and adjacent structures. EUS guided FNA biopsy enables cytopathological diagnosis of cancers and nodal metastases. EUS is well-suited for TNM tumor staging as it can assess depth of tumor penetration, locoregional nodal spread and vascular invasion. It also has applications in diagnosis of cholangiocarcinoma, evaluation of pancreatic cysts and masses, and celiac plexus neurolysis for pain relief.
This document discusses laparoscopic common bile duct exploration (LCBDE) for the treatment of CBD stones. It outlines the advantages of the laparoscopic approach, including reduced costs, hospitalization and recovery time compared to open surgery. It describes the two main laparoscopic techniques for CBD stone removal - trans-cystic duct approach and laparoscopic choledochotomy. Key factors that determine technique selection include stone size and location, cystic/CBD duct anatomy and size, and surgeon skill. Standard port placements and step-by-step descriptions of each technique are provided. Complications are discussed. The document concludes with a brief overview of bilioenteric bypass indications and options.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
Minimally invasive surgery uses small incisions and miniaturized imaging systems to perform major operations with less trauma than traditional open surgery. The techniques were developed starting in the early 1900s and improved with advances like rod lens endoscopes, flexible instruments, and fluoroscopic imaging. Laparoscopic surgery involves inflating the abdominal cavity with gas to provide space to see and operate. Thoracoscopy may require deflating one lung. Other minimally invasive techniques provide access through subcutaneous tissues or body cavities without requiring incisions into organs. Endoluminal and intraluminal procedures operate from within lumens like blood vessels or the digestive tract.
This document discusses the management of colon cancers. It covers various treatment options including surgery, chemotherapy, and radiation therapy depending on the stage of cancer. For stage III colon cancer, adjuvant chemotherapy with FOLFOX or CapeOx is preferred after surgery to improve disease-free and overall survival based on clinical trials. Surgery aims to do an R0 resection with adequate margins and lymph node sampling. Laparoscopic surgery has comparable oncologic outcomes to open surgery.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
This presentation of introduction of laparoscopic surgery made by Dr. R.K. Mishra Director and chief surgeon World Laparoscopy Hospital. Dr. Mishra in this presentation has explained present pas and future of laparoscopic surgery. Laparoscopy is a surgical procedure which uses a special surgical instrument called a laparoscope to look inside the body, or to perform certain operations. World Laparoscopy Hospital is the center of excellence for laparoscopic and da vinci robotic surgery training and considered as one of the best institute in the world. For more detail about laparoscopic surgery please visit: http://www.laparoscopyhospital.com
1. A matched retrospective study found that breast-conserving therapy (BCT) performed for eligible patients is as effective as modified radical mastectomy (MRM) with respect to local tumor control, disease-free survival, and distant disease-free survival.
2. BCT may be a superior treatment option for most Chinese primary breast cancer patients.
3. The document provides details on the surgical techniques for different levels of axillary lymph node dissection.
Baseball diamond concept for port position in laparoscopyJibran Mohsin
1) The document proposes the "Baseball Diamond Concept" for optimal port placement in laparoscopy, with three main principles: the primary port and working ports should be placed with half the instrument inside and half outside the abdomen; the primary port should be positioned between the working ports to allow for depth perception; and the manipulation angle between working instruments should be approximately 60 degrees.
2) It explains the rationales for each principle, including lever mechanics, elevation angles, avoidance of direct coupling between instruments and ports, and optimal depth perception with a contralateral primary port position.
3) Guidelines are provided for measuring and applying the concepts based on the target of dissection and average instrument lengths and hand sizes.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Recurrent rectal cancer is common even after treatment by experts. It can recur locally in up to 10% of patients after primary cancer resection. Management of recurrence aims to improve quality of life through symptom control, prolong survival, and provide a cure when possible with minimal morbidity. Radical resection of the recurrent tumor is crucial for long-term cure, but only 20-30% of patients with recurrent rectal cancer will have a potentially curative operation due to the need for an R0 resection. Five-year cancer-specific survival is 44% for patients who have a complete R0 resection but only 26% and 10% for R1 and R2 resections, respectively. Neoadjuvant chemoradiation
1) Advances in the management of pancreatic cancers including improved preoperative assessment using CT, MRI, EUS and PET scans to determine resectability.
2) Surgical approaches to resectable pancreatic cancer including pylorus-preserving versus standard Whipple procedure and debates around extent of lymphadenectomy.
3) Outcomes have modestly improved with resection rates around 20%, operative mortality of 9% and 5 year survival of 12%, though pancreatic cancer prognosis remains poor.
Natural Orifice Transluminal Endoscopic Surgery, NOTES.
"scarless" abdominal surgery with an endoscope passed through a natural orifice (MOUTH, URETHRA, ANUS, VAGINA) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars.
Gastric cancer causes over 10,000 deaths per year in the United States. Surgical resection with D2 lymphadenectomy is the standard treatment and improves survival compared to D1 lymphadenectomy. Adjuvant chemotherapy or chemoradiation after surgery has also been shown to improve survival for locally advanced gastric cancer. Minimally invasive approaches for gastric cancer resection have been shown to be as effective as open surgery with benefits of reduced blood loss, shorter hospital stays, and improved quality of life.
this is early experiences of laparoscopic adrenal tumor removal in cmh Rawalpindi Pakistan which need more focus and innovation . it is less pain full and early recovery ensuere
This document discusses the history and essentials of laparoscopy, also known as minimally invasive surgery. Some of the key points covered include:
- Laparoscopy was pioneered in the early 1900s but gained popularity in the 1980s when procedures like laparoscopic cholecystectomy were developed.
- It allows surgeons to access the abdominal cavity through small incisions rather than large incisions, reducing trauma and recovery time for patients.
- Modern laparoscopy utilizes specialized instruments, high-definition cameras, 3D/4K imaging, and robotic systems to give surgeons better visualization and precision.
- It is now used diagnostically and therapeutically for many abdominal procedures, with
NOTES (Natural Orifice Transluminal Endoscopic Surgery)- By Dr. Onkardronkarsingh
Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an experimental surgical technique that performs abdominal operations through natural orifices like the mouth, urethra, anus or vagina without external incisions. NOTES aims to reduce surgical trauma and pain for patients by avoiding incisions. It also shortens recovery time and eliminates risks of complications from external incisions like infections and hernias. While still in development, NOTES shows promise as a less invasive future of surgery.
Presentation describing surgical technique and principles of anastomosis, factors for good healing in the post operative phase, risk factors for leak and the role of staplers in modern day surgical practice, advantages over hand sewn anastomosis.
It has not changed the nature of disease
The basic principles of good surgery still apply,including appropriate case selection, excellent exposure,adequate retraction and a high level technical expertise
If a procedure makes no sense with conventional access, it will make no sense with a minimal access approach
The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convalescence,the more exquisite his healed wound.
We actually do not know what is there stored for us, but we believe that laparoscopy is trending towards advancement and nano and robotic technology is going to replace in future.
3D cameras have come into existence and various newer technologies are being invented.
EUS can be used to stage cancers of the esophagus, stomach, rectum, lung and diagnose pancreatic cancer. It allows evaluation of abnormalities in the GI tract wall and adjacent structures. EUS guided FNA biopsy enables cytopathological diagnosis of cancers and nodal metastases. EUS is well-suited for TNM tumor staging as it can assess depth of tumor penetration, locoregional nodal spread and vascular invasion. It also has applications in diagnosis of cholangiocarcinoma, evaluation of pancreatic cysts and masses, and celiac plexus neurolysis for pain relief.
This document discusses laparoscopic common bile duct exploration (LCBDE) for the treatment of CBD stones. It outlines the advantages of the laparoscopic approach, including reduced costs, hospitalization and recovery time compared to open surgery. It describes the two main laparoscopic techniques for CBD stone removal - trans-cystic duct approach and laparoscopic choledochotomy. Key factors that determine technique selection include stone size and location, cystic/CBD duct anatomy and size, and surgeon skill. Standard port placements and step-by-step descriptions of each technique are provided. Complications are discussed. The document concludes with a brief overview of bilioenteric bypass indications and options.
Bile duct injury is a rare but potentially devastating complication of cholecystectomy that can result in biliary peritonitis, sepsis, and cirrhosis. It is most commonly caused by misidentification of structures during laparoscopic cholecystectomy. Management involves controlling infection, delineating biliary anatomy, and reestablishing biliary drainage, usually through surgical hepaticojejunostomy. Prevention relies on identification of anatomical variations, achieving a "critical view of safety" before duct division, and open conversion if needed. Proper management requires a multidisciplinary approach between surgeons, radiologists, and gastroenterologists.
Minimally invasive surgery uses small incisions and miniaturized imaging systems to perform major operations with less trauma than traditional open surgery. The techniques were developed starting in the early 1900s and improved with advances like rod lens endoscopes, flexible instruments, and fluoroscopic imaging. Laparoscopic surgery involves inflating the abdominal cavity with gas to provide space to see and operate. Thoracoscopy may require deflating one lung. Other minimally invasive techniques provide access through subcutaneous tissues or body cavities without requiring incisions into organs. Endoluminal and intraluminal procedures operate from within lumens like blood vessels or the digestive tract.
This document discusses the management of colon cancers. It covers various treatment options including surgery, chemotherapy, and radiation therapy depending on the stage of cancer. For stage III colon cancer, adjuvant chemotherapy with FOLFOX or CapeOx is preferred after surgery to improve disease-free and overall survival based on clinical trials. Surgery aims to do an R0 resection with adequate margins and lymph node sampling. Laparoscopic surgery has comparable oncologic outcomes to open surgery.
ACHALASIA CARDIA: ENDOSCOPIC THERAPY (POEM)Dr Amit Dangi
POEM is a highly effective treatment for achalasia, providing long-term symptom relief in over 90% of patients. Studies have shown POEM to have similar efficacy to laparoscopic Heller myotomy with benefits including shorter procedure time, less pain, and shorter hospital stay. POEM allows for a longer myotomy and more complete treatment of achalasia compared to Heller myotomy and has been shown to be particularly effective for type 3 achalasia. While short-term complications are low, concerns remain around POEM's learning curve. Further research is still needed regarding its use in special cases like sigmoid achalasia and treatment failure patients.
This presentation of introduction of laparoscopic surgery made by Dr. R.K. Mishra Director and chief surgeon World Laparoscopy Hospital. Dr. Mishra in this presentation has explained present pas and future of laparoscopic surgery. Laparoscopy is a surgical procedure which uses a special surgical instrument called a laparoscope to look inside the body, or to perform certain operations. World Laparoscopy Hospital is the center of excellence for laparoscopic and da vinci robotic surgery training and considered as one of the best institute in the world. For more detail about laparoscopic surgery please visit: http://www.laparoscopyhospital.com
1. A matched retrospective study found that breast-conserving therapy (BCT) performed for eligible patients is as effective as modified radical mastectomy (MRM) with respect to local tumor control, disease-free survival, and distant disease-free survival.
2. BCT may be a superior treatment option for most Chinese primary breast cancer patients.
3. The document provides details on the surgical techniques for different levels of axillary lymph node dissection.
Baseball diamond concept for port position in laparoscopyJibran Mohsin
1) The document proposes the "Baseball Diamond Concept" for optimal port placement in laparoscopy, with three main principles: the primary port and working ports should be placed with half the instrument inside and half outside the abdomen; the primary port should be positioned between the working ports to allow for depth perception; and the manipulation angle between working instruments should be approximately 60 degrees.
2) It explains the rationales for each principle, including lever mechanics, elevation angles, avoidance of direct coupling between instruments and ports, and optimal depth perception with a contralateral primary port position.
3) Guidelines are provided for measuring and applying the concepts based on the target of dissection and average instrument lengths and hand sizes.
A multidisciplinary approach that includes surgery, medical oncology, and radiation oncology is required for optimal treatment of patients with rectal cancer
Recurrent rectal cancer is common even after treatment by experts. It can recur locally in up to 10% of patients after primary cancer resection. Management of recurrence aims to improve quality of life through symptom control, prolong survival, and provide a cure when possible with minimal morbidity. Radical resection of the recurrent tumor is crucial for long-term cure, but only 20-30% of patients with recurrent rectal cancer will have a potentially curative operation due to the need for an R0 resection. Five-year cancer-specific survival is 44% for patients who have a complete R0 resection but only 26% and 10% for R1 and R2 resections, respectively. Neoadjuvant chemoradiation
1) Advances in the management of pancreatic cancers including improved preoperative assessment using CT, MRI, EUS and PET scans to determine resectability.
2) Surgical approaches to resectable pancreatic cancer including pylorus-preserving versus standard Whipple procedure and debates around extent of lymphadenectomy.
3) Outcomes have modestly improved with resection rates around 20%, operative mortality of 9% and 5 year survival of 12%, though pancreatic cancer prognosis remains poor.
Indications to CTC are increasing
CTC is recommended in all cases of unfeasibility of colonoscopy
CTC is not ready for mass screening but is ideal for screening on an individual basis.
Ca Pancreas is a systemic disease from the outset, with metastasis often present even after curative resection. Diagnosis typically occurs late, with only 5% of patients surviving 5 years. Imaging tools like CT, EUS, and MRI are used to determine resectability and stage the cancer. Biopsy and tumor markers help establish the diagnosis, while ERCP can provide palliative biliary stenting. Despite improved imaging, there are currently no effective screening strategies due to the disease's asymptomatic nature and non-specific presentation until late stages.
This document summarizes information about different screening and diagnostic tests for colorectal cancer. It notes that colonoscopy is currently the best method, but that it requires high adenoma detection rates, especially for right-sided cancers, and must also detect serrated lesions which can be precursors to cancer. CT colonography's accuracy varies by location and radiologist skill in detecting polyps and serrated lesions. Capsule endoscopy has potential but currently misses some cancers. Improving techniques aim to enhance detection rates for all methods and better identify serrated lesions, which require careful follow up colonoscopy.
This study investigated long-term survival outcomes of 320 patients who underwent radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) or colorectal liver metastases (CLM) between 1999-2010. Minimum 5-year follow-up data was available for 89% of patients, with median follow-up of 115.3 months. For HCC patients, 5-year and 10-year overall survival rates were 38.5% and 23.4%. For CLM patients, 5-year and 10-year overall survival rates were 27.6% and 15%. The study concludes RFA can provide 10-year overall survival rates of over 23% for HCC and 15% for CLM
Gallbladder carcinoma is fifth most common gastrointestinal malignancy. Main indication for cholecystectomy is gallstone disease. Majority of gallbladder carcinomas are diagnosed during the course of histopathological evaluation of specimens obtained at cholecystectomy. Accomplishing radical cholecystectomy is advisable in these patients. Technically difficult gallbladder dissection during the course of laparoscopic surgery should raise a high suspicion of malignancy. Specimen retrieval bags should be used in all cases to avoid external spillage of bile giving rise to port side metastasis. A good outcome depends on prompt diagnosis and radical surgical resection. It is essential for a general surgeon to be aware of predisposing factors, pathology, patterns of presentation, and surgical options in gallbladder carcinoma.
This document discusses the management of gallbladder cancer. It covers diagnosis, staging, and surgical treatment approaches based on tumor stage. For early stage T1a tumors found incidentally after cholecystectomy, simple cholecystectomy may be adequate. For T1b and T2 tumors, radical resection including lymph node dissection is recommended due to higher risk of residual disease and lymph node involvement. For locally advanced T3/T4 or node positive cancers, radical surgery with hepatic resection or multi-organ resection is supported, though morbidity and mortality are high; N2 node involvement carries a poor prognosis. Staging laparoscopy is important to identify unresectable disease not apparent on imaging.
This study aimed to determine if specific computed tomography (CT) scan features could predict the need for operative management in patients with nonstrangulating small bowel obstruction (SBO). The researchers reviewed CT scans of 63 patients with SBO and found that the presence of a transition point had the strongest association with requiring surgery. A transition point indicates a distinct change in bowel caliber from dilated to collapsed segments. On multivariable analysis, a transition point was the only CT feature that significantly predicted operative intervention. The presence of a transition point on CT should alert surgeons to an increased likelihood that a patient with nonstrangulating SBO may need surgery.
Detailed Seminar on Carcinoma Pancreas with -
Anatomy, Epidemiology, Enteropathogenesis, Pathology, Staging , Diagnostic workup and different modalities of Treatment
Improving early detection of gastric cancer a novel systematic alphanumeric c...Alex Mauricio
This document discusses a novel systematic alphanumeric-coded endoscopic approach called SACE for improving early detection of gastric cancer. SACE facilitates a complete examination of the upper GI tract using sequential overlapping photo-documentation and an alphanumeric coding system to identify eight regions and 28 areas of the stomach surface. SACE also incorporates a simple coordinate system using anatomical landmarks to precisely locate normal and abnormal areas. The effectiveness of SACE was demonstrated in a screening study that diagnosed early gastric cancer in 0.30% of healthy subjects. Implementing SACE worldwide could significantly improve early detection of gastric cancer.
Laparoscopic radical gastrectomy for gastric cancer management is feasible in highly complex centers with advanced laparoscopic service with comparable oncological results to open procedures with free margins, adequate lymph node count, with a low complication rate and very low recurrence rate.
There are several risks associated with poor colorectal lesion localization, the most significant being wrong site surgery. Endoscopic tattooing can help mitigate these risks with an easy, fast method for the gastroenterologist to employ and a clear, precise marker for the surgeon to visualize.
Colorectal cancer (CRC) has potential to spread within the peritoneal cavity, and this transcoelomic
dissemination is termed “peritoneal metastases” (PM).The aim of this article was to summarise the current
evidence regarding CRC patients at high risk of PM. Colorectal cancer is the second most common cause of cancer
death in the UK. Prompt investigation of suspicious symptoms is important, but there is increasing evidence that
screening for the disease can produce significant reductions in mortality.High quality surgery is of paramount
importance in achieving good outcomes, particularly in rectal cancer, but adjuvant radiotherapy and chemotherapy
have important parts to play. The treatment of advanced disease is still essentially palliative, although surgery for
limited hepatic metastases may be curative in a small proportion of patients.
Information about Obstructed Recto Sigmoid Malignancy by Dr Dhaval Mangukiya.
Details of introduction of obstructed recto sigmoid malignancy, Epidemiology, Pathophysiology, Complications, Early Presentation, Stools, History, Late Presentation, Diagnosis, Imaging, Contrast enema, Screenig, Treatment, Management, Surgical management, Surgical options etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
Ntc dr muthusamy bridge to surgery talk final 6 18MUCINGroup
This document discusses endoscopic evaluation and staging of pancreatic cancer. It begins by outlining the algorithm for evaluating suspected pancreatic cancer with CT/MRI and EUS. Key questions after detecting a pancreatic mass include determining resectability and predicting tumor stage. Stages are defined as resectable, borderline, locally advanced, and metastatic based on criteria such as vascular involvement. Examples of EUS images illustrating resectable, locally advanced, and borderline resectable cancers are provided. The document concludes that neoadjuvant therapy is increasingly used for borderline resectable pancreatic cancer and requires durable biliary drainage during treatment.
Barrett's esophagus is a condition where the normal squamous epithelium of the esophagus is replaced by intestinal metaplastic columnar epithelium. It is considered a precursor to esophageal adenocarcinoma and is graded based on the presence and degree of dysplasia. Endoscopic screening and surveillance is recommended depending on the grade of dysplasia. Endoscopic resection and ablation techniques can be used to treat dysplastic Barrett's esophagus and early esophageal cancers. Esophageal cancer staging involves endoscopic ultrasound and biopsy while endoscopic therapies including resection, ablation, dilation and stenting can treat esophageal cancers with curative or palliative intent.
Laparoscopic surgery for small bowel tumoursforegutsurgeon
This document discusses the role of laparoscopic surgery for small bowel tumors. It outlines that laparoscopy can be used for diagnosis, staging, and in some cases curative resection of small bowel tumors, extending techniques used for gastric and colorectal cancers. Specific tumor types that may be suitable for laparoscopic resection include gastrointestinal stromal tumors and adenocarcinomas. The document reviews techniques for laparoscopic resection and anastomosis of different small bowel segments.
Acs0535 Procedures For Rectal Cancer 2004medbookonline
This document discusses procedures for treating rectal cancer. It begins by outlining the goals of treatment which are to cure or control the cancer, maintain bowel continuity and function, and minimize morbidity. A variety of treatment regimens are available from local excision to multimodality therapy involving chemoradiation and surgery. The key steps in treatment are preoperative evaluation and staging of the cancer, determination of the surgical approach and postoperative care. Modern treatment often involves multimodality therapy with chemoradiation before and after surgery.
This document discusses several non-specific surgical infections including syphilis, gonorrhea, cancrum oris, anthrax, and actinomycosis. It provides details on the causative agents, transmission, clinical presentation, diagnosis, and treatment of each infection. Key points covered include that syphilis and gonorrhea are sexually transmitted bacterial infections, cancrum oris is a rapidly progressive infection more common in immunocompromised individuals, while anthrax causes skin, respiratory, or intestinal illness depending on transmission route.
This document provides an overview of the spleen, splenic injuries, and approaches to splenic surgery. It describes the spleen's anatomy, vascular supply, functions, and types of injuries. For splenic injuries, it discusses evaluation with FAST and CT scans, injury grading scales, and management approaches like angiography, embolization, splenorrhaphy versus splenectomy. It then covers surgical techniques for open and laparoscopic splenectomy, including positioning, mobilization, hilar dissection and hemostasis. Postoperative risks are also summarized.
Cleft lip and palate beliefs vary globally and are often tied to cultural and religious beliefs about causation. In many areas, clefts are believed to be acts of God, punishment for ancestral sins, or caused by spirits or witchcraft. These beliefs can influence treatment decisions and cause feelings of shame. Understanding local beliefs is important for providing culturally-sensitive care.
This document provides information on fistula-in-ano, including its anatomy, classification, clinical assessment, imaging studies, and management. It begins with descriptions of the anal region anatomy and then defines a fistula-in-ano. It classifies fistulas based on Parks' classification and as simple or complex. Treatment depends on the classification and may include fistulotomy, seton placement, or advances flaps to drain infection while preserving sphincter function. The goal is to eradicate the fistula tract without recurrence and incontinence.
1. Pancreatic cystic neoplasms include serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms.
2. Mucinous cystic neoplasms present as large septated cysts more commonly in young women and have thick irregular walls that may contain calcifications. Surgical resection is the treatment of choice.
3. Serous cystic neoplasms typically appear as well-circumscribed masses composed of numerous small cysts and have a characteristic honeycomb appearance. They generally have an excellent prognosis with surgical resection reserved for symptomatic cases.
This randomized controlled trial compared early laparoscopic cholecystectomy (within 24 hours of presentation) to delayed cholecystectomy (after clinical resolution) for patients with predicted mild gallstone pancreatitis. The study found that early cholecystectomy significantly reduced hospital length of stay (16 hours vs 43 hours) and rates of ERCP procedures (15% vs 29%) compared to delayed cholecystectomy. However, early cholecystectomy was associated with a higher risk of minor complications. Limitations included the inability to accurately predict pancreatitis severity early on and the study being conducted at a single center.
This document summarizes information about hydatid cysts, which are caused by infection with the larval stage of the Echinococcus tapeworm. It describes the lifecycle of E. granulosus and how humans can become infected through contact with dog feces. Hydatid cysts most commonly form in the liver and lungs, and may grow slowly over many years without symptoms. Clinical features depend on the infected organ and size of cysts. Imaging tests and serology can help diagnose cysts, while treatment involves antiparasitic drugs, percutaneous drainage, or surgical removal based on cyst type and location. Close follow up is needed due to risk of recurrence.
This document provides an overview of mesenteric ischemia, including its various types, risk factors, clinical features, diagnosis, and management. It begins with definitions of relevant terms like ischemia, infarction, embolism, and thrombosis. It then describes the different types of mesenteric ischemia - acute, chronic, and non-occlusive. For each type, it outlines typical causes, risk factors, clinical presentations, diagnostic approaches, and treatment options, which may involve endovascular or open surgical revascularization procedures. It concludes by noting the generally poor prognosis of acute mesenteric ischemia but improved outcomes with timely diagnosis and treatment.
This document discusses raised intracranial pressure (ICP) and its physiology. It notes that unchecked elevated ICP can lead to herniation and brain death. ICP is determined by a balance of cerebrospinal fluid volume, cerebral blood volume, and brain parenchyma. Increased volume in one compartment must be compensated by decreases in others. Elevated ICP decreases cerebral perfusion pressure and blood flow, which can cause ischemia. Herniation syndromes like central transtentorial and uncal herniation can occur if pressure gradients are not relieved. Symptoms of increased ICP include headache, vomiting, and papilledema.
This document provides an overview of mesenteric ischemia. It begins by describing the arterial blood supply to the gut and then introduces and classifies mesenteric ischemia. The main causes are arterial embolism, thrombosis, venous thrombosis, and non-occlusive ischemia. Clinical features are nonspecific abdominal pain but diagnosis involves imaging like CT angiography. Management involves gastrointestinal decompression, fluid resuscitation, antibiotics, and revascularization through endovascular or open techniques. Prognosis is poor with acute mesenteric ischemia having a mortality over 60%.
1. Pre-operative preparation begins at initial patient contact and aims to optimize patient outcomes through thorough assessment, medical optimization, risk evaluation, and informed consent.
2. A complete history, physical exam, and relevant lab/imaging investigations are used to evaluate any medical issues and surgical risks. Comorbidities like cardiovascular or respiratory diseases require specialized management.
3. High-risk patients undergo detailed optimization, including treating infections, stabilizing medications, and potentially admitting to critical care post-operatively. Proper pre-op skin/hair preparation, antibiotic prophylaxis timing, and elimination help reduce surgical site infections.
Meningiomas are the most common benign brain tumors. They originate from the meninges and are usually benign, though some can be atypical or malignant. Complete surgical resection is the primary treatment and aims for Simpson Grade I removal. Factors like tumor location, size, and shape impact recurrence risk. While radiation can be used for incomplete resection or recurrence, no medical therapies have significantly impacted meningioma progression. Careful preoperative planning including vascular imaging is important. Total resection is often achievable with meticulous dissection at the tumor-arachnoid interface while avoiding overzealous coagulation. Extended endoscopic approaches have higher complication risks than traditional microsurgery. Case examples demonstrated total resection of meningi
Optimization Of High Risk Surgical PatientsKIST Surgery
1. Preoperative optimization of high surgical risk patients can reduce morbidity and mortality by identifying risks and managing coexisting medical conditions.
2. Key aspects of preoperative assessment and optimization include evaluating cardiac, respiratory, gastrointestinal and other systemic risks; optimizing management of conditions like diabetes and coagulopathies; and considering perioperative strategies like goal-directed therapy.
3. High risk patients who may benefit from postoperative critical care admission include those with predicted mortality over 5% or who contribute disproportionately to postoperative deaths.
This document discusses intestinal ischemia, which occurs when blood flow to the intestines is reduced. It can affect the small or large intestine and be caused by arterial occlusion, venous occlusion, or vasospasm. Intestinal ischemia is classified based on time of onset, symptoms, degree of blood flow compromise, and affected bowel segment. The main types are acute mesenteric ischemia, chronic mesenteric ischemia, and non-occlusive mesenteric ischemia (NOMI). Clinical features vary depending on type but may include abdominal pain, nausea, vomiting, and bloody stool. Diagnosis involves imaging like CT angiography. Treatment involves resuscitation, antibiotics, pain control, and revascularization through open surgery or endovascular techniques
This document provides an overview of intestinal obstruction, including classification, pathophysiology, causes, diagnosis, and treatment. It discusses the different types of intestinal obstruction including dynamic, adynamic, small bowel, and large bowel obstruction. Common causes of mechanical small and large bowel obstruction are described. The diagnostic evaluation focuses on distinguishing mechanical obstruction from ileus and determining the etiology, degree, and nature of the obstruction. Treatment involves fluid resuscitation, gastrointestinal drainage, antibiotics, and potentially surgical intervention depending on the severity and nature of the obstruction.
Intravenous Fluids In Surgical PatientsKIST Surgery
1) There are two main types of intravenous fluids used in surgical patients - crystalloids and colloids. Crystalloids contain electrolytes dissolved in water, while colloids contain larger soluble molecules that remain in the blood vessels.
2) The goals of fluid therapy are to maintain adequate intravascular volume based on the patient's fluid needs, deficits, and losses. Fluid requirements are calculated based on formulas accounting for maintenance needs and replacing ongoing losses.
3) Enhanced Recovery After Surgery (ERAS) protocols aim to optimize fluid management in the preoperative, intraoperative and postoperative periods by restricting unnecessary fluids to reduce complications like ileus.
This document discusses different types of intracranial hematomas including epidural hematomas, subdural hematomas, and intracerebral hematomas. Epidural hematomas are usually caused by skull fractures that tear dural arteries. Subdural hematomas most commonly result from tearing of bridging veins during angular head acceleration. Intracerebral hematomas are associated with extensive cortical contusions that disrupt larger brain vessels. Surgical evacuation is often indicated for large or expanding hematomas causing increased intracranial pressure.
This journal club presentation summarizes a randomized clinical trial comparing Lichtenstein open mesh hernia repair versus laparoscopic TAPP repair. The study found that laparoscopic TAPP repair resulted in less postoperative pain, fewer complications, and shorter hospital stay compared to open repair. However, the study had limitations in generalizability and did not account for all possible postoperative complications. Overall, the randomized trial provided evidence that laparoscopic TAPP repair may offer advantages over open repair for unilateral inguinal hernias.
- Single stage laparoscopic CBD exploration and cholecystectomy was compared to two stage ERCP followed by laparoscopic cholecystectomy for patients with gallbladder and CBD stones.
- The study found single stage management had fewer postoperative complications, shorter hospital stay, lower costs, and higher patient satisfaction compared to two stage management.
- However, two stage management had more morbidity and mortality risks associated with ERCP including acute pancreatitis, perforation, and death.
This document summarizes benign breast disorders. It begins with embryology and anatomy of the breast. It then discusses various benign breast conditions such as fibroadenomas, breast cysts, periductal mastitis, papillomas and sclerosing adenosis. It provides details on clinical features, investigations, diagnosis and management of these common benign breast disorders. Specific imaging findings and histopathological characteristics are also highlighted. The document serves as a comprehensive review of benign breast conditions for medical residents.
As the world population is aging, Health tourism has become vitally important and will be increased day by day. Because
of the availability of quality health services and more favorable prices as well as to shorten the waiting list for medical
services regionally and internationally. There are some aspects of managing and doing marketing activities in order for
medical tourism to be feasible, in a region called as clustering in a region with main stakeholders groups includes Health
providers, Tourism cluster, etc. There are some related and affecting factors to be considered for the feasibility of medical
tourism within this study such as competitiveness, clustering, Entrepreneurship, SMEs. One of the growth phenomenon
is Health tourism in the city of Izmir and Turkey. The model of five competitive forces of Porter and The Diamond model
that is an economical model that shows the four main factors that affect the competitiveness of a nation and its industries
in this study. The short literature of medical tourism and regional clustering have been mentioned.
BBB and BCF
control the entry of compounds into the brain and
regulate brain homeostasis.
restricts access to brain cells of blood–borne compounds and
facilitates nutrients essential for normal metabolism to reach brain cells
Nutritional deficiency Disorder are problems in india.
It is very important to learn about Indian child's nutritional parameters as well the Disease related to alteration in their Nutrition.
This presentation gives information on the pharmacology of Prostaglandins, Thromboxanes and Leukotrienes i.e. Eicosanoids. Eicosanoids are signaling molecules derived from polyunsaturated fatty acids like arachidonic acid. They are involved in complex control over inflammation, immunity, and the central nervous system. Eicosanoids are synthesized through the enzymatic oxidation of fatty acids by cyclooxygenase and lipoxygenase enzymes. They have short half-lives and act locally through autocrine and paracrine signaling.
Can Traditional Chinese Medicine Treat Blocked Fallopian Tubes.pptxFFragrant
There are many traditional Chinese medicine therapies to treat blocked fallopian tubes. And herbal medicine Fuyan Pill is one of the more effective choices.
Storyboard on Acne-Innovative Learning-M. pharm. (2nd sem.) CosmeticsMuskanShingari
Acne is a common skin condition that occurs when hair follicles become clogged with oil and dead skin cells. It typically manifests as pimples, blackheads, or whiteheads, often on the face, chest, shoulders, or back. Acne can range from mild to severe and may cause emotional distress and scarring in some cases.
**Causes:**
1. **Excess Oil Production:** Hormonal changes during adolescence or certain times in adulthood can increase sebum (oil) production, leading to clogged pores.
2. **Clogged Pores:** When dead skin cells and oil block hair follicles, bacteria (usually Propionibacterium acnes) can thrive, causing inflammation and acne lesions.
3. **Hormonal Factors:** Fluctuations in hormone levels, such as during puberty, menstrual cycles, pregnancy, or certain medical conditions, can contribute to acne.
4. **Genetics:** A family history of acne can increase the likelihood of developing the condition.
**Types of Acne:**
- **Whiteheads:** Closed plugged pores.
- **Blackheads:** Open plugged pores with a dark surface.
- **Papules:** Small red, tender bumps.
- **Pustules:** Pimples with pus at their tips.
- **Nodules:** Large, solid, painful lumps beneath the surface.
- **Cysts:** Painful, pus-filled lumps beneath the surface that can cause scarring.
**Treatment:**
Treatment depends on the severity and type of acne but may include:
- **Topical Treatments:** Such as benzoyl peroxide, salicylic acid, or retinoids to reduce bacteria and unclog pores.
- **Oral Medications:** Antibiotics or oral contraceptives for hormonal acne.
- **Procedures:** Such as chemical peels, extraction of comedones, or light therapy for more severe cases.
**Prevention and Management:**
- **Cleanse:** Regularly wash skin with a gentle cleanser.
- **Moisturize:** Use non-comedogenic moisturizers to keep skin hydrated without clogging pores.
- **Avoid Irritants:** Such as harsh cosmetics or excessive scrubbing.
- **Sun Protection:** Use sunscreen to prevent exacerbation of acne scars and inflammation.
Acne treatment can take time, and consistency in skincare routines and treatments is crucial. Consulting a dermatologist can help tailor a treatment plan that suits individual needs and reduces the risk of scarring or long-term skin damage.
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)GeorgeKieling1
Home
Organization
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
- Video recording of this lecture in English language: https://youtu.be/RvdYsTzgQq8
- Video recording of this lecture in Arabic language: https://youtu.be/ECILGWtgZko
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Congestive Heart failure is caused by low cardiac output and high sympathetic discharge. Diuretics reduce preload, ACE inhibitors lower afterload, beta blockers reduce sympathetic activity, and digitalis has inotropic effects. Newer medications target vasodilation and myosin activation to improve heart efficiency while lowering energy requirements. Combination therapy, following an assessment of cardiac function and volume status, is the most effective strategy to heart failure care.
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)
Diagnostic Staging Laparoscopy
1. Diagnostic Staging Laparoscopy
in GI malignancies
Dr. Pranjal Rokaya
Resident General Surgery
KIST MCTH
Moderator
Prof. Dr. Rupesh Mukhiya
13th February, 2023
2. Outline
• Introduction
• Indication
• Contraindication
• Surgical approach
• Exploratory principles
• Risk and complications
• Laparoscopic ultrasound
• Diagnostic accuracy and yield in
different GI malignancies
3. Introduction
• Diagnostic staging laparoscopy (DSL) is performed to determine the feasibility of
the proposed cancer operation.
• DSL complements preoperative assessment of radiographic imaging, which has
limitations for identifying regional extension of primary tumor and/or metastatic
disease such as peritoneal involvement. [1,2]
1. Blackshaw GR, Barry JD, Edwards P, Allison MC, Thomas GV, Lewis WG. Laparoscopy significantly improves the perceived preoperative stage of gastric cancer. Gastric
Cancer. 2003;6(4):225-229. doi:10.1007/s10120-003-0257-0.
2. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for diagnostic laparoscopy. Reviewed and approved in April 2010. Available at:
https://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/ (Accessed on Feb 11, 2023).
4. DSL: Goal
• Identify and disprove the presence of local, regional, and/ or metastatic disease.
• Aids in identifying extra organ disease that would preclude an attempt at a
curative resection.
• Prerequisite: Availability and acceptance of nonoperative palliative treatment for
unresectable tumors.
5. DSL: Indications[2]
Assessment for resectability with curative intent of primary digestive cancers:
a. Esophageal cancer at GE junction.
b. Gastric cancer
c. Pancreatic and periampullary cancer
d. Biliary tract cancer …Contd
2. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for diagnostic laparoscopy. Reviewed and approved in April 2010. Available at:
https://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/ (Accessed on Feb 11, 2023).
6. DSL: Indications[2]
Staging prior to administration of neoadjuvant chemotherapy or radiotherapy.
Assessment of equivocal MRI, CT, or PET scan for primary, regional, or distant
disease.
Assessment of inconclusive histology following radiographic guided FNA of
suspicious sites of disease.
Assessment for resectability of liver metastasis in patients with colon or rectal
cancer in combination with a laparoscopic ultrasound.
2. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for diagnostic laparoscopy. Reviewed and approved in April 2010. Available at:
https://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/ (Accessed on Feb 11, 2023).
7. Contraindications [2]
• Inability to tolerate laparoscopy.
• Previously confirmed metastatic or unresectable disease.
2. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for diagnostic laparoscopy. Reviewed and approved in April 2010. Available at:
https://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/ (Accessed on Feb 11, 2023).
8. Surgical approach
A. Incision placement
Initial trocar placement should be remote from prior surgical incisions or
suspected metastatic disease.
11. Surgical approach
B. Staging procedure
One stage procedure
Perform DSL as sole intended procedure.
Advantage: Identify patients who may be more appropriately treated with
chemo/radiotherapy as first line treatment.
Disadvantage: 2nd definitive procedure required.
12. Surgical approach
B. Staging procedure
Two-stage procedure
DSL and definite operation in the same setting, if no unresectable /distant disease
is identified.
Advantage : Only one operative setting with one anesthetic administration.
Disadvantage: Possible uncertainty of frozen section report on biopsy.
13. Surgical approach
C. Collection of fluid for cytology
Fluid sampled for cytology in patients with ascites.
In patients w/o ascites, peritoneal washing is typically not performed.
14. Exploratory principles
Access to peritoneal cavity obtained.
General exploration of peritoneal surfaces done.
Surfaces in pelvis, colic gutters are evaluated.
15. Exploratory principles
Thorough assessment of local and regional sited performed.
Abnormal lymphadenopathy adequately sampled via
laparoscope.
Single suspicious lymph node resected in entirety if possible.
16. Exploratory principles
Complete evaluation of liver surface performed using combination
of altered patient positioning and offsetting angled laparoscope.
Intraoperative laparoscopic ultrasound may be performed to
identify metastatic disease.
17. Biopsies
• Performed on suspicious lesions.
• In two stages, a frozen section is obtained; otherwise submitted for final
histologic evaluation.
• If metastatic disease is confirmed on the frozen section, operation is concluded.
18. Risk and Complications
• Morbidity a/w DSL for patients with esophageal, gastric, and pancreatic cancer
ranges from 0-2.5%; no mortality related to DSL [3,4].
• Operative morbidity and mortality of diagnostic laparotomy range from 13-21%
and 10-21% respectively.
• Thus, DSL is safe to perform to identify candidates for primary resection vs other
modalities.
3. Muntean V, Oniu T, Lungoci C, et al. Staging laparoscopy in digestive cancers. J Gastrointestin Liver Dis. 2009;18(4):461-467.
4. Conlon KC, Dougherty E, Klimstra DS, Coit DG, Turnbull AD, Brennan MF. The value of minimal access surgery in the staging of patients with potentially resectable
peripancreatic malignancy. Ann Surg. 1996;223(2):134-140. doi:10.1097/00000658-199602000-00004
19. a. Port site tumor implantation
• Less than 1 %; median time to occurrence 8 months [5].
• In a review of 1650 procedures, almost all patients who developed port site
recurrence also had local recurrence/distant disease.
• Risk of port site implantation was comparable to that of laparotomy incision [6,7]
.
5. Shoup M, Brennan MF, Karpeh MS, Gillern SM, McMahon RL, Conlon KC. Port site metastasis after diagnostic laparoscopy for upper gastrointestinal tract
malignancies: an uncommon entity. Ann Surg Oncol. 2002;9(7):632-636. doi:10.1007/BF02574478
6. Ziprin P, Ridgway PF, Peck DH, Darzi AW. The theories and realities of port-site metastases: a critical appraisal. J Am Coll Surg. 2002;195(3):395-408.
doi:10.1016/s1072-7515(02)01249-8
7. Curet MJ. Port site metastases. Am J Surg. 2004;187(6):705-712. doi:10.1016/j.amjsurg.2003.10.015
20. Approaches to reduce port site implantation [7]
• Place trocars perpendicular to the peritoneum.
• Prevent carbon dioxide leakage around trocars.
• Minimize handling of tumor tissue.
• Protect extraction sites.
• Bag specimens intra-abdominally to avoid spillage.
…contd
7. Curet MJ. Port site metastases. Am J Surg. 2004;187(6):705-712. doi:10.1016/j.amjsurg.2003.10.015
21. Approaches to reduce port site implantation
• Remove the entire lesion rather than a partial biopsy if possible.
• Deflate the abdomen with trocars in place.
• Close the fascia of the trocar port site while avoiding liquid spillage into the
wound.
22. b. Vascular and organ injury
• May occur at the time of port placement, during organ manipulation, or while
performing biopsies.
23. Laparoscopic ultrasound (LUS)
• Adjunct to preoperative radiographic imaging and DSL for staging.
• No RCT or systemic review has been done to determine if LUS offers an advantage
over laparoscopy alone for detecting unresectable diseases.
24. Factors affecting successful DSL
• Patient-related: Presence of intraabdominal adhesions, obesity.
• Prelaparoscopic staging: Advanced tumors are more likely to have a higher yield
at DSL.
• Surgical skill: eg: exploring lesser sac or coeliac nodes and taking biopsies.
• Quality of preoperative imaging
Recent advances in surgery, 40th edition
25. Laparoscopic ultrasound (LUS)
• In a prospective study of 53 patients with pancreatic cancer, LUS altered
management in 28 patients [8]. The positive predictive value of LUS for
determining resectability was 91 percent [9].
• In a series of 50 consecutive patients with pancreatic cancer, there was no
significant difference in sensitivity, specificity, or overall accuracy between
preoperative CT scan and LUS [10].
8. Taylor AM, Roberts SA, Manson JM. Experience with laparoscopic ultrasonography for defining tumour resectability in carcinoma of the pancreatic head and
periampullary region. Br J Surg. 2001;88(8):1077-1083. doi:10.1046/j.0007-1323.2001.01826.x
9. Viganò L, Ferrero A, Amisano M, Russolillo N, Capussotti L. Comparison of laparoscopic and open intraoperative ultrasonography for staging liver tumours. Br J Surg.
2013;100(4):535-542. doi:10.1002/bjs.9025
10. Pietrabissa A, Caramella D, Di Candio G, et al. Laparoscopy and laparoscopic ultrasonography for staging pancreatic cancer: critical appraisal. World J Surg.
1999;23(10):998-1003. doi:10.1007/s002689900614
26. Diagnostic accuracy and Yield
• Conventional imaging studies often understate the intraabdominal extent of
cancer. [2]
• Accuracy: Number of unresectable diseases detected by DSL divided by the total
number of unresectable cases
• Yield : No. of unresectable patients detected by DSL divided by a total number of
patients undergoing DSL. [11]
2. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for diagnostic laparoscopy. Reviewed and approved in April 2010. Available at:
https://www.sages.org/publications/guidelines/guidelines-for-diagnostic-laparoscopy/ (Accessed on Feb 11, 2023).
11. Connor S, Barron E, Wigmore SJ, Madhavan KK, Parks RW, Garden OJ. The utility of laparoscopic assessment in the preoperative staging of
suspected hilar cholangiocarcinoma. J Gastrointest Surg. 2005;9(4):476-480. doi:10.1016/j.gassur.2004.10.009
27. Esophageal cancer
• A review of 195 patients with esophageal cancers found that DSL altered
treatment plans in 29 patients (15%) [33].
• No patients with proximal or middle esophageal cancer had a disease-altering
disease.
• 17% of patients with distal cancer had a regional or metastatic disease that
altered the initial treatment plan.
33. de Graaf GW, Ayantunde AA, Parsons SL, Duffy JP, Welch NT. The role of staging laparoscopy in oesophagogastric cancers. Eur J Surg Oncol.
2007;33(8):988-992. doi:10.1016/j.ejso.2007.01.007
28. Esophageal cancer
• To limit aggressive t/t in patients with locally
advanced disease, DSL performed in patients
with esophageal and EGJ adenocarcinomas.
• Adenocarcinoma arising from the
intrabdominal segment is prone to develop
intraperitoneal metastasis.
Siewert classification of EGJ tumor
29. Esophageal cancer: NCCN guidelines [12]
• DSL performed in patients with equivocal radiographic imaging with suspicion of
metastasis but nondiagnostic FNA.
• Patients with EJ cancers but not proximal and mid-esophageal cancer should
routinely undergo DSL.
• During DSL for EGJ cancer, subphrenic and pelvic peritoneal lavage for cytology is
performed.
12. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Esophageal and esophagogastric junction cancers. Version
1.2020 - March 18, 2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf (Accessed on Feb 12 , 2022).
30. Gastric cancer
• Retrospective and prospective studies on the yield of DSL found that
peritoneal/metastatic disease was found in 30-53% of patients with negative
preoperative CT/MRI evaluation [16,14,15].
• A prospective study of 100 patients undergoing DSL found peritoneal spread/
liver metastasis in 21 patients all of whom had T3/T4 advanced cancers [13].
13. Blackshaw GR, Barry JD, Edwards P, Allison MC, Thomas GV, Lewis WG. Laparoscopy significantly improves the perceived preoperative stage of
gastric cancer. Gastric Cancer. 2003;6(4):225-229. doi:10.1007/s10120-003-0257-0
14. Muntean V, Mihailov A, Iancu C, et al. Staging laparoscopy in gastric cancer. Accuracy and impact on therapy. J Gastrointestin Liver Dis.
2009;18(2):189-195.
15. Yano M, Tsujinaka T, Shiozaki H, et al. Appraisal of treatment strategy by staging laparoscopy for locally advanced gastric cancer. World J Surg.
2000;24(9):1130-1136. doi:10.1007/s002680010183
16. Kapiev A, Rabin I, Lavy R, et al. The role of diagnostic laparoscopy in the management of patients with gastric cancer. Isr Med Assoc J.
2010;12(12):726-728.
31. Gastric cancer
• Between 20-30% of patients who had disease beyond T1 on EUS; with negative
CT scan had peritoneal metastasis [17,18].
• The risk of occult peritoneal dissemination is even higher for advanced (T4)
tumors or with linitis plastica appearance; where DSL altered mx in up to 50% of
patients [19,20].
17.. Lowy AM, Mansfield PF, Leach SD, Ajani J. Laparoscopic staging for gastric cancer. Surgery. 1996;119(6):611-614. doi:10.1016/s0039-6060(96)80184-x
18. Sarela AI, Lefkowitz R, Brennan MF, Karpeh MS. Selection of patients with gastric adenocarcinoma for laparoscopic staging. Am J Surg. 2006;191(1):134-138.
doi:10.1016/j.amjsurg.2005.10.015
19. Simon M, Mal F, Perniceni T, et al. Accuracy of staging laparoscopy in detecting peritoneal dissemination in patients with gastroesophageal adenocarcinoma. Dis
Esophagus. 2016;29(3):236-240. doi:10.1111/dote.12332
20. Leake PA, Cardoso R, Seevaratnam R, et al. A systematic review of the accuracy and indications for diagnostic laparoscopy prior to curative-intent resection of
gastric cancer. Gastric Cancer. 2012;15 Suppl 1:S38-S47. doi:10.1007/s10120-011-0047-z
32. Gastric cancer: NCCN guidelines
• Preoperative DSL is recommended for any medically fit patients:
a. Who appears to have more than T1 lesion on EUS.
b. No histologic confirmation of stage IV disease.
c. Who would not otherwise require palliative gastrectomy because of symptoms.
33. Pancreatic and periampullary cancer
• Many studies evaluating the yield of DSL haven't differentiated between pancreatic
and periampullary cancers.
• Accuracy in predicting resectability:
CT scan: 85-100 %. DSL : >90% [21,22]
• Two meta-analyses have found that 4-21% of patients could have avoided laparotomy
had they undergone DSL following CT imaging [23,24].
21. Holzman MD, Reintgen KL, Tyler DS, Pappas TN. The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies. J
Gastrointest Surg. 1997;1(3):236-244. doi:10.1016/s1091-255x(97)80115-1
22. Stefanidis D, Grove KD, Schwesinger WH, Thomas CR Jr. The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review. Ann Oncol.
2006;17(2):189-199. doi:10.1093/annonc/mdj013
23. Pisters PW, Lee JE, Vauthey JN, Charnsangavej C, Evans DB. Laparoscopy in the staging of pancreatic cancer. Br J Surg. 2001;88(3):325-337.
doi:10.1046/j.1365-2168.2001.01695.x
24. Allen VB, Gurusamy KS, Takwoingi Y, Kalia A, Davidson BR. Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing
the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev. 2016;7(7):CD009323. Published 2016 Jul 6.
doi:10.1002/14651858.CD009323.pub3
34. Pancreatic and periampullary cancer
• Few studies have suggested that patients with cancers of the body or tail of the
pancreas are more likely to benefit from DSL than those with pancreatic head
involvement [25,26].
• DSL identified occult disease twice as frequently in pancreatic body/tail
compared to pancreatic head cancers.
25. Jimenez RE, Warshaw AL, Rattner DW, Willett CG, McGrath D, Fernandez-del Castillo C. Impact of laparoscopic staging in the treatment of
pancreatic cancer. Arch Surg. 2000;135(4):409-415. doi:10.1001/archsurg.135.4.409
26. Liu RC, Traverso LW. Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by computed tomography. Surg
Endosc. 2005;19(5):638-642. doi:10.1007/s00464-004-8165-x
35. Pancreatic and periampullary cancer
• Most studies have shown little advantage of DSL for periampullary cancers [22,27].
• Unnecessary laparotomy was avoided in only 2.3% of patients with periampullary
cancer compared to 35% of patients with tumors of the body/tail [28].
22. Stefanidis D, Grove KD, Schwesinger WH, Thomas CR Jr. The current role of staging laparoscopy for adenocarcinoma of the pancreas: a review. Ann
Oncol. 2006;17(2):189-199. doi:10.1093/annonc/mdj013
27. Nieveen van Dijkum EJ, Romijn MG, Terwee CB, et al. Laparoscopic staging and subsequent palliation in patients with peripancreatic carcinoma. Ann
Surg. 2003;237(1):66-73. doi:10.1097/00000658-200301000-00010
28. Barreiro CJ, Lillemoe KD, Koniaris LG, et al. Diagnostic laparoscopy for periampullary and pancreatic cancer: what is the true benefit?. J Gastrointest
Surg. 2002;6(1):75-81. doi:10.1016/s1091-255x(01)00004-x
36. Pancreatic and periampullary cancer: NCCN guidelines
• DSL is recommended for all patients with pancreatic body or tail cancer.
• Selective use of laparoscopy is recommended for periampullary cancers.
37. Biliary tract cancer
• The sensitivity and negative predictive value of DSL in identifying peritoneal and
superficial liver metastasis was 60 and 48% [29].
• DSL identified metastasis in 23% of patients who had negative preoperative
imaging.
• The overall yield for detecting unresectable biliary cancer using DSL ranged from
48% [30].
29. Barreiro CJ, Lillemoe KD, Koniaris LG, et al. Diagnostic laparoscopy for periampullary and pancreatic cancer: what is the true benefit?. J Gastrointest Surg.
2002;6(1):75-81. doi:10.1016/s1091-255x(01)00004-x
30. Weber SM, DeMatteo RP, Fong Y, Blumgart LH, Jarnagin WR. Staging laparoscopy in patients with extrahepatic biliary carcinoma. Analysis of 100 patients. Ann Surg.
2002;235(3):392-399. doi:10.1097/00000658-200203000-00011
38. Biliary cancer: NCCN guidelines
• Routine DSL for patients with cholangiocarcinoma of proximal bile duct and gall
bladder cancer but not for distal biliary cancer.
39. Colorectal cancer
• DSL infrequently used for patients with colon or rectal cancer as resection is
necessary for most patients.
• In a review of 56 patients with liver metastasis from colorectal cancer, DSL
identified only 3 of 8 patients with the unresectable disease [31].
• Additional value of DSL in metastatic disease hasn’t been established [32].
31. Koea J, Rodgers M, Thompson P, Woodfield J, Holden A, McCall J. Laparoscopy in the management of colorectal cancer metastatic to the liver. ANZ
J Surg. 2004;74(12):1056-1059. doi:10.1111/j.1445-1433.2004.03267.x
32. Cotte E, Peyrat P, Piaton E, et al. Lack of prognostic significance of conventional peritoneal cytology in colorectal and gastric cancers: results of
EVOCAPE 2 multicentre prospective study. Eur J Surg Oncol. 2013;39(7):707-714. doi:10.1016/j.ejso.2013.03.021
40. Hepatocellular cancer (HCC)
• DSL has a theoretical advantage:
Detection of small intrahepatic metastasis.
Safe biopsy of primary and additional lesions.
Assessment of liver remnant and severity of cirrhosis (biopsy).
Detection of extrahepatic disease.
DSL with EUS leads to upstaging in 16-39% of patients with potentially resectable
HCC and is recommended.
Recent advances in Surgery, 40th edition